A patient with heart failure, who is frail: How does this affect therapeutic decisions?

Patients with heart failure (HF) are heterogeneous, not only related to comorbidities but also in the presentation of frailty syndrome. Frailty syndrome also affects patients with HF across the lifespan. Frailty in patients with HF has a significant impact on clinical features, diagnosis, management, adverse medical outcomes and costs. In everyday clinical practice, frail patients with HF require an individualized approach, often imposing the need to modify therapeutic decisions. The aim of this review is to illustrate how frailty and multimorbidity in HF can affect therapeutic decisions. The scientific evidence underlying this publication was obtained from an analysis of papers indexed in the PubMed database. The search was limited to articles published between 1990 and July 2022. The search was limited to full-text papers published in English. The database was searched for relevant MeSH phrases and their combinations and keywords including: "elderly, frail"; "frailty, elderly"; "frail older adults"; "frailty, older adults"; "adult, frail older"; "frailty, heart failure"; "frailty, multimorbidity"; "multimorbidity, heart failure"; "multimorbidity, elderly"; "older adults, cardiovascular diseases". In therapeutic decisions regarding patients with HF, additionally burdened with multimorbidity and frailty, it becomes necessary to individualize the approach in relation to optimization and treatment of coexisting diseases, frailty assessment, pharmacological and non-pharmacological treatment and in the implementation of invasive procedures in the form of implantable devices or cardiac surgery.

The how and why of assessing frailty syndrome in cardiac surgery.

Frailty syndrome (FS) is one of the most important variables that have a proven impact on the increased risk of morbidity and mortality in cardiac surgery. However, FS assessment is not routinely incorporated into daily clinical practice or included in commonly used risk assessment models. The inclusion of FS in perioperative risk prediction models in cardiac surgery would not only allow for a more accurate assessment but could also assist in the selection of an appropriate treatment strategy while favoring the appropriate use of clinical resources. The identification of FS in the qualification process must not be seen as an absolute contraindication to cardiac surgery but as an opportunity to adequately prepare the patient for the procedure. However, the literature is heterogeneous in terms of the selection of an appropriate tool for identifying FS. Selected tools commonly used in the assessment of FS in patients with cardiovascular disease, including those of greatest relevance in cardiac surgery, are presented in this editorial.

Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research?

Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.

Cardiac Cachexia: A Well-Known but Challenging Complication of Heart Failure.

Heart failure (HF) is a common complication of various cardiac diseases, and its incidence constantly increases. This is caused mainly by aging of populations and improvement in the treatment of coronary artery disease. As HF patients age, they tend to develop comorbidities, creating new problems for health-care professionals. Sarcopenia, defined as the loss of muscle mass and function, and cachexia, defined as weight loss due to an underlying illness, are muscle wasting disorders of particular relevance in the heart failure population, but they go mostly unrecognized. The coexistence of chronic HF and metabolic disorders facilitates the development of cachexia. Cachexia, in turn, significantly worsens a patient's prognosis and quality of life. The mechanisms underlying cachexia have not been explained yet and require further research. Understanding its background is crucial in the development of treatment strategies to prevent and treat tissue wasting. There are currently no specific European guidelines or recommended therapy for cachexia treatment in HF ("cardiac cachexia").

Multidimensional Approach to Frailty.

The concept of frailty syndrome (FS) was first described in the scientific literature three decades ago. For a very long time, we understood it as a geriatric problem, recently becoming one of the dominant concepts in cardiology. It identifies symptoms of FS in one in 10 elderly people. It is estimated that in Europe, 17% of elderly people have FS. The changes in FS resemble and often overlap with changes associated with the physiological aging process of the body. Although there are numerous scientific reports confirming that FS is age correlated, it is not an unavoidable part of the aging process and does not apply only to the elderly. FS is a reversible clinical condition. To maximize benefits of frailty-reversing activities for patient with frailty, identification of its determinants appears to be fundamental. Many of the determinants of the FS have already been known: reduction in physical activity, malnutrition, sarcopenia, polypharmacy, depressive symptom, cognitive disorders, and lack of social support. This review shows that insight into FS determinants is the starting point for building both the comprehensive definition of FS and the adoption of the assessment method of FS, and then successful clinical management.

Short-Term Outcomes of Percutaneous Trephination with a Platelet Rich Plasma Intrameniscal Injection for the Repair of Degenerative Meniscal Lesions. A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study.

Meniscal tears are the most common orthopaedic injuries, with chronic lesions comprising up to 56% of cases. In these situations, no benefit with surgical treatment is observed. Thus, the purpose of this study was to investigate the effectiveness and safety of percutaneous intrameniscal platelet rich plasma (PRP) application to complement repair of a chronic meniscal lesion. This single centre, prospective, randomized, double-blind, placebo-controlled study included 72 patients. All subjects underwent meniscal trephination with or without concomitant PRP injection. Meniscal non-union observed in magnetic resonance arthrography or arthroscopy were considered as failures. Patient related outcome measures (PROMs) were assessed. The failure rate was significantly higher in the control group than in the PRP augmented group (70% vs. 48%, P = 0.04). Kaplan-Meyer analysis for arthroscopy-free survival showed significant reduction in the number of performed arthroscopies in the PRP augmented group. A notably higher percentage of patients treated with PRP achieved minimal clinically significant difference in visual analogue scale (VAS) and Knee injury and Osteoarthritis Outcome Score (KOOS) symptom scores. Our trial indicates that percutaneous meniscal trephination augmented with PRP results in a significant improvement in the rate of chronic meniscal tear healing and this procedure decreases the necessity for arthroscopy in the future (8% vs. 28%, P = 0.032).

Frailty Syndrome: Nursing Interventions.

BACKGROUND: Frailty syndrome is now becoming a challenge for multidisciplinary teams. Frailty assessment in elderly patients is recommended due to the associated cascade of irreversible alterations that ultimately result in disability. AIMS: The purpose of this article is to identify interventions, which can be implemented and performed by nurses as part of a multidisciplinary plan. Nursing strategies related to nutrition, polypharmacy, adherence to treatment, falls, exercise, and mood and cognitive intervention are described. DESIGN: Discussion paper. DATA SOURCES: Relevant and up-to-date literature from PubMed, MEDLINE, and Scopus databases regarding the selected issues, such as nutritional status, polypharmacy, falls, physical activity, and cognitive functions. CONCLUSION: Frailty is considered preventable or even reversible with the appropriate interventions, which can help maintain or even restore physical abilities, cognitive function, or nutritional status in frail elderly patients. Hence, the nursing interventions are significant in clinical practice and should be implemented for frail patients. IMPLICATIONS FOR NURSING: Health-care providers, especially nurses, in their clinical practice should recognize not only elderly patients but also elderly patients with concurrent frailty, requiring intensified therapeutic interventions tailored to their individual needs. Frailty syndrome is undoubtedly a challenge for multidisciplinary teams providing health care for geriatric patients.

Health-related quality of life of patients suffering from cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is a particular example of a chronic disease with progressive course. Current statistical data shows that the life span of patients with CF has extended. Therefore, it is necessary to undertake interdisciplinary actions aiming at improving the efficiency of medical activities as well as minimalizing the influence of those interventions on the patients' quality of prolonged life. OBJECTIVES: The aim of the study was to depict the QoL of patients suffering from mucoviscidosis and show the differences in the assessment of patients' QoL depending on age and sex. MATERIAL AND METHODS: The study covered 30 patients with CF. Mean age of the respondent group was 24.83 ± 6.98; mean age of females 25.8 ± 7.27, whereas of males - 23.5 ± 6.56. A specific questionnaire for testing cystic fibrosis quality of life (CFQoL) of patients was used in the study. RESULTS: Generally patients with CF evaluated their QoL as low. In the study with the use of a CFQoL questionnaire they evaluated their QoL as the lowest in a subscale: future concerns. In most domains women got lower mean values than men. A dependence between patients' QoL and their age was ascertained. The older the patient is, the lower QoL is in the case of subscales (CFQoL): physical, emotional and social functioning, chest symptoms, interpersonal relationships, body image, career concerns. CONCLUSIONS: Patients with CF generally evaluate their QoL as low; there are differences in the evaluation of QoL between women and men. There is a relation between patients' QoL their age. The older the patient is, the worse his QoL in most subscales is.

Health-related quality of life of patients with cystic fibrosis assessed by the SF-36 questionnaire.

INTRODUCTION: Cystic fibrosis (CF) is a genetic disorder, which is most common among Caucasians. There are about 100,000 people suffering from this disorder in the world, including 25 000 in Europe. Although the first mention of cystic fibrosis is thought to have occurred in 1595, recognition of the entire clinical spectrum of CF and the resultant development of contemporary knowledge occurred in the 20th century. In the past, CF was considered a fatal childhood disorder; however, contemporary statistical data shows that 50% of people with cystic fibrosis have a chance to live up to 30 years of age, and the lifespan of children born in the 1990s is projected to be at least 40 years. Consequently, the number of adults with cystic fibrosis is increasing, making it necessary for multidisciplinary actions aimed at the improvement of clinical management of the condition as well as minimizing the influence of CF and its treatment on the quality of continually extending life of patients. Since cystic fibrosis interferes with almost all important aspects of human functioning, quality of life (QoL) of individuals with CF should be constantly and closely monitored, thus allowing for consideration of their needs and providing an opportunity to modify the therapeutic approach if necessary. The aim of this study was to visualize the QoL of people with cystic fibrosis, to identify differences in their assessment of QoL depending on sex and age, as well as to compare the QoL of patients with CF with a control group of people without CF. MATERIAL AND METHODS: The study was conducted among patients hospitalized at the Clinic of Pulmonology and Cystic Fibrosis at the Institute of Tuberculosis and Lung Diseases in Rabka-Zdrój from February to April 2012. The study encompassed 30 patients (19 women and 11 men), aged between 16 and 42 years, with acute episodes of bronchopulmonary disease. A Short Form-36 (SF-36) questionnaire was used to evaluate the health-related quality of life. The control group encompassed 30 healthy individuals with the same sex ratio and similar age ratio as in the group of patients. RESULTS: The analysis of quality of life with the use of the SF-36 questionnaire showed that in general the quality of life of the assessed patients was low. The patients scored on average below 50 in the following subscales: Role Physical (RP), General Health (GP), Vitality (VT), Social Functioning (SF), Physical Component Summary (PCS) and Mental Component Summary (MCS). In other subscales the results slightly exceeded 50. In women, low quality of life was found in the following subscales: Role Physical, Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Physical Component Summary (PCS) and Mental Component Summary (MCS). In men, average results below 50 were found in the following subscales: General Health (GH) and Vitality (VT). Moreover, in all subscales, the quality of life assessed by women was lower than that reported by men.Patients > 25 years assessed their quality of life as lower in all subscales except for the Role Emotional (RE) subscale. Statistically significant differences were identified with regards to Vitality (VT) and Mental Health (MH). The analysis of the influence of CF patients' age on their quality of life, conducted with the use of the SF-36 questionnaire, showed that there were statistically significant correlations (p < 0.05) between age and the following domains: Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), Vitality (VT), Social Functioning (SF), Mental Health (MH) and Physical Component Summary (PCS). The comparison between the QoL of patients with CF and those of a control group of individuals not suffering from CF demonstrated that there were statistically significant differences in all subscales. Patients' quality of life was significantly poorer than quality of life of individuals without CF. CONCLUSIONS: 1. Patients with CF generally perceive their quality of life as low.2. There are differences in the assessment of quality of life between women and men.3. The older the patients, the worse their quality of life assessment in most subscales.4. There are critical differences in the quality of life assessment between patients with CF and a control group encompassing individuals without CF. Patients with CF find their quality of life poorer.