3 Things We’ve Learned About Frailty in Heart Failure Recently
As I often say to audiences when I give talks, we have learned a lot about frailty in heart failure over the last couple of decades. Rewinding to 2012 when I was introduced to the concept of frailty and how it intersects with heart failure, the literature in this area was pretty sparse. On one hand, it made it manageable to read, digest, and write about this topic for my PhD benchmarks. On the other hand, it meant that we didn’t know that much and therefore couldn’t even begin to address this issue. Fast forward to 2026, we have learned a lot! We have generated estimates of how common frailty is in heart failure and how patient-reported and clinical outcomes are affected by frailty, and we have started to figure out the underlying biology of frailty in heart failure. But just like the saying goes, “the more you know, the more you don’t know,” we still need to learn a lot more about frailty in heart failure. Our group has tried to chip away at this yet-to-be-unearthed knowledge and have learned a few things recently that we wanted to share.
Physical frailty is associated with better symptom monitoring and management in heart failure.
Yes, you read that correctly. This result is a fresh, hot-off-the-press finding from our NIH/NINR R21 mixed methods study where we wanted to understand if and how physical frailty was linked with how patients monitor and manage their symptoms. When I wrote the grant (and resubmitted the grant twice), I hypothesized that physical frailty would be associated with worse symptom monitoring and management, thinking that physical frailty might impede a patient’s ability to perform self-care (like how cognitive dysfunction affects self-care). My hypothesis was wrong. In fact, better symptom monitoring and management was associated with physical frailty; those physically frail had, on average, 8.9 and 10.3 points higher (better) scores on the Self-Care of Heart Failure Index symptom monitoring and management scales, respectively, compared with those non-frail.
We also looked at how all these things (physical frailty, symptom monitoring, symptom management) were associated with six-month clinical events and found that, regardless of how well someone monitors and manages their symptoms, physical frailty was associated with worse outcomes. There were similar findings regarding health status. Bottomline, while physically frail adults with heart failure have better symptom monitoring and management (probably out of necessity), they still have poor outcomes. You can read more about these findings in the paper published in Journal of Cardiovascular Nursing. And stay tuned for more to come!
Physical frailty is associated with social risk factors in heart failure, especially retirement or unemployment.
There is a bit of a backstory to this one. This analysis came to fruition thanks to a coffee meeting with a friend and colleague. It was March 2024, and the deadline for the general abstract submissions for the Heart Failure Society of America Annual Scientific Meeting was just around the corner. We were talking about putting something together, and it dawned on me that I had never really looked at social risk factors in relation to physical frailty; most (actually, all) of my prior research had been laser-focused on biological, physiological, and clinical risk factors of physical frailty. Why not look at social risk factors? Both my F31 and K12 studies collected standard sociodemographic factors in identical ways, so we merged data from these two studies. In parallel, I was teaching Applied Statistics II in our PhD program, covering material related to interactions, hierarchical regression, and logistic regression. So, to be uber-efficient, I analyzed the data, presented it to the students, and then wrote an abstract over two weeks. The preliminary findings were unique and additive, and I was eager to mull over, disseminate, and build on these findings.
Unfortunately, a few things disrupted this plan: Hurricane Helene swept through Atlanta in September 2024 and forced the cancellation of the Heart Failure Society of America Annual Scientific Meeting, there was a drastic shift in funding priorities in early 2025, and I was frankly swamped with keeping my other research going. But I didn’t want this analysis to get buried! I finally found the time and resources (with huge thanks to my PhD student, Zijiao Wang!) to get this across the finish line. So, what did we find? The three main things were: 1) the block of social risk factors significantly predicted frailty, 2) retirement or unemployment was associated with significantly higher odds of frailty (indicating that perhaps retirement/unemployment is a sentinel event), and 3) after accounting for all of this, women are still more likely to be frail than men. Definitely a lot of interesting signals to pursue in the future! And the other thing I learned: research ideas are sparked in many different places, including informal chats with friends at coffee shops. You can read more about these findings in the paper published in Journal of Cardiac Failure - Intersections.
Physical frailty is already present in about half of adults with heart failure at time of diagnosis.
This novel finding comes from Dr. Mary Roberts Davis’s mixed methods study (funded by the OHSU K12 Building Interdisciplinary Research Careers in Women’s Health Career Development Award). For this study, she tackled a difficult subject: capturing symptoms, frailty, and prior healthcare utilization data among adults recently diagnosed with heart failure. Patients newly diagnosed with heart failure have a lot going on as they navigate this life-altering diagnosis – so a major thanks to the patients who participated! Using the FRAIL scale (a self-report derivative of the original Frailty Phenotype Criteria), nearly half of the participants were frail and most of the rest were pre-frail. And in line with our previous meta-analysis findings, women were more likely to be frail than men. Also building on our prior findings, being frail was a significant predictor of worse dyspnea at diagnosis.
This finding of frailty being highly prevalent at diagnosis gives us a little more data on the temporal relationship between frailty and heart failure. Similar to the chicken and egg conundrum, which comes first? While it can be said that heart failure takes a while to be diagnosed and therefore frailty may develop in response to undiagnosed (and untreated) heart failure, there was probably some underlying frailty from other causes already taking root (e.g. from aging or other comorbidities). This finding also underscores the need to assess frailty at time of diagnosis and repeatedly thereafter. By assessing frailty over time, beginning with diagnosis, we can ascertain if frailty will be reversible with heart failure medications and/or devices or if some other management strategy is needed (e.g. exercise, nutrition). There are a lot more rich data and findings, including findings on symptoms and healthcare utilization, in the paper published in Journal of Cardiac Failure - Intersections.
There are many other groups around the world leading research efforts to unpack the mechanisms of frailty in heart failure, ascertain the reversibility of frailty with advanced therapies, design and deploy interventions to address frailty in heart failure, and incorporate the patient’s perspective on frailty in heart failure. Seemingly every few weeks, I read another article on frailty in heart failure that gives us just a bit more insight into this area. Bit-by-bit, we are working together to learn more and better equip ourselves to help our patients feel and function better while living with heart failure.
