Shinshu Med J, 71⑴：53～61, 2023

The Changes in Frailty and Death within Six Months of Discharge
in Heart Failure Patients 80 Years and Older
Risa Otsuka1）2）, Tomoko Kamimura3）＊ and Takeshi Tomita4）
1） Department of Medical Sciences, Graduate School of Medicine, Shinshu University2） Department of Rehabilitation, Shinshu University Hospital3） Department of Medical Sciences, Graduate School of Medicine, Shinshu University
4） North Alps Medical Center Azumi Hospital, Department of Cardiology

Aim : The prognostic impact of frailty in patients with heart failure (HF) is of interest because the cascade offrailty and HF accelerates deterioration. However, few studies have examined the deterioration of frailty in older
HF patients. Therefore, we examined changes in frailty and death within six months after discharge from thehospital to clarify the reasons for the poor prognoses and to explore risk factors that influence each of them.
Methods : This was a single-center prospective cohort study of hospitalized HF patients aged 80≧ years.
Frailty was measured using the Clinical Frailty Scale (CFS). Reasons for poor prognosis were examined, anddischarge attributes were compared between the CFS worsening and death groups and the CFS maintaining/
improving group at six months after discharge.
Results : The subjects consisted of 96 patients (89.3±4.6 years), and their CFS at six months was that 68 had
improved or maintained, 12 had worsened, 14 had died, and two were missing. Reasons for worsening frailty
included worsening cardiovascular disease and comorbidities, fall fracture, and dementia. Risk factors that could
influence mortality (e.g., BNP, hemoglobin, CFS) were similar to previous studies, and few risk factors were
found that could influence frailty deterioration (e.g., ACE-I/ARB not prescribed).
Conclusions : Some older HF patients experience worsening of frailty and death after hospital discharge. However,the potential factors associated with frailty deterioration are unknown, suggesting that treatment and careapproaches should be tailored to individual conditions such as cardiovascular diseases, comorbidities, fall risk,
and dementia. Shinshu Med J 71 : 53―61, 2023
(Received for publication July 6, 2022 ; accepted in revised form September 15, 2022)
Key words : frailty, heart failure, prognosis, geriatrics, older adults

Ⅰ Introduction

accelerates deterioration.
A meta-analysis of Uchmanowicz2）showed that the

Frailty is a condition associated with aging and ispresence of frailty in HF increased the hazards ofcharacterized by the reduced ability to cope withall-cause death and HF-related hospitalization by

daily or acute stressors due to decreased physiologic

means of 48 ％ and 40 ％, respectively. Kanenawa3）

reserve and function across multiple organs1）. In heart

further showed that severe frailty was independently

failure (HF) patients, the prognostic impact of frailty

associated with all-cause death and HF-related hos-is of interest because the cascade of frailty and HF

pitalizations among 596 discharged patients (meanage 76.6 ± 10.1 years).

＊

Corresponding author : Tomoko Kamimura
Department of Medical Sciences, Graduate School of
Medicine, Shinshu university, 3-1-1 Asahi, Matsumoto,
Nagano 390-8621, Japan
E-mail : tkamimu@shinshu-u.ac.jp

No. 1, 2023

It has been suggested that risk factors affecting
death and re-hospitalization among older HF patients
may differ from those in younger patients4）5）. However, to our knowledge, no report has examined the53

Otsuka・Kamimura・Tomita

prognostic impact of severity of frailty in the elderly

February 2020 to August 2021. Exclusion criteria were

without excluding patients with cognitive or physicalas follows : (1) death in the hospital, (2) development

disabilities.

of a serious illness other than HF during hospitaliza-

To our knowledge, there have also been no reportstion, and (3) refusal to participate in the study. We

examining changes in frailty or reasons for worsening

defined discharge from the hospital as the baseline

frailty in these patients after discharge from the hos-and followed up with the patients six months after

pital. Identifying the relationship between frailty anddischarge. We conducted the study in accordance withprognosis, as well as the reasons for worsening frailty,

the Declaration of Helsinki and with the approval ofwould be beneficial in the patient’s treatment andthe Shinshu University Ethics Committee (approvalcare.

numbers : 4648, 5039) and the participating hospitals.

Therefore, in the present study, we examined risk

Ｂ

Variables

factors affecting prognosis, including worsening frailty

We collected data from hospital medical records.

and death, and reasons for worsening frailty andBaseline clinical data included age, gender, history ofdeath in HF patients aged 80 years and older.

HF hospitalization, length of hospitalization, cause of

While there is still no consensus on a gold stan-

HF, comorbidities, and discharge prescriptions. Data

dard for frailty assessment, we used the Clinicalat discharge included New York Heart Association

6）
7）

that considers frailty to be an(NYHA) classification, B-type natriuretic peptide

accumulation of age-related deficits. In the CFS, a(BNP), left ventricular ejection fraction (LVEF), body

medical professional evaluates a patient’s comorbidi-

mass index (BMI), hemoglobin (Hb), albumin (Alb),

ties and functional and cognitive status and grades

estimated glomerular filtration rate (e-GFR), andFrailty Scale (CFS)7）

the patient’s overall condition on a 9-point stage .

Barthel Index (BI).

The CFS was implemented in this study because it is

CFS was assessed by an occupational therapist.

widely used to measure health outcomes in geriatric

Since the CFS stages were revised in September

medicine and cardiology units8） due to its simplicity

2020, the data from the old stages collected prior

9）and good sensitivity for frailty detection .

to that date were converted to the revised stages.

The purpose of this study was to examine CFS

Because many clinical studies consider CFS stage 5changes and death in HF patients aged 80 years andor higher to be frail, this criterion was used in thisolder between discharge and 6 months later, to de-study8）.

termine reasons for worsening frailty and death andＣ

to explore risk factors that influence worsening frail-

We examined whether the CFS stage that the HF
patient was in improved, maintained, or worsenedty and death.
Ⅱ Methods
Ａ

Follow up

Study design and participants

between discharge and 6 months after discharge.
CFS assessment at 6 months after discharge was
performed by an occupational therapist who evaluat-

A prospective cohort study was conducted on con-ed the patients at discharge through interviews in

secutive patients aged 80 years or older who were

the outpatient clinic, by telephone, and by mailadmitted for HF to the cardiology department of asurvey. When the CFS stage worsened, whether

hospital in Nagano Prefecture, Japan. This was a re-there were any rehospitalizations or irregular visits

gional core hospital that provided percutaneous coro-due to the occurrence of a new disease or worsening

nary intervention and did not perform cardiac sur-of an existing disease was examined by analyzing

gery but provided medical treatment and cardiac

the medical records and interviewing patients/fami-

rehabilitation according to the guidelines. HF waslies. If yes, the main disease was used as the reason

diagnosed by cardiologists using the Framingham

for worsening frailty. If a patient died within six

criteria. We conducted recruitment for the study frommonths of discharge，it was confirmed either in the54

Shinshu Med J

Vol. 71Frailty in HF patients over 80 years

Fig. 1

Study population flow chartpatient’s records or by telephone．

we excluded 12 patients due to in-hospital death, fourＤdue to the development of serious non-HF symptoms

Statistical analysis
Baseline characteristics of patients in the CFS

worsening and death groups at 6 months after discharge were compared with those in the CFS main-

during hospitalization, and two due to their refusal toparticipate ; 96 were followed up (Fig. 1).
The 96 patients’ characteristics at baseline aretaining/improving group. Sub-analyses were per-presented in Table 1. Overall, patients’ mean age ±formed as appropriate for any characteristics that

SD was 89.3 ± 4.6 years, and 52 (54.0 ％) were male.

differed significantly.

The first HF hospitalization was noted in 47 (49.0 ％)We presented continuous data as means and stan-patients, and the median [IQR] of the length of hospi-

dard deviations (SD) for normally distributed vari-

talization was 19.5 [15.0-29.0] days. Patients’ comor-

ables and as medians and interquartile ranges (IQR)

bidities included atrial fibrillation 70 (72.9 ％), cogni-

for variables with non-normal distributions. We con-tive disorder 46 (47.9 ％), sleep apnea syndrome 28

ducted the Shapiro-Wilk test to determine if each(29.2 ％), and diabetes mellitus (DM) 26 (27.1 ％). Pre-variable was normally distributed. We expressed

scription at discharge included a diuretic, 67 (69.8 ％),categorical data as numbers and percentages. To

and an angiotensin converting enzyme inhibitor/

evaluate group differences, we conducted Student’s

angiotensin Ⅱ receptor blocker (ACE-I/ARB), 57

t-test or Mann-Whitney U test for continuous data

(59.4 ％). NYHA classification was Ⅱ in 12 (12.5 ％) of

and the Chi-squared test or Fisher’s exact test forpatients, Ⅲ in 75 (78.1 ％ ) of patients, and Ⅳ in 9

categorical data. The Bonferroni post-hoc test was(9.4 ％ ) of patients. The median [IQR] of BNP wasused for multiple comparisons. We analyzed the data

255.8 [134.2-506.1] pg/ml. Further, 58 (60.4 ％ ) pa-

using SPSS version 28 (IBM, Armonk, NY, USA) andtients had an LVEF ≧50 ％. The mean ± SD of Hb

R version 4. 1. 2 (R Core Team 2017, Vienna, Austria).

and Alb were 11.6 ± 2.2 g/dl and 3.4 ± 0.5 g/dl, re-It was a two-tailed test, and we considered p-values

spectively. The median [IQR] of e-GFR and BI were＜0.05 statistically significant.

37.0 [26.0-47.0] ml/min/1.73m2 and 87.5 [65.0-100.0],

Ⅲ Results
Among 114 older adult patients admitted for HF,
No. 1, 2023

respectively. At discharge, CFS stage of the patients
ranged from 4 to 8. The number of patients withfrailty (CFS≧5) was 91 (94.8 ％).
55

Otsuka・Kamimura・Tomita
Table 1Age (years)
Male gender, n(％)
First HF hospitalization, n(％)
Length of hospitalization(days)
Cause of HF, n(％)
Valvular heart disease†
Hypertension‡
Ischemic heart disease‡
Other heart diseases§
Comorbidities, n(％)
Atrial fibrillation‡

Baseline patient characteristics (n＝96)89.3±4.6

52 (54.2 ％)47 (49.0 ％)19.5 [15.0-29.0]
75 (78.1 ％)62 (64.6 ％)
18 (18.8 ％)9 (9.4 ％)
70 (72.9 ％)Cognitive disorder¶

46 (48.4 ％)Sleep apnea syndrome‡28 (29.2 ％)Diabetes mellitus‡

26 (27.1 ％)COPD/Asthma‡

17 (17.7 ％)Prescriptions at discharge, n(％)
Diuretic
ACE-I/ARBMRA
β blocker
Digoxin
SGLT2-I

67 (69.8 ％)
57 (59.4 ％)
52 (54.2 ％)
39 (40.6 ％)
10 (10.4 ％)
7 (7.3 ％)Conditions at discharge
NYHA class, n(％) Ⅱ
Ⅲ
Ⅳ
BNP (pg/ml)
LVEF, n(％)≧50 ％41-49 ％≦40 ％BMI (kg/m2)

12 (12.5 ％)
75 (78.1 ％)
9 (9.4 ％)255.8 [134.2-506.1]
58 (60.4 ％)
19 (19.8 ％)
19 (19.8 ％)20.0 [18.1-22.3]
11.6±2.2
3.4±0.5

Hemoglobin (g/dl)
Albumin (g/dl)
e-GFR (ml/min/1.73m2)

37.0 [26.0-47.0]
87.5 [65.0-100.0]
5 (5.2 ％)
30 (31.3 ％)
41 (42.7 ％)9 (9.4 ％)
11 (11.5 ％)91 (94.8 ％)Barthel Index
CFS stage

4
5
6
7
8
Presence of frailty (CFS≧5)

Data are presented as mean ± standard deviation, median [interquartile range] or n(％).
† Yes, in the presence of moderate or severe valvular disease.
‡ Yes, in the presence of diagnosis.
§ Cardiomyopathy, invasive heart disease, ventricular septal defect, sarcoidosis, amyloidosis.
¶ Mini-Mental State Examination ＜24 or Clinical Dementia Rating 0.5＞as measured during hospitalization.
Abbreviations : HF, heart failure ; COPD, chronic obstructive pulmonary disease ; ACE-I, angiotensin-converting-enzyme
inhibitor ; ARB, angiotensin Ⅱ receptor blocker ; MRA, mineralocorticoid receptor antagonist ; SGLT2-I, sodium-glucose
cotransporter 2 inhibitors ; NYHA, New York Heart Association ; BNP, B-type natriuretic peptide ; LVEF, left ventricularejection fraction ; BMI, body mass index ; e-GFR, estimated glomerular filtration rate ; CFS, clinical frailty scale.

Change in CFS stage 6 months after discharge

I/ARBs (p＜0.05) (Table 2).

was as follows : one patient (1.0 ％) improved, 67 pa-

Compared to the CFS maintaining/improving group,

tients (69.8 ％) maintained, 12 patients (12.5 ％) exhib-

the death group had fewer first HF hospitalizations

ited worsening, 14 patients (14.6 ％) died, and 2 pa-(p＜0.01), more severe NYHA (p＜0.01), higher BNP

tients had missing data (2.1 ％) (Fig. 2). The reasons(p＜0.05), lower Hb (p＜0.01), lower Alb (p＜0.01),

for worsening frailty, in multiple responses and inlower e-GFR (p＜0.05), lower BI (p＜0.01), and moredescending order, were as follows : worsening HF (nsevere CFS (p＜0.01) (Table 2).

＝9), worsening cancer (n＝2), onset of fall fracture (nA sub-analysis was performed to examine con-＝2), onset of dementia (n＝2), onset of cerebrovascu-

founding factors for the two attributes, i.e., DM andlar disease (CVA) (n＝1), and worsening epilepsy (n＝prescribed ACE-I/ARBs that were significantly dif-1). The reasons for death were worsening HF (n＝ferent between the CFS worsening group and the10), senility (n＝2), infection (n＝1), and chronic

CFS maintaining/improving group (Table 3). The

kidney disease (CKD) (n＝1).

patients who were prescribed ACE-I/ARB had short-Compared to the CFS maintaining/improving

er length of hospitalization (p＜0.05), higher BMI (p＜group, the CFS worsening group had fewer patients0.01), and higher BI (p＜0.01) than those who werewith DM (p＜0.05) and fewer patients prescribed ACE-

not prescribed ACE-I/ARB. The patients with DM

56

Shinshu Med J

Vol. 71Frailty in HF patients over 80 years

Fig. 2

Change in CFS stage 6 months after discharge and reasons for worsening frailty and deathIn this study, attributes that may influence all-

had higher BMI than those without DM (p＜0.05).

cause death include no first HF hospitalization, BNP,Ⅳ Discussion
Ａ

NYHA, Hb, Alb, e-GFR, BI, and CFS (all data at thetime of discharge). In addition to history of HF hospi-

Mortality and risk factors for deathIn this study, the all-cause mortality at 6 months

talization and NYHA, which are variables that reflect

after discharge was 14.9 ％, and the reasons for deaththe severity of HF, systematic reviews, meta-analyses,

were HF, senility, infection, and CKD, which seemed

and large cohort studies have shown that BNP12）,

to reflect the actual situation in a regional core hospi-

anemia13）, Alb14）, renal function15）, ADL11）, and frailty2）

tal that did not perform cardiac surgery. The mortal-

are risk factors for death. The present study showed3）

ity was higher than 7.9 ％ in Kanenawa’s study (mean10）

age 76.6±10.1 years, n＝596) and 8.5 ％ in Suzuki’s

similar trends to these results.
Ｂ

Worsening frailty rate and risk factors

study (mean age 80 years, n＝504) ; these studies were

In this study, 12.5 ％ of the patients had worsening

conducted in hospitals where cardiac surgery was

frailty 6 months after discharge from the hospital,

11）

study

and they visited the hospital irregularly or were new(mean age 88.3±5.1 years, n＝372) conducted in non-patients at the hospital due to worsening HF, onset

operative hospitals. Post-discharge mortality varies

of CVA, worsening of comorbidities, fall fracture, andaccording to the characteristics of the hospitals stud-

onset of dementia. Yang16） reviewed and discussed

ied. In Kanenawa’s study, 43.4 ％ of the patients had

the impact of dementia on the prognosis of HF pa-

CFS 5 or higher, with 94.8 ％ in the present study,

tients, including pathophysiological reasons, andand in Suzuki’s study, 19 ％ had NYHA Ⅲ and Ⅳ ,pointed out the need to focus on dementia in thewith 87.5 ％ in the present study, suggesting that thetreatment and care of HF patients. In this study, HF

high mortality in the present study was due to ex-patients with worsening frailty developed dementia

clusion of patients in good condition who were eligi-

after discharge from the hospital, supporting Yang’s

ble for cardiac surgery. However, the median BI in

point.

performed, but was lower than those of Obata’s

Obata’s study was 65, with 87.5 in the present study,

No previous studies have examined risk factors forsuggesting that there were more patients in relatively

worsening frailty, but a similar study examined risk

good condition among non-surgical hospitals.

factors for rehospitalization. They have shown thatNo. 1, 2023

57

Otsuka・Kamimura・Tomita
Table 2 Comparison of baseline attributes between the CFS maintaining/improving and the CFS worsening or thedeath groups

Variables

Maintaining/Improving

WorseningDeath(n＝68)(n＝12)(n＝14)

Age (years)

88.7 ± 4.4

90.3 ± 3.6

90.6 ± 5.9

Male gender, n(％)

38 (67.9 ％)

4 (33.3 ％)

9 (64.0 ％)First HF hospitalization, n(％)

40 (58.8 ％)

4 (33.3 ％)

3 (14.0 ％) ＊＊Length of hospitalization (days)

19.5 [15.0-28.0]

15.5 [12.5-22.8]

29.5 [12.8-53.0]

Valvular heart disease, n(％)

54 (79.4 ％)

9 (75.0 ％)10 (71.4 ％)Hypertension, n(％)

45 (66.2 ％)

9 (75.0 ％)

8 (57.1 ％)Ischemic heart disease, n(％)

14 (20.6 ％)1 (8.3 ％)

3 (21.4 ％)Atrial fibrillation, n(％)

47 (69.1 ％)

9 (75.0 ％)12 (85.7 ％)Cognitive disorder, n(％)

35 (51.5 ％)

3 (25.0 ％)6 (46.2 ％)Sleep apnea syndrome, n(％)

15 (22.1 ％)

6 (50.0 ％)

7 (50.0 ％)Diabetes mellitus, n(％)

24 (35.3 ％)0 (0.0 ％) ＊2 (14.0 ％)COPD/Asthma, n(％)

15 (22.1 ％)

1 (8.3 ％)

1 (8.3 ％)Diuretic, n(％)

42 (61.8 ％)

11 (91.7 ％)13 (92.9 ％)ACE-I/ARB, n(％)

47 (69.1 ％)

3 (25.0 ％)＊

6 (43.0 ％)MRA, n(％)

34 (50.0 ％)

7 (58.3 ％)

9 (64.3 ％)β blocker, n(％)

30 (44.1 ％)

6 (50.0 ％)3 (21.4 ％)Digoxin, n(％)

8 (11.8 ％)2 (16.7 ％)0 (0.0 ％)SGLT2-I, n(％)

5 (7.4 ％)0 (0.0 ％)

2 (14.3 ％)Ⅱ

10 (14.7 ％)2 (16.7 ％)0 (0.0 ％)Ⅲ

57 (83.8 ％)

9 (75.0 ％)6 (43.0 ％)NYHA, n(％)Ⅳ
BNP(pg/ml)
LVEF50％≧, n(％)＊＊

1 (1.5 ％)

1 (8.3 ％)

8 (57.0 ％)221.0 [134.5-434.8]

228.5 [90.0-458.8]

590.1 [239.5-1385.5]＊

41 (60.3 ％)

9 (75.0 ％)6 (42.9 ％)19.9 [18.2-21.9]

19.4 [18.1-21.5]

20.2 [17.7-23.2]

Hemoglobin(g/dl)

11.9 ± 2.0

11.9 ± 1.9

9.5 ± 2.1＊＊

Albumin(g/dl)

3.5 ± 0.5

3.7 ± 0.4

2.8 ± 0.5＊＊

e-GFR(mL/min/1.73m2)

39.0 [28.3-49.0]

33.5 [25.3-43.0]

24.0 [20.3-39.5]＊

Barthel Index

90.0 [66.3-100.0]

87.5 [75.0-100.0]

32.5 [5.0-100.0]＊＊

4-6

59 (86.8 ％)

12 (100.0 ％)5 (35.7 ％)

7-8

9 (13.2 ％)0 (0.0 ％)

9 (64.3 ％)BMI (kg/m2)

CFS, n(％)＊＊

Data are presented as mean ± standard deviation, median [interquartle range] or n(％).
Bonferroni post-hoc test between the CFS maintained/improved vs. the CFS worsened groups, and between the CFS
maintained/improved vs. the mortality groups.
＊＊＊
p＜0.05 ; vs. Maintained/Improved group.
p＜0.01 ; vs. Maintained/Improved group.
Abbreviations : CFS, clinical frailty scale ; HF, heart failure ; COPD, chronic obstructive pulmonary disease ; ACE-I,
angiotensin-converting-enzyme inhibitor ; ARB, angiotensin Ⅱ receptor blocker ; MRA, mineralocorticoid receptor
antagonist ; SGLT2-I, sodium-glucose cotransporter 2 inhibitors ; NYHA, New York Heart Association ; BNP, B-typenatriuretic peptide ; LVEF, left ventricular ejection fraction ; BMI, body mass index ; e-GFR, estimated glomerular
filtration rate.

the risk ratio for each factor of rehospitalization tends

ent study also found lower risk ratios and fewer sig-

to be lower in older adults than in younger adults andnificant risk factors for worsening frailty than forthat risk factors for rehospitalization are less detect-death.

able than those for death at any age4）5）17）18）. The pres58

In this study, attributes that may influence worsShinshu Med J

Vol. 71Frailty in HF patients over 80 years
Table 3 Sub-analysis, comparison of baseline attributes with and without ACE-I/ARB and with and without
diabetes mellitus
ACE-I/ARB＋

Diabetes mellitus－＋－

Variables(n＝50)(n＝30)(n＝24)(n＝56)

Age (years)

88.9 ± 4.0

89.1 ± 4.9

87.9 ± 4.0

89.4 ± 4.4

Male gender, n(％)

34 (59.6 ％)18 (46.2 ％)15 (62.5 ％)

27 (48.2 ％)First HF hospitalization, n(％)

32 (56.1 ％)

15 (38.5 ％)

15 (62.5 ％)

29 (51.8 ％)Length of hospitalization (days)

18.0 [14.8-24.0]

22.5 [14.8-33.3] ＊18.0 [15.0-24.0]

19.5 [14.3-29.5]

Valvular heart disease, n(％)

38 (76.0 ％)25 (83.3 ％)

19 (79.2 ％)

44 (78.6 ％)Hypertension, n(％)

36 (72.0 ％)18 (60.0 ％)16 (66.7 ％)38 (67.9 ％)Ischemic heart disease, n(％)

10 (20.0 ％)5 (16.7 ％)4 (16.7 ％)

11 (19.6 ％)Atrial fibrillation, n(％)

35 (70.0 ％)21 (70.0 ％)16 (66.7 ％)40 (71.4 ％)Cognitive disorder, n(％)

25 (50.0 ％)13 (43.3 ％)

11 (45.8 ％)

27 (48.2 ％)Sleep apnea syndrome, n(％)

13 (26.0 ％)8 (26.7 ％)

6 (25.0 ％)15 (26.8 ％)Diabetes mellitus, n(％)

18 (36.0 ％)6 (20.0 ％)COPD/Asthma, n(％)

12 (24.0 ％)4 (13.3 ％)

4 (16.7 ％)

12 (21.4 ％)Diuretic, n(％)

32 (64.0 ％)21 (70.0 ％)12 (50.0 ％)41 (73.2 ％)

18 (75.0 ％)32 (57.1 ％)MRA, n(％)

26 (52.0 ％)15 (50.0 ％)12 (50.0 ％)29 (51.8 ％)β blocker, n(％)

20 (40.0 ％)16 (53.3 ％)

10 (41.7 ％)

26 (46.4 ％)Digoxin, n(％)

5 (10.0 ％)5 (16.7 ％)4 (16.7 ％)

6 (10.7 ％)ACE-I/ARB, n(％)

SGLT2-I, n(％)
NYHA, n(％)

4 (8.0 ％)1 (3.3 ％)

3 (12.5 ％)2 (3.6 ％)Ⅱ

10 (20.0 ％)2 (6.7 ％)

3 (12.5 ％)

9 (16.1 ％)Ⅲ

40 (80.0 ％)27 (90.0 ％)21 (87.5 ％)

46 (82.1 ％)Ⅳ

0 (0.0 ％)1 (3.3 ％)0 (0.0 ％)1 (1.8 ％)210.7 [118.0-395.7]

261.4 [133.2-484.7]

235.3 [104.1-501.5]

225.4 [134.2-436.5]

30 (60.0 ％)20 (66.7 ％)

13 (54.2 ％)37 (66.1 ％)21.5 [18.6-23.2]

19.6 [18.0-20.9] ＊BNP(pg/ml)
LVEF50％≧, n(％)
2

BMI (kg/m )Hemoglobin(g/dl)
Albumin(g/dl)
2＊＊

20.7 [18.6-23.2]

18.6 [17.5-20.4]

12.0 ± 1.8

11.8 ± 2.3

12.5 ± 4.6

11.7 ± 2.1

3.6 ± 0.4

3.5 ± 0.5

3.5 ± 0.5

3.6 ± 0.3

e-GFR(mL/min/1.73m )37.0 [26.0-45.3]

40.5 [33.3-50.3]

35.0 [28.5-46.8]

39.0 [26.3-49.0]

Barthel Index

92.5 [80.0-100.0]

75.0 [57.5-91.3] ＊＊92.5 [80.0-100.0]

90.0 [65.0-100.0]

4-6

46 (92.0 ％)25 (83.3 ％)

24 (100.0 ％)47 (86.0 ％)

7-8

4 (8.0 ％)

5 (16.7 ％)0 (0.0 ％)

9 (16.0 ％)CFS, n(％)

Data are presented as mean ± standard deviation, median [interquartile range] or n(％).
＊＊
p＜0.05 ; Presence vs. Absence.
p＜0.01 ; Presence vs. Absence.
Abbreviations : ACE-I, angiotensin-converting-enzyme inhibitor ; ARB, angiotensin Ⅱ receptor blocker ; HF, heart
failure ; COPD, chronic obstructive pulmonary disease ; MRA, mineralocorticoid receptor antagonist ; SGLT2-I,
sodium-glucose cotransporter 2 inhibitors ; NYHA, New York Heart Association ; BNP, B-type natriuretic
peptide ; LVEF, left ventricular ejection fraction ; BMI, body mass index ; e-GFR, estimated glomerular filtration
rate ; CFS, clinical frailty scale.
＊ening frailty included not being prescribed ACE-I/

and Sunaga20） showed that ACE-I/ARBs were also

ARB at discharge and no DM. In heart failure withadvantageous in patients who were frail before ad-

reduced ejection fraction (HFrEF), ACE-I/ARBs are

mission and in older male HF patients, respectively.

19）

recommended to improve prognosis . In heart fail-The results of this study also support the favorable

ure with preserved ejection fraction (HFpEF), Oh4）

effect of ACE-I/ARB on prognosis, but the ACE-I/

No. 1, 2023

59

Otsuka・Kamimura・Tomita

ARB-treated patients in this study had shorter hos-

medical professionals have assessed the CFS, its re-pital stays, higher BMI, and higher ADL than the

producibility has not been evaluated.

non-ACE-I/ARB-treated patients. This differenceＤ

Clinical Implications

might be one of the reasons why the subjects were

Despite the aforementioned limitations, this study

not prescribed ACE-I/ARB due to their poor condi-

found that some older HF patients experienced wors-

tion and intolerance to the drug.

ening of frailty or died six months after hospital dis-

The results of this study indicating that the ab-charge. Moreover, the reasons for frailty deteriora-

sence of DM affects poor prognosis contradict thetion included worsening of HF, other cardiovascular

results of previous studies. Although there is a reportdiseases, comorbidities, fall fractures, and dementia.

that DM does not affect poor prognosis in older

These findings suggest the need for individualized

patients

3）
21）, further investigation of the prognostic

efforts to prevent fall fractures, dementia, worsening

impact of DM in older HF patients presented in thisof HF, other cardiovascular diseases, and comorbidi-

study may be warranted.

ties among patients. Meanwhile, the causes of frailty

Ｃdeterioration may be partially preventable or pallia-

Limitations
There are several limitations to this study. First, it

is uncertain whether the results are generalizable

tive, but this has not been examined and requires
further research.

because it was a single-center study in a hospital

Acknowledgements

without cardiac surgery facilities, and the small sample size did not allow for analysis considering confounding factors. Second, changes in frailty were as-

The authors would like to thank all the participantsin this study.

sessed at two time points, so that detailed changes

Disclosure statementthat occurred during the 6 months after discharge
from the hospital were not taken into account. Third,

The authors declare no conflict of interest.

CFS is a semi-quantitative scale of frailty. Although
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