Frailty and clinical outcomes in non-cardiovascular surgery heart failure patients: a meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

WANG Bingqian ¹ ,  GU Ning ²

1. Nanjing University of Traditional Chinese Medicine, Nanjing 210046, P. R. China;
2. Department of Cardiology, Nanjing Hospital of Traditional Chinese Medicine of Nanjing University of Traditional Chinese Medicine, Nanjing 210022, P. R. China;

Corresponding author：

GU Ning, Email: guning@njucm.edu.cn

Keywords：

Frailty; Heart failure; All-cause mortality; Hospitalization; Combined endpoint; Meta-analysis

DOI：

10.7507/1672-2531.202201026

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To systematically review the influence of frailty on the prognosis of non-cardiovascular surgery heart failure (HF) patients and to provide references for its prevention and management. Methods CNKI, VIP, CBM, WanFang Data, PubMed, EMbase, Web of Science, and The Cochrane Library were searched to collect cohort studies on the prognosis of non-cardiovascular surgery HF patients with frailty from inception to November 1^st, 2021. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of the included studies. Then, meta-analysis was performed using RevMan 5.3 software and Stata 14.0 software. Results A total of 20 studies involving 11 127 patients were included. The results of meta-analysis showed that frailty increased the risk of all-cause mortality (HR=1.72, 95%CI 1.61 to 1.84, P<0.000 01), hospitalization (HR=2.06, 95%CI 1.26 to 3.37, P=0.004), and combined endpoint (HR=1.59, 95%CI 1.37 to 1.84, P<0.000 01) in non-cardiovascular surgery HF patients. Conclusion Current evidence shows that frailty can increase the risk of all-cause mortality, hospitalization, and combined endpoints in non-cardiovascular surgery HF patients. Due to the limited quantity and quality of the included studies, more high-quality studies are needed to verify the above conclusion.

Citation： WANG Bingqian, GU Ning. Frailty and clinical outcomes in non-cardiovascular surgery heart failure patients: a meta-analysis. Chinese Journal of Evidence-Based Medicine, 2022, 22(4): 394-402. doi: 10.7507/1672-2531.202201026 Copy

1.	Uchmanowicz I, Nessler J, Gobbens R, et al. Coexisting frailty with heart failure. Front Physiol, 2019, 10: 791.
2.	Tieland M, Trouwborst I, Clark BC. Skeletal muscle performance and ageing. J Cachexia Sarcopenia Muscle, 2018, 9(1): 3-19.
3.	Tkaczyszyn M, Drozd M, Węgrzynowska-Teodorczyk K, et al. Depleted iron stores are associated with inspiratory muscle weakness independently of skeletal muscle mass in men with systolic chronic heart failure. J Cachexia Sarcopenia Muscle, 2018, 9(3): 547-556.
4.	Brzeszczynska J, Meyer A, McGregor R, et al. Alterations in the in vitro and in vivo regulation of muscle regeneration in healthy ageing and the influence of sarcopenia. J Cachexia Sarcopenia Muscle, 2018, 9(1): 93-105.
5.	Bellumkonda L, Tyrrell D, Hummel SL, et al. Pathophysiology of heart failure and frailty: a common inflammatory origin. Aging Cell, 2017, 16(3): 444-450.
6.	Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet, 2013, 381(9868): 752-762.
7.	Bottle A, Kim D, Hayhoe B, et al. Frailty and co-morbidity predict first hospitalisation after heart failure diagnosis in primary care: population-based observational study in England. Age Ageing, 2019, 48(3): 347-354.
8.	Khan H, Kalogeropoulos AP, Georgiopoulou VV, et al. Frailty and risk for heart failure in older adults: the health, aging, and body composition study. Am Heart J, 2013, 166(5): 887-894.
9.	Khan MS, Samman Tahhan A, Vaduganathan M, et al. Trends in prevalence of comorbidities in heart failure clinical trials. Eur J Heart Fail, 2020, 22(6): 1032-1042.
10.	Metra M. September 2018 at a glance: co-morbidities, heart failure with preserved ejection fraction and mineralocorticoid receptor antagonists. Eur J Heart Fail, 2018, 20(9): 1245-1246.
11.	Bielecka-Dabrowa A, Ebner N, Dos Santos MR, et al. Cachexia, muscle wasting, and frailty in cardiovascular disease. Eur J Heart Fail, 2020, 22(12): 2314-2326.
12.	Vitale C, Jankowska E, Hill L, et al. Heart Failure Association/European Society of Cardiology position paper on frailty in patients with heart failure. Eur J Heart Fail, 2019, 21(11): 1299-1305.
13.	Tse G, Gong M, Nunez J, et al. Frailty and mortality outcomes after percutaneous coronary intervention: a systematic review and meta-analysis. J Am Med Dir Assoc, 2017, 18(12): 1097.e1-1097.e10.
14.	Anand A, Harley C, Visvanathan A, et al. The relationship between preoperative frailty and outcomes following transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur Heart J Qual Care Clin Outcomes, 2017, 3(2): 123-132.
15.	Panayi AC, Orkaby AR, Sakthivel D, et al. Impact of frailty on outcomes in surgical patients: a systematic review and meta-analysis. Am J Surg, 2019, 218(2): 393-400.
16.	Tse G, Gong M, Wong SH, et al. Frailty and clinical outcomes in advanced heart failure patients undergoing left ventricular assist device implantation: a systematic review and meta-analysis. J Am Med Dir Assoc, 2018, 19(3): 255-261.
17.	Yang X, Lupón J, Vidán MT, et al. Impact of frailty on mortality and hospitalization in chronic heart failure: a systematic review and meta-analysis. J Am Heart Assoc, 2018, 7(23): e008251.
18.	Zhang Y, Yuan M, Gong M, et al. Frailty and clinical outcomes in heart failure: a systematic review and meta-analysis. J Am Med Dir Assoc, 2018, 19(11): 1003-1008.
19.	Boxer R, Kleppinger A, Ahmad A, et al. The 6-minute walk is associated with frailty and predicts mortality in older adults with heart failure. Congest Heart Fail, 2010, 16(5): 208-213.
20.	Cacciatore F, Abete P, Mazzella F, et al. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Eur J Clin Invest, 2005, 35(12): 723-730.
21.	迟俊婷. 衰弱对慢性心力衰竭患者生活质量及预后影响的研究. 兰州: 兰州大学, 2021.
22.	Gastelurrutia P, Lupón J, Altimir S, et al. Fragility is a key determinant of survival in heart failure patients. Int J Cardiol, 2014, 175(1): 62-66.
23.	Martín-Sánchez FJ, Rodríguez-Adrada E, Mueller C, et al. The effect of frailty on 30-day mortality risk in older patients with acute heart failure attended in the emergency department. Acad Emerg Med, 2017, 24(3): 298-307.
24.	Kamiya K, Adachi T, Iwatsu K, et al. Association between a pre-admission limitation in walking ability and post-discharge adverse outcomes among hospitalized patients with heart failure: report from a multicenter prospective cohort study. Int J Cardiol, 2021, 337: 105-112.
25.	Lupón J, González B, Santaeugenia S, et al. Prognostic implication of frailty and depressive symptoms in an outpatient population with heart failure. Rev Esp Cardiol. 2008, 61(8): 835-842.
26.	Madan SA, Fida N, Barman P, et al. Frailty assessment in advanced heart failure. J Card Fail, 2016, 22(10): 840-844.
27.	Matsue Y, Kamiya K, Saito H, et al. Prevalence and prognostic impact of the coexistence of multiple frailty domains in elderly patients with heart failure: the FRAGILE-HF cohort study. Eur J Heart Fail, 2020, 22(11): 2112-2119.
28.	McNallan SM, Singh M, Chamberlain AM, et al. Frailty and healthcare utilization among patients with heart failure in the community. JACC Heart Fail, 2013, 1(2): 135-141.
29.	Rodríguez-Pascual C, Paredes-Galán E, Ferrero-Martínez AI, et al. The frailty syndrome is associated with adverse health outcomes in very old patients with stable heart failure: a prospective study in six Spanish hospitals. Int J Cardiol, 2017, 236: 296-303.
30.	彭一星, 王曼, 杨德辉, 等. 衰弱综合征对老年心力衰竭患者预后的影响分析. 中华保健医学杂志, 2018, 20(5): 382-385.
31.	McNallan SM, Chamberlain AM, Gerber Y, et al. Measuring frailty in heart failure: a community perspective. Am Heart J, 2013, 166(4): 768-774.
32.	Sunaga A, Hikoso S, Yamada T, et al. Prognostic impact of clinical frailty scale in patients with heart failure with preserved ejection fraction. ESC Heart Fail, 2021, 8(4): 3316-3326.
33.	Sze S, Zhang J, Pellicori P, et al. Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction. Clin Res Cardiol, 2017, 106(7): 533-541.
34.	Tanaka S, Kamiya K, Hamazaki N, et al. Incremental value of objective frailty assessment to predict mortality in elderly patients hospitalized for heart failure. J Card Fail, 2018, 24(11): 723-732.
35.	Vidán MT, Blaya-Novakova V, Sánchez E, et al. Prevalence and prognostic impact of frailty and its components in non-dependent elderly patients with heart failure. Eur J Heart Fail, 2016, 18(7): 869-875.
36.	李德勇, 刘祥, 徐先静, 等. 衰弱对沙库巴曲/缬沙坦治疗老年人心力衰竭效果的影响. 中华老年医学杂志, 2020, 39(7): 779-782.
37.	Zheng PP, Yao SM, He W, et al. Frailty related all-cause mortality or hospital readmission among adults aged 65 and older with stage-B heart failure inpatients. BMC Geriatr, 2021, 21(1): 125.
38.	顾俊, 胡晓云, 李云玲, 等. 衰弱指数对老年心力衰竭患者预后的评估. 中华老年心脑血管病杂志, 2021, 23(10): 1027-1029.
39.	Fung E, Hui E, Yang X, et al. Heart failure and frailty in the community-living elderly population: what the UFO study will tell us. Front Physiol, 2018, 9: 347.
40.	Pandey A, Kitzman D, Reeves G. Frailty Is Intertwined with heart failure: mechanisms, prevalence, prognosis, assessment, and management. JACC Heart Fail, 2019, 7(12): 1001-1011.
41.	Hassan M, Ellahham S, Ibrahim HS. Frailty in heart failure: a coalesce of international guidelines. J Clin Exp Cardiolog, 2019, 10(7): 100636.
42.	Dent E, Kowal P, Hoogendijk EO. Frailty measurement in research and clinical practice: a review. Eur J Intern Med, 2016, 31: 3-10.
43.	Jha SR, Hannu MK, Newton PJ, et al. Reversibility of frailty after bridge-to-transplant ventricular assist device implantation or heart transplantation. Transplant Direct, 2017, 3(7): e167.
44.	Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci, 2001, 56(3): 146-156.
45.	Joseph SM, Rich MW. Targeting frailty in heart failure. Curr Treat Options Cardiovasc Med, 2017, 19(4): 31.
46.	Selthofer-Relatić K, Kibel A, Delić-Brkljačić D, et al. Cardiac obesity and cardiac cachexia: is there a pathophysiological link. J Obes, 2019, 2019: 9854085.
47.	Ramonfaur D, Skali H, Kitzman DW, et al. Abstract 10392: association of frailty with incident heart failure with preserved and reduced ejection fraction in late life: the Aric study. Circulation, 2021, 144(Supp 1): A10392.
48.	Loop MS, Van Dyke MK, Chen L, et al. Comparison of length of stay, 30-day mortality, and 30-day readmission rates in medicare patients with heart failure and with reduced versus preserved ejection fraction. Am J Cardiol, 2016, 118(1): 79-85.
49.	Testa G, Liguori I, Curcio F, et al. Multidimensional frailty evaluation in elderly outpatients with chronic heart failure: a prospective study. Eur J Prev Cardiol, 2019, 26(10): 1115-1117.
50.	Ferrucci L, Fabbri E. Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. Nat Rev Cardiol, 2018, 15(9): 505-522.
51.	Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation, 2018, 137(12): e67-e492.
52.	Joyce E. Frailty in advanced heart failure. Heart Fail Clin, 2016, 12(3): 363-374.
53.	Denfeld QE, Winters-Stone K, Mudd JO, et al. Identifying a relationship between physical frailty and heart failure symptoms. J Cardiovasc Nurs, 2018, 33(1): 1-7.
54.	Nadruz W, Kitzman D, Windham BG, et al. Cardiovascular dysfunction and frailty among older adults in the community: the ARIC study. J Gerontol A Biol Sci Med Sci, 2017, 72(7): 958-964.
55.	Jha SR, Ha HS, Hickman LD, et al. Frailty in advanced heart failure: a systematic review. Heart Fail Rev, 2015, 20(5): 553-560.
56.	Sanders NA, Supiano MA, Lewis EF, et al. The frailty syndrome and outcomes in the TOPCAT trial. Eur J Heart Fail, 2018, 20(11): 1570-1577.
57.	McDonagh J, Martin L, Ferguson C, et al. Frailty assessment instruments in heart failure: a systematic review. Eur J Cardiovasc Nurs, 2018, 17(1): 23-35.

1. Uchmanowicz I, Nessler J, Gobbens R, et al. Coexisting frailty with heart failure. Front Physiol, 2019, 10: 791.
2. Tieland M, Trouwborst I, Clark BC. Skeletal muscle performance and ageing. J Cachexia Sarcopenia Muscle, 2018, 9(1): 3-19.
3. Tkaczyszyn M, Drozd M, Węgrzynowska-Teodorczyk K, et al. Depleted iron stores are associated with inspiratory muscle weakness independently of skeletal muscle mass in men with systolic chronic heart failure. J Cachexia Sarcopenia Muscle, 2018, 9(3): 547-556.
4. Brzeszczynska J, Meyer A, McGregor R, et al. Alterations in the in vitro and in vivo regulation of muscle regeneration in healthy ageing and the influence of sarcopenia. J Cachexia Sarcopenia Muscle, 2018, 9(1): 93-105.
5. Bellumkonda L, Tyrrell D, Hummel SL, et al. Pathophysiology of heart failure and frailty: a common inflammatory origin. Aging Cell, 2017, 16(3): 444-450.
6. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet, 2013, 381(9868): 752-762.
7. Bottle A, Kim D, Hayhoe B, et al. Frailty and co-morbidity predict first hospitalisation after heart failure diagnosis in primary care: population-based observational study in England. Age Ageing, 2019, 48(3): 347-354.
8. Khan H, Kalogeropoulos AP, Georgiopoulou VV, et al. Frailty and risk for heart failure in older adults: the health, aging, and body composition study. Am Heart J, 2013, 166(5): 887-894.
9. Khan MS, Samman Tahhan A, Vaduganathan M, et al. Trends in prevalence of comorbidities in heart failure clinical trials. Eur J Heart Fail, 2020, 22(6): 1032-1042.
10. Metra M. September 2018 at a glance: co-morbidities, heart failure with preserved ejection fraction and mineralocorticoid receptor antagonists. Eur J Heart Fail, 2018, 20(9): 1245-1246.
11. Bielecka-Dabrowa A, Ebner N, Dos Santos MR, et al. Cachexia, muscle wasting, and frailty in cardiovascular disease. Eur J Heart Fail, 2020, 22(12): 2314-2326.
12. Vitale C, Jankowska E, Hill L, et al. Heart Failure Association/European Society of Cardiology position paper on frailty in patients with heart failure. Eur J Heart Fail, 2019, 21(11): 1299-1305.
13. Tse G, Gong M, Nunez J, et al. Frailty and mortality outcomes after percutaneous coronary intervention: a systematic review and meta-analysis. J Am Med Dir Assoc, 2017, 18(12): 1097.e1-1097.e10.
14. Anand A, Harley C, Visvanathan A, et al. The relationship between preoperative frailty and outcomes following transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur Heart J Qual Care Clin Outcomes, 2017, 3(2): 123-132.
15. Panayi AC, Orkaby AR, Sakthivel D, et al. Impact of frailty on outcomes in surgical patients: a systematic review and meta-analysis. Am J Surg, 2019, 218(2): 393-400.
16. Tse G, Gong M, Wong SH, et al. Frailty and clinical outcomes in advanced heart failure patients undergoing left ventricular assist device implantation: a systematic review and meta-analysis. J Am Med Dir Assoc, 2018, 19(3): 255-261.
17. Yang X, Lupón J, Vidán MT, et al. Impact of frailty on mortality and hospitalization in chronic heart failure: a systematic review and meta-analysis. J Am Heart Assoc, 2018, 7(23): e008251.
18. Zhang Y, Yuan M, Gong M, et al. Frailty and clinical outcomes in heart failure: a systematic review and meta-analysis. J Am Med Dir Assoc, 2018, 19(11): 1003-1008.
19. Boxer R, Kleppinger A, Ahmad A, et al. The 6-minute walk is associated with frailty and predicts mortality in older adults with heart failure. Congest Heart Fail, 2010, 16(5): 208-213.
20. Cacciatore F, Abete P, Mazzella F, et al. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Eur J Clin Invest, 2005, 35(12): 723-730.
21. 迟俊婷. 衰弱对慢性心力衰竭患者生活质量及预后影响的研究. 兰州: 兰州大学, 2021.
22. Gastelurrutia P, Lupón J, Altimir S, et al. Fragility is a key determinant of survival in heart failure patients. Int J Cardiol, 2014, 175(1): 62-66.
23. Martín-Sánchez FJ, Rodríguez-Adrada E, Mueller C, et al. The effect of frailty on 30-day mortality risk in older patients with acute heart failure attended in the emergency department. Acad Emerg Med, 2017, 24(3): 298-307.
24. Kamiya K, Adachi T, Iwatsu K, et al. Association between a pre-admission limitation in walking ability and post-discharge adverse outcomes among hospitalized patients with heart failure: report from a multicenter prospective cohort study. Int J Cardiol, 2021, 337: 105-112.
25. Lupón J, González B, Santaeugenia S, et al. Prognostic implication of frailty and depressive symptoms in an outpatient population with heart failure. Rev Esp Cardiol. 2008, 61(8): 835-842.
26. Madan SA, Fida N, Barman P, et al. Frailty assessment in advanced heart failure. J Card Fail, 2016, 22(10): 840-844.
27. Matsue Y, Kamiya K, Saito H, et al. Prevalence and prognostic impact of the coexistence of multiple frailty domains in elderly patients with heart failure: the FRAGILE-HF cohort study. Eur J Heart Fail, 2020, 22(11): 2112-2119.
28. McNallan SM, Singh M, Chamberlain AM, et al. Frailty and healthcare utilization among patients with heart failure in the community. JACC Heart Fail, 2013, 1(2): 135-141.
29. Rodríguez-Pascual C, Paredes-Galán E, Ferrero-Martínez AI, et al. The frailty syndrome is associated with adverse health outcomes in very old patients with stable heart failure: a prospective study in six Spanish hospitals. Int J Cardiol, 2017, 236: 296-303.
30. 彭一星, 王曼, 杨德辉, 等. 衰弱综合征对老年心力衰竭患者预后的影响分析. 中华保健医学杂志, 2018, 20(5): 382-385.
31. McNallan SM, Chamberlain AM, Gerber Y, et al. Measuring frailty in heart failure: a community perspective. Am Heart J, 2013, 166(4): 768-774.
32. Sunaga A, Hikoso S, Yamada T, et al. Prognostic impact of clinical frailty scale in patients with heart failure with preserved ejection fraction. ESC Heart Fail, 2021, 8(4): 3316-3326.
33. Sze S, Zhang J, Pellicori P, et al. Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction. Clin Res Cardiol, 2017, 106(7): 533-541.
34. Tanaka S, Kamiya K, Hamazaki N, et al. Incremental value of objective frailty assessment to predict mortality in elderly patients hospitalized for heart failure. J Card Fail, 2018, 24(11): 723-732.
35. Vidán MT, Blaya-Novakova V, Sánchez E, et al. Prevalence and prognostic impact of frailty and its components in non-dependent elderly patients with heart failure. Eur J Heart Fail, 2016, 18(7): 869-875.
36. 李德勇, 刘祥, 徐先静, 等. 衰弱对沙库巴曲/缬沙坦治疗老年人心力衰竭效果的影响. 中华老年医学杂志, 2020, 39(7): 779-782.
37. Zheng PP, Yao SM, He W, et al. Frailty related all-cause mortality or hospital readmission among adults aged 65 and older with stage-B heart failure inpatients. BMC Geriatr, 2021, 21(1): 125.
38. 顾俊, 胡晓云, 李云玲, 等. 衰弱指数对老年心力衰竭患者预后的评估. 中华老年心脑血管病杂志, 2021, 23(10): 1027-1029.
39. Fung E, Hui E, Yang X, et al. Heart failure and frailty in the community-living elderly population: what the UFO study will tell us. Front Physiol, 2018, 9: 347.
40. Pandey A, Kitzman D, Reeves G. Frailty Is Intertwined with heart failure: mechanisms, prevalence, prognosis, assessment, and management. JACC Heart Fail, 2019, 7(12): 1001-1011.
41. Hassan M, Ellahham S, Ibrahim HS. Frailty in heart failure: a coalesce of international guidelines. J Clin Exp Cardiolog, 2019, 10(7): 100636.
42. Dent E, Kowal P, Hoogendijk EO. Frailty measurement in research and clinical practice: a review. Eur J Intern Med, 2016, 31: 3-10.
43. Jha SR, Hannu MK, Newton PJ, et al. Reversibility of frailty after bridge-to-transplant ventricular assist device implantation or heart transplantation. Transplant Direct, 2017, 3(7): e167.
44. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci, 2001, 56(3): 146-156.
45. Joseph SM, Rich MW. Targeting frailty in heart failure. Curr Treat Options Cardiovasc Med, 2017, 19(4): 31.
46. Selthofer-Relatić K, Kibel A, Delić-Brkljačić D, et al. Cardiac obesity and cardiac cachexia: is there a pathophysiological link. J Obes, 2019, 2019: 9854085.
47. Ramonfaur D, Skali H, Kitzman DW, et al. Abstract 10392: association of frailty with incident heart failure with preserved and reduced ejection fraction in late life: the Aric study. Circulation, 2021, 144(Supp 1): A10392.
48. Loop MS, Van Dyke MK, Chen L, et al. Comparison of length of stay, 30-day mortality, and 30-day readmission rates in medicare patients with heart failure and with reduced versus preserved ejection fraction. Am J Cardiol, 2016, 118(1): 79-85.
49. Testa G, Liguori I, Curcio F, et al. Multidimensional frailty evaluation in elderly outpatients with chronic heart failure: a prospective study. Eur J Prev Cardiol, 2019, 26(10): 1115-1117.
50. Ferrucci L, Fabbri E. Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. Nat Rev Cardiol, 2018, 15(9): 505-522.
51. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation, 2018, 137(12): e67-e492.
52. Joyce E. Frailty in advanced heart failure. Heart Fail Clin, 2016, 12(3): 363-374.
53. Denfeld QE, Winters-Stone K, Mudd JO, et al. Identifying a relationship between physical frailty and heart failure symptoms. J Cardiovasc Nurs, 2018, 33(1): 1-7.
54. Nadruz W, Kitzman D, Windham BG, et al. Cardiovascular dysfunction and frailty among older adults in the community: the ARIC study. J Gerontol A Biol Sci Med Sci, 2017, 72(7): 958-964.
55. Jha SR, Ha HS, Hickman LD, et al. Frailty in advanced heart failure: a systematic review. Heart Fail Rev, 2015, 20(5): 553-560.
56. Sanders NA, Supiano MA, Lewis EF, et al. The frailty syndrome and outcomes in the TOPCAT trial. Eur J Heart Fail, 2018, 20(11): 1570-1577.
57. McDonagh J, Martin L, Ferguson C, et al. Frailty assessment instruments in heart failure: a systematic review. Eur J Cardiovasc Nurs, 2018, 17(1): 23-35.

Chinese Journal of Evidence-Based Medicine

Frailty and clinical outcomes in non-cardiovascular surgery heart failure patients: a meta-analysis

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