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Physical Frailty is Modifiable in Young Cardiac Rehabilitation Patients

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Abstract

Frailty is a standardized, quantitative metric used to assess multisystem physiologic reserve and vulnerability to poor health outcomes. Cardiac rehabilitation (CR) positively impacts patient outcomes, including frailty, in adult cardiovascular disease (CVD); however, both the frailty paradigm and CR are understudied in pediatric CVD. This retrospective, single-center cohort study aimed to determine baseline composite frailty for pediatric-onset CVD patients and examine its change throughout CR using a proposed frailty assessment tool. Youth with pediatric-onset CVD participating in CR were stratified into five CVD diagnostic groups: post-heart transplant (HTx) (n = 34), post-ventricular assist device (VAD) (n = 12), single ventricle (n = 20) and biventricular (n = 29) congenital heart disease, and cardiomyopathy (n = 25), and frailty was assessed at baseline and every 30 days during CR. Post-HTx and post-VAD groups had significantly higher median frailty scores at baseline (6/10 and 5.75/10, respectively) driven by reduced strength, gait speed, and functional status. All groups except post-VAD displayed a significant absolute reduction in frailty from baseline to 120 days (HTx: − 3.5; VAD: − 3; SV CHD: − 1; BV CHD: − 1; CM: − 1.5), with similar median post-CR scores (1–3/10 in all groups). These improvements did not significantly correlate with number of CR sessions attended. This study established that frailty exhibits discriminatory utility across pediatric-onset CVD groups at baseline and is significantly modifiable over time. Improvements in frailty and other fitness metrics are likely due to a combination of post-operative recovery, post-diagnosis pharmacological and lifestyle changes, and CR. Further study of this frailty tool is needed to explore its prognostic utility.

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Acknowledgements

We would like to acknowledge the Cincinnati Children’s Heart Institute Exercise Laboratory and Cardiac Rehabilitation Program for providing the data used in this manuscript.

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No funds, grants, or other organizational support was received for the submitted work.

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Authors and Affiliations

  1. Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Jack A. Hermsen, Alexander R. Opotowsky, Adam W. Powell, Clifford Chin & Samuel G. Wittekind

  2. Division of Cardiology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    Alexander R. Opotowsky, Adam W. Powell, Wayne A. Mays, Clifford Chin, Justine D. Shertzer, Matthew J. Harmon & Samuel G. Wittekind

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  1. Jack A. Hermsen
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Contributions

This manuscript conveys original work performed at Cincinnati Children's Hospital Medical Center. All authors meet the ICMJE Recommendations for Authorship and the four required criteria of substantial contribution to the work, drafting/revising, final approval, and agreement to be accountable for all aspects of the work. All authors have read and approved submission of the manuscript, and the manuscript has not been published and is not being considered for publication elsewhere in whole or part in any language except as an abstract. The manuscript was proofed and edited by a native-English speaker. All communication should be directed to the corresponding author.

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Correspondence to Samuel G. Wittekind.

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The authors have no relevant financial, non-financial, or competing interests to disclose.

Ethical Approval

This research study was conducted retrospectively from data obtained for clinical purposes. We consulted with the institutional review board (IRB) at Cincinnati Children’s Hospital who determined that our study did not need ethical approval. An IRB exemption of ethical approval was granted from the institutional review board at Cincinnati Children’s Hospital.

Informed Consent

Written informed consent was obtained from the guardian, and written assent was obtained from participants younger than 18 years of age according to the guidelines established by the IRB at Cincinnati Children’s Hospital. Written informed consent was obtained from participants 18 years of age and older.

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Fig. Supplement 1.

Baseline Absolute Values for the Five Frailty Components(*, P<0.05; **, P<0.01; ***, P<0.001; ****, P<0.0001)% pred SMM, percent predicted skeletal muscle mass; 2MWD, two minute walk distance; BiV CHD, biventricular congenital heart disease; CM, cardiomyopathy; HGS, hand grip strength; Post-HTx, post-heart transplant; Post-VAD, post-ventricular assist device; SV CHD, single ventricle congenital heart diseaseBaseline composite frailty scores broken down into the absolute values of their five component assessments (not converted to the 0-2 age/sex standardized scores; absolute Lansky/Karnofsky Scores are still age and sex standardized) and compared between each CVD group using non-parametric Kruskal–Wallis Tests. % pred SMM and Lansky/Karnofsky scores were significantly lower in post-HTx and post-VAD compared to BiV CHD and CM. The other frailty components did not display any significant differences in between-group absolute scores at baseline. (PPTX 99 kb)

Fig. Supplement 2

. Individual Composite Temporal Frailty Scores across CVD Diagnostic GroupsBiV CHD, biventricular congenital heart disease; CM, cardiomyopathy; Post-HTx, post-heart transplant; Post-VAD, post-ventricular assist device; SV CHD, single ventricle congenital heart disease.Individual patient frailty scores were plotted for each diagnostic group at each time point which highlighted the downward trend in frailty seen in all diagnostic groups for most patients from baseline to 120 days. This analysis also clearly showed patient drop out across all diagnostic groups by four months but especially in the post-VAD group. (PPTX 118 kb)

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Hermsen, J.A., Opotowsky, A.R., Powell, A.W. et al. Physical Frailty is Modifiable in Young Cardiac Rehabilitation Patients. Pediatr Cardiol 43, 1799–1810 (2022). https://doi.org/10.1007/s00246-022-02917-w

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