The study aimed to determine the incremental utility of objective criteria for frailty assessment compared to subjective evaluation alone in elderly patients being considered for valvular surgery. Providers re-assessed 101 patients for frailty using a Likert scale and surgical risk classification after viewing objective frailty measurements of walking tests, grip strength, activities of daily living, and quality of life. The results showed that objective frailty measures led to a change in the providers' frailty or risk assessment in over 40% of patients, with hand grip strength being the most influential objective criterion.

1. BACKGROUND
• Frailty assessment of valve surgical candidates has been
mainly based on the traditional “eyeball” test, which is
limited by its observational nature, leading to personal
biases, low reproducibility among physicians and centers,
and a lack of a scientifically proven technique.
• Recently, there has been increasing recognition of the need
to quantify the frailty of patients using objective criteria.
• The most commonly used definition of frailty is based on the
criteria of Fried et al., which assess up to 5 domains—
nutritional status (weight loss), energy (exhaustion),
physical activity (leisure time activity), mobility (gait speed),
and strength (grip strength).
SPECIFIC AIM
• To determine the incremental utility of objective criteria for
frailty assessment and to assess clinical factors that lead to
discrepancy between subjective and objective
measurements.
METHODS
Patient Population
• Patients evaluated at the Minneapolis Heart Institute at
Abbott Northwestern Hospital, between February 2014 and
March 2015.
• Willing and capable of signing informed consent.
• Patient has diagnosis of valvular heart disease or coronary
artery disease, and is being considered for percutaneous or
surgical interventional procedure (e.g., percutaneous
coronary intervention (PCI), coronary artery bypass grafting
(CABG), valve replacement).
Data analysis
• Providers examined each patient and independently graded
frailty with a Likert scale (1 to 7, with 7 being most frail) and
assessed surgical risk (low, intermediate, high, prohibitive).
• Each patient underwent prospective, objective
measurement of frailty with assessments of 15-foot and 6-
min walk times, handgrip strength, activities of daily living
(Katz index), and SF-12 quality-of-life.
• Providers were informed of the objective frailty data, and
were asked to re-grade frailty.
• Statistical significance set a priori at p<0.05. All values are
mean with standard deviation.
TABLES
Demographics and Clinical Data of Patients in Median door to balloon time (minutes) based upon onset of chest pain
to time of balloon
Baseline Characteristics
FIGURES
CONCLUSIONS
• The “eyeball” test was insufficient for assessing
frailty in ~40% of elderly patients being considered
for surgery.
• In addition to physical status, other domains such as
cognitive ability, mood, and mental health should be
considered to obtain a more complete assessment of
frailty
• Objective frailty measures should be routinely
considered in the assessment of these patients, and
further study on their incremental value for risk
prognostication is needed.
DISCLOSURES
• The authors have no disclosures to report
ABSTRACT
BACKGOUND: Frailty is an independent
predictor of surgical outcome, and its
assessment is fundamental to the
management of elderly patients being
considered for valvular surgery. In current
practice, providers frequently rely on
subjective evaluations (i.e., the “eyeball” test).
However, the accuracy of these subjective
assessments remain largely unknown.
METHODS: We examined 101 patients who
were being evaluated in our valve clinic. Each
patient underwent prospective, objective
measurement of frailty with assessments of
15-foot and 6-min walk times, handgrip
strength, activities of daily living (Katz index),
and SF-12 quality-of-life. Providers examined
each patient and independently graded frailty
with a Likert scale (1 to 7, with 7 being most
frail) and assessed surgical risk (low,
intermediate, high, prohibitive), and then were
asked to repeat these assessments after
being informed of the objective frailty data.
RESULTS: Study patients were elderly (age,
77±14 yrs; 60 men) and with a high
prevalence of morbidities (STS-PROM,
5.8±3.8%). Overall, frailty scores on the Likert
scale decreased (i.e., less frailty) once the
provider became aware of the objective data
(3.7±2.0 vs. 3.4±2.0; p=0.003). For the binary
classification of frailty (i.e., frail or not), the net
reclassification rate after awareness of the
objective data was 41%. A change of ≥2
points on the Likert scale occurred in 22%.
Handgrip strength was the most common
objective measure used for net
reclassification: 26% of patients initially
deemed to be frail subsequently passed
handgrip testing, while 30% of patients initially
felt to be not frail subsequently failed. Overall,
reclassification of surgical risk occurred in
26% of patients with awareness of objective
frailty measures.
CONCLUSIONS: In this study, the “eyeball”
test was insufficient for assessing frailty in
~40% of elderly patients being considered for
surgery. Objective frailty measures should be
routinely considered in the assessment of
these patients, and further study on their
incremental value for risk prognostication is
needed.
CORRESPONDENCE
Paul Sorajja, MD
Director, Center for Valve and Structural
Heart Disease
Minneapolis Heart Institute
Email: paul.sorajja@allina.com
Phone: (612) 863-8751
Prospective Evaluation of the ‘Eyeball’ Test for Assessing Frailty in Elderly Patients with Valvular Heart Disease
Aisha Ahmed, Akila Pai, Nicholas Plimpton, John Lesser, Richard Bae, Wesley A. Pedersen, Lisa Tindell, R. Saeid Farivar, Kevin Harris, and Paul Sorajja
Center for Valve and Structural Heart Disease, Minneapolis Heart Institute, and the Valve Science Center, Minneapolis Heart Institute Foundation
Abbott Northwestern Hospital, Minneapolis, MN
SUMMARY
• Frailty scores on the Likert scale decreased (i.e., less
frailty) once the provider became aware of the
objective data (3.7±2.0 vs. 3.4±2.0; p=0.003).
• For the binary classification of frailty (i.e., frail or not),
the net reclassification rate after awareness of the
objective data was 41%. A change of ≥2 points on the
Likert scale occurred in 22%.
• Handgrip strength was the most common objective
measure used for net reclassification: 26% of patients
initially deemed to be frail subsequently passed
handgrip testing, while 30% of patients initially felt to
be not frail subsequently failed. Overall,
reclassification of surgical risk occurred in 26% of
patients with awareness of objective frailty measures.
RESULTS
REFERENCES
• Fried L.P., Tangen C.M., Walston J., Frailty in
older adults: evidence for a phenotype. J Gerontol
Med Sci. 2001;56A:M146-M156.
• Rodés-Cabau J, Mok M. Working Toward a Frailty
Index in Transcatheter Aortic Valve Replacement: A
Major Move Away From the “Eyeball Test”⁎. J Am
Coll Cardiol Intv. 2012;5(9):982-983.
All patients
N=101
Age (yr) 76.8 ±13.8
Men – no. (%) 60 (60)
Hypertension – no. (%) 89 (89)
Diabetes – no. (%) 29 (29)
Atrial fibrillation – no. (%) 54 (54)
COPD – no. (%) 18 (18)
O2-dependent 3 (3)
CAD – no. (%) 58 (58)
Prior PCI – no. (%) 37 (37)
Prior CABG – no. (%) 19 (19)
>1 prior sternotomy 5 (5)
ICD – no. (%) 3 (3)
PPM – no. (%) 8 (8)
BMI 28.7 ±6.6
Creatinine – g/dl 1.1 ±0.5
LVEF (%) 58 ±12
Left ventricular hypertrophy 27 (27)
Moderate or severe AS – no. (%) 41 (41)
Moderate or severe MR – no . (%) 30 (30)
Other valvular disease – no (%) 29 (29)
STS-PROM (%) 5.2 ±3.8
Baseline Assessment
Passed 15 Foot Walk
N=101
Failed 15 Foot Walk
N=101
Frail 21 28
Not Frail 48 3
Total incorrect: 24
Baseline Assessment Passed Katz ADL
assessment
N=101
Failed Katz ADL
assessment
N=101
Frail 41 8
Not Frail 50 1
Total incorrect: 42
Baseline Assessment Passed Handgrip
strength assessment
N=101
Failed Handgrip
strength assessment
N=101
Frail 26 21
Not Frail 23 30
Total incorrect: 56
Frailty Markers
Handgrip Strength Assessment
15 Foot Walk Assessment
Katz ADL Assessment