Efficacy and Safety of Heart Failure Treatment According to Frailty Status: A Systematic Review

BACKGROUND: Guideline-directed treatment is often withheld in frail patients with heart failure (HF) due to concerns about intolerability, yet they may benefit given the higher risk of HF complications. This systematic review evaluates the efficacy and safety of HF therapy according to frailty levels. METHODS: We searched Medline, Embase, and Web of Science for randomized clinical trials on HF therapies reporting outcomes by frailty status (as defined by the study). Data were summarized in a harvest plot, and a meta-analysis was conducted where possible. RESULTS: We identified 12 studies: 6 on medication; 3 on exercise/rehabilitation; and 1 each on disease management programs, telemonitoring, and implantable cardioverter-defibrillators. Most studies found no significant interaction between intervention and frailty, except for some specific outcomes where certain interventions had an interaction in favor of the frail. CONCLUSIONS: HF therapies, with the exception of implantable cardioverter-defibrillators, are safe and appear to have at least similar benefits in frail and nonfrail patients. Given higher event rates in frail patients, the absolute risk reduction for the studied interventions is greater in frail patients. Optimal guideline-directed treatment should therefore also be considered for frail patients.