Frailty in heart disease
Cardiology review: pending. This page has not yet been reviewed by a cardiologist.
Frailty is common in people with heart disease and is linked to how they do after heart attacks, heart operations and valve procedures.
Between about 1 in 10 and 6 in 10 older adults with heart disease are frail. A 2014 review found frailty carried a relative risk above 2 for death and complications across heart conditions and procedures. Later pooled estimates are smaller in some settings, such as chronic heart failure (see below). This guide covers how common frailty is and what it predicts, what cardiology guidance says, and which tools fit which situations. It is written for clinicians and is not a guideline.
Sources: Afilalo 2014 [1].
Why frailty matters in heart disease
How common it is
- Older adults with cardiovascular disease: about 10% to 60% are frail, depending on how much heart disease they have and which tool and cut-off is used (review, Afilalo 2014).
- Heart failure: almost half are frail (44.5%; 26 studies, 6,896 patients).
- Cardiac surgery (bypass, valve surgery or heart transplant): about 3 in 10 are frail (30.2%; 78 studies, which varied widely).
- Percutaneous coronary intervention (PCI): about 26% of 1.3 million people older than 65 were frail (CFS 5 to 9) in a US registry, 2018 to 2021.
- Cardiac rehabilitation: 46% are frail at the start by frailty index or Kihon Checklist (14 studies), and 40% by frailty phenotype (11 studies), in a meta-analysis of 34 studies.
Sources: Afilalo 2014 [1], Denfeld 2017 [2], Sarmadi 2025 [3], Peterson 2025 [4], MacEachern 2024 [5].
What it predicts
- Across stable heart disease, acute coronary syndromes, heart failure, surgery and transcatheter procedures, frailty carries a relative risk above 2 for death and complications, and it adds to standard risk models (review, Afilalo 2014).
- Chronic heart failure: frailty was linked to a 48% higher hazard of death (HR 1.48; 29 studies, 18,757 patients). It was linked to a 40% higher hazard of hospital admission (HR 1.40; 11 studies, 13,525 patients).
- PCI: in-hospital death was 0.5% in people who were not frail (CFS 1 to 2) and 20.3% in those who were severely frail (CFS 7 to 9).
- Heart attack: the study included 3,381 people with myocardial infarction at five Swedish hospitals (2017–2019), and 12.6% of them were frail (CFS 5 to 9). After adjustment, they had over three times the hazard of death at 6 months of people with CFS 1 to 3 (HR 3.32). People with CFS 4 were analyzed as a separate group.
- Cardiac surgery: in a review of 19 studies (66,448 patients), frail patients had about twice the odds of operative death after adjustment, compared with patients who were not frail (OR 1.97). This estimate was pooled from the 4 studies that reported adjusted operative mortality.
- Aortic valve replacement: in 1,215 people having transcatheter aortic valve implantation (TAVI) in Japan, 1-year mortality rose from 7.2% at CFS 1 to 3 to 44.1% at CFS 7 or more.
Frailty is not a reason to withhold treatment. Reviewers and registry authors say it should inform shared decisions about care, not exclude people from it.
Frailty can change. In one 12-week cardiac rehabilitation program, the mean frailty index of the 2,322 people who completed it fell from 0.34 to 0.26. The frailest improved most. These results describe only the people who finished, and frailer people were more likely to drop out. In people who complete cardiac rehabilitation, frailty often improves.
Sources: Afilalo 2014 [1], Peterson 2025 [4], Uchmanowicz 2020 [6], Ekerstad 2022 [7], Lee 2021 [8], Shimura 2017 [9], Kehler 2020 [10].
What cardiology guidance says
- Canadian Cardiovascular Society (CCS), heart failure guidelines, 2017. Assess everyone with known or suspected heart failure for frailty, along with multimorbidity, cognitive impairment, dementia and depression (strong recommendation, high-quality evidence). The guidelines name the Edmonton Frail Scale, the Clinical Frailty Scale and interRAI-based scales. They also say treatment should not be restricted on age alone. In frail older people, medicines may be started at lower doses and titrated more slowly.
- CCS, TAVI position statement, 2019. It recommends assessing frailty with a validated tool as part of the TAVI work-up.
- CCS and Canadian Heart Failure Society, 2023. The frail heart failure phenotype is one of five phenotypes in this update. It needs special attention, careful drug titration and consideration of cardiac rehabilitation.
- CCS consensus conference on heart disease in older people, 2002. Frailty was already one of its themes. Kenneth Rockwood was a co-author of the conference report.
- American Heart Association, acute coronary syndromes in older adults, 2023. Assess frailty in a way that is at least standardized within each institution.
- American Heart Association, coronary revascularization in older adults, 2025. Carry out a comprehensive geriatric risk assessment alongside the usual clinical, hemodynamic, anatomical and technical assessments.
- American College of Cardiology, 2026 statement (from ACC's summary). Screen routinely for frailty and cognitive impairment in outpatient clinics and after hospital stays.
Several of these documents note that there is no agreement yet on a single best frailty tool.
Sources: Ezekowitz 2017 (CCS) [11], Asgar 2019 (CCS) [12], Ducharme 2023 (CCS–CHFS) [13], Fitchett 2004 (CCS) [14], Damluji 2023 (AHA) [15], Damluji 2025 (AHA) [16], ACC summary 2026 [17], Alexander 2026 (ACC) [18].
Which GMR tools fit, and when
Clinical Frailty Scale Classification Tool (full or short version)
- What it is. For clinicians. You answer questions about the patient's usual health, about 2 weeks before any acute illness, and a fixed decision tree gives a CFS level from 1 (very fit) to 9 (terminally ill). The full version asks about each activity and condition (up to 39 questions, about 5 minutes). The short version uses counts (2 to 7 questions, about 1 to 2 minutes).
- Evidence for the CFS in heart disease (rated directly, not by questionnaire). The CFS has been studied before PCI, after myocardial infarction, before TAVI and surgical valve replacement, before cardiac surgery and in heart failure. Canadian heart failure guidelines name it, and the US PCI registry form records it.
- Caution. In the studies that report who rated it, clinicians, nurses or trained research assistants rated the CFS directly. Our tools reach a CFS level from questionnaire answers through a classification tree. The classification tree was tested against geriatrician ratings in 115 older adults at one centre (Theou 2021), not specifically in heart disease. Confirm the level with your clinical judgement.
- When it fits. Use it to help you record a CFS level, scoring the patient's usual state before any acute illness. A CFS of 5 or more is the usual "frail" line.
- Open the Clinical Frailty Scale Classification Tool (full version)
- Open the Clinical Frailty Scale Classification Tool (short version)
Fit-to-Frail Index Calculator
- What it is. For individuals to fill in about themselves. 62 questions (about 10 to 15 minutes) give a frailty index from 0 to 1. The index is compared with people of the same age and sex in the Canadian Longitudinal Study on Aging (CLSA), ages 45 to 85.
- Evidence for frailty indexes in heart disease. Frailty indexes have predicted outcomes in cardiac rehabilitation in Halifax (25 items) and in US adults with cardiovascular disease (46 items). In cardiac rehabilitation, frailty often improves in people who complete it. These studies used their own item lists, not the Fit-to-Frail items.
- Caution. The Poor-to-Excellent categories compare the person with people of the same age and sex in the CLSA, not with heart patients. They are not frailty grades.
- When it fits. Use it when a patient can complete a questionnaire about themselves and you want a frailty index. As the tool page says, the result is for information only and is not a diagnosis. Use the frailty index as the measure of frailty. The "Copy for the chart" line also gives the percentile and category, worded as a comparison with people in the CLSA.
Pictorial Fit-Frail Scale (beta)
- What it is. Pictures in 14 categories, completed by the person, a care partner or a health professional. It gives a score from 0 to 43 and a frailty index.
- Caution. This is an early test version with placeholder pictures. Do not use it for clinical decisions.
Sources: Peterson 2025 [4], Ekerstad 2022 [7], Shimura 2017 [9], Kehler 2020 [10], Ezekowitz 2017 (CCS) [11], Ekerstad 2011 [19], Prendiville 2023 [20], Sebastian 2026 [21], Pienta 2026 [22], Theou 2021 [23], Sison 2023 [24], Quach 2023 [25], Quach 2026 [26]; the tool pages on this site.
Bedside performance tests: the Essential Frailty Toolset
The 2019 CCS TAVI position statement recommends assessing frailty with a validated tool as part of the TAVI work-up. The Essential Frailty Toolset (EFT) scores 0 to 5 from four items: five chair rises without using the arms, the Mini-Mental State Examination, hemoglobin and serum albumin. In the FRAILTY-AVR study of 1,020 older adults having transcatheter or surgical aortic valve replacement, the EFT was the strongest of seven frailty scales at predicting death at 1 year.
None of the tools on this site is the EFT. For the EFT, use the Frailty Tool app by Dr. Jonathan Afilalo, a cardiologist at the Jewish General Hospital and McGill University in Montreal. Dr. Afilalo was first author of FRAILTY-AVR and a co-author of the 2019 CCS TAVI statement.
Frailty Tool app (external)
- Free, for iPhone and Android.
- It guides you through the EFT step by step, with a timer and illustrations for the physical tests. It calculates the EFT score and a 1-year mortality risk.
- App last updated May 2026.
The app and its scoring belong to its authors. GMR Toolkit only links to it. This site does not host or score the Essential Frailty Toolset.
Sources: Asgar 2019 (CCS) [12], Solomon 2021 [27], Afilalo 2017 [28], Frailty Tool app [29].
Research on frailty and heart disease
These are published papers from our group on frailty and heart disease, each with a short plain-language summary.
Frailty index deficit interchangeability: an empirical test using random survival forests in adults with cardiovascular disease
Quach J, Theou O, Rockwood K, Kehler S, Blodgett J. Age Ageing. 2026;55(9):afag262.
A frailty index counts how many health problems a person has from a list. This study asked whether it matters which ones. It used a 46-item frailty index to predict death in 3,669 US adults living with cardiovascular disease (NHANES 1999–2018), with survival models and machine learning. Indexes built from the top-ranked items did best at about 10 items, then got worse. Indexes of randomly chosen items kept improving and caught up by about 35 items for death from any cause and 20 for cardiovascular death. For death from any cause, keeping items separate predicted somewhat better than one combined score. The authors argue that one score keeps the index general and practical. With enough items, which items were used made little difference to predicting death.
Machine learning for frailty assessment and outcome prediction in cardiovascular disease: a scoping review
Quach J, Theou O, Maxwell S, Abidi SSR, Song X, Rockwood K, Kehler DS. Ageing Res Rev. 2026;118:103122.
This scoping review found 31 studies (2016–2025) that used machine learning with frailty measures in people with cardiovascular disease, 71% of them in heart failure. The frailty phenotype, frailty index and Clinical Frailty Scale were the most used of 13 frailty measures. Reported AUCs were 0.80 to 0.96 for predicting frailty and 0.70 to 0.93 for predicting death. Only 3 studies tested their models in external data, and 4 reported calibration.
Cardiac rehabilitation and frailty: a systematic review and meta-analysis
MacEachern E, Quach J, Giacomantonio N, Theou O, Hillier T, Abel-Adegbite I, Gonzalez-Lara M, Kehler DS. Eur J Prev Cardiol. 2024;31(16):1960–1976.
This review pooled 34 studies (19,360 participants) of frailty in cardiac rehabilitation. Frailty at the start of rehabilitation was common: 46% by frailty index or Kihon Checklist (14 studies) and 40% by frailty phenotype (11 studies). Frailty improved after rehabilitation (6 studies), and higher frailty at the start was linked to higher mortality.
The association of frailty on cardiac rehabilitation goal achievement
MacEachern E, Quach J, Giacomantonio N, Theou O, Hillier T, Firth W, Kehler DS. Front Cardiovasc Med. 2024;11:1441336.
The study included 759 people referred to cardiac rehabilitation (2005–2015; mean age 59.5, 24% female), and 80% of them achieved a rehabilitation goal. People who were less frail at the start, on a 25-item frailty index, were more likely to reach a goal. Those with an index below 0.20 had about 4.7 times the odds of those above 0.40.
Comparing virtual and center-based cardiac rehabilitation on changes in frailty
MacEachern E, Giacomantonio N, Theou O, Quach J, Firth W, Abel-Adegbite I, Kehler DS. Int J Environ Res Public Health. 2023;20(2):1554.
The study included 132 people in a Halifax cardiac rehabilitation program (2021–2022). It compared virtual rehabilitation with a centre-based program that COVID-19 restrictions had shortened to 6 weeks. Frailty was measured on a 65-item frailty index. Overall, the type of program made no difference to the change in frailty. People who were frailer at the start improved more with virtual than with centre-based rehabilitation.
Association of admission frailty and frailty changes during cardiac rehabilitation with 5-year outcomes
Quach J, Kehler DS, Giacomantonio N, McArthur C, Blanchard C, Firth W, Rockwood K, Theou O. Eur J Prev Cardiol. 2023;30(9):807–819.
The study followed 3,371 people in a 12-week cardiac rehabilitation program in Halifax, Nova Scotia (2005–2015). Frailty was measured with a 25-item frailty index at the start and end. People who were frailer at the start had a higher risk of death, hospital admission and emergency visits over 5 years. Frailty improved by 0.07 on average. Improvement was linked to a longer time before any hospital admission, but not to the other outcomes.
The impact of cardiovascular health and frailty on mortality for males and females across the life course
Quach J, Theou O, Godin J, Rockwood K, Kehler DS. BMC Med. 2022;20(1):394.
The study included 35,207 US adults aged 20 to 85 (NHANES 1999–2015), followed for a median of 8.1 years. It combined a 33-item frailty index (cardiovascular items left out) with the American Heart Association's Life's Simple 7 score. In females, frailty and poorer cardiovascular health were together linked to a higher risk of death, and the combined risk was similar across ages. In males, the combined risk was higher at ages 60 and 70, but not at 30 to 50.
See all our papers on the "Our research" tab
Related guides
Different tools label different people as frail. In FRAILTY-AVR, the share of the same patients labelled frail ranged from 26% to 68% depending on the scale. In UK outpatients with chronic heart failure it ranged from 30% to 52%. When you record frailty, name the tool and the score.
Read 'Frail' means different things on different tools.
Sources: Sison 2023 [24], Afilalo 2017 [28], Theou 2013 [30], Sze 2019 [31], Frailty Science (Johns Hopkins) [32].
References
- Afilalo J, Alexander KP, Mack MJ, Maurer MS, Green P, Allen LA, et al. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014;63(8):747-62. doi:10.1016/j.jacc.2013.09.070. PMID: 24291279.
- Denfeld QE, Winters-Stone K, Mudd JO, Gelow JM, Kurdi S, Lee CS. The prevalence of frailty in heart failure: a systematic review and meta-analysis. Int J Cardiol. 2017;236:283-9. doi:10.1016/j.ijcard.2017.01.153. PMID: 28215466.
- Sarmadi S, Sanaie N, Zare-Kaseb A. Prevalence and risk factors of frailty among cardiac surgery patients: a systematic review and meta-analysis. Ann Med. 2025;57(1):2576638. doi:10.1080/07853890.2025.2576638. PMID: 41137434.
- Peterson B, Kochar A, Young R, Senman B, Rymer J, Wojdyla D, et al. Effect of frailty on in-hospital mortality and complications of PCI: an NCDR registry report. J Am Coll Cardiol. 2025;85(24):2416-20. doi:10.1016/j.jacc.2025.04.027. PMID: 40533131.
- MacEachern E, Quach J, Giacomantonio N, Theou O, Hillier T, Abel-Adegbite I, et al. Cardiac rehabilitation and frailty: a systematic review and meta-analysis. Eur J Prev Cardiol. 2024;31(16):1960-76. doi:10.1093/eurjpc/zwae239. PMID: 39036978.
- Uchmanowicz I, Lee CS, Vitale C, Manulik S, Denfeld QE, Uchmanowicz B, et al. Frailty and the risk of all-cause mortality and hospitalization in chronic heart failure: a meta-analysis. ESC Heart Fail. 2020;7(6):3427-37. doi:10.1002/ehf2.12827. PMID: 32955168.
- Ekerstad N, Javadzadeh D, Alexander KP, Bergström O, Eurenius L, Fredrikson M, et al. Clinical Frailty Scale classes are independently associated with 6-month mortality for patients after acute myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2022;11(2):89-98. doi:10.1093/ehjacc/zuab114. PMID: 34905049.
- Lee JA, Yanagawa B, An KR, Arora RC, Verma S, Friedrich JO. Frailty and pre-frailty in cardiac surgery: a systematic review and meta-analysis of 66,448 patients. J Cardiothorac Surg. 2021;16(1):184. doi:10.1186/s13019-021-01541-8. PMID: 34172059.
- Shimura T, Yamamoto M, Kano S, Kagase A, Kodama A, Koyama Y, et al. Impact of the Clinical Frailty Scale on outcomes after transcatheter aortic valve replacement. Circulation. 2017;135(21):2013-24. doi:10.1161/CIRCULATIONAHA.116.025630. PMID: 28302751.
- Kehler DS, Giacomantonio N, Firth W, Blanchard CM, Rockwood K, Theou O. Association between cardiac rehabilitation and frailty. Can J Cardiol. 2020;36(4):482-9. doi:10.1016/j.cjca.2019.08.032. PMID: 31837892.
- Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, et al. 2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of heart failure. Can J Cardiol. 2017;33(11):1342-433. doi:10.1016/j.cjca.2017.08.022. PMID: 29111106.
- Asgar AW, Ouzounian M, Adams C, Afilalo J, Fremes S, Lauck S, et al. 2019 Canadian Cardiovascular Society position statement for transcatheter aortic valve implantation. Can J Cardiol. 2019;35(11):1437-48. doi:10.1016/j.cjca.2019.08.011. PMID: 31679616.
- Ducharme A, Zieroth S, Ahooja V, Anderson K, Andrade J, Boivin-Proulx LA, et al. Canadian Cardiovascular Society-Canadian Heart Failure Society focused clinical practice update of patients with differing heart failure phenotypes. Can J Cardiol. 2023;39(8):1030-40. doi:10.1016/j.cjca.2023.04.022. PMID: 37169222.
- Fitchett D, Rockwood K, Chan BT, Schultz S, Bogaty P, Gillis A, et al. Canadian Cardiovascular Society Consensus Conference 2002: management of heart disease in the elderly patient. Can J Cardiol. 2004;20 Suppl A:7A-16A. PMID: 15190403. Available from: https://pubmed.ncbi.nlm.nih.gov/15190403/
- Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, et al. Management of acute coronary syndrome in the older adult population: a scientific statement from the American Heart Association. Circulation. 2023;147(3):e32-62. doi:10.1161/CIR.0000000000001112. PMID: 36503287.
- Damluji AA, Nanna MG, Mason P, Lowenstern A, Orkaby AR, Washam JB, et al. Coronary artery revascularization in the older adult population: a scientific statement from the American Heart Association. Circulation. 2025;152(25):e494-525. doi:10.1161/CIR.0000000000001387. PMID: 41250995.
- American College of Cardiology. ACC scientific statement addresses cognitive impairment, frailty in patients with CV disease [Internet]. 2026 Aug 10 [cited 2026 Oct 12]. Available from: https://www.acc.org/Latest-in-Cardiology/Journal-Scans/2026/08/10/15/19/ACC-Scientific-Statement-Addresses-Cognitive-Impairment-Frailty
- Alexander KP, Damluji AA, Erqou S, Ferrucci L, Forman DE, Galasko D, et al. Cognitive impairment and frailty in older adults with cardiovascular disease: 2026 ACC scientific statement. J Am Coll Cardiol. 2026 Aug 10 [Epub ahead of print]. doi:10.1016/j.jacc.2026.07.009. PMID: 42573541.
- Ekerstad N, Swahn E, Janzon M, Alfredsson J, Löfmark R, Lindenberger M, et al. Frailty is independently associated with short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction. Circulation. 2011;124(22):2397-404. doi:10.1161/CIRCULATIONAHA.111.025452. PMID: 22064593.
- Prendiville T, Leahy A, Gabr A, Ahmad F, Afilalo J, Martin GP, et al. Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis. Open Heart. 2023;10(2):e002354. doi:10.1136/openhrt-2023-002354. PMID: 37567604.
- Sebastian SA, Yehya A. Clinical frailty scale for risk stratification in elderly patients with heart failure: a meta-analysis. Curr Probl Cardiol. 2026;51(12):103432. doi:10.1016/j.cpcardiol.2026.103432. PMID: 42641835.
- Pienta M, He C, Clark MJ, Fanning JS, Azoury FM, Grelecki L, et al. Clinical Frailty Scale assessment before cardiac surgery. Ann Thorac Surg. 2026;121(3):696-703. doi:10.1016/j.athoracsur.2025.10.028. PMID: 41223914.
- Theou O, Pérez-Zepeda MU, van der Valk AM, Searle SD, Howlett SE, Rockwood K. A classification tree to assist with routine scoring of the Clinical Frailty Scale. Age Ageing. 2021;50(4):1406-11. doi:10.1093/ageing/afab006. PMID: 33605412.
- Sison SDM, Shi SM, Kim KM, Steinberg N, Jeong S, McCarthy EP, et al. A crosswalk of commonly used frailty scales. J Am Geriatr Soc. 2023;71(10):3189-98. doi:10.1111/jgs.18453. PMID: 37289180.
- Quach J, Kehler DS, Giacomantonio N, McArthur C, Blanchard C, Firth W, et al. Association of admission frailty and frailty changes during cardiac rehabilitation with 5-year outcomes. Eur J Prev Cardiol. 2023;30(9):807-19. doi:10.1093/eurjpc/zwad048. PMID: 36799963.
- Quach J, Theou O, Rockwood K, Kehler S, Blodgett J. Frailty index deficit interchangeability: an empirical test using random survival forests in adults with cardiovascular disease. Age Ageing. 2026;55(9):afag262. doi:10.1093/ageing/afag262. PMID: 42696642.
- Solomon J, Moss E, Morin JF, Langlois Y, Cecere R, de Varennes B, et al. The Essential Frailty Toolset in older adults undergoing coronary artery bypass surgery. J Am Heart Assoc. 2021;10(15):e020219. doi:10.1161/JAHA.120.020219. PMID: 34315236.
- Afilalo J, Lauck S, Kim DH, Lefèvre T, Piazza N, Lachapelle K, et al. Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study. J Am Coll Cardiol. 2017;70(6):689-700. doi:10.1016/j.jacc.2017.06.024. PMID: 28693934.
- Afilalo J. Frailty Tool [mobile application]. Version 1.1.4. 2026 May 12 [cited 2026 Oct 12]. Available from: https://apps.apple.com/ca/app/frailty-tool/id1330330931 and https://play.google.com/store/apps/details?id=com.jonathanafilalo.frailtytool
- Theou O, Brothers TD, Mitnitski A, Rockwood K. Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality. J Am Geriatr Soc. 2013;61(9):1537-51. doi:10.1111/jgs.12420. PMID: 24028357.
- Sze S, Pellicori P, Zhang J, Weston J, Clark AL. Identification of frailty in chronic heart failure. JACC Heart Fail. 2019;7(4):291-302. doi:10.1016/j.jchf.2018.11.017. PMID: 30738977.
- Frailty Science, Johns Hopkins Older Americans Independence Center. Guidance on selecting a frailty assessment instrument [Internet]. [cited 2026 Oct 12]. Available from: https://frailtyscience.org/frailty-assessment-instruments/