Elsevier

Resuscitation

Volume 167, October 2021, Pages 242-250
Resuscitation

Review
Prognostic association of frailty with post-arrest outcomes following cardiac arrest: A systematic review and meta-analysis

https://doi.org/10.1016/j.resuscitation.2021.06.009Get rights and content

Highlights

  • Frailty is a robust predictor of patient-important health outcomes and is often overlooked.

  • Individuals with frailty have approximately 3× the odds of dying during hospitalization after in-hospital cardiac arrest.

  • Frailty should be considered during shared-decision making about end-of-life care.

Abstract

Objective

To synthesize the current evidence examining the association between frailty and a series of post-arrest outcomes following the provision of cardiopulmonary resuscitation (CPR).

Data sources

We searched MEDLINE, PubMed (exclusive of MEDLINE), EMBASE, CINAHL, and Web of Science from inception to August 2020 for observational studies that examined an association between frailty and post-arrest health outcomes, including in-hospital and post-discharge mortality. We conducted citation tracking for all eligible studies.

Study selection

Our search yielded 20,480 citations after removing duplicate records. We screened titles, abstracts and full-texts independently and in duplicate.

Data extraction

The prognosis research strategy group (PROGRESS) and the critical appraisal and data extraction for systematic review of prediction modelling studies (CHARMS) guidelines were followed. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) instrument. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations for prognostic factor research.

Data synthesis

Four studies were included in this review and three were eligible for statistical pooling. Our sample comprised 1,134 persons who experienced in-hospital cardiac arrest (IHCA). The mean age of the sample was 71 years. The study results were pooled according to the specific frailty instrument. Three studies used the Clinical Frailty Scale (CFS) and adjusted age (our minimum confounder); the presence of frailty was associated with an approximate three-fold increase in the odds of dying in-hospital after IHCA (aOR = 2.93; 95% CI = 2.43–3.53, high certainty). Frailty was also associated with decreased incidence of ROSC (return of spontaneous circulation) and discharge home following IHCA. One study with high risk of bias used the Hospital Frailty Risk Score and reported a 43% decrease in the odds of discharge home for patients with frailty following IHCA.

Conclusion

High certainty evidence was found for an association between frailty and in-hospital mortality following IHCA. Frailty is a robust prognostic factor that contributes valuable information and can inform shared-decision making and policies surrounding advance care directives.

Registration: PROSPERO Registration # CRD42020212922

Introduction

Frailty is a multidimensional syndrome characterized by a heightened vulnerability to adverse health events and diminished physiologic reserve, inhibiting homeostatic recovery from stressors.1, 2 Frailty is a robust predictor of patient-important health outcomes and health service use across all ages.3, 4, 5 Geriatric syndromes, like frailty, are commonly overlooked by health care providers and disease-centric models of care.6, 7 Emphasis has been placed on measuring frailty alongside routine clinical assessments in acute care, home care, and long-term care to support clinical decision-making and health system planning.8, 9, 10

Clinicians and resuscitation scientists have recently examined the utility of frailty to inform shared-decision making surrounding the provision of cardiopulmonary resuscitation (CPR) and other resuscitative measures following cardiac arrest. Approximately one-in-ten will survive a cardiac arrest in the hospital setting, with worse odds for arrests that occur in the community.11, 12 Many survivors report physical disabilities, cognitive impairment, mental illness, or decreased quality of life post-arrest,13, 14, 15 highlighting the importance of pragmatic discussions regarding advance care directives.

Public perceptions and media portrayals of survival following CPR are known to be optimistic.16, 17, 18 Prior work demonstrates that pre-emptive discussions regarding resuscitative measures and patient prognosis improves knowledge and can influence end-of-life care decisions.19, 20 Advanced knowledge of patient prognosis following cardiac arrest is necessary to determine if resuscitation efforts are futile and ensure value-congruent care. Frailty provides a concise measure to gauge patient resilience and may support decision-making around the provision of CPR and end-of-life care.

Our objective was to synthesize the available evidence on the association between frailty and patient-important outcomes following the provision of CPR, when accounting for age.

Section snippets

Methods

The reporting of this review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; a completed checklist can be found in Appendix A in the Supplementary material.21 We conducted this systematic review and meta-analysis per recommendations from Riley and colleagues and the Prognosis Research Strategy Group (PROGRESS) group.22, 23, 24, 25 The critical appraisal and data extraction for systematic reviews of prediction modelling studies

Results

The literature search yielded 20,480 citations after removing duplicate records; four studies were included in the review and three were eligible for statistical pooling (Fig. 1). Agreement between reviewers was weak for title and abstract screening (kappa = 0.4) but excellent for full-text screening (kappa = 0.97). Table 1 displays the individual study characteristics, including 1,134 persons who experienced IHCA between 2008 and 2018. No studies examining frailty and relevant outcomes

Discussion

We conducted a systematic review and meta-analysis to evaluate the association between frailty and post-arrest outcomes in individuals who require CPR for cardiac arrest. Our pooled estimates for frailty, when measured with the CFS, found that individuals with frailty have approximately three times the odds of dying during hospitalization after an IHCA. This translates to a 13% increase in absolute risk of death for individuals with frailty, surpassing our clinical importance threshold of a 10%

Conclusion

This study identified that frailty, when measured with the CFS, is an essential prognostic factor to consider when discussing goals of care with patients or conducting resuscitation research. When measured with the CFS, individuals with frailty had approximately three times the odds of dying in-hospital after an IHCA. Low-certainty evidence suggests that individuals with frailty are less likely to be discharged home after an IHCA. Future research is needed to examine the prognostic value of

Conflicts of interest

The authors note that Dr. Jerry P Nolan is a co-author of this paper and he also the acting editor-in-chief of the Resuscitation Journal. The authors have no other conflicts of interest to declare.

CRediT authorship contribution statement

Fabrice I. Mowbray: Conceptualization, Methodology, Formal analysis, Data curation, Writing - original draft, Writing - review & editing. Donna Manlongat: Conceptualization, Data curation, Writing - original draft, Writing - review & editing. Rebecca H. Correia: Conceptualization, Data curation, Writing - review & editing. Ryan P. Strum: Conceptualization, Data curation, Writing - review & editing. Shannon M. Fernando: Conceptualization, Methodology, Writing - original draft, Writing - review &

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