Frailty makes a difference in an increasingly aging population. Frailty and pre-frailty are major prognostic factors for mortality and cardiovascular events in the context of preoperative cardiac evaluation. It should not be reduced to a synonym of aging or chronological age. Aging is a heterogeneous and unique process, which complicates the implementation of standardized assessment criteria at an international level, as reflected in the latest 2024 publications from the European Society of Cardiology. Despite efforts and progress toward unifying criteria, the reality is that additional and more complex scales are often required in clinical practice.

We now turn to the present study. This is a prospective observational study conducted at a single center in Himeji, Japan (one of the most aged countries in the world, together with Spain), including patients aged 65 years or older undergoing elective cardiac surgery. Frailty was assessed using the J-CHS (Japanese Cardiovascular Health Study) 5-item scale: weight loss, exhaustion, low physical activity, slowness of gait, and weakness. Frailty was defined as a score ≥3. This was compared with a new simplified model based on gait speed, serum albumin, and grip strength, evaluating its diagnostic performance and its association with mid-term prognosis (3 years). The main outcome variables were mortality and major cardiovascular events.

The final analysis included 261 patients (mean age 73 years, 30% women) who completed preoperative frailty assessment. The most frequent procedures were vascular surgery (n=106) and aortic surgery (n=106), followed by coronary revascularization surgery. According to standardized J-CHS criteria, 33% of patients were classified as frail and 67% as non-frail. During follow-up, 13 deaths occurred: cerebrovascular disease (3), pneumonia (2), heart failure (1), aortic dissection (1), cancer (1), sepsis (1), and undetermined causes (4).

For frailty diagnosis, the authors compared three simplified models. Model 1 was based solely on gait speed. Model 2 added hypoalbuminemia, and Model 3 incorporated grip strength measured by dynamometry. The three-variable model improved diagnostic performance, achieving an overall accuracy close to 80%, with higher specificity and the highest positive predictive value, significantly outperforming simpler models. Model 3 demonstrated greater discriminative capacity to identify frail patients compared with the J-CHS scale.

From a prognostic perspective, frailty identified using Model 3 was independently associated with an increased risk of mortality and major cardio-cerebrovascular events at three years after surgery. Patients classified as frail showed significantly lower survival and higher readmission rates, with results comparable to those obtained using J-CHS criteria. The authors conclude that this simplified three-variable model reliably identifies frail patients and predicts mid-term prognosis after surgery.

The three-item model improves accuracy in detecting frailty compared with simpler approaches. It shows high specificity and prognostic capacity comparable to the standard scale, establishing an independent association with mortality and major cardiovascular events. The authors therefore conclude that this simplified model represents a practical and reliable tool for cardiovascular surgical risk stratification, with prognostic value comparable to more complex scales.

COMMENTARY:

This study reflects a clear shift in approach: we move from “knowing that frailty matters” to “knowing how to measure it.” For non-geriatric specialists, frailty may sometimes appear abstract, nonspecific, or conceptually diffuse. However, the possibility of extracting objective variables to identify frail patients represents a significant advance. It is not enough to remain at the starting point defining a theoretical construct; we must move toward an operational instrument, and this article establishes accessible parameters for any specialist.

The study is straightforward, and its simplicity supports reproducibility, making implementation in daily practice entirely feasible. It does not require specific training programs or highly specialized personnel. This tool is aligned with multidisciplinary team decision-making. Albumin is a nutritional and systemic marker available from routine blood testing, while gait speed and grip strength can be measured rapidly during outpatient assessment.

From a more geriatric-oriented perspective, it is important to remember that frailty is a multidimensional syndrome. An approach focused exclusively on the physical domain may underestimate its true prevalence. One of the main limitations acknowledged by the authors is the absence of cognitive assessment: early or established cognitive impairment, its severity, behavioral disturbances, mood disorders, and sleep disorders are not evaluated. Finally, social assessment—another cornerstone of comprehensive geriatric evaluation—is not considered.

In summary, this study has important practical implications. It provides a useful and pragmatic tool for Heart Team discussions, helping to optimize and individualize therapeutic strategies, identify candidates for prehabilitation, and guide the selection of less invasive techniques according to clinical context. Identifying frailty should serve to improve the care pathway, not to exclude patients from potential treatment options.

REFERENCE:

Honda T, Ogawa M, Inuki H, Kubo N, Aritoshi T, Shiba M, et al. A simplified frailty assessment using three objective measures predicts mid-term outcomes after cardiac surgery. Gen Thorac Cardiovasc Surg. 2025; e-pub ahead of print. doi:10.1007/s11748-025-02233-z.