Clinical Frailty Scale can quickly predict mortality in patients with heart failure

Frailty is closely linked to adverse outcomes in older adults, particularly those with heart failure. Numerous epidemiologic studies show that frailty has important prognostic value in this population, underscoring the need for routine assessment. At the same time, the concept of frailty has expanded beyond the physical domain to include cognitive and other dimensions, making comprehensive evaluation increasingly complex and less feasible in everyday practice. The Clinical Frailty Scale (CFS) offers a practical alternative: a 9-point, bedside, visually assessed tool that can be completed in minutes. However, key questions remain-how closely this impression-based score reflects objective measures of physical and cognitive function, and whether CFS independently predicts mortality among patients hospitalized with heart failure.

Against this backdrop, the potential predictive value of CFS was studied by a research team led by Dr. Taisuke Nakade from the Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan, along with Dr. Yuya Matsue, also from the same university. The team involved collaborators from other institutions in Japan and the United States. Their findings were published online in The Journal of the American College of Cardiology on October 15, 2025.

Describing the motivation for this research, Dr. Nakade notes that, "Although conventional assessments-such as grip strength, gait speed, chair stand, the short physical performance battery, and the 6-minute walk test-have well-established prognostic value, they often require specialized equipment, time, and trained personnel, limiting their use in practical settings. Conversely, the CFS offers a rapid, visually assessed, bedside evaluation that requires no equipment or specialized training." If the predictive value of CFS for patients with heart failure is confirmed, it would help doctors to quickly identify which patients would need additional support and monitoring after discharge.

The researchers looked at anonymized patient information from the Japanese Registry of Acute Decompensated Heart Failure–Next (JROADHF-NEXT). This dataset drew from 87 hospitals across Japan, covered 3,905 patients. It included details of CFS scores, physical endurance data, cognitive performance scores, and patient follow-up for at least 2 years after being treated for heart failure.

Dr. Nakade and team found that, at discharge, the majority of patients had CFS scores of 4 or higher, indicating that most patients with heart failure were of pre-frail status or worse. More importantly, the 2-year mortality rate rose by 1.42 times for each additional point of a patient's CFS score. This meant that the risk of death within 2 years of treatment for a patient with heart failure having CFS greater than 7 was 6.59 times greater than that of someone with CFS of 2 or less.

Regarding other tests of physical and cognitive performance, the team found that there were moderate to strong correlations with CFS scores. "These associations remained significant and consistent after adjustment for age, sex, and additional clinical covariates, demonstrating that higher CFS scores were independently linked to both physical and cognitive impairment," says Dr. Nakade.

The team evaluated how well different models predicted 2-year all-cause mortality. Adding objective physical and cognitive test scores to a biomarker-based baseline model improved discrimination. Replacing those objective tests with the CFS score further enhanced performance, indicating that CFS provides robust, incremental prognostic value for risk assessment after heart failure hospitalization.

The implications of these findings are profound. CFS can be used to identify high-risk patients right from the point of admission, allowing doctors to prioritize them and provide tailored treatment that is well within the patient's tolerance. Similarly, extended care, rehabilitation, post-discharge monitoring, and quality tracking can also be modified to meet the patient's frailty status.

As Dr. Nakade concludes, "Ultimately, embedding CFS into routine workflows may help bridge the gap between prognostic insight and tangible improvements in patient outcomes."