This integrated review examines the bidirectional relationship between frailty and heart failure in older adults, highlighting how frailty independently predicts incident HF while HF accelerates frailty progression through inflammation, sarcopenia, and deconditioning. Frailty is strongly associated with higher mortality, reduced quality of life, and poorer tolerance of guideline-directed medical therapy, with the newly proposed Heart Failure Frailty Score (HFFS) offering a dedicated assessment tool. Clinically, routine frailty screening and targeted interventions—including exercise rehabilitation, nutritional support, and structured medication review—are essential to optimise outcomes in this vulnerable population.
Heart failure (HF) and frailty frequently coexist in older adults and are associated with poor clinical outcomes. Frailty affects 15-76% of patients with chronic HF depending on the clinical setting and assessment tool used, with prevalence approaching 90% in hospitalised patients with heart failure with preserved ejection fraction (HFpEF). This integrated review synthesises current evidence on the bidirectional relationship between frailty and HF, including shared pathophysiological mechanisms, epidemiology, prognostic implications, assessment strategies, and contemporary management approaches. Available evidence indicates that frailty independently predicts incident HF and is associated with progressive deterioration in cardiac structure and function. Conversely, HF accelerates frailty progression through systemic inflammation, skeletal muscle hypoperfusion, sarcopenia, neurohormonal activation, malnutrition, and hospital-associated deconditioning. Frailty contributes to impaired quality of life, reduced self-care capacity, prolonged hospitalisation, poorer tolerance of guideline-directed medical therapy, and higher all-cause mortality risk. Current assessment strategies include physical performance measures, multidimensional frailty instruments, and comprehensive geriatric assessment. The recently developed Heart Failure Frailty Score (HFFS) represents the first HF-specific multidimensional frailty instrument. Management strategies include exercise rehabilitation, nutritional optimisation, structured medication review, and integration of frailty assessment into advanced HF decision-making. Future research should prioritise prospective validation of HF-specific frailty tools and randomised trials evaluating frailty-targeted interventions in HF populations.
