From Prognostic Marker to Actionable Care Pathway: Implementing Frailty Assessment in Cardiovascular Care for Older Adults

Abstract

Frailty is common among older adults receiving cardiovascular care and is consistently associated with death, disability, prolonged hospitalisation, readmission and poor recovery after acute illness or intervention. Yet routine assessment remains uneven, and the transition from measuring vulnerability to changing care is poorly specified. This critical narrative review examines how frailty assessment can be implemented as a clinically actionable component of cardiovascular practice rather than as an isolated prognostic label. Literature published from 1994 to 31 May 2026 was identified through live searches of accessible scholarly indexes and verification resources, with emphasis on validated frailty constructs, cardiovascular cohorts, implementation studies, clinical trials and professional guidance. The evidence is strongest for prognostic discrimination in cardiac surgery, transcatheter valve intervention, acute coronary syndromes, heart failure and atrial fibrillation. It is weaker for demonstrating that screening alone improves patient-centred outcomes. Tool performance varies because physical phenotype, deficit accumulation, clinical judgement and multidomain instruments measure related but non-identical constructs; disease severity and acute decompensation can also distort scores. Implementation therefore requires explicit matching of the instrument to the decision, a two-stage pathway from brief case finding to targeted multidomain assessment, and predefined responses involving medication review, rehabilitation, nutrition, cognition, function, goals of care and transition planning. Barriers include time pressure, uncertainty about ownership, training deficits, electronic-record friction, lack of downstream services and concern that frailty labels may be used to deny treatment. Evidence from rehabilitation and contemporary coronary trials shows that frailty should inform treatment selection and supportive care, not serve as a categorical exclusion criterion. A minimum implementation standard should document baseline status, assessor, instrument, timing, limitations, linked actions and reassessment. Future research must prioritise pragmatic cluster trials, treatment-effect heterogeneity, equitable validation, longitudinal trajectories and implementation outcomes that connect assessment to decisions and functional recovery.