Evaluating the QUAD Score in Patients Aged ≥80 Years with Heart Failure with Reduced Ejection Fraction
Abstract
Introduction
Guideline-recommended medical therapy (GRMT) for heart failure with reduced ejection fraction (HFrEF) comprises four pillars, and their proactive implementation improves prognosis. The QUAD score promotes GRMT in HFrEF, but its applicability in older, frailer populations remains uncertain.
Methods
This retrospective observational study included patients ≥80 years with LVEF ≤40% who completed therapy titration between October 2023 – March 2025. Patients were identified from a Cardiology in Older People Service (COPS) and general cardiology clinics. Frailty markers (Clinical Frailty Scale, timed up-and-go) and clinical data were collected at baseline. QUAD scores were calculated at baseline and treatment end, defined as the date that medical optimisation was considered complete. Primary outcomes were all cause-mortality and hospitalisation for heart failure at one year. Secondary outcomes were time taken to final therapy titration and clinician-documented treatment exemptions.
Results
71 patients were included (mean age 85.2 years). At treatment completion, QUAD scores were excellent in 35%, good in 34% and poor in 31%. COPS patients were older and frailer (mean CFS 5.1 vs 4.5) and less likely to achieve excellent scores (31% vs 41%). Mean time to titration completion was 184 days. At one-year, all-cause mortality was 22.5%, and 31% had at least one heart failure hospitalisation. Mortality was highest in those with a good score. At treatment completion, 65% were not on all four GRMT pillars although only 35% had treatment exemptions. COPS patients had significantly more exemptions (46% vs 22%, χ² test, p=0.048; 95% CI 2.0 to 43.8).
Conclusion
Optimal GRMT remains challenging in frail older patients. As only a third had treatment exemptions, further optimisation is possible, and prospective QUAD score use may improve uptake. Unlike prior cohorts, mortality was highest with good rather than poor scores, suggesting non-cardiac causes may limit validity in this age group.
Comments
Query and supporting comment
Your study is really valuable and interesting
It relates to my own abstract submitted regarding studying both frailty (and other End of life risk prognostic indicator) prevalence in an adult Heart failure population- from a large 1.1 million sized ICS population.
I am making a note of your finding of Highest all cause mortality being with good Quad score
published research by Abel 1.Abel AAI, Samuel NA, Cuthbert JJ, Brown OI, Pellicori P, Kazmi S, Cleland JGF, Johnson MJ, Clark AL. Hospital admissions in the last year of life of patients with heart failure. Eur Heart J Qual Care Clin Outcomes. 2024 Mar 1;10(2):168-175.et al
clearly showed- most people living with heart failure- do not die of their heart failure itself. 84% of all deaths in their study were NON heart failure related- Similarly non heart failure related hospitalisations were far higher and far more common than those due to the HF itself. Non cardiac causes for admissions accounted for >71% of all hospitalisations- across all HF subtypes (much higher in HFpEF).
Non HF related admissions being even higher in those with severe Frailty- study Sze et all showing > 88% hospitalisations being non cardiac related. 1.Sze S, Pellicori P, Zhang J, Weston J, Squire IB, Clark AL. Effect of frailty on treatment, hospitalisation and death in patients with chronic heart failure. Clin Res Cardiol. 2021 Aug;110(8):1249-1258.
So this evidence in correlations your findings- seem to indicate- a strong case for NOT applying the QUAD score especially in moderate to severe frailty?. Where non HF related death is so much more likely? and hospitalisations are most likely to be driven by frailty severity (and far greater adverse drug event risks) ?
Especially given such limited evidence for GDMT in this group (who were mostly excluded from trials) Woodford H, Pollock L Appropriate management of heart failure in older people with frailty | The BMJ 2024;387:e078188