Frailty and heart failure: Clinical impact, biomarkers, and phenotypic differences

Frailty is a multidimensional geriatric syndrome characterized by reduced physiologic reserve and increased vulnerability to stressors. Its prevalence is particularly high among patients with heart failure (HF), reflecting the interplay between aging, multimorbidity, and chronic cardiovascular disease. Frailty independently predicts poor outcomes, including higher hospitalization rates, mortality, and impaired quality of life. The Fried Frailty Phenotype defines frailty as the presence of three or more of the following five criteria: unintentional weight loss, exhaustion, weakness (grip strength), slow walking speed, and low physical activity. In this review, we explore the complex relationship between frailty and HF, with a focus on pathophysiology, clinical outcomes, biomarkers, and therapeutic considerations. We highlight differences across HF phenotypes-heart failure with reduced ejection fraction (HFrEF), preserved ejection fraction (HFpEF), and mildly reduced ejection fraction (HFmrEF)-underscoring the importance of tailored, phenotype-specific approaches. We also discuss emerging biomarkers including the stress hyperglycemia ratio (SHR) in HFpEF. Finally, we address limitations of current evidence and future directions for integrating frailty assessment into HF management.