In Tolstoy’s novel The Death of Ivan Ilyich, the protagonist, a robust individual and a highranking judge, sustains a fall while hanging curtains. This initially trivial injury begins a slow decline in his physical function accompanied by emotional despair. He starts dragging his feet and avoids going up the stairs. He complains of persistent and inexplicable pain in his sides and subsequently is unable to carry his bags. Progressive deterioration in his functional status ensues, culminating in a state of dependence. This functional decline in turn leads to social isolation. Cardiologists commonly encounter but overlook a similar scenario in day-to-day practice. In their zeal to address the cardiovascular issues at hand, they often fail to consider and even neglect the readily apparent signs of physical and cognitive decline in their patients. Although Tolstoy’s masterful description of slow decline in physical function that leads to mortality dates back to 1886, physicians recognize this process today as physical frailty. Despite many years of research into this decline in multiple physiological systems, our mechanistic understanding of frailty remains elusive and underdefined, inconsistently measured, and only rarely integrated in clinical practice.[1]
In this issue of JACC, Nakade et al[2] provide new data from the J ROAD HF-NEXT registry, which is a large, prospective cohort study (n = 3,905) of patients with acute decompensated heart failure in Japan. The investigators evaluated the Clinical Frailty Scale (CFS), which is a 9-point visual assessment tool to measure the frailty status of an older patient. In the present study, CFS score was strongly associated with impairments in strength, gait speed, and cognitive functioning. It also predicted 2-year mortality independent of the standard risk models. The analysis is elegantly executed and appropriately concludes that frailty status should be quantified and documented in patients with heart failure because it predicts underlying physical and cognitive decline and is an independent predictor of 2-year mortality.
The study has some key strengths. The investigators used a structured approach with a standardized training protocol and face-to-face assessment prior to discharge. More important, physical function was also assessed using objectively validated instruments including grip strength, gait speed, chair stand, and the 6-minute walk test. Domains reflecting cognitive function were assessed using the Mini-Cog. Higher CFS scores were associated with worse declines in physical and cognitive functioning, and that association followed a doseresponse pattern. Even compared with other formal instruments, the CFS can potentially provide clinically actionable information to improve discrimination for mortality risk. It affirms that in the current era of precision medicine, artificial intelligence, and advances in multidomain biomarkers, a face-to-face bedside assessment of physical function provides a powerful prognostic tool for patients living with heart failure.
Despite the usefulness of CFS as a bedside tool, it is still not a standardized and universal instrument to diagnose frailty. Unlike other instruments, such as the Fried phenotype or the Rockwood frailty index, the CFS is mostly subjective in its assessment.[3] It relies on clinician judgment, descriptive narratives from patients and caregivers, and visual cues. Despite its simplicity, the CFS is prone to interoperator variability and lacks discrimination at extreme values. For example, consider 2 patients, both of whom are 82 years of age, who live alone, and ambulate independently but slowly. One uses a cane while ambulating indoors and prepares simple meals, and the other climbs stairs daily and still drives locally. Depending on the clinician who completes the assessment, both could receive a CFS score of 4 (ie, vulnerable) or 5 (ie, mild frailty), despite meaningful differences in mobility, independence, and physiological reserves. By the same token, patients who are bedbound with dementia may also be clustered with CFS scores of 8 or 9, regardless of the presence or absence of multimorbidity or physical disability. This ceiling effect limits the ability of the instrument to calibrate risk. The study does not report reliability and reproducibility testing across sites, affecting broader adoption.
The use of the Mini-Cog to assess cognitive functioning is clinically useful but comes with drawbacks.[1,4] The Mini-Cog screens for severe cognitive deficits but fails to capture important domains such as executive functioning, working memory, and processing speed. These factors further influence cardiovascular disease management and results in higher incidence of readmission, adherence, and participation in cardiac rehabilitation. Although the routine integration of the Mini-Cog into cardiovascular assessments may provide clinical value, a more in-depth cognitive battery of tests should be evaluated in the context of physical frailty in heart failure patients.[4] Practical barriers hinder the implementation of formal physical and cognitive function evaluations into the cardiology workflow.[1,4] Partnering with geriatricians on cardiovascular teams may partially address these challenges.[5]
Importantly, patients with higher CFS scores received less guideline-directed medical therapy, invasive procedures, and referrals for specialized care. The many models presented in this work reflect that frailty predicts mortality independent of these complexities. But these data also highlights the problem of “therapeutic nihilism” that is associated with advanced physical dysfunction.[6] When evaluating the higher mortality rate in heart failure patients with advanced frailty, the question arises frequently: are frail patients dying more often because they are frail or because they are undertreated? National cardiovascular societies must address this issue in clinical guideline documents and position statements, with a focus on older adults with advanced geriatric syndromes, including frailty and cognitive decline.
Finally, the study by Nakade et al[2] was based in Japan, with a homogeneous culture and health care practices. The CFS was developed in a Canadian cohort, and established thresholds may not be fully generalizable. More than 75% of patients had CFS scores ≥4, reflecting high prevalence and risk for clustering and floor and ceiling effects. When most patients are labeled as frail or prefrail, meaningful stratification becomes difficult.
Despite these limitations, the investigators should be commended for this well-done study that confirms the CFS as a practical, scalable, and informative instrument for clinical practice. The deeper issue about frailty remains: the field still lacks a uniform, societyendorsed definition of frailty. Frailty is a biological and physical phenotype that is different from chronological age alone, multimorbidity, or disability.[7] But in cardiovascular medicine, we still have loose definitions of frailty and its domains. Further screening and diagnostic instruments to capture frailty are not unified for clinical practice or cardiovascular trial networks. Taken together, frailty is inconsistently assessed and rarely documented or included in risk assessment models for hospital performance. Professional societies must jointly embrace a core definition of frailty for cardiovascular care and clinical practice.[8] This definition should encompass physical performance, cognitive status, and functional reserve.[1] In some ways, the specific instrument or measure selected is less important than having a standardized approach to screening and diagnosis. Once we achieve this standard definition, it should trigger key clinical care pathways: early rehabilitation, deprescribing, advanced care planning, and risk-guided drug and device prescription.[9] We have enough observational studies illustrating the association between frailty and adverse cardiovascular outcomes. A coordinated strategy to diagnose and manage patients with frailty is the necessary next step. It is time for cardiovascular societies to take action. Until then, we will continue to observe what Tolstoy described: the gradual decline of physical function, misinterpreted by clinicians and invisible to health care systems.
J Am Coll Cardiol. 2026;87(1):33–35 © 2026 American College of Cardiology Foundation
Cite this: Frailty in Cardiovascular Disease - Medscape - Feb 13, 2026.
