Research Article|Articles in Press

Hand Grip Strength Predicts Mortality and Quality of Life in Heart Failure: Insights From the Singapore Cohort of Patients With Advanced Heart Failure

Published:December 13, 2022DOI:


      • Frailty is common in patients with heart failure and is associated with worse outcomes.
      • Grip strength is a simple, standardized way of measuring frailty.
      • Decreases in grip strength are associated with worse survival rates and quality of life.
      • Grip strength may help to select patients most likely to benefit from certain therapies.



      Frailty is prevalent among patients with heart failure (HF) and is associated with increased mortality rates and worse patient-centered outcomes. Hand grip strength (GS) has been proposed as a single-item marker of frailty and a potential screening tool to identify patients most likely to benefit from therapies that target frailty so as to improve quality of life (QoL) and clinical outcomes. We assessed the association of longitudinal decline in GS with all-cause mortality and QoL. Decline in GS is associated with increased risk of all-cause mortality and worse overall and domain-specific (physical, functional, emotional, social) QoL among patients with advanced HF.


      We used data from a prospective, observational cohort of patients with New York Heart Association class III or IV HF in Singapore. Patients’ overall and domain-specific QoL were assessed, and GS was measured every 4 months. We constructed a Kaplan-Meier plot with GS at baseline dichotomized into categories of weak (≤ 5th percentile) and normal (> 5th percentile) based on the GS in a healthy Singapore population of the same sex and age. Missing GS measurements were imputed using chained equations. We jointly modeled longitudinal GS measurements and survival time, adjusting for comorbidities. We used mixed effects models to evaluate the associations between GS and QoL.


      Among 251 patients (mean age 66.5 ± 12.0 years; 28.3% female), all-cause mortality occurred in 58 (23.1%) patients over a mean follow-up duration of 3.0 ± 1.3 years. Patients with weak GS had decreased survival rates compared to those with normal GS (log-rank P = 0.033). In the joint model of longitudinal GS and survival time, a decrease of 1 unit in GS was associated with a 12% increase in rate of mortality (hazard ratio: 1.12; 95% confidence interval: 1.05–1.20; P = < 0.001). Higher GS was associated with higher overall QoL (β (SE) = 0.36 (0.07); P = < 0.001) and higher domain-specific QoL, including physical (β [SE] = 0.13 [0.03]; P = < 0.001), functional (β [SE] = 0.12 [0.03]; P = < 0.001), and emotional QoL (β [SE] = 0.08 [0.02]; P = < 0.001). Higher GS was associated with higher social QoL, but this was not statistically significant (β [SE] = 0.04 [0.03]; P = 0.122).


      Among patients with advanced HF, longitudinal decline in GS was associated with worse survival rates and QoL. Further studies are needed to evaluate whether incorporating GS into patient selection for HF therapies leads to improved survival rates and patient-centered outcomes.

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        • Gerber Y
        • Weston SA
        • Redfield MM
        • Chamberlain AM
        • Manemann SM
        • Jiang R
        • et al.
        A contemporary appraisal of the heart failure epidemic in Olmsted County, Minnesota, 2000 to 2010.
        JAMA Intern Med. 2015; 175: 996-1004
        • Jha SR
        • Hannu MK
        • Chang S
        • Montgomery E
        • Harkess M
        • Wilhelm K
        • et al.
        The prevalence and prognostic significance of frailty in patients with advanced heart failure referred for heart transplantation.
        Transplantation. 2016; 100: 429-436
        • Dominguez-Rodriguez A
        • Abreu-Gonzalez P
        • Jimenez-Sosa A
        • Gonzalez J
        • Caballero-Estevez N
        • Martín-Casañas FV
        • et al.
        The impact of frailty in older patients with non-ischaemic cardiomyopathy after implantation of cardiac resynchronization therapy defibrillator.
        EP Europace. 2015; 17: 598-602
        • Vidán MT
        • Blaya-Novakova V
        • Sánchez E
        • Ortiz J
        • Serra-Rexach JA
        • Bueno H
        Prevalence and prognostic impact of frailty and its components in non-dependent elderly patients with heart failure.
        Eur J Heart Fail. 2016; 18: 869-875
        • Kitzman DW
        • Whellan DJ
        • Duncan P
        • Pastva AM
        • Mentz RJ
        • Reeves GR
        • et al.
        Physical rehabilitation for older patients hospitalized for heart failure.
        New Engl J Med. 2021; 385: 203-216
        • Yang X
        • Lupón J
        • Vidán MT
        • Ferguson C
        • Gastelurrutia P
        • Newton PJ
        • et al.
        Impact of frailty on mortality and hospitalization in chronic heart failure: a systematic review and meta‐analysis.
        J Am Heart Assoc. 2018; 7e008251
        • Pandey A
        • Kitzman D
        • Whellan DJ
        • Duncan PW
        • Mentz RJ
        • Pastva AM
        • et al.
        Frailty among older decompensated heart failure patients: prevalence, association with patient-centered outcomes, and efficient detection methods.
        JACC: Heart Fail. 2019; 7: 1079-1088
        • Chung CJ
        • Wu C
        • Jones M
        • Kato TS
        • Dam TT
        • Givens RC
        • et al.
        Reduced handgrip strength as a marker of frailty predicts clinical outcomes in patients with heart failure undergoing ventricular assist device placement.
        J Card Fail. 2014; 20: 310-315
        • Mudge AM
        • Pelecanos A
        • Adsett JA
        Frailty implications for exercise participation and outcomes in patients with heart failure.
        J Am Geriatr Soc. 2021; 69: 2476-2485
        • Flint KM
        • Matlock DD
        • Lindenfeld J
        • Allen LA
        Frailty and the selection of patients for destination therapy left ventricular assist device.
        Circulation: Heart Fail. 2012; 5: 286-293
        • Mehra MR
        • Canter CE
        • Hannan MM
        • Semigran MJ
        • Uber PA
        • Baran DA
        • et al.
        The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: a 10-year update.
        J Heart Lung Transplant. 2016; 35: 1-23
        • Fried LP
        • Tangen CM
        • Walston J
        • Newman AB
        • Hirsch C
        • Gottdiener J
        • et al.
        Frailty in older adults: evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Searle SD
        • Mitnitski A
        • Gahbauer EA
        • Gill TM
        • Rockwood K
        A standard procedure for creating a frailty index.
        BMC Geriatr. 2008; 8: 24
        • Leong DP
        • Teo KK
        • Rangarajan S
        • Lopez-Jaramillo P
        • Avezum A
        • Orlandini Jr, A
        • et al.
        Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study.
        Lancet. 2015; 386: 266-273
        • Fukumori N
        • Yamamoto Y
        • Takegami M
        • Yamazaki S
        • Onishi Y
        • Sekiguchi M
        • et al.
        Association between hand-grip strength and depressive symptoms: Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS).
        Age Ageing. 2015; 44: 592-598
        • Pavasini R
        • Serenelli M
        • Celis-Morales CA
        • Gray SR
        • Izawa KP
        • Watanabe S
        • et al.
        Grip strength predicts cardiac adverse events in patients with cardiac disorders: an individual patient pooled meta-analysis.
        Heart. 2019; 105: 834-841
        • Chang Y-T
        • Wu H-L
        • Guo H-R
        • Cheng Y-Y
        • Tseng C-C
        • Wang M-C
        • et al.
        Handgrip strength is an independent predictor of renal outcomes in patients with chronic kidney diseases.
        Nephrol Dial Transplant. 2011; 26: 3588-3595
        • Izawa KP
        • Watanabe S
        • Osada N
        • Kasahara Y
        • Yokoyama H
        • Hiraki K
        • et al.
        Handgrip strength as a predictor of prognosis in Japanese patients with congestive heart failure.
        Eur J Cardiovasc Prev Rehabil. 2009; 16: 21-27
        • Joyce E
        • Howell EH
        • Senapati A
        • Starling RC
        • Gorodeski EZ
        Prospective assessment of combined handgrip strength and Mini-Cog identifies hospitalized heart failure patients at increased post-hospitalization risk.
        ESC Heart Fail. 2018; 5: 948-952
        • Malhotra C
        • Foo R
        • Singh R
        • Ozdemir S
        • Teo I
        • Sim D
        • et al.
        Study protocol for a cohort study of patients with advanced heart failure in Singapore.
        BMJ Open. 2018; 8e022248
        • Rogers JG
        • Patel CB
        • Mentz RJ
        • Granger BB
        • Steinhauser KE
        • Fiuzat M
        • et al.
        Palliative care in heart failure: the PAL-HF Randomized, Controlled Clinical Trial.
        J Am Coll Cardiol. 2017; 70: 331-341
        • Becher MU
        • Balata M
        • Hesse M
        • Draht F
        • Zachoval C
        • Weltermann B
        • et al.
        Rationale and design of the EPCHF trial: the early palliative care in heart failure trial (EPCHF).
        Clin Res Cardiol. 2022; 111: 359-367
        • Cella DF
        • Tulsky DS
        • Gray G
        • Sarafian B
        • Linn E
        • Bonomi A
        • et al.
        The Functional Assessment of Cancer Therapy scale: development and validation of the general measure.
        J Clin Oncol. 1993; 11: 570-579
        • Papageorgiou G
        • Mauff K
        • Tomer A
        • Rizopoulos D
        An overview of joint modeling of time-to-event and longitudinal outcomes.
        Ann Rev Statis Applic. 2019; 6: 223-240
        • Rizopoulos D
        Joint models for longitudinal and time-to-event data: With applications in R.
        CRC press, Danvers, MA2012
        • van Buuren S
        • Groothuis-Oudshoorn K
        MICE: Multivariate Imputation by Chained Equations in R.
        J Statist Softw. 2011; 45: 1-67
        • Purser JL
        • Kuchibhatla MN
        • Fillenbaum GG
        • Harding T
        • Peterson ED
        • Alexander KP
        Identifying frailty in hospitalized older adults with significant coronary artery disease.
        J Am Geriatr Soc. 2006; 54: 1674-1681
        • Maurer MS
        • Horn E
        • Reyentovich A
        • Dickson W
        • Pinney S
        • Goldwater D
        • et al.
        Can a left ventricular assist device in individuals with advanced systolic heart failure improve or reverse frailty?.
        J Am Geriatr Soc. 2017; 65: 2383-2390
        • Rutledge T
        • Reis VA
        • Linke SE
        • Greenberg BH
        • Mills PJ
        Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes.
        J Am Coll Cardiol. 2006; 48: 1527-1537

      Linked Article

      • Quantifying the eyeball test: grip strength at the nexus of frailty, cachexia and sarcopenia in heart failure
        Journal of Cardiac Failure
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          I know it when I see it...” – This famous phrase, written by Supreme Court Justice Potter Stewart in his concurrence to the majority decision in Jacobellis vs. Ohio in 1964, has a well-known parallel in clinical medicine: the “eyeball” test. Perhaps nowhere in cardiovascular medicine is the eyeball test more widely applied than in the assessment of frailty, a clinical entity marked by changes in physiologic and cognitive function that leaves an individual more susceptible to adverse outcomes in response to stress.
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