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Moras E, Zaid S, Gandhi K, Barman N, Birnbaum Y, Virani SS, Tamis-Holland J, Jneid H, Krittanawong C. Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population. Curr Atheroscler Rep 2024; 26:231-248. [PMID: 38722473 DOI: 10.1007/s11883-024-01203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE OF REVIEW To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population. RECENT FINDINGS Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.
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Affiliation(s)
- Errol Moras
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Syed Zaid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Kruti Gandhi
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nitin Barman
- Cardiac Catheterization Laboratory, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Yochai Birnbaum
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX, USA
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Van Nguyen T, Nguyen HTK, Wong WJ, Ahmad F, Nguyen TN. The prescription of beta-blockers in older patients with heart failure with reduced ejection fraction: an observational study in Vietnam. Sci Rep 2024; 14:12923. [PMID: 38839862 PMCID: PMC11153617 DOI: 10.1038/s41598-024-63479-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 05/29/2024] [Indexed: 06/07/2024] Open
Abstract
This study in older hospitalized patients with heart failure with reduced ejection fraction (HFrEF) aimed to examine the prevalence of beta-blocker prescription and its associated factors. A total of 190 participants were recruited from July 2019 to July 2020. The inclusion criteria included: (1) aged ≥ 60 years, (2) having a diagnosis of chronic HFrEF in the medical records, (3) hospitalized for at least 48 h. The participants had a mean age of 75.5 ± 9.1, and 46.8% were female. Of these, 55.3% were prescribed beta-blockers during admission. To explore the factors associated with beta-blocker prescription, multivariable logistic regression analysis was applied and the results were presented as odds ratios (OR) and 95% confidence intervals (CI). On multivariate logistic regression models, higher NYHA classes (OR 0.49, 95%CI 0.26-0.94), chronic obstructive pulmonary disease (OR 0.17, 95% CI 0.04-0.85), chronic kidney disease (OR 0.40, 95% CI 0.19-0.83), and heart rate under 65 (OR 0.34, 95% CI 0.12-0.98) were associated with a reduced likelihood of prescription. In this study, we found a low rate of beta-blocker prescriptions, with only around half of the participants being prescribed beta-blockers. Further studies are needed to examine the reasons for the under-prescription of beta-blockers, and to evaluate the long-term benefits of beta-blockers in elderly patients with HFrEF in this population.
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Affiliation(s)
- Tan Van Nguyen
- Department of Geriatrics and Gerontology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
- Department of Interventional Cardiology, Thong Nhat Hospital, Ho Chi Minh City, Vietnam.
| | - Hoa T K Nguyen
- Department of Geriatrics and Gerontology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Wei Jin Wong
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Fahed Ahmad
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Tu Ngoc Nguyen
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
- The George Institute of Global Health, UNSW, Sydney, Australia.
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Parrini I, Lucà F, Rao CM, Cacciatore S, Riccio C, Grimaldi M, Gulizia MM, Oliva F, Andreotti F. How to Manage Beta-Blockade in Older Heart Failure Patients: A Scoping Review. J Clin Med 2024; 13:2119. [PMID: 38610883 PMCID: PMC11012494 DOI: 10.3390/jcm13072119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/22/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Beta blockers (BBs) play a crucial role in enhancing the quality of life and extending the survival of patients with heart failure and reduced ejection fraction (HFrEF). Initiating the therapy at low doses and gradually titrating the dose upwards is recommended to ensure therapeutic efficacy while mitigating potential adverse effects. Vigilant monitoring for signs of drug intolerance is necessary, with dose adjustments as required. The management of older HF patients requires a case-centered approach, taking into account individual comorbidities, functional status, and frailty. Older adults, however, are often underrepresented in randomized clinical trials, leading to some uncertainty in management strategies as patients with HF in clinical practice are older than those enrolled in trials. The present article performs a scoping review of the past 25 years of published literature on BBs in older HF patients, focusing on age, outcomes, and tolerability. Twelve studies (eight randomized-controlled and four observational) encompassing 26,426 patients were reviewed. The results indicate that BBs represent a viable treatment for older HFrEF patients, offering benefits in symptom management, cardiac function, and overall outcomes. Their role in HF with preserved EF, however, remains uncertain. Further research is warranted to refine treatment strategies and address specific aspects in older adults, including proper dosing, therapeutic adherence, and tolerability.
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Affiliation(s)
- Iris Parrini
- Department of Cardiology, Mauriziano Hospital, Largo Filippo Turati, 62, 10128 Turin, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Via Melacrino 1, 89124 Reggio Calabria, Italy;
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Via Melacrino 1, 89124 Reggio Calabria, Italy;
| | - Stefano Cacciatore
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, Via Ferdinando Palasciano, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | | | - Fabrizio Oliva
- “A. De Gasperis” Cardiovascular Department, Division of Cardiology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy;
| | - Felicita Andreotti
- Cardiovascular and Respiratory Sciences, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy;
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Zeitler EP, Joly J, Leggett CG, Wong SL, O’Malley AJ, Kraft SA, Mackwood MB, Jones ST, Skinner JS. The role of comorbidities, medications, and social determinants of health in understanding urban-rural outcome differences among patients with heart failure. J Rural Health 2024; 40:386-393. [PMID: 37867249 PMCID: PMC10954420 DOI: 10.1111/jrh.12803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/18/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE There is now a 20% disparity in all-cause, excess deaths between urban and rural areas, much of which is driven by disparities in cardiovascular death. We sought to explain the sources of these disparities for Medicare beneficiaries with heart failure with reduced ejection fraction (HFrEF). METHODS Using a sample of Medicare Parts A, B, and D, we created a cohort of 389,528 fee-for-service beneficiaries with at least 1 heart failure hospitalization from 2008 to 2017. The primary outcome was 30-day mortality after discharge; 1-year mortality, readmissions, and return emergency room (ER) admissions were secondary outcomes. We used hierarchical, logistic regression modeling to determine the contribution of comorbidities, guideline-directed medical therapy (GDMT), and social determinants of health (SDOH) to outcomes. RESULTS Thirty-day mortality rates after hospital discharge were 6.3% in rural areas compared to 5.7% in urban regions (P < .001); after adjusting for patient health and GDMT receipt, the 30-day mortality odds ratio for rural residence was 1.201 (95% CI 1.164-1.239). Adding the SDOH measure reduced the odds ratio somewhat (1.140, 95% CI 1.103-1.178) but a gap remained. Readmission rates in rural areas were consistently lower for all model specifications, while ER admissions were consistently higher. CONCLUSIONS Among patients with HFrEF, living in a rural area is associated with an increased risk of death and return ER visits within 30 days of discharge from HF hospitalization. Differences in SDOH appear to partially explain mortality differences but the remaining gap may be the consequence of rural-urban differences in HF treatment.
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Affiliation(s)
- Emily P. Zeitler
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Joanna Joly
- University of Alabama at Birmingham, Division of Cardiovascular Disease, Birmingham, AL
| | | | - Sandra L. Wong
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Medical Center, Department of Surgery, Lebanon, NH
| | - A. James O’Malley
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Sally A. Kraft
- Dartmouth-Hitchcock Medical Center, Center for Population Health, Lebanon, NH
| | - Matthew B. Mackwood
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Medical Center, Department of General Internal Medicine, Lebanon, NH
| | - Sarah T. Jones
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Jonathan S. Skinner
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth College, Department of Economics, Hanover, NH
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Abramsson L, Backman A, Lövheim H, Edvardsson D, Gustafsson M. Use of heart failure medications in older individuals and associations with cognitive impairment. BMC Geriatr 2023; 23:524. [PMID: 37644427 PMCID: PMC10463854 DOI: 10.1186/s12877-023-04223-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND To achieve the best treatment of heart failure, it is important to use all recommended drugs at their target doses. Given that underuse of medications can occur in individuals with cognitive impairment, we investigated the filled prescriptions and target doses of heart failure medication for older individuals with and without cognitive impairment as well as associated factors. METHODS The study was based on two separate datasets. The first dataset, which was based on data from questionnaires sent to nursing homes in Sweden, included 405 individuals with heart failure. The data were linked with the Swedish Prescribed Drug Register and the National Patient Register to obtain information regarding filled prescriptions of heart failure medications and heart failure diagnoses among the population. In the second dataset, medical records of individuals aged 75 years or older admitted to a hospital in northern Sweden were reviewed and individuals with heart failure were identified. Target doses of heart failure medications were evaluated in 66 individuals who lived at home. RESULTS Filled prescriptions of mineralocorticoid receptor antagonists and loop diuretics were significantly more common in individuals without cognitive impairment (OR 1.087; 95% CI 1.026-1.152, p < 0.05) and (OR 1.057; 95% CI 1.017-1.098, p < 0.05), respectively. There were no significant differences between individuals with and without cognitive impairment in terms of achieving target doses for any of the drug classes. A higher age was associated with fewer filled prescriptions and less ability to reach the target doses of beta blockers (OR 0.950; 95% CI 0.918-0.984, p < 0.05) and (OR 0.781; 95% CI 0.645-0.946, p < 0.05), respectively. CONCLUSIONS Our results suggest that individuals with cognitive impairment are partly undertreated for heart failure in that they had fewer filled prescriptions of important heart medications. Separately, the relatively low proportion of older individuals reaching target doses is an important observation and indicates that treatment of heart failure could be further optimised among older individuals.
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Affiliation(s)
- Linnea Abramsson
- Department of Integrative Medical Biology, Umeå University, Umeå, 901 87, Sweden
| | - Annica Backman
- Department of Nursing, Umeå University, Umeå, 901 87, Sweden
| | - Hugo Lövheim
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
- Wallenberg Center for Molecular Medicine, Umeå, Sweden
| | - David Edvardsson
- School of Nursing and Midwifery, La Trobe University, Bundoora, Vic, 3084, Australia
| | - Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, Umeå, 901 87, Sweden.
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Saleem S, Khandoker AH, Alkhodari M, Hadjileontiadis LJ, Jelinek HF. Investigating the effects of beta-blockers on circadian heart rhythm using heart rate variability in ischemic heart disease with preserved ejection fraction. Sci Rep 2023; 13:5828. [PMID: 37037871 PMCID: PMC10086029 DOI: 10.1038/s41598-023-32963-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/05/2023] [Indexed: 04/12/2023] Open
Abstract
Heart failure is characterized by sympathetic activation and parasympathetic withdrawal leading to an abnormal autonomic modulation. Beta-blockers (BB) inhibit overstimulation of the sympathetic system and are indicated in heart failure patients with reduced ejection fraction. However, the effect of beta-blocker therapy on heart failure with preserved ejection fraction (HFpEF) is unclear. ECGs of 73 patients with HFpEF > 55% were recruited. There were 56 patients in the BB group and 17 patients in the without BB (NBB) group. The HRV analysis was performed for the 24-h period using a window size of 1,4 and 8-h. HRV measures between day and night for both the groups were also compared. Percentage change in the BB group relative to the NBB group was used as a measure of difference. RMSSD (13.27%), pNN50 (2.44%), HF power (44.25%) and LF power (13.53%) showed an increase in the BB group relative to the NBB group during the day and were statistically significant between the two groups for periods associated with high cardiac risk during the morning hours. LF:HF ratio showed a decrease of 3.59% during the day. The relative increase in vagal modulated RMSSD, pNN50 and HF power with a decrease in LF:HF ratio show an improvement in the parasympathetic tone and an overall decreased risk of a cardiac event especially during the morning hours that is characterized by a sympathetic surge.
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Affiliation(s)
- Shiza Saleem
- Department of Biomedical Engineering, Khalifa University, 127788, Abu Dhabi, United Arab Emirates.
| | - Ahsan H Khandoker
- Department of Biomedical Engineering, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
| | - Mohanad Alkhodari
- Healthcare Engineering Innovation Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Leontios J Hadjileontiadis
- Department of Biomedical Engineering, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
| | - Herbert F Jelinek
- Department of Biomedical Engineering, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Biotechnology Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
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7
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Gilstrap L, Solomon N, Chiswell K, James O'Malley A, Skinner JS, Fonarow GC, Bhatt DL, Yancy CW, Devore AD. The Association Between Beta-blocker and Renin-Angiotensin System Inhibitor Use After Heart Failure With Reduced Ejection Fraction Hospitalization and Outcomes in Older Patients. J Card Fail 2023; 29:434-444. [PMID: 36516937 PMCID: PMC10798429 DOI: 10.1016/j.cardfail.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Beta-blockers (BB) and renin-angiotensin system inhibitors (RASi) are foundational for the treatment of heart failure with reduced ejection fraction (HFrEF). However, given the increased risk of side effects in older patients, uncertainty remains as to whether, on net, older patients benefit as much as the younger patients studied in trials. METHODS AND RESULTS Using the Get With The Guidelines-Heart Failure registry linked with Medicare data, overlap propensity weighted Cox proportional hazard models were used to examine the association between BB and RASi use at hospital discharge and 30-day and 1-year outcomes among patients with HFrEF. Among the 48,711 patients (aged ≥65 years) hospitalized with HFrEF, there were significant associations between BB and/or RASi use at discharge and lower rates of 30-day and 1-year mortality, including those over age 85 (30-day hazard ratio 0.56, 95% confidence interval 0.45-0.70; 1-year hazard ratio 0.69, 95% confidence interval 0.61-0.78). In addition, the magnitude of benefit associated with BB and/or RASi use after discharge did not decrease with advancing age. Even among the oldest patients, those over age 85, with hypotension, renal insufficiency or frailty, BB and/or RASi use at discharge was still associated with lower 1-year mortality or readmission. CONCLUSIONS Among older patients hospitalized with HFrEF, BB and/or RASi use at discharge is associated with lower rates of 30-day and 1-year mortality across all age groups and the magnitude of this benefit does not seem to decrease with advancing age. These data suggest that, absent a clinical contraindication, BB and RASi should be considered in all patients hospitalized with HFrEF before or at hospital discharge, regardless of age.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Nicole Solomon
- Duke University Clinical Research Institute, Durham, North Carolina
| | - Karen Chiswell
- Duke University Clinical Research Institute, Durham, North Carolina
| | - A James O'Malley
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jonathan S Skinner
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Gregg C Fonarow
- University of California Los Angles, Division of Cardiology, Los Angeles, California
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Division of Cardiovascular Medicine, Boston, Massachusetts
| | - Clyde W Yancy
- Northwestern University, Division of Cardiology, Chicago, Illinois
| | - Adam D Devore
- Duke University Clinical Research Institute, Durham, North Carolina.
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Goyal P, Zullo AR, Gladders B, Onyebeke C, Kwak MJ, Allen LA, Levitan EB, Safford MM, Gilstrap L. Real-world safety of neurohormonal antagonist initiation among older adults following a heart failure hospitalization. ESC Heart Fail 2023; 10:1623-1634. [PMID: 36807850 DOI: 10.1002/ehf2.14317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023] Open
Abstract
AIMS To optimize guideline-directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established. METHODS AND RESULTS We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008-2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time-varying exposure) and all-cause mortality, all-cause rehospitalization, and fall-related adverse events over the 90 day period following hospitalization. We calculated inverse probability-weighted hazard ratios (IPW-HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW-HRs for mortality were 0.80 [95% CI (0.78-0.83)] for 1 NHA, 0.70 [95% CI (0.66-0.75)] for 2, and 0.94 [95% CI (0.83-1.06)] for 3. The IPW-HRs for readmission were 0.95 [95% CI (0.93-0.96)] for 1 NHA, 0.89 [95% CI (0.86-0.91)] for 2, and 0.96 [95% CI (0.90-1.02)] for 3. The IPW-HRs for fall-related adverse events were 1.13 [95% CI (1.10-1.15)] for 1 NHA, 1.25 [95% CI (1.21-1.30)] for 2, and 1.64 [95% CI (1.54-1.76)] for 3. CONCLUSIONS Initiating 1-2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall-related adverse events.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, RI, USA
| | - Barbara Gladders
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Chukwuma Onyebeke
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Min Ji Kwak
- Department of Internal Medicine, McGovern Medical School, Houston, TX, USA
| | - Larry A Allen
- Division of Cardiology, University of Colorado Schools of Medicine, Aurora, CO, USA
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Lauren Gilstrap
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH, USA
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Zeitler EP, Austin AM, Leggett CG, Gilstrap LG, Friedman DJ, Skinner JS, Al-Khatib SM. Complications and Mortality Following CRT-D Versus ICD Implants in Older Medicare Beneficiaries With Heart Failure. JACC. HEART FAILURE 2022; 10:147-157. [PMID: 35241242 DOI: 10.1016/j.jchf.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study sought to assess the comparative effectiveness of cardiac resynchronization therapy with defibrillator (CRT-D) over implantable cardioverter-defibrillator (ICD) alone in older Medicare patients with heart failure with reduced ejection fraction (HFrEF). BACKGROUND Despite growing numbers of older patients with HFrEF, the benefits of cardiac resynchronization therapy (CRT) in this group are largely unknown. METHODS A cohort of fee-for-service Medicare beneficiaries ≥65 years of age with HFrEF and enrolled in Medicare Part D who underwent CRT-D or ICD implantation from January 2008 to August 2015 was identified. Beneficiaries were divided by age (65-74, 75-84, and 85+ years), and outcomes were compared between the CRT-D and ICD groups after inverse probability weighting. RESULTS Compared with the ICD group, the CRT-D group was older and more likely to be White, be female, and have left bundle branch block. After weighting, overall complications were high across age and device groups (14%-20%). The 1-year mortality was high across all groups. In the 2 oldest age strata, the hazard of death was lower in the CRT-D group (HR: 0.90; 95% CI: 0.86-0.95 and HR: 0.81; 95% CI: 0.72-0.90, respectively; P < 0.001); the hazard of heart failure hospitalization was lower for CRT-D vs ICD in the 85+ years age group (HR: 0.82; 95% CI: 0.74-0.92; P < 0.001). CONCLUSIONS In older Medicare beneficiaries undergoing ICD with or without CRT, complications and 1-year mortality were high. Compared with ICD alone, CRT-D was associated with a lower hazard of mortality in patients ≥74 years of age and lower hazard of HF hospitalization in those ≥85 years of age. These findings support the use of CRT in eligible older patients undergoing ICD implantation.
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Affiliation(s)
- Emily P Zeitler
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Christopher G Leggett
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Lauren G Gilstrap
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Daniel J Friedman
- Duke University Medical Center and Duke Clinical Research Institute, Durham North Carolina, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Sana M Al-Khatib
- Duke University Medical Center and Duke Clinical Research Institute, Durham North Carolina, USA
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10
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Wang Z, Chen X, Wu Y, Jiang W, Yang L, Wang H, Liu S, Liu Y. Admission Resting Heart Rate as an Independent Predictor of All-Cause Mortality in Elderly Patients with Hip Fracture. Int J Gen Med 2021; 14:7699-7706. [PMID: 34764683 PMCID: PMC8575447 DOI: 10.2147/ijgm.s333971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/27/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose To investigate the relationship between admission resting heart rate (RHR) and all-cause mortality in elderly patients with hip fracture. Methods A retrospective cohort study with 837 patients based on the established hip fracture database was conducted. Admission RHR was measured via electrocardiogram, and patients were grouped by the median RHR value (beats per minute, bpm). The main outcomes were 1-year and total all-cause mortality. Cox proportional hazard models and restricted cubic spline were used to assess the relationship between RHR and mortality. Sensitivity analyses were further performed to determine whether the results were stable. Results The mean and median RHR were 82.3 and 80.0 bpm, respectively. After a median follow-up of 31.8 months, the 1-year and total all-cause mortality were 17.6% and 31.2%. Multivariable Cox analyses showed that high RHR was an independent risk factor for 1-year mortality (HR = 1.51; 95% CI: 1.08–2.13; p = 0.016), and total mortality (HR = 1.44; 95% CI: 1.12–1.85; p = 0.005). For each 10 bpm increase in RHR, the risk of 1-year death increased by 23.0% (HR = 1.23; 95% CI: 1.09–1.39; p = 0.001), and total death increased by 21.0% (HR = 1.21; 95% CI: 1.09–1.34; p < 0.001). A typical J-shaped curve was observed in the restricted cubic spline for the association between RHR and 1-year mortality, with the lowest mortality risk at 70 bpm. Sensitivity analyses yielded similar findings. Conclusion An increase in RHR was independently associated with all-cause mortality, and may be a useful prognostic predictor for elderly patients with hip fracture.
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Affiliation(s)
- Zhicong Wang
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Xi Chen
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Yuxuan Wu
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Wei Jiang
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Ling Yang
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Hong Wang
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Shuping Liu
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Yuehong Liu
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
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Gao S, Yin G, Xia Q, Wu G, Zhu J, Lu N, Yan J, Tan X. Development and Validation of a Nomogram to Predict the 180-Day Readmission Risk for Chronic Heart Failure: A Multicenter Prospective Study. Front Cardiovasc Med 2021; 8:731730. [PMID: 34557533 PMCID: PMC8452908 DOI: 10.3389/fcvm.2021.731730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/09/2021] [Indexed: 02/05/2023] Open
Abstract
Background: The existing prediction models lack the generalized applicability for chronic heart failure (CHF) readmission. We aimed to develop and validate a widely applicable nomogram for the prediction of 180-day readmission to the patients. Methods: We prospectively enrolled 2,980 consecutive patients with CHF from two hospitals. A nomogram was created to predict 180-day readmission based on the selected variables. The patients were divided into three datasets for development, internal validation, and external validation (mean age: 74.2 ± 14.1, 73.8 ± 14.2, and 71.0 ± 11.7 years, respectively; sex: 50.2, 48.8, and 55.2% male, respectively). At baseline, 102 variables were submitted to the least absolute shrinkage and selection operator (Lasso) regression algorithm for variable selection. The selected variables were processed by the multivariable Cox proportional hazards regression modeling combined with univariate analysis and stepwise regression. The model was evaluated by the concordance index (C-index) and calibration plot. Finally, the nomogram was provided to visualize the results. The improvement in the regression model was calculated by the net reclassification index (NRI) (with tenfold cross-validation and 200 bootstraps). Results: Among the selected 2,980 patients, 1,696 (56.9%) were readmitted within 180 days, and 1,502 (50.4%) were men. A nomogram was established by the results of Lasso regression, univariate analysis, stepwise regression and multivariate Cox regression, as well as variables with clinical significance. The values of the C-index were 0.75 [95% confidence interval (CI): 0.72-0.79], 0.75 [95% CI: 0.69-0.81], and 0.73 [95% CI: 0.64-0.83] for the development, internal validation, and external validation datasets, respectively. Calibration plots were provided for both the internal and external validation sets. Five variables including history of acute heart failure, emergency department visit, age, blood urea nitrogen level, and beta blocker usage were considered in the final prediction model. When adding variables involving hospital discharge way, alcohol taken and left bundle branch block, the calculated values of NRI demonstrated no significant improvements. Conclusions: A nomogram for the prediction of 180-day readmission of patients with CHF was developed and validated based on five variables. The proposed methodology can improve the accurate prediction of patient readmission and have the wide applications for CHF.
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Affiliation(s)
- Shanshan Gao
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College (SUMC), Cardiology, Shantou, China
| | - Gang Yin
- Heart Failure center, Qingdao Central Hospital, Cardiology, Qingdao, China
| | - Qing Xia
- Heart Failure center, Qingdao Central Hospital, Cardiology, Qingdao, China
| | - Guihai Wu
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College (SUMC), Cardiology, Shantou, China
| | - Jinxiu Zhu
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College (SUMC), Cardiology, Shantou, China
| | - Nan Lu
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College (SUMC), Cardiology, Shantou, China
| | - Jingyi Yan
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College (SUMC), Cardiology, Shantou, China
| | - Xuerui Tan
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College (SUMC), Cardiology, Shantou, China
- *Correspondence: Xuerui Tan
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