Multimorbidity in Older Adults with Heart Failure

Relationship between comorbidity and health outcomes in patients with heart failure: a systematic review and meta-analysis

BACKGROUND

The prevalence of heart failure (HF) is expected to rise due to increased survivorship and life expectancy of patients with acute heart conditions. Patients with HF and other multiple comorbid conditions are likely to have poor health outcomes. This study aimed to assimilate the current body of knowledge and to provide the pooled effect of HF patients' comorbid conditions on health outcomes.

METHODS

A systematic search was performed using MEDLINE, EMBASE and CINAHL databases. Observational studies evaluating the relationship between comorbid conditions and the health outcomes of HF were included. The pooled effect sizes of comorbidity on the identified health outcomes were calculated using a random effects model, and the heterogeneity was evaluated using I2 statistics.

RESULTS

A total of 42 studies were included in this review, and a meta-analysis was performed using the results of 39 studies. In the pooled analysis, the presence of a comorbid condition showed a significant pooled effect size in relation to the prognostic health outcomes: all-cause mortality (HR 1.31; 95% CI 1.18, 1.45), all-cause readmission (HR 1.16; 95% CI 1.09, 1.23), HF-related readmission (HR 1.13; 95% CI 1.05, 1.23), and non-HF-related readmission (HR 1.17; 95% CI 1.07, 1.27). Also, comorbidity was significantly associated with health-related quality of life and self-care confidence. Furthermore, we identified a total of 32 comorbid conditions from included studies. From these, 16 individual conditions were included in the meta-analyses, and we identified 10 comorbid conditions to have negative effects on overall prognostic outcomes: DM (HR 1.16, 95% CI 1.11, 1.22), COPD (HR 1.31, 95% CI 1.23, 1.39), CKD (HR 1.18, 95% CI 1.14, 1.23, stroke (HR 1.25, 95% CI 1.17, 1.31), IHD (HR 1.17, 95% CI 1.11, 1.23), anemia (HR 1.42, 95% CI 1.14, 1.78), cancer (HR 1.17, 95% CI 1.04, 1.32), atrial fibrillation (HR 1.25, 95% CI 1.01, 1.54), dementia (HR 1.19, 95% CI 1.03, 1.36) and depression (HR 1.17, 95% CI 1.04, 1.31).

CONCLUSIONS

Comorbid conditions have significantly negative pooled effects on HF patient health outcomes, especially in regard to the prognostic health outcomes. Clinicians should carefully identify and manage these conditions when implementing HF interventions to improve prognostic outcomes.

End-Stage/Advanced Heart Failure: Geriatric Palliative Care Considerations

Heart failure remains a condition with high morbidity and mortality affecting 23 million people globally with a cost burden equivalent to 5.4% of the total health care budget in the United States. These costs include repeated hospitalizations as the disease advances and care that may not align with individual wishes and values. The coincidence of comorbid conditions with advanced heart failure poses significant challenges in the geriatric population. Advance care planning, medication education, and minimizing polypharmacy are primary palliative opportunities leading to specialist palliative care such as symptom management at end of life and timing of referral to hospice.

Effects of myocardial ischemia/reperfusion injury on plasma metabolomic profile during aging

Background

Heart disease is a frequent cause of hospitalization and mortality for elderly patients. A common feature of both heart disease and aging itself is the involvement of metabolic organ alterations ultimately leading to changes in circulating metabolite levels. However, the specific contribution of aging and ischemic injury to the metabolic dysregulation occurring in older adults with ischemic heart disease is still unknown.

Aim

To evaluate the effects of aging and ischemia/reperfusion (I/R) injury on plasma metabolomic profiling in mice.

Methods

Young and aged mice were subjected to a minimally invasive model of I/R injury or sham operation. Complete evaluation of cardiac function and untargeted plasma metabolomics analysis were performed.

Results

We confirmed that aged mice from the sham group had impaired cardiac function and augmented left ventricular (LV) dimensions compared to young sham‐operated mice. Further, we found that ischemic injury did not drastically reduce LV systolic/diastolic function and dyssynchrony in aged compared to young mice. Using an untargeted metabolomics approach focused on aqueous metabolites, we found that ischemic injury does not affect the plasma metabolomic profile either in young or old mice. Our data also demonstrate that age significantly affects circulating metabolite levels (predominantly amino acids, phospholipids and organic acids) and perturbs several pathways involved in amino acid, glucid and nucleic acid metabolism as well as pyridoxal‐5′‐phosphate salvage pathway in both sham and ischemic mice.

Conclusions

Our approach increases our understanding of age‐associated plasma metabolomic signatures in mice with and without heart disease excluding confounding factors related to metabolic comorbidities.

Artificial intelligence supported patient self-care in chronic heart failure: a paradigm shift from reactive to predictive, preventive and personalised care

Heart failure (HF) is one of the most complex chronic disorders with high prevalence, mainly due to the ageing population and better treatment of underlying diseases. Prevalence will continue to rise and is estimated to reach 3% of the population in Western countries by 2025. It is the most important cause of hospitalisation in subjects aged 65 years or more, resulting in high costs and major social impact. The current "one-size-fits-all" approach in the treatment of HF does not result in best outcome for all patients. These facts are an imminent threat to good quality management of patients with HF. An unorthodox approach from a new vision on care is required. We propose a novel predictive, preventive and personalised medicine approach where patients are truly leading their management, supported by an easily accessible online application that takes advantage of artificial intelligence. This strategy paper describes the needs in HF care, the needed paradigm shift and the elements that are required to achieve this shift. Through the inspiring collaboration of clinical and high-tech partners from North-West Europe combining state of the art HF care, artificial intelligence, serious gaming and patient coaching, a virtual doctor is being created. The results are expected to advance and personalise self-care, where standard care tasks are performed by the patients themselves, in principle without involvement of healthcare professionals, the latter being able to focus on complex conditions. This new vision on care will significantly reduce costs per patient while improving outcomes to enable long-term sustainability of top-level HF care.

Multi-morbidity burden, psychological distress, and quality of life in implantable cardioverter defibrillator recipients: Results from a nationwide study

BACKGROUND

The prevalence of multi-morbidity in implantable cardioverter defibrillator (ICD) recipients is approximately 25%. Multi-morbidity is associated with poor health and psychological outcomes in this population and may affect ICD recipients' quality-of-life (QOL). The purpose of this study was to determine the prevalence of psychological distress (anxiety, depressive symptoms, and Type-D personality) in ICD recipients with varying levels of comorbidities, and to examine the association between multi-morbidity burden and QOL in this population.

METHODS

All adults listed in the Swedish ICD and Pacemaker Registry in 2012 with an ICD implanted for at least one year were invited to participate in this study. Binary logistic regression was used to predict QOL using the EQ-5D mean index dichotomized based on median QOL scores. Multi-morbidity burden scores were based on quartile groupings.

RESULTS

A total of 2658 ICD recipients participated in the study (with a mean age of 65, 20.6% female, mean implant duration of 4.7 years, with 35.4% implanted for primary prevention of sudden cardiac arrest). Greater multi-morbidity burden, female sex, not working outside the home, history of ICD shock, negative ICD experience, higher levels of ICD-related concerns, and the presence of anxiety, depression, or Type D personality were associated with worse QOL in ICD recipients. Predictors differed by multi-morbidity burden level.

CONCLUSIONS

Multi-morbidity burden and psychological distress is an essential factor related to QOL. This issue should be discussed with potential ICD recipients prior to implant. Further exploration of increased recognition and treatment of psychological distress in ICD recipients is warranted.

Admission diagnoses among patients with heart failure: Variation by ACO performance on a measure of risk-standardized acute admission rates

BACKGROUND

A key quality metric for Accountable Care Organizations (ACOs) is the rate of hospitalization among patients with heart failure (HF). Among this patient population, non-HF-related hospitalizations account for a substantial proportion of admissions. Understanding the types of admissions and the distribution of admission types across ACOs of varying performance may provide important insights for lowering admission rates.

METHODS

We examined admission diagnoses among 220 Medicare Shared Savings Program ACOs in 2013. ACOs were stratified into quartiles by their performance on a measure of unplanned risk-standardized acute admission rates (RSAARs) among patients with HF. Using a previously validated algorithm, we categorized admissions by principal discharge diagnosis into: HF, cardiovascular/non-HF, and noncardiovascular. We compared the mean admission rates by admission type as well as the proportion of admission types across RSAAR quartiles (Q1-Q4).

RESULTS

Among 220 ACOs caring for 227,356 patients with HF, the median (IQR) RSAARs per 100 person-years ranged from 64.5 (61.7-67.7) in Q1 (best performers) to 94.0 (90.1-99.9) in Q4 (worst performers). The mean admission rates by admission types for ACOs in Q1 compared with Q4 were as follows: HF admissions: 9.8 (2.2) vs 14.6 (2.8) per 100 person years (P < .0001); cardiovascular/non-HF admissions: 11.1 (1.6) vs 15.9 (2.6) per 100 person-years (P < .0001); and noncardiovascular admissions: 42.7 (5.4) vs 69.6 (11.3) per 100 person-years (P < .0001). The proportion of admission due to HF, cardiovascular/non-HF, and noncardiovascular conditions was 15.4%, 17.5%, and 67.1% in Q1 compared with 14.6%, 15.9%, and 69.4% in Q4 (P < .007).

CONCLUSIONS

Although ACOs with the best performance on a measure of all-cause admission rates among people with HF tended to have fewer admissions for HF, cardiovascular/non-HF, and noncardiovascular conditions compared with ACOs with the worst performance (highest admission rates), the largest difference in admission rates were for noncardiovascular admission types. Across all ACOs, two-thirds of admissions of patients with HF were for noncardiovascular causes. These findings suggest that comprehensive approaches are needed to reduce the diverse admission types for which HF patients are at risk.

Multimorbidity patterns in high-need, high-cost elderly patients

Introduction

Patients with complex health care needs (PCHCN) are individuals who require numerous, costly care services and have been shown to place a heavy burden on health care resources. It has been argued that an important issue in providing value-based primary care concerns how to identify groups of patients with similar needs (who pose similar challenges) so that care teams and care delivery processes can be tailored to each patient subgroup. Our study aims to describe the most common chronic conditions and their combinations in a cohort of elderly PCHCN.

Methods

We focused on a cohort of PCHCN residing in an area served by a local public health unit (the “Azienda ULSS4-Veneto”) and belonging to Resource Utilization Bands 4 and 5 according to the ACG System. For each patient we extracted Expanded Diagnosis Clusters, and combined them with information available from Rx-MGs diagnoses. For the present work we focused on 15 diseases/disorders, analyzing their combinations as dyads and triads. Latent class analysis was used to elucidate the patterns of the morbidities considered in the PCHCN.

Results

Five disease clusters were identified: one concerned metabolic-ischemic heart diseases; one was labelled as neurological and mental disorders; one mainly comprised cardiac diseases such as congestive heart failure and atrial fibrillation; one was largely associated with respiratory conditions; and one involved neoplasms.

Conclusions

Our study showed specific common associations between certain chronic diseases, shedding light on the patterns of multimorbidity often seen in PCHCN. Studying these patterns in more depth may help to better organize the intervention needed to deal with these patients.

Heart failure in the elderly: ten peculiar management considerations

Chronic heart failure (HF) is a disease with significantly higher prevalence in the elderly or patients older than 65 years old. Typically, older patients have more risk factors for HF, more comorbidities, and are more likely to have recurrent admissions for acute decompensations. With HF burden on health care systems primarily related to hospital and nursing home costs, it is critical that elderly patients are approached with a clear understanding of certain unique clinical, laboratory, imaging, and pharmacokinetic differences that can alter their management and outcomes. Psychosocial factors have major implications on adherence to therapy as well as decisions on advanced care for elderly HF patients. In this article, we highlight ten peculiar management considerations when approaching older patients with HF. We discuss issues related to epidemiology, diagnostic challenges, pharmacotherapy, and palliative care; all of which can impact this unique population and, more importantly, the disease burden as a whole.

Frailty in Heart Failure: Implications for Management

Frailty is a complex clinical syndrome associated with ageing and chronic illness, resulting from multiple organ impairment; physiological reserves decrease and vulnerability to stressors increase. The role of frailty in cardiovascular disease has become increasingly recognised. Up to 79% of patients with heart failure are frail. Moreover, frailty is associated with a worse quality of life and poor prognosis. This review summarises the available literature on frailty in HF and highlights indications for its management.

Epidemiology, Pathophysiology, and Prognosis of Heart Failure in Older Adults

Heart failure is the quintessential cardiovascular syndrome of aging that results from common cardiovascular conditions in older adults in conjunction with age-associated changes in cardiovascular structure and function. To a large extent, heart failure is a geriatric syndrome in much the same way that dementia, falls, and frailty are geriatric syndromes. The incidence and prevalence of heart failure increase strikingly with age and make heart failure the most common reason for hospitalization among older adults. Although outcomes for older adults with heart failure have improved over time, mortality, hospitalization, and rehospitalization rates remain high.

The Complexity of Characteristics, Diagnoses and Treatment of Older Patients With Pulmonary Hypertension

BACKGROUND

Older patients with pulmonary hypertension (PH) are more likely to have complex comorbidity than younger patients with pulmonary arterial hypertension (PAH). The best approach to the evaluation and management of these patients is unclear.

METHODS

We, retrospectively, reviewed the clinical records of patients older than 60 years referred for evaluation for PAH. We recorded patient demographics, comorbidity, functional classification (FC), right heart catheterization data, echocardiographic data, chest radiographic images and pulmonary function results. We recorded the final diagnoses according to World Health Organization (WHO) subgroups and treatment outcomes based on changes in FC.

RESULTS

Ninety-seven records were reviewed in detail. The mean age was 71.2 ± 7.5 years with 66% women. Cardiovascular disease was the most frequent comorbidity. Mean PA pressure by catheterization was 39.5 ± 12.2mmHg (n = 65). The overall distribution after evaluation included 21 (21.6%) Group 1, 35 (36.1%) Group 2, 16 (16.5%) Group 3, 18 (18.6%) mixed Group 2 and 3, 6 (6.2%) Group 4 and 1 (1%) Group 5 patients. Group 1 patients were treated with PAH specific drug, and 12 patients had an improvement in FC with treatment.

CONCLUSIONS

Older patients with suspected PH often have significant cardiovascular and respiratory comorbidity. Comprehensive evaluations are needed to determine the severity of PH and associated diseases and to initiate treatment focused on FC. Patients in WHO Group 2 and mixed Group 2 and 3 were frequently identified and constituted a diagnostic and treatment challenge in this study. Older patients with PAH may benefit from PAH specific drugs.

Polypharmacy and Multimorbidity Among Medicaid Enrollees: A Multistate Analysis

The purpose of this study is to explore the associations between polypharmacy and multimorbidity using conventional and novel measures of polypharmacy. In this cross-sectional study, data on fee-for-service (FFS) Medicaid enrollees with at least 1 chronic condition and aged 18-64 years (N = 38,329) were derived from the 2010 Medicaid Analytic eXtract (MAX) files of Maryland and West Virginia. Polypharmacy, by the authors' novel definition, was determined as simultaneous use of ≥5 drugs for a consecutive period of 60 days. Multimorbidity was defined as having ≥2 chronic conditions based on the US Department of Health and Human Services framework. The association between multimorbidity and polypharmacy was examined with chi-square tests and logistic regression. Polypharmacy prevalence was estimated at 50.9% using the novel definition, as compared to 16.7% and 64.9% for the 2 commonly used conventional measures, respectively. For all 3 definitions, individuals with multimorbidity were more likely to have polypharmacy than those without multimorbidity (P < 0.001). The authors also consistently found, using all definitions, that those who were older, female, white, and eligible for Medicaid because of cash assistance were more likely to have polypharmacy (all P < 0.001). Polypharmacy was highly prevalent and significantly associated with multimorbidity among Medicaid FFS enrollees irrespective of the definitions used. The new measure may provide a more comprehensive and accurate estimation of polypharmacy than the conventional measures. These findings suggest the need for a paradigm shift from disease-specific care to patient-centered collaborative care to manage patients with multimorbidity and polypharmacy.

P2X7 Receptor and APOE Polymorphisms and Survival from Heart Failure: A Prospective Study in Frail Patients in a Geriatric Unit

Heart failure (HF) is one of the most frequent cause of hospitalization in elderly and often coexists with concurrent geriatric syndromes, like cognitive disturbances; various pathophysiological mechanisms are shared by HF and cognitive decline, notably a substrate of low-grade inflammation. We investigated whether SNPs in the purinergic receptor (P2X7R) and apolipoprotein (APO) E genes, both involved in a series of inflammatory responses, are associated to HF or cognitive impairment and are able to predict post-discharge mortality in the elderly. We prospectively analyzed 198 patients (age 85 ± 8 years, predominantly females) admitted to a Geriatric unit for acute HF, whose diagnosis was based on clinical signs, brain natriuretic peptide (BNP) values and ecocardiography in uncertain diagnosis (BNP values between 100 and 400 pg/mL); cognitive performance was assesed by Short Portable Mental Status Questionnaire (SPMSQ). In all the participants, SNPs rs208294 and rs3751143 for P2X7R gene and rs429558 and rs7412 for APOE gene were assessed. Information on all-cause mortality was adjudicated by medical records review 36 months after discharge. We found no relationship between P2X7R and APOE polymorphisms and 36-month post-discharge mortality; a better outcome for overall survival was observed in patients with BNP values below the median (281 pg/mL) (p=0.002) persisting after adjustment for renal function and age, and in those with cognitive impairment (p<0.001). Patients harboring APOE-ε4 genotype showed higher BNP concentrations than noncarriers (1289.9 ± 226.9 vs 580.5 ± 90.2 pg/mL respectively,p=0.004), whereas none of the studied SNPs were associated to impairment in cognitive performance. In conclusion, neither P2X7R or APOE genotype seem to predict long-term mortality in elderly patients. Interestingly, APOE-ε4 genotype was associated to higher BNP values, suggesting a putative interaction between genetic and biochemical markers in identifying people at risk for HF.

Impact of Exercise Programs on Hospital Readmission Following Hospitalization for Heart Failure: A Systematic Review

Given persistently high 30-day readmission rates among patients hospitalized for heart failure, there is an ongoing need to identify new interventions to reduce readmissions. Although exercise programs can improve outcomes among ambulatory heart failure patients, it is not clear whether this benefit extends to reducing readmissions following heart failure hospitalization. We therefore conducted a systematic review of the literature to identify randomized controlled trials examining the impact of exercise programs on hospital readmissions among patients recently hospitalized for heart failure. We searched Ovid MEDLINE, EMBASE, and the Wiley Cochrane Library for studies that fulfilled pre-defined criteria, including that the exercise program pre-specify activity type and exercise frequency, duration, and intensity. Exercise interventions could occur at any location including within the hospital, at an outpatient facility, or at home. Among 1213 unique publications identified, only one study fulfilled inclusion criteria. This study was a single-site randomized controlled trial that consisted of a 12-week exercise program in a cohort of 105 patients with a principal diagnosis of HF at a metropolitan hospital in Australia. This study revealed a reduction in 12-month all-cause and cardiovascular-related hospitalization rates. However, inferences were limited by its single-site study design, small sample size, premature termination, and high risk for selection, performance, and detection bias. As no studies have built upon the findings of this study, it remains unknown whether exercise programs can improve readmission rates among patients recently hospitalized for heart failure, a significant gap in the literature.

Epidemiology, pathophysiology, and prognosis of heart failure in the elderly

Heart failure (HF) represents the quintessential disorder of cardiovascular aging, reflecting the convergence of age-related changes in the cardiovascular system and other organ systems and the increasing prevalence of cardiovascular diseases at older age. The prevalence and incidence of HF increase progressively with advancing age, and HF imposes an enormous burden on society in mortality, morbidity, and associated health care costs. Despite major advances in treatment of HF over the last 25 years, the prognosis remains poor, with median survival rates of less than 5 years in older adults. As the population ages, it is anticipated that the number of older people with HF will increase dramatically over the next several decades.