Geriatric Cardiology: An Emerging Discipline

Age-specific mortality trends in heart failure over 25 years: a retrospective Danish nationwide cohort study

BACKGROUND

Despite advances in heart failure care reducing mortality in clinical trials, it remains unclear whether real-life cohorts have had similar improvements in life expectancy across the age spectrum. We aimed to investigate how mortality trends changed in patients with heart failure over the past 25 years, stratified by age groups.

METHODS

Using Danish nationwide registries, we identified patients with new-onset heart failure aged 18-95 years. The 5-year all-cause mortality risk and the absolute risk difference of mortality between patients with heart failure and age-matched and sex-matched heart failure-free controls were assessed using Kaplan-Meier estimates and multivariable Cox regression models. Mortality trends were analysed across five calendar periods (1996-2000, 2001-05, 2006-10, 2011-15, and 2016-20) and three age groups (<65 years, 65-79 years, and ≥80 years).

FINDINGS

194 997 patients with heart failure were included. Mortality significantly decreased from 1996-2000 (66% [95% CI 65·5-66·4]) to 2016-20 (43% [42·1-43·4]), with similar results shown in all age groups (<65 years: 35% [33·9-36·1] to 15% [14·6-16·3]; 65-79 years: 64% [63·1-64·5] to 39% [37·6-39·6]; and ≥80 years: 84% [83·1-84·3] to 73% [71·7-73·9]). Adjusted mortality rates supported these associations. The absolute risk difference declined notably in younger age groups (<65 years: 29·9% [28·8-31·0] to 12·7% [12·0-13·4] and 65-79 years: 41·1% [40·3-41·9] to 25·1% [24·4-25·8]), remaining relatively stable in those aged 80 years or older (30·6% [29·9-31·3] to 28% [27·2-28·8]).

INTERPRETATION

Over 25 years, there has been a consistent decrease in mortality among patients with heart failure across age groups, albeit less prominently in patients aged 80 years or older. Further insight is needed to identify effective strategies for improving disease burden in older patients with heart failure.

FUNDING

None.

TRANSLATION

For the Danish translation of the abstract see Supplementary Materials section.

Hospital admissions in the last year of life of patients with heart failure

AIM

To explore the frequency, causes, and pattern of hospitalisation for patients with chronic heart failure (HF) in the 12 months preceding death. We also investigated cause of death.

METHODS

Patients referred to a secondary care HF clinic were routinely consented for follow-up between 2001 and 2020 and classified into three phenotypes: (i) HF with reduced ejection fraction (HFrEF), (ii) HF with preserved ejection fraction (HFpEF) with plasma N-terminal pro B-type natriuretic peptide (NT-proBNP) 125-399 ng L-1, and (iii) HFpEF with NT-proBNP ≥400 ng L-1. Hospital admissions in the last year of life were classified as: HF, other cardiovascular (CV), or non-cardiovascular (non-CV). The cause of death was systematically adjudicated.

RESULTS

A total of 4925 patients (38% women; median age at death 81 [75-87] years) had 9127 hospitalisations in the last year of life. The median number of hospitalisations was 2 (1-3) and total days spent in hospital was 12 (2-25). Out of the total, 83% of patients had ≥1 hospitalisation but only 20% had ≥1 HF hospitalisation; 24% had ≥1 CV hospitalisation; 70% had ≥1 non-CV hospitalisation. Heart failure hospitalisations were most common in patients with HFrEF, but in all groups, at least two thirds of admissions were for non-CV causes. There were 788 (16%) deaths due to progressive HF, of which 74% occurred in hospital.

CONCLUSION

For patients with chronic HF in the last year of life, most hospitalisations were for non-CV causes regardless of HF phenotype. Most patients had no HF hospitalisations in their last year of life. Most deaths were from causes other than progressive HF.

Defining an Abnormal Geriatric Assessment: Which Deficits Matter Most?

At present, there is no clear definition of what constitutes an abnormal geriatric assessment (GA) in geriatric oncology. Various threshold numbers of abnormal GA domains are often used, but how well these are associated with treatment plan modification (TPM) and whether specific GA domains are more important in this context remains uncertain. A retrospective review of the geriatric oncology clinic database at Princess Margaret Cancer Centre in Toronto, Canada, including new patients seen for treatment decision making from May 2015 to June 2022, was conducted. Logistic regression modelling was performed to determine the association between various predictor variables (including the GA domains and numerical thresholds) and TPM. The study cohort (n = 736) had a mean age of 80.7 years, 46.1% was female, and 78.3% had a VES-13 score indicating vulnerability (≥3). In the univariable analysis, the best-performing threshold number of abnormal domains based on area under the curve (AUC) was 4 (AUC 0.628). The best-performing multivariable model (AUC 0.704) included cognition, comorbidities, and falls risk. In comparison, the multivariable model with the sole addition of the threshold of 4 had an AUC of 0.689. Overall, an abnormal GA may be best defined as one with abnormalities in the domains of cognition, comorbidities, and falls risk. The optimal numerical threshold to predict TPM is 4.

Aging and cardiac implantable electronic device complications: is the procedure safe in older patients?

BACKGROUND

In this study, we investigated whether there is a higher incidence of cardiac implantable electronic devices (CIED) procedures related complications in older (≥ 75 years) than in younger (< 75 years) patients.

METHODS

This retrospective cohort study enrolled patients who had undergone CIED procedures (de novo implantation, system upgrade, generator substitution, pocket revision or lead replacement) at two heart centers in Turkey between January 2011 and May 2023. The primary composite endpoint included clinically significant hematoma (CSH), pericardial effusion or tamponade, pneumothorax, and infection related to the device system. Secondary outcomes included each component of the composite end point.

RESULTS

The overall sample included 1923 patients (1419 < 75 years and 504 aged ≥ 75 years). There was no difference between the groups in terms of cumulative events defined as primary outcome (3.5% vs. 4.4%, p = 0.393). Infection related to device system was significantly higher in the ≥ 75 age group (1.8% vs. 3.4%, p = 0.034). There was no significant difference between the groups in terms of clinically significant hematoma and pneumothorax (0.7% vs. 0.4%, p = 0.451, 1.4% vs. 1.0%, p = 0.477, respectively). In multivariate model analysis, no association was found between age ≥ 75 years and infection related to the device system.

CONCLUSION

Infection rates were relatively higher in the patient group aged ≥ 75 years. This patient group should be evaluated more carefully in terms of infection development before and after the procedure.

Can the Multidimensional Prognostic Index (MPI) be a predictive instrument for mortality in older adult liver transplant candidates?

PURPOSE

The most recent guidelines recommend that selection of liver transplant recipient patients be guided by a multidimensional approach that includes frailty assessment. Different scales have been developed to identify frail patients and determine their prognosis, but the data on older adult candidates are still inconclusive. The aim of this study was to compare the accuracy of the Liver Frailty Index (LFI) and the Multidimensional Prognostic Index (MPI) as predictors of mortality in a cohort of older people patients being evaluated for liver transplantation.

METHODS

This retrospective study was conducted on 68 patients > 70 years being followed at the University Hospital of Padua in 2018. Clinical information on each patient, Model For End-Stage Liver Disease (MELD), Body Mass Index (BMI), Activities of Daily Living (ADL), Mini Nutritional Assessment (MNA), LFI, MPI, and date-of-death, were recorded. The observational period was 3 years.

RESULTS

We studied 68 individuals (25 women), with a mean age 72.21 ± 1.64 years. Twenty-five (36.2%) patients died during the observational period. ROC curve analysis showed both MPI and LFI to be good predictors of mortality (AUC 0.7, p = 0.007, and AUC 0.689, p = 0.015, respectively). MELD (HR 1.99, p = 0.001), BMI (HR 2.34, p = 0.001), and poor ADL (HR 3.34, p = 0.04) were risk factors for mortality in these patients, while male sex (HR 0.1, p = 0.01) and high MNA scores (HR 0.57, p = 0.01) were protective factors.

CONCLUSION

Our study confirmed the prognostic value of MPI in older adult patients awaiting liver transplantation. In this cohort, good nutritional status and male sex were protective factors, while high MELD and BMI scores and poor functional status were risk factors.

Comprehensive Geriatric Care in Older Adults: Walking Ability after an Acute Fracture

BACKGROUND/OBJECTIVES

Comprehensive Geriatric Care (CGC) is a specific multimodal treatment for older patients. In the current study, we aimed to investigate walking performance after CGC in medically ill patients versus those with fractures.

METHODS

The timed up and go test (TuG), a 5-grade scale assessment (1 = no walking impairment to 5 = no walking ability at all) for evaluating individual walking ability was performed in all patients who underwent CGC prior to and after treatment. Factors associated with improvement in walking ability were analyzed in the subgroup of patients with fractures.

RESULTS

Out of 1263 hospitalized patients, 1099 underwent CGC (median age: 83.1 years (IQR 79.0-87.8 years); 64.1% were female). Patients with fractures (n = 300) were older than those without (n = 799), (median 85.6 versus 82.4 years, p = 0.001). Improvement in TuG after CGC was found in 54.2% of the fracture patients compared to just 45.9% of those without fractures. In fracture group patients, TuG improved from median 5 on admission to median 3 on discharge (p = 0.001). In fracture patients, improvement in walking ability was associated with higher Barthel index values on admission (median 45 (IQR: 35-55) versus 35 (IQR: 20-50): p = 0.001) and Tinetti assessment scores (median 9 (IQR: 4-14.25) versus 5 (IQR: 0-13); p = 0.001) and was negatively associated with the diagnosis of dementia (21.4% versus 31.5%; p = 0.058).

CONCLUSION

CGC improved walking ability in more than half of all patients examined. Older patients in particular might benefit from undergoing the procedure after an acute fracture. A better initial functional status favors a positive result following the treatment.

Barriers and motivators to specializing in geriatrics and strategies for recruitment: scoping review

While the barriers to specializing in geriatrics are known, motivators behind why medical trainees choose geriatrics are not as well understood. It is also unknown if recruitment strategies in the literature address these barriers and motivators. The aim of this systematic scoping review is to examine the current literature on recruitment strategies alongside motivators and barriers for specializing in geriatrics. Eligible articles for this scoping review either focused on motivators or barriers among trainees (medical students, resident-physicians, fellows) or recruitment strategies. A scoping search was conducted in MEDLINE, Embase, CINAHL, and PsychINFO. Data was extracted on article characteristics and themes. 88 of 2064 articles were eligible and included. Personal fulfillment emerged as the most common theme for motivators, contrary to prior studies that cite positive role modeling. Financial disincentive remained the most common barrier, followed by limited exposure and "futile" practice. Promising interventions beyond financial compensation include defining geriatrics better, emphasizing the high job satisfaction rates, increasing clinical exposure for medical students, and additional funding for academic centers to recruit academic geriatricians. Policymakers and medical educators should consider multiple strategies that target the motivators, as well as the barriers to pursuing geriatrics.

Improving outcomes for older hypertensive patients: is more intensive treatment better?

INTRODUCTION

With population aging, late-life hypertension is becoming an increasingly important issue. Mounting evidence has documented additional cardiovascular benefits induced by a more intensive target, lower than what are recommended in most current guidelines for systolic blood pressure (SBP) reduction in older patients with hypertension. However, the optimal target remains less clear.

AREAS COVERED

In the present review, we summarized the evolution of the perspective into late-life hypertension and the development of the 'optimal' target for SBP reduction in older patients with hypertension. More importantly, new evidence from latest antihypertensive drug-placebo studies, blood pressure target studies, and high-quality meta-analysis regarding the effect of intensive SBP treatment in older patients were covered and discussed in detail.

EXPERT OPINION

In summary, robust evidence supports that a SBP target of <130 mmHg is safe and will induce additional cardiovascular benefits in general older patients with hypertension. This benefit seems to be consistent, but less degreed in older patients with comorbidities such as chronic kidney disease or diabetes mellitus. However, such an intensive SBP target should be judiciously applied in older patients under extreme conditions. Collectively, edging down the relaxed SBP targets to <130 mmHg in most of the current guidelines is in imperative need.

Stress cardiac magnetic resonance for mortality prediction and decision-making: registry of 2496 elderly patients with chronic coronary syndrome

INTRODUCTION AND OBJECTIVES

The management of elderly patients with chronic coronary syndrome (CCS) is challenging. We explored the prognostic value and usefulness for decision-making of ischemic burden determined by vasodilator stress cardiac magnetic resonance (CMR) imaging in elderly patients with known or suspected CCS.

METHODS

The study group comprised 2496 patients older than 70 years who underwent vasodilator stress CMR for known or suspected CCS. The ischemic burden (number of segments with stress-induced perfusion deficit) was calculated following the 17-segment model. Subsequently, we retrospectively analyzed its association with all-cause mortality and the effect of CMR-guided revascularization.

RESULTS

During a median follow-up of 4.58 years, there were 430 deaths (17.2%). A higher ischemic burden was an independent predictor of mortality (HR, 1.04; 95%CI, 1.01-1.07 for each additional ischemic segment; P=.006). This association was also found in patients older than 80 years and in women (P <.001). An interaction between revascularization and mortality was detected toward deleterious consequences at low ischemic burden and a protective effect in patients with extensive ischemia.

CONCLUSIONS

Vasodilator stress CMR is a valuable tool to stratify risk in elderly patients with CCS and might be helpful to guide decision-making in this scenario.

Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study

BACKGROUND

Older cardiac patients are at high risk of readmission and mortality. Transitional care interventions (TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a randomized nurse-coordinated TCI combining case management, disease management and home-based rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients' participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral study outcomes. In addition, understanding these experiences could contribute to the design and application of future transitional care interventions for frail older cardiac patients.

METHODS

A generic qualitative approach was used. Semi-structured interviews were performed with 16 patients ≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data about intervention delivery were analysed.

RESULTS

Three themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the program in participants' recovery varied. Some participants reported physical improvements while others felt impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some participants did not recognize the added value. Participants with an existing healthcare provider network preferred to consult these providers instead of the providers who were involved in the transitional care intervention.

CONCLUSION

Our results contribute to an explanation of the neutral study of a nurse-coordinated transitional care intervention. For future purpose, it is important to identify which patients might benefit most from TCIs. Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older cardiac patients' needs, considering their frailty, self-management skills and existing formal and informal caregiver networks.

Improved Balance and Gait Ability and Basic Activities of Daily Living after Comprehensive Geriatric Care in Frail Older Patients with Fractures

(1) Purpose: Comprehensive geriatric care (CGC) is a multidisciplinary treatment approach for elderly patients. We aimed to investigate outcomes in fracture patients who had been treated using this approach in a large geriatric unit. (2) Methods: This observational cohort study assessed the gait function (using the Tinetti Balance and Gait Test (TBGT)) and basic activities of daily living (ADL) (using the Barthel index (BI)) before and after CGC and compared the results. Baseline data, walking ability assessments (Timed Up and Go, TUG), and cognitive status (mini mental status examination, MMSE) were also analyzed in the subgroup of patients with versus without fractures. (3) Results: Out of 1263 hospitalized patients, 1099 received CGC (median age: 83.1 years (IQR: 79.0–87.8 years); 64.1% were female). TBGT improvement was observed in 90.7% and BI increased in 82.7% of fracture patients. A TBGT improvement of >5 was noted in 47.3% and was associated with female sex, a lower BI at admission (median: 40 versus 45; p = 0.010), and poorer mobility on admission (TUG: median 5 versus 4; p = 0.001). An improvement in BI of ≥15 was observed in 63.0% of the cases, and was associated with a better cognitive status (MMSE: median 25 versus 18; p = 0.001) and inversely associated with diabetes mellitus and a previous stroke. (4) Conclusion: CGC in specialized geriatric units improves the balance and gait and the basic ADL in geriatric patients. After fracture, female patients are more likely to experience improvements in gait and balance, while patients with better cognitive condition are more likely to experience improvements in ADL.

The association of multimorbidity to mortality in older adults after permanent pacemaker placement

BACKGROUND

In the United States 2018 bradycardia guideline, the current class III recommendation that patients with permanent pacemaker (PPM) indications and high multimorbidity burden may not have meaningful clinical benefit from PPM therapy is based on limited data.

METHODS

Observational study (January 1, 2008-December 31, 2015) of adults ≥65 years (N = 16,678) who underwent PPM implantation. Exposure variable: Elixhauser comorbidity number (ECN, 29 well-validated conditions).

PRIMARY OUTCOME

≤1-year mortality; secondary outcome: > 1-year mortality.

RESULTS

Those who died ≤1-year were older, had a lower body mass index (BMI), and higher ECN (p < .001). Cumulative survival at 1-year was 92.3% (95% confidence interval [CI]: 91.9-92.7). One-year survival decreased by increasing ECN-with a difference at 1-year between lowest and highest ECN category of 17.3% (ECN 0-1: 97.1% [95% CI: 96.3-97.7]; ECN ≥8: 79.8% [95% CI: 77.9-81.5]). For those who survived the first year, cumulative survival at 8-years was 51.2% (95% CI = 49.8-52.6) with a difference between ECN 0-1 and ≥8 of 43.4%. Increasing ECN was associated equally with ≤1-year (HR 1.28 [95% CI: 1.25-1.30]) and >1-year (HR 1.19 [95% CI: 1.17-1.20]) mortality. A predictive model including age, sex, BMI, PPM type, race, and ECN had greater discriminative ability (p < .0001) than a bedside model (age, sex) for the primary outcome.

CONCLUSION

Across the heterogeneity of indications for PPM placement, multimorbidity is increasingly common. The association of multimorbidity to mortality (≤1-year, >1-year) should be routinely discussed during the shared decision-making process as an important prognostic geriatric domain variable.

Future Perspectives on the Role of Frailty in Cardiovascular Diseases

Frailty is a clinical concept which is gaining increased momentum not only in geriatrics, but in all specialties treating adult patients. In these Future Perspectives, the following roles of frailty in the field of cardiovascular diseases (CVD) will be discussed as a narrative review: (1) Frailty as an adjunct to assess CVD patients in addition to traditional risk scores; (2) bidirectional relationship between frailty and CVD; (3) widening the scope of endpoints in CVD trials-inclusion of frailty; (4) finally, the relationship between geriatrics and cardiology will be shortly discussed.

The association between patterns of physical activity and sedentary time with frailty in relation to cardiovascular disease

OBJECTIVE

The associations of moderate-vigorous physical activity (MVPA) bouts and patterns of sedentary time (ST) with frailty according to cardiovascular disease (CVD) status are unknown.

METHODS

Accelerometry in adults ≥50 years old from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey were used. Bouted and sporadic MVPA in ≥10-minute or <1-minute bouts were assessed based on meeting a percentage of physical activity guidelines of 150 minutes/wk, respectively. ST patterns included: prolonged ST lasting ≥30 minutes, and the frequency, intensity, and duration of breaks from ST. A 46-item frailty index defined frailty. Multivariable linear regression was used.

RESULTS

There were 827 and 1490 CVD-free and CVD participants, respectively. Meeting a higher percentage of the physical activity guidelines through bouted MVPA was associated with lower frailty in CVD-only participants (P < 0.05 for CVD interaction). Sporadic MVPA was associated with lower frailty levels in both groups. Prolonged ST was associated with worse frailty in CVD (P > 0.05 for CVD interaction). Frequency of ST breaks was not associated with frailty. Average ST break intensity was protective in both groups. The duration of breaks in ST was associated with lower frailty in CVD participants only (P > 0.05 for CVD interaction).

CONCLUSION

Insufficient MVPA and prolonged ST are detrimental despite CVD status.

Improving Care Using a Bidirectional Geriatric Cardiology Consultative Conference

More than 13 million persons in the United States aged 65 and older have cardiovascular disease (CVD), and this population is expected to increase exponentially over the next several decades. In the absence of clinical studies that would inform how best to manage this population, there is an urgent need for collaborative, thoughtful approaches to their care. Although cardiologists are traditionally regarded as leaders in the care of older adults with CVD, these individuals have multiple comorbidities, physiological differences, and distinct goals of care than younger patients that require a specialized geriatric lens. Thus, collaboration is needed between geriatricians, cardiologists, and other specialists to address the unique needs of this growing population. Accordingly, clinicians at New York University Langone Health and School of Medicine established a monthly Geriatric Cardiology Conference to foster an integrative approach to the care of older adults with CVD by uniting specialists across disciplines to collaborate on treatment strategies. At each conference, an active case is discussed and analyzed in detail, and a consensus is reached among participants regarding optimal treatment strategies. The conference attracts faculty and trainees at multiple levels from geriatrics, cardiology, and cardiothoracic surgery. The model may serve as a paradigm for other institutions moving towards geriatric-informed care of older adults with CVD.

Is it time for comprehensive geriatric assessment to move beyond primary care? The case for targeting medical sub-specialty practice

Comprehensive geriatric assessment (CGA) as a consultative service for older adults with complex medical and psychosocial challenges has existed for decades. However, studies have often showed inconsistent acceptance and implementation of geriatric recommendations by primary care providers (PCPs) raising doubts about the overall benefits of CGA in this setting. Press and colleagues investigated the patient- and provider-related factors that affect recommendation implementation, and like previous studies, they too found similarly low rates of implementation. In this commentary, we acknowledge the perennial challenges that exist to improving the acceptance of CGA in primary care practice, and we suggest an alternative target: medical sub-specialty practice. By highlighting three medical sub-specialty fields (oncology, nephrology, and cardiology), which have demonstrated that CGA can be incorporated into their respective clinical practices, we argue that CGA may prove to have greater impact in these settings than in primary care. We also propose initial research steps that could further delineate the trends, outcomes, and next steps for such consultations.

Clinical implications of aging with HIV infection: perspectives and the future medical care agenda

: The increasing number of aging HIV-infected (HIV+) persons comprises a unique population at risk for illnesses and syndromes traditionally associated with the elderly. As a result, similar to the current need for primary care providers to manage chronic noninfectious comorbidities among aging persons with well controlled HIV infection, HIV clinical care will need to routinely involve geriatric medicine in a new HIV-geriatric discipline. The objective of this article is to provide a conceptual framework in which HIV and geriatric management considerations for healthcare professionals caring for HIV+ persons are integrated. The provision of contemporary HIV clinical care extends well beyond the achievement of HIV virologic suppression and antiretroviral therapy management and includes a need for careful characterization of geriatric syndromes based upon functional capacity and extent of disability. Screening for geriatric syndromes is both a multidisciplinary and multidimensional process, designed to evaluate an older person's functional ability, physical health, cognition, overall mental health, and socio-environmental circumstances. Although routine incorporation of geriatric assessment into clinical trials involving HIV+ persons is feasible, a current challenge is the availability of a consensus clinical definition of frailty or vulnerability. To maximize the efficiency, value, and convenience of outpatient care visits for older HIV+ persons, these visits should include encounters with multiple providers, including primary care clinicians, social workers, and geriatricians. Challenges may exist in the routine provision of these assessments to older HIV+ persons, but clearly such cross-disciplinary collaboration will not only markedly enhance the care of aging HIV+ persons but may also constitute a model of successful healthcare management that can be applied to all aging persons with changing healthcare needs.