Heart failure in the elderly: age-related differences in clinical profile and mortality

Is the clinical presentation of chronic heart failure different in elderly versus younger patients and those with preserved versus reduced ejection fraction?

BACKGROUND

Whether the clinical presentation and in particular prevalence of symptoms and signs of heart failure (HF) is different in elderly versus younger patients and in those with reduced (HFrEF) versus preserved (HFpEF) left ventricular ejection fraction (LVEF) is a matter of ongoing debate.

AIMS

To compare detailed clinical characteristics of these important subgroups and to develop a prediction rule for the differentiation of HFpEF and HFrEF based on clinical parameters.

METHODS

The analysis was based on the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) comprising 622 patients ≥60 years with HF including the whole LVEF spectrum.

RESULTS

In the groups ≥75 years and with HFpEF typical symptoms and clinical signs of HF were more prevalent as compared to those <75 years or with HFrEF, respectively. The burden of comorbidities was higher in the older age group. HFrEF could not be differentiated from HFpEF by symptom history and clinical examination alone. However, a combination of age, presence of pulmonary rales, systolic blood pressure, cause of heart failure, osteoporosis, current smoking, NT-proBNP, haemoglobin, QRS width and heart rhythm allowed to identify HFrEF versus HFpEF with a sensitivity of 81% and specificity of 90% (c-statistics 0.91).

CONCLUSIONS

More symptoms and signs of HF were present both in the older age group and in patients with HFpEF. HFpEF versus HFrEF could be differentiated by a set of simple clinical, laboratory and ECG parameters but not by symptom history and physical examination alone.

Clinical profile, management, and mortality in very-elderly patients hospitalized with acute decompensated heart failure: An analysis from the ATTEND registry

BACKGROUND

Acute decompensated heart failure (ADHF) is a leading cause of hospitalization among the elderly. Discussion of optimal management of ADHF in older patients is a growing health care priority. The aim of this study was to examine the clinical profile, management, and mortality in patients admitted with ADHF according to age.

METHODS

We analyzed 4824 patients enrolled in the Acute Decompensated Heart Failure Syndromes registry from April 2007 to December 2011. Patient characteristics, management, and in-hospital outcomes were compared among four age groups (<65, 65-74, 75-84, and ≥85 years).

RESULTS

The mean age of the overall population was 73 years; approximately 20% were aged ≥85 years. Older patients were more likely to be women and have preserved left ventricular ejection fraction (LVEF) and decreased renal function. Intravenous treatments were well administered in both young and elderly patients irrespective of LVEF. Invasive procedures were less frequently performed in the eldest group. The median length of hospital stay was 21 days, and in-hospital cardiac death in the eldest group was four-fold higher than that in the youngest group (2.2% vs. 8.9%, P<0.001).

CONCLUSIONS

Clinical characteristics of ADHF differ considerably with age, and cardiac death increases linearly with age. Despite a higher rate of preserved systolic function in very-elderly individuals aged ≥85 years, in-hospital mortality was higher, suggesting that more suitable treatments for the elderly might be needed.

Noncardiovascular death, especially infection, is a significant cause of death in elderly patients with acutely decompensated heart failure

BACKGROUND

Despite marked improvements in treatment strategies for heart failure (HF), the mortality rate of elderly patients with HF is still high. Detailed causes of death have not been fully understood.

METHODS AND RESULTS

We studied 459 consecutive patients with acute decompensated HF (ADHF) emergently admitted to our hospital from 2007 to 2011. Patients were divided into 2 groups: <75 years old (younger group; n = 225) and ≥75 years old (elderly group; n = 234). All-cause death, cardiovascular death, and noncardiovascular death were assessed as adverse outcomes. Compared with the younger group, the elderly group was characterized by a higher proportion of women and hypertensive patients and higher left ventricular ejection fraction. During a mean follow-up of 20.7 months, a total of 174 patients (37.9%) died. All-cause death was significantly higher in the elderly group than in the younger group (46.6% vs 28.9%; P < .0001), and this difference was caused by an increase in noncardiovascular deaths (20.9% vs 9.3%; P < .001), especially deaths due to infection (10.7% vs 4.0%; P < .01). Cardiovascular deaths did not differ between the 2 groups.

CONCLUSIONS

Noncardiovascular deaths, most of which were caused by infection, were frequent among elderly patients with ADHF.

Predictors of long-term adverse outcomes in elderly patients over 80 years hospitalized with heart failure. - A report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD)-

BACKGROUND

Aging is associated with adverse outcomes in patients with cardiac diseases. Whether elderly patients hospitalized with heart failure (HF) had increased risks for mortality and rehospitalization compared with younger patients during the long-term follow-up was examined. The predictors of these adverse outcomes were also identified.

METHODS AND RESULTS

The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) studied prospectively the characteristics and treatments in a broad sample of 2,675 patients hospitalized with worsening HF and the outcomes were followed up. The majority of elderly patients were female, had lower body mass index (BMI), a higher rate of ischemic, valvular, and hypertensive heart disease as etiologies of HF, a lower estimated glomerular filtration rate (eGFR), lower hemoglobin, and higher left ventricular ejection fraction values. Even after adjustment for covariates, the elderly patients were associated with higher risks of adverse outcomes. The predictors for all-cause death were: lower eGFR, lower BMI, male sex, sustained ventricular tachycardia or fibrillation (VT/VF), and the use of diuretics at discharge.

CONCLUSIONS

Among patients hospitalized with HF, elderly patients had a worse prognosis than younger patients. Lower eGFR, lower BMI, male sex, sustained VT/VF, and diuretic use were independent predictors for all-cause death in these patients with higher risk.

Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft

OBJECTIVE

This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders.

METHODS

This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist.

RESULTS

The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms.

CONCLUSIONS

The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility.

[Heart failure patients in Primary Care: aging, comorbidities and polypharmacy]

OBJECTIVE

To assess heart failure prevalence, epidemiology, co-morbidities and polypharmacy in our region from electronic patient records. To evaluate gender differences in heart failure patients.

DESIGN

Descriptive, cross-sectional study.

SETTING

Primary care Lleida (Spain).

PARTICIPANTS

All patients from 21 primary care centers with the diagnosis of heart failure in medical records were included.

MAIN OUTCOME MEASUREMENTS

Demographic data, comorbidities and therapeutical subgroups in patients with a diagnosis of heart failure in their clinical record.

RESULTS

Heart failure was found in 0.99% (3017 from 306229 patients), of whom 59% were women, and a mean age of 80 years. Comorbidities: hypertension 67%, diabetes 30%, hyperlipidemia 26.5%, obesity 27%, ischemic heart disease 19%, stroke 11%, atrial fibrillation 31%, COPD 26%, renal failure 12%. Hypertension, hyperlipidemia and obesity were more frequent in women, COPD, ischemic heart disease and renal failure in men. There were no differences in diabetes, stroke and atrial fibrillation. Patients were prescribed a median of 8 different therapeutic subgroups (P25=6 and P75=11). Women were more frequently prescribed diuretics (76%), cardiac glycosides (22%) and ACE inhibitors/angiotensin II receptor antagonists, and men ACE inhibitors/angiotensin II receptor antagonists in combination with beta-blockers.

CONCLUSIONS

Heart failure patients in primary care are elderly, with significant co-morbidities and treated with a high number of drugs. Gender differences exist in cardiovascular risk factors, co-morbidities, and also in therapy.

Clinical features, treatment practices, and hospital and long-term outcomes of older patients hospitalized with decompensated heart failure: The Worcester Heart Failure Study

OBJECTIVES

To examine age-specific differences in clinical presentation, receipt of therapeutic practices and lifestyle recommendations, and hospital and long-term survival in patients hospitalized for acute heart failure HF.

DESIGN

Population-based study.

SETTING

The Worcester Heart Failure Study, a population-based study of residents of the a large Central New England metropolitan area hospitalized for decompensated HF at 11 greater-Worcester medical centers.

PARTICIPANTS

Four thousand five hundred thirty-four patients hospitalized for decompensated HF during 1995 and 2000.

MEASUREMENTS

Medical records were reviewed for demographic, clinical, and treatment characteristics and hospital survival status. Long-term follow-up of discharged hospital patients was conducted through 2005. Patients were compared according to four age groups (<65, 65-74, 75-84, and > or =85).

RESULTS

Mean age was 76; 24.0% were aged 85 and older. Patients aged 75 and older were more likely to be female and to have multiple comorbidities, a lower body mass index at the time of hospitalization, and higher ejection fraction findings. Older patients were significantly more likely to receive symptom-modifying medications and less likely to receive disease-modifying medications than younger patients. Older age was directly associated with higher in-hospital, 30-day, and 1-year death rates in crude and multivariable-adjusted analyses.

CONCLUSION

The results of this community-wide study suggest that clinical, treatment, and prognostic factors differ according to age in patients hospitalized for decompensated HF. These high-risk patients warrant special attention in future studies to improve their management and long-term survival.

Long-term survival in patients older than 80 years hospitalised for heart failure. A 5-year prospective study

BACKGROUND

Although heart failure (HF) is frequent in elderly patients, few studies have focused on patients older than 80 years.

AIMS

To evaluate the clinical features, treatment and long-term prognosis of HF in patients older than 80 years.

METHODS AND RESULTS

Consecutive patients hospitalised for a first HF episode in the Somme Department (France) during 2000 were prospectively included. Of the 799 included patients, 305 (38%) were aged over 80 years. The elderly patients were mostly women with a high prevalence of atrial fibrillation, ischaemic and hypertensive heart disease. Ejection fraction (EF) was assessed in 68.5% of elderly patients and 61% had EF >or=50%. Angiotensin-converting enzyme inhibitors, beta-blockers, oral anticoagulants and statins were prescribed less frequently in elderly patients. The 5-year survival in elderly patients was 19%, dramatically lower than the survival of age- and sex-matched general population (48%). Cardiovascular causes were recorded in over 60% of deaths. On multivariable analysis, cancer, renal insufficiency, old myocardial infarction, diabetes, hyponatraemia and age were predictors of mortality in elderly patients. Reduced EF was a potent predictor of death (HR 1.72, 95%CI 1.24-2.37, p=0.001) in elderly patients.

CONCLUSION

Long-term prognosis in HF patients older than 80 years is poor, with a dramatic excess mortality compared to the elderly general population. Life-saving drugs are largely underused in elderly HF patients.

Lack of improvement of clinical outcomes by a low-cost, hospital-based heart failure management programme

OBJECTIVE

Heart failure (HF) is a major health problem resulting in a high financial burden for the healthcare system. Many previous HF management programmes reduced adverse clinical outcomes and costs, but they usually involved several professional figures as well as huge investments, requiring resources and budgets not often available in our healthcare system. We evaluated the effects of our HF management programme, which included patient education and regular outpatient contact with the HF team, on re-hospitalisation and death, optimising the few resources already available at our hospital.

METHODS

Two hundred consecutive patients admitted to the internal medicine department with a diagnosis of HF were randomised to the intervention group (nurse-led education programme, facilitated telephone communication and follow-up visits with an internist at 15 days, 1 and 6 months) or to the usual care group (follow-up by their primary care physician). The primary endpoints were all-cause readmissions and all-cause deaths during the 6-month post-discharge period.

RESULTS

There were 81 all-cause hospital readmissions in the intervention group and 82 in the control group (P = NS). Fourteen patients (14%) in the intervention group and eight patients (8%) in the control group died during the study period (P = NS). Unplanned outpatient visits were less frequent in the intervention group than in the control group (39 [28%] versus 99 [72%], P < 0.001).

CONCLUSIONS

The present low-cost HF management programme reduced unplanned outpatient visits but proved ineffective in reducing subsequent readmissions and in improving clinical status. More intense follow-up monitoring and more resources are needed to achieve better results.

Physiologic aspects of aging: impact on cancer management and decision making, part I

A gradual diminution in the physiologic reserve or functional capacity over time is the characteristic hallmark of aging, and this has a direct impact on the choice of cancer therapy and its toxicity profile in elderly patients with cancer. With the expected rapid rise of the older population as a subgroup, oncologists will increasingly treat elderly patients. Provision of competent care to this increasing pool of older patients with cancer necessitates that oncology professionals become familiar with age-associated changes in organ physiology and their impact on cancer treatment and toxicity. In this comprehensive review, we have listed changes in cardiovascular, gastrointestinal, pulmonary, and renal physiology with aging. Also enumerated is the impact of these changes on cancer therapy and toxicity in each organ system-based section. Cardiovascular changes primarily lead to reduction of the cardiac functional reserve, with a consequent increase in the risk of congestive heart failure. Changes in gastrointestinal physiology lead to increased mucosal damage. A reduction in pulmonary reserve has implications for postradiation complications, and a decline in renal function leads to an increased potential for nephrotoxicity. These changes impair the ability of older patients with cancer to tolerate cancer therapy and increase their risk of toxicities. This may lead to an overall decline in functional status, resulting frailty, poor quality of life, and ultimately poor outcomes. Becoming familiar with age-related physiologic changes is the first step for oncologists seeking to better tailor their treatments. This, combined with adoption of some of the clinical interventions suggested in this review, can help better manage the geriatric oncology patient. Further research is necessary for the development of more specific evidence-based recommendations.