Knowledge Gaps in Cardiovascular Care of the Older Adult Population: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Geriatrics Society

Nephrology-tailored geriatric assessment as decision-making tool in kidney failure

BACKGROUND

Dialysis might not benefit all older patients with kidney failure, particularly those with multimorbid conditions and frailty. Patients' and healthcare professionals' awareness of the presence of geriatric impairments could improve outcomes by tailoring treatment plans and decisions for individual patients.

OBJECTIVE

We aimed to explore the perspectives of patients and healthcare professionals on nephrology-tailored geriatric assessment to fuel decision-making for treatment choices in older patients with kidney failure.

DESIGN

In an exploratory qualitative study using focus groups, participants discussed perspectives on the use and value of nephrology-tailored geriatric assessment for the decision-making process to start or forego dialysis.

PARTICIPANTS AND MEASUREMENTS

Patients (n = 18) with kidney failure, caregivers (n = 4), and professionals (n = 25) were purposively sampled from 10 hospitals. Interviews were audio-recorded, transcribed verbatim and inductively analysed using thematic analysis.

RESULTS

Three main themes emerged that supported or impeded decision-making in kidney failure: (1) patient psycho-social situation; (2) patient-related factors on modality choice; (3) organisation of health care. Patients reported feeling vulnerable due to multiple chronic conditions, old age, experienced losses in life and their willingness to trade longevity for quality of life. Professionals recognised the added value of nephrology-tailored geriatric assessment in three major themes: (i) facilitating continual holistic assessment, (ii) filling the knowledge gap, and (iii) uncovering important patient characteristics.

CONCLUSIONS

nephrology-tailored geriatric assessment was perceived as a valuable tool to identify geriatric impairments in older patients with kidney failure. Integration of its outcomes can facilitate a more holistic approach to inform choices and decisions about kidney replacement therapy.

The association between frailty and in-hospital mortality in critically ill patients with congestive heart failure: results from MIMIC-IV database

Background

Frailty correlates with adverse outcomes in many cardiovascular diseases and is prevalent in individuals with heart failure (HF). The Hospital Frailty Risk Score (HFRS) offers an integrated, validated solution for frailty assessment in acute care settings, but its application in critically ill patients with congestive HF lacks exploration. This study aimed to identify the association between frailty assessed by the HFRS and in-hospital mortality in critically ill patients with congestive HF.

Methods

This observational study retrospectively enrolled 12,179 critically ill patients with congestive HF. Data from the Medical Information Mart for Intensive Care IV database was used. The HFRS was calculated to assess frailty. Patients were categorized into three groups: non-frailty (HFRS < 5, n = 7,961), pre-frailty (5 ≤ HFRS < 15, n = 3,684), and frailty (HFRS ≥ 15, n = 534). Outcomes included in-hospital mortality, length of intensive care unit stay, and length of hospital stay. Multiple logistic regression and Locally Weighted Scatterplot Smoothing (LOWESS) smoother were used to investigate the association between frailty and outcomes. Subgroup analysis was employed to elucidate the correlation between frailty levels and in-hospital mortality across diverse subgroups.

Results

12,179 patients were enrolled, 6,679 (54.8%) were male, and the average age was 71.05 ± 13.94 years. The overall in-hospital mortality was 11.7%. In-hospital mortality increased with the escalation of frailty levels (non-frailty vs. pre-frailty vs. frailty: 9.7% vs. 14.8% vs. 20.2%, P < 0.001). The LOWESS curve demonstrated that the HFRS was monotonically positively correlated with in-hospital mortality. Upon controlling for potential confounders, both pre-frailty and frailty statuses were found to be independently linked to a heightened risk of mortality during hospitalization (odds ratio [95% confidence interval]: pre-frailty vs. non-frailty: 1.27 [1.10-1.47], P = 0.001; frailty vs. non-frailty: 1.40 [1.07-1.83], P = 0.015; P for trend < 0.001). Significant interactions between frailty levels and in-hospital mortality were observed in the following subgroups: race, heart rate, creatinine, antiplatelet drug, diabetes, cerebrovascular disease, chronic renal disease, and sepsis.

Conclusion

In critically ill patients with congestive HF, frailty as assessed by the HFRS emerged as an independent predictor for the risk of in-hospital mortality. Prospective, randomized studies are required to determine whether improvement of frailty levels could improve clinical prognosis.

The Importance of Cultural Awareness in the Management of Heart Failure: A Narrative Review

Heart failure is a commonly encountered clinical syndrome arising from a range of etiologic cardiovascular diseases and manifests in a phenotypic spectrum of varying degrees of systolic and diastolic ventricular dysfunction. Those affected by this life-limiting illness are subject to an array of burdensome symptoms, poor quality of life, prognostic uncertainty, and a relatively onerous and increasingly complex treatment regimen. This condition occurs in epidemic proportions worldwide, and given the demographic trend in societal ageing, the prevalence of heart failure is only likely to increase. The marked upturn in international migration has generated other demographic changes in recent years, and it is evident that we are living and working in ever more ethnically and culturally diverse communities. Professionals treating those with heart failure are now dealing with a much more culturally disparate clinical cohort. Given that the heart failure disease trajectory is unique to each individual, these clinicians need to ensure that their proposed treatment options and responses to the inevitable crises intrinsic to this condition are in keeping with the culturally determined values, preferences, and worldviews of these patients and their families. In this narrative review, we describe the importance of cultural awareness across a range of themes relevant to heart failure management and emphasize the centrality of cultural competence as the basis of appropriate care provision.

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review PART II-Pharmacological Approach for Management of Elderly Patients with Peripheral Atherosclerotic Lesions outside Coronary Territory

BACKGROUND

Aging is a key risk factor for atherosclerosis progression that is associated with increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity, quality of life, and it is associated with reduced life expectancy. As most multicenter randomized trials exclude elderly and very elderly patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home, there is insufficient data on the management of older patients presenting with atherosclerotic lesions outside coronary territory. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment. In addition, due to a variety of severe comorbidities in the elderly, the average daily number of pills taken by octogenarians exceeds nine. Polypharmacy frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and non-adherence. Therefore, we have attempted to gather data on the medical treatment in patients with extra-cardiac atherosclerotic lesions indicating where there is some evidence of the management in elderly patients and where there are gaps in evidence-based medicine. Public PubMed databases were searched to review existing evidence on the effectiveness of lipid-lowering, antithrombotic, and new glucose-lowering medications in patients with extra-cardiac atherosclerotic occlusive disease.

Effectiveness of low-density lipoprotein cholesterol reduction with lipid lowering therapy for secondary prevention amongst older individuals: a nationwide cohort study

BACKGROUND

Data about the clinical benefit from initial low-density lipoprotein cholesterol (LDL-C) reduction with lipid lowering treatment for secondary prevention and risk of major vascular events amongst older as compared with younger individuals treated during routine clinical care are limited. We investigated this in a nationwide cohort.

METHODS

Individuals aged ≥ 50 years with a first-time hospitalisation for a cardiovascular event (index event, including acute coronary syndrome, non-haemorrhagic stroke, transient ischaemic attack and coronary revascularisation), 1 January 2008 to 31 October 2018, who subsequently used lipid lowering treatment, and had an LDL-C measurement before and after the event were included. Hazard ratios (HRs) for major vascular events per 1 mmol/L reduction in LDL-C were estimated for the included 21,751 older and 22,681 younger individuals (≥/<70 years old) using Cox regression.

RESULTS

LDL-C lowering was associated with a 12% lower risk of major vascular events in older individuals per 1 mmol/L reduction in LDL-C (HR 0.88, 95% confidence interval [CI] 0.84-0.93), with no significant difference compared with the risk reduction amongst younger individuals (HR 0.88, 95% CI 0.83-0.93; P-value for difference between age groups: 0.86). The risk reduction was more pronounced when post hoc restricting, as a proxy for compliance, to new users with an LDL-C reduction above the lowest decile for both older (0.81, 95% CI 0.73-0.90) and younger (0.81, 95% CI 0.72-0.91) individuals.

CONCLUSIONS

This study strongly supports a similar relative clinical benefit of LDL-C reduction with lipid lowering treatment for secondary prevention of major vascular events amongst individuals aged ≥70 and <70 years.

Lipidomics identified novel cholesterol-independent predictors for risk of incident coronary heart disease: Mediation of risk from diabetes and aggravation of risk by ambient air pollution

INTRODUCTION

Previous lipidomics studies have identified various lipid predictors for cardiovascular risk, however, with limited predictive increment, sometimes using too many predictor variables at the expense of practical efficiency.

OBJECTIVES

To search for lipid predictors of future coronary heart disease (CHD) with stronger predictive power and efficiency to guide primary intervention.

METHODS

We conducted a prospective nested case-control study involving 1,621 incident CHD cases and 1:1 matched controls. Lipid profiling of 161 lipid species for baseline fasting plasma was performed by liquid chromatography-mass spectrometry.

RESULTS

In search of CHD predictors, seven lipids were selected by elastic-net regression during over 90% of 1000 cross-validation repetitions, and the derived composite lipid score showed an adjusted odds ratio of 3.75 (95% confidence interval: 3.15, 4.46) per standard deviation increase. Addition of the lipid score into traditional risk model increased c-statistic to 0.736 by an increment of 0.077 (0.063, 0.092). From the seven lipids, we found mediation of CHD risk from baseline diabetes through sphingomyelin (SM) 41:1b with a considerable mediation proportion of 36.97% (P < 0.05). We further found that the positive associations of phosphatidylcholine (PC) 36:0a, SM 41:1b, lysophosphatidylcholine (LPC) 18:0 and LPC 20:3 were more pronounced among participants with higher exposure to fine particulate matter or its certain components, also to ozone for LPC 18:0 and LPC 20:3, while the negative association of cholesteryl ester (CE) 18:2 was attenuated with higher black carbon exposure (P < 0.05).

CONCLUSION

We identified seven lipid species with greatest predictive increment so-far achieved for incident CHD, and also found novel biomarkers for CHD risk stratification among individuals with diabetes or heavy air pollution exposure.

Predicting mortality and re-hospitalization for heart failure: a machine-learning and cluster analysis on frailty and comorbidity

BACKGROUND

Machine-learning techniques have been recently utilized to predict the probability of unfavorable outcomes among elderly patients suffering from heart failure (HF); yet none has integrated an assessment for frailty and comorbidity. This research seeks to determine which machine-learning-based phenogroups that incorporate frailty and comorbidity are most strongly correlated with death or readmission at hospital for HF within six months following discharge from hospital.

METHODS

In this single-center, prospective study of a tertiary care center, we included all patients aged 65 and older discharged for acute decompensated heart failure. Random forest analysis and a Cox multivariable regression were performed to determine the predictors of the composite endpoint. By k-means and hierarchical clustering, those predictors were utilized to phenomapping the cohort in four different clusters.

RESULTS

A total of 571 patients were included in the study. Cluster analysis identified four different clusters according to frailty, burden of comorbidities and BNP. As compared with Cluster 4, we found an increased 6-month risk of poor outcomes patients in Cluster 1 (very frail and comorbid; HR 3.53 [95% CI 2.30-5.39]), Cluster 2 (pre-frail with low levels of BNP; HR 2.59 [95% CI 1.66-4.07], and in Cluster 3 (pre-frail and comorbid with high levels of BNP; HR 3.75 [95% CI 2.25-6.27])).

CONCLUSIONS

In older patients discharged for ADHF, the cluster analysis identified four distinct phenotypes according to frailty degree, comorbidity, and BNP levels. Further studies are warranted to validate these phenogroups and to guide an appropriate selection of personalized, model of care.

LDL-C Reduction With Lipid-Lowering Therapy for Primary Prevention of Major Vascular Events Among Older Individuals

BACKGROUND

Reducing low-density lipoprotein (LDL) cholesterol with lipid-lowering therapy has consistently been shown to lower the risk of cardiovascular disease in primary prevention trials where the majority of individuals are aged <70 years. For older individuals, however, evidence is less clear.

OBJECTIVES

In this study, the authors sought to compare the clinical effectiveness of lowering LDL cholesterol by means of lipid-lowering therapy for primary prevention of cardiovascular disease among older and younger individuals in a Danish nationwide cohort.

METHODS

We included individuals aged ≥50 years who had initiated lipid-lowering therapy from January 1, 2008, to October 31, 2017, had no history of atherosclerotic cardiovascular disease, and had a baseline and a within-1-year LDL cholesterol measurement. We assessed the associated risk of major vascular events among older individuals (≥70 years) by HRs per 1 mmol/L reduction in LDL cholesterol compared with younger individuals (<70 years).

RESULTS

For both the 16,035 older and the 49,155 younger individuals, the median LDL cholesterol reduction was 1.7 mmol/L. Each 1 mmol/L reduction in LDL cholesterol in older individuals was significantly associated with a 23% lower risk of major vascular events (HR: 0.77; 95% CI: 0.71-0.83), which was equal to that of younger individuals (HR: 0.76; 95% CI: 0.71-0.80; P value for difference = 0.79). Similar results were observed across all secondary analyses.

CONCLUSIONS

Our study supports a relative clinical benefit of lowering LDL cholesterol for primary prevention of major vascular events in individuals aged ≥70 years similarly as in individuals aged <70 years.

A two-point strategy to clarify prognosis in >80 year olds experiencing out of hospital cardiac arrest

BACKGROUND

The global population is aging, with the number of ≥80-year-olds projected to triple over the next 30 years. Rates of out-of-hospital cardiac arrest (OHCA) are also increasing within this age group.

METHODS

The Victorian Ambulance Cardiac Arrest Registry was utilised to identify OHCAs in patients aged ≥80 years between 2002-2021. Predictors of survival to discharge were defined and a prognostic score derived from this cohort.

RESULTS

77,628 patients experienced OHCA of whom 25,269 (32.6%) were ≥80 years (80-90 years = 18,956; 90-100 years = 6,148; >100 years = 209). The number of patients ≥80 years increased over time both absolutely (p = 0.002) and proportionally (p = 0.028). 619 (2.4%) patients survived to discharge without change over time. Older ages had no difference in witnessed OHCA status but were less likely to have shockable rhythm (OR 0.50 (95% CI 0.44-0.57) for 90-100-year-olds, OR 0.28 (95% CI 0.12-0.63) for 90-100-year-olds). If OHCA was witnessed and there was a shockable rhythm then survival was 14%; if one factor was present survival was 5-6% and if neither factor was present, survival was 0.09%. These survival rates enabled derivation of a simplified prognostic assessment score - the '15/5/0' score - highly comparable to a previously-published American cohort.

CONCLUSIONS

Elderly OHCA rates have increased to one-third of caseload. The most important factors predicting survival were whether the OHCA was witnessed and there was a shockable rhythm. We present a simple two-point '15/5/0' prognostic score defining which patients will gain most from advanced resuscitative measures.

Complete or Culprit-Only PCI in Older Patients with Myocardial Infarction

BACKGROUND

The benefit of complete revascularization in older patients (≥75 years of age) with myocardial infarction and multivessel disease remains unclear.

METHODS

In this multicenter, randomized trial, we assigned older patients with myocardial infarction and multivessel disease who were undergoing percutaneous coronary intervention (PCI) of the culprit lesion to receive either physiology-guided complete revascularization of nonculprit lesions or to receive no further revascularization. Functionally significant nonculprit lesions were identified either by pressure wire or angiography. The primary outcome was a composite of death, myocardial infarction, stroke, or any revascularization at 1 year. The key secondary outcome was a composite of cardiovascular death or myocardial infarction. Safety was assessed as a composite of contrast-associated acute kidney injury, stroke, or bleeding.

RESULTS

A total of 1445 patients underwent randomization (720 to receive complete revascularization and 725 to receive culprit-only revascularization). The median age of the patients was 80 years (interquartile range, 77 to 84); 528 patients (36.5%) were women, and 509 (35.2%) were admitted for ST-segment elevation myocardial infarction. A primary-outcome event occurred in 113 patients (15.7%) in the complete-revascularization group and in 152 patients (21.0%) in the culprit-only group (hazard ratio, 0.73; 95% confidence interval [CI], 0.57 to 0.93; P = 0.01). Cardiovascular death or myocardial infarction occurred in 64 patients (8.9%) in the complete-revascularization group and in 98 patients (13.5%) in the culprit-only group (hazard ratio, 0.64; 95% CI, 0.47 to 0.88). The safety outcome did not appear to differ between the groups (22.5% vs. 20.4%; P = 0.37).

CONCLUSIONS

Among patients who were 75 years of age or older with myocardial infarction and multivessel disease, those who underwent physiology-guided complete revascularization had a lower risk of a composite of death, myocardial infarction, stroke, or ischemia-driven revascularization at 1 year than those who received culprit-lesion-only PCI. (Funded by Consorzio Futuro in Ricerca and others; FIRE ClinicalTrials.gov number, NCT03772743.).

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Comparative analysis of level of evidence and class of recommendation for 50 clinical practice guidelines released by the European Society of Cardiology from 2011 to 2022

BACKGROUND

The European Society of Cardiology (ESC) clinical practice guidelines are essential tools for decision-making.

AIM

To analyze the level of evidence (LOE) and the class of recommendations in the ESC guidelines released in the last 12 years.

METHODS

We evaluated 50 ESC guidelines released from 2011 to 2022, related to 27 topics and categorized them into seven macro-groups. We analyzed every recommendation in terms of LOE and class of recommendation, calculating their relative proportions and changes over time in consecutive editions of the same guideline.

RESULTS

A total of 6972 recommendations were found, with an increase in number per year over time. Among the 50 ESC guidelines, the proportional distribution of classes of recommendations was 49% for Class I, 29% for Class IIa, 15% for Class IIb, and 8% for Class III. Overall, 16% of the recommendations were classified as LOE A, 31% LOE B and 53% LOE C. The field of preventive cardiology had the largest proportion of LOE A, while the lowest was in the field of valvular, myocardial, pericardial and pulmonary diseases. The overall proportion of LOE A recommendations in the most recent guidelines compared to their prior versions increased from 17% to 20%.

CONCLUSIONS

The recommendations included in the ESC guidelines widely differ in terms of quality of evidence, with only 16% supported by the highest quality of evidence. Although a slight global increase in LOE A recommendations was observed in recent years, further scientific research efforts are needed to increase the quality of evidence.

Epigenetic Reader Bromodomain-Containing Protein 4 in Aging-Related Vascular Pathologies and Diseases: Molecular Basis, Functional Relevance, and Clinical Potential

Aging is a key independent risk factor of various vascular diseases, for which the regulatory mechanisms remain largely unknown. Bromodomain-containing protein 4 (BRD4) is a member of the Bromodomain and Extra-Terminal domain (BET) family and is an epigenetic reader playing diverse roles in regulating transcriptional elongation, chromatin remodeling, DNA damage response, and alternative splicing in various cells and tissues. While BRD4 was initially recognized for its involvement in cancer progression, recent studies have revealed that the aberrant expression and impaired function of BRD4 were highly associated with aging-related vascular pathology, affecting multiple key biological processes in the vascular cells and tissues, providing new insights into the understanding of vascular pathophysiology and pathogenesis of vascular diseases. This review summarizes the recent advances in BRD4 biological function, and the progression of the studies related to BRD4 in aging-associated vascular pathologies and diseases, including atherosclerosis, aortic aneurism vascular neointima formation, pulmonary hypertension, and essential hypertension, providing updated information to advance our understanding of the epigenetic mechanisms in vascular diseases during aging and paving the way for future research and therapeutic approaches.

Predictors of mortality and clinical outcomes following implantable cardioverter-defibrillator therapy in elderly patients: A retrospective single-center cohort study

Background and aims

Implantable cardioverter-defibrillators (ICDs) are frequently used to prevent sudden cardiac death in patients with high-risk arrhythmias. However, the use of ICD therapy in elderly patients beyond the predicted age of life expectancy is still controversial. We aimed to evaluate the predictors of mortality and clinical outcomes following ICD implantation in elderly patients.

Methods

We conducted a retrospective analysis of 145 elderly patients aged 72 years and older who received ICD implantation between January 2010 and August 2015. We collected and analyzed baseline data, including clinical, demographic, and medical history, the reason for ICD therapy, procedural data, and echocardiography results. Follow-up data included the development of complications and mortality. The predictors of mortality were identified using the univariate and multivariable Cox regression models.

Results

During the median follow-up duration of 30.5 [18.0-48.0] months, 141 cases completed follow-up (mean age = 76.0 ± 3.7 years). Forty-four patients experienced at least one episode of ICD therapy. Inappropriate shock, recurrent shock, and device-related infection were the most frequent complications observed in our study. Of the 145 patients, 42 died during the follow-up period, with an average survival time of 22.4 months after ICD implantation. Among these patients, 11 received ICD for primary prevention, and 31 received it for secondary prevention. Cardiovascular problems were the leading cause of death. We found that a low baseline ejection fraction (EF) was an independent predictor of mortality (hazard ratio = 0.93, 95% confidence interval: 0.90-0.98; p = 0.008).

Conclusion

Our study suggests that ICD therapy is a valuable treatment option for elderly patients beyond their predicted age of life expectancy. The study highlights the importance of baseline EF as a significant predictor of mortality in these patients.

Cardiology and lifestyle medicine

Poor lifestyle habits, such as physical inactivity and poor diets, are highly prevalent within society and even more so among patients with chronic disease. The need to stem poor lifestyle habits has led to the development of a new field of Lifestyle Medicine, whose mission is to prevent, treat, and even reverse chronic diseases through lifestyle interventions. Three fields within Cardiology relate to this mission: Cardiac Rehabilitation, Preventive Cardiology, and Behavioral Cardiology. Each of these three fields have contributed substantially to the reduction of cardiovascular disease (CVD) morbidity and mortality. The historic contributions of these three cardiac fields are reviewed as well as the challenges each of these fields has faced in optimizing the application of lifestyle medicine practices. A shared agenda between Cardiology and the American College of Lifestyle Medicine could further the utilization of behavioral interventions. This review suggests seven steps that could be shared by these organizations and other medical societies. First, there is a need to develop and promulgate the assessment of lifestyle factors as "vital signs" during patient visits. Second, developing a strong partnership between the fields of Cardiology and Physiatry could improve important aspects of cardiac care, including a potential redesign of cardiac stress testing. Third, behavioral evaluations should be optimized at patients' entrée points into medical care since these may be considered "windows of opportunity". Fourth, there is a need to broaden cardiac rehabilitation into inexpensive programs and make this program eligible for patients with risk factors but no known CVD. Fifth, lifestyle medicine education should be integrated into the core competencies for relevant specialties. Sixth, there is a need for inter-societal advocacy to promote lifestyle medicine practices. Seventh, the well-being effects of healthy lifestyle behaviors, such as their impact on one's sense of vitality, should be emphasized.

Management of Stable Angina in the Older Adult Population

As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.

Acute coronary syndrome in very elderly patients-a real-world experience

Very elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes (ACS). Notably, age represents both a proxy of frailty and an exclusion criterion in clinical randomized trials, which probably contributes to lack of data and undertreatment of real-world elderly patients. The aim of the study is to describe patterns of treatment and outcome of very elderly patients with ACS. All consecutive patients aged ≥ 80 years old (yo) admitted between January 2017 and December 2019 with ACS were included. The primary endpoint was in-hospital occurrence of major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, new onset cardiogenic shock, definite/probable stent thrombosis, and ischemic stroke. The secondary endpoints were in-hospital incidence of Thrombolysis in Myocardial Infarction (TIMI) major/minor bleedings, contrast-induced nephropathy (CIN), six-month all-cause mortality, and unplanned readmission. One hundred ninety-three patients (mean age 84.1 ± 3.5 yo, 46% females) were included, of whom 86 (44.6%), 79 (40.9%), and 28 (14.5%) presented with ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA), respectively. The vast majority of patients received an invasive strategy, with 92.7% undergoing coronary angiography and 84.4% to percutaneous coronary intervention (PCI). Aspirin was administered to 180 (93.3%) patients, clopidogrel to 89 (46.1%) patients, and ticagrelor to 85 (44%) patients. In-hospital MACE occurred in 29 patients (15.0%), whereas 3 (1.6%) and 12 patients (7.2%) experienced in-hospital TIMI major and TIMI minor bleeding, respectively. Of the overall population, 177 (91.7%) were discharged alive. After discharge, 11 patients (6.2%) died of all-cause death, whereas 42 patients (23.7%) required a new hospitalization within six months. Invasive strategy of ACS in elderly patients seems safe and effective. Six-month new hospitalization appears inevitably related to age.

Clinical Predictors and Prognosis of Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) without ST-Segment Elevation in Older Adults

A non-neglectable percentage of patients with non-ST elevation myocardial infarction (NSTEMI) show non-obstructive coronary arteries (MINOCA). Specific data in older patients are scarce. We aimed to identify the clinical predictors of MINOCA in older patients admitted for NSTEMI and to explore the long-term prognosis of MINOCA. This was a single-center, observational, consecutive cohort study of older (≥70 years) patients admitted for NSTEMI between 2010 and 2014 who underwent coronary angiography. Univariate and multivariate Cox regression were performed to analyze the association of variables with MINOCA and all-cause mortality and with major adverse cardiac events (MACE), defined as a combined endpoint of all-cause mortality and nonfatal myocardial infarction and a combined endpoint of cardiovascular mortality, nonfatal myocardial infarction, and unplanned revascularization. The registry included 324 patients (mean age 78.8 ± 5.4 years), of which 71 (21.9%) were diagnosed with MINOCA. Predictors of MINOCA were female sex, left bundle branch block, pacemaker rhythm, chest pain at rest, peak troponin level, previous MI, Killip ≥2, and ST segment depression. Regarding prognosis, patients with obstructive coronary arteries (stenosis ≥50%) and the subgroup of MINOCA patients with plaques <50% had a similar prognosis; while MINOCA patients with angiographically smooth coronary arteries had a reduced risk of MACE. We conclude that the following: (1) in elderly patients admitted for NSTEMI, certain universally available clinical, electrocardiographic, and analytical variables are associated with the diagnosis of MINOCA; (2) elderly patients with MINOCA have a better prognosis than those with obstructive coronary arteries; however, only those with angiographically smooth coronary arteries have a reduced risk of all-cause mortality and MACE.

Clinical Perspectives on Cardiac Rehabilitation After Heart Failure in Elderly Patients with Frailty: A Narrative Review

The purpose of this narrative review is to examine rehabilitation modalities for patients with heart failure and Frailty who require comprehensive intervention. Ischemic heart disease is the leading cause of death worldwide, accounting for 16% of global mortality. Due to population growing and aging, the total number of heart failure patients continues to rise, a condition known as the heart failure pandemic. Furthermore, frailty has been associated with an increased risk for heart failure and increased morbidity and mortality. The 2021 update of the 2017 ACC expert consensus decision pathway for optimization of HF treatment has become more concerning, citing frailty as one of the 10 most important issues associated with heart failure with reduced ejection fraction (HFrEF). Frailty and heart failure share common pathological mechanisms and are associated with poor clinical outcomes. Most studies of frailty in patients with heart failure primarily focus on physical frailty, and associations between psycho-psychological and social factors such as cognitive dysfunction and social isolation have also been reported. These results suggest that a more comprehensive assessment of frailty is important to determine the risk in patients with heart failure. Therefore, mechanisms of the three domains, including not only physical frailty but also cognitive, psychological, spiritual, and social aspects, should be understood. In addition to interventions in these three domains, nutritional and pharmacological interventions are also important and require tailor-made interventions for the widely varied conditions associated with heart failure and frailty. Although several studies have shown a relationship between frailty and prognosis in patients with heart failure, interventions to improve the prognosis have not yet been established. Further information is needed on frailty intervention by a multidisciplinary team to improve the prognosis.

Comparing health outcomes between coronary interventions in frail patients aged 75 years or older with acute coronary syndrome: a systematic review

Aim

To assess the current evidence comparing the health outcomes of coronary interventions in frail patients aged 75 years or older with acute coronary syndrome.

Findings

Available studies are observational and limited by incomplete statistical adjustment required for robust causal analysis. There may be a signal for improved outcomes in acute coronary syndrome patients treated invasively vs conservatively.

Message

Robust studies are needed to inform the optimal selection of coronary interventions in frail older patients with acute coronary syndrome.

Purpose

To assess current evidence comparing the impact of available coronary interventions in frail patients aged 75 years or older with different subtypes of acute coronary syndrome (ACS) on health outcomes.

Methods

Scopus, Embase and PubMed were systematically searched in May 2022 for studies comparing outcomes between coronary interventions in frail older patients with ACS. Studies were excluded if they provided no objective assessment of frailty during the index admission, under-represented patients aged 75 years or older, or included patients with non-ACS coronary disease without presenting results for the ACS subgroup. Following data extraction from the included studies, a qualitative synthesis of results was undertaken.

Results

Nine studies met all eligibility criteria. All eligible studies were observational. Substantial heterogeneity was observed across study designs regarding ACS subtypes included, frailty assessments used, coronary interventions compared, and outcomes studied. All studies were assessed to be at high risk of bias. Notably, adjustment for confounders was limited or not adequately reported in all studies. The comparative assessment suggested a possible efficacy signal for invasive treatment relative to conservative treatment but possibly at the risk of increased bleeding events.

Conclusions

There is a paucity of evidence comparing health outcomes between different coronary interventions in frail patients aged 75 years or older with ACS. Available evidence is at high risk of bias. Given the growing importance of ACS in frail patients aged 75 years or older, new studies are needed to inform optimal ACS care for this population. Future studies should rigorously adjust for confounders.

Comparison of the prognostic value of frailty assessment tools in patients aged ≥ 65 years hospitalized in a cardiac care unit with acute coronary syndrome

BACKGROUND

Frailty is associated with adverse events in elderly patients with acute coronary syndrome (ACS). Our aim was to compare the prognostic value of four frailty scales in patients aged ≥ 65 years hospitalized with ACS in a cardiac care unit (CCU).

METHODS

Patients aged ≥ 65 years with ACS were included. Frailty was assessed using the Fried frailty scale (reference standard), the Edmonton Frail Scale (EFS), the FRAIL scale, and the Clinical frailty scale (CFS). The primary end point was all-cause mortality and the secondary end point was unscheduled rehospitalization.

RESULTS

One hundred and seventy four patients aged ≥ 65 years with ACS were recruited. The median follow-up was 637.5 days. Frailty was identified in 41.4%, 40.2%, 39.1% and 36.3% patients by the Fried frailty scale, EFS, FRAIL scale and CFS, respectively. The agreement coefficients were 0.88, 0.86, and 0.79 for the FRAIL scale, EFS and CFS, respectively. In the Cox regression model, frailty was associated with all-cause mortality regardless of the scale used (univariate: hazard ratio [HR] 95% CI = 10.5, 2.4-46.8 Fried frailty scale; 12.0, 2.7-53.4 FRAIL scale; 7.1, 2.0-25.2 EFS; 8.3, 2.4-29.6 CFS. Multivariate: HR = 5.1, 1.1-23.8 Fried frailty scale; 5.7, 1.2-26.8 FRAIL scale; 3.7, 1.0-14.0 EFS; 4.2, 1.1-15.9 CFS). The FRAIL scale had the highest HR. In the univariate analysis, frailty was associated with unscheduled rehospitalization (HR = 3.2, 1.7-6.0 Fried frailty scale; 3.4, 1.8-6.3 FRAIL scale; 3.5, 1.8-6.6 EFS; 3.1, 1.7-5.8 CFS). In the multivariate analysis, only the EFS independently predicted unscheduled rehospitalization (HR = 2.2, 1.1-4.63).

CONCLUSIONS

Frailty assessed by the Fried frailty scale, FRAIL scale, EFS and CFS is associated with all-cause mortality and unscheduled rehospitalization in elderly patients hospitalized in a CCU with ACS. The adjusted HR of the FRAIL scale for all-cause mortality was the highest among the scales compared, whereas the EFS was an independent predictor of unscheduled rehospitalization. These data should be taken into consideration when choosing a frailty assessment tool.

Cardiorespiratory Fitness and Mortality in Patients Aged 60 to 90 Years

Chronological age alone does not fully reflect a patient's prognosis. We sought to assess the association of cardiorespiratory fitness (quantified by METs) with all-cause mortality among patients aged 60 to 90 years. This retrospective study included patients who underwent exercise treadmill testing at an integrated healthcare system from 2011 to 2019. Patients were categorized into age groups: 60 to <70 years, 70 to <80 years, and 80 to 90 years; and cardiorespiratory fitness level: low (<5 METs), moderate (5 to 10 METs), and high fitness (>10 METs). Mean follow-up was 3.5 years. A total of 40,520 patients were included (mean age 67.7 ± 4.7 years, 48.6% women). Of whom, 27,021 were 60 to <70 years old (66.7%); 12,638 70 to <80 years old (31.2%); and 1,861 80 to 90 years old (4.6%). There were 3,494 patients categorized as low (8.6%), 21,863 as moderate (54%), and 15,163 as high fitness (37.4%). Low fitness level was independently associated with lower survival (hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.15 to 2.24). Using age 60 to 70 group with high fitness level as reference, the age 80 to 90 group with high fitness level had better survival than their younger counterparts with low fitness level (age 80 to 90 years high fitness level: HR 2.9, 95% CI 1.2 to 7.2; age 60 to 70 years low fitness level: HR 4.3, 95% CI 3.1 to 5.9; age 70 to 80 years low fitness level: HR 6.8, 95% CI 5.2 to 8.9) on adjusted analysis. In conclusion, higher cardiorespiratory fitness is associated with better survival. Patients >80 years old with high fitness level have comparable or even better survival than their younger counterparts with submoderate fitness levels. Chronological age alone should not be the only factor when considering prognosis.

Frailty, Guideline-Directed Medical Therapy, and Outcomes in HFrEF: From the GUIDE-IT Trial

OBJECTIVES

In this study, we sought to evaluate the association of frailty with the use of optimal guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF).

BACKGROUND

The burden of frailty in HFrEF is high, and the patterns of GDMT use according to frailty status have not been studied previously.

METHODS

A post hoc analysis of patients with HFrEF enrolled in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment in Heart Failure) trial was conducted. Frailty was assessed with the use of a frailty index (FI) using a 38-variable deficit model, and participants were categorized into 3 groups: class 1: nonfrail, FI <0.21); class 2: intermediate frailty, FI 0.21-0.31), and class 3: high frailty, FI >0.31). Multivariate-adjusted Cox models were used to study the association of frailty status with clinical outcomes. Use of optimal GDMT over time (beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists) across frailty strata was assessed with the use of adjusted linear and logistic mixed-effect models.

RESULTS

The study included 879 participants, of which 56.3% had high frailty burden (class 3 FI). A higher frailty burden was associated with a significantly higher risk of HF hospitalization or death in adjusted Cox models: high frailty vs nonfrail HR: 1.76, 95% CI: 1.20-2.58. On follow-up, participants with high frailty burden also had a significantly lower likelihood of achieving optimal GDMT: high frailty vs non-frail GDMT triple therapy use at study end: 17.7% vs 28.4%; P interaction, frailty class × time <0.001.

CONCLUSIONS

Patients with HFrEF with a high burden of frailty have a significantly higher risk for adverse clinical outcomes and are less likely to be initiated and up-titrated on an optimal GDMT regimen.

State of Knowledge on Molecular Adaptations to Exercise in Humans: Historical Perspectives and Future Directions

For centuries, regular exercise has been acknowledged as a potent stimulus to promote, maintain, and restore healthy functioning of nearly every physiological system of the human body. With advancing understanding of the complexity of human physiology, continually evolving methodological possibilities, and an increasingly dire public health situation, the study of exercise as a preventative or therapeutic treatment has never been more interdisciplinary, or more impactful. During the early stages of the NIH Common Fund Molecular Transducers of Physical Activity Consortium (MoTrPAC) Initiative, the field is well-positioned to build substantially upon the existing understanding of the mechanisms underlying benefits associated with exercise. Thus, we present a comprehensive body of the knowledge detailing the current literature basis surrounding the molecular adaptations to exercise in humans to provide a view of the state of the field at this critical juncture, as well as a resource for scientists bringing external expertise to the field of exercise physiology. In reviewing current literature related to molecular and cellular processes underlying exercise-induced benefits and adaptations, we also draw attention to existing knowledge gaps warranting continued research effort. © 2021 American Physiological Society. Compr Physiol 12:3193-3279, 2022.

Age-specific modifiable risk factor profiles for cardiovascular disease and all-cause mortality: a nationwide, population-based, prospective cohort study

Background

National investigations on age-specific modifiable risk factor profiles for cardiovascular disease (CVD) and mortality are scarce in China, the country that is experiencing a huge cardiometabolic burden exacerbated by population ageing.

Methods

This is a nationwide prospective cohort study of 193,846 adults in the China Cardiometabolic Disease and Cancer Cohort Study, 2011-2016. Among 139,925 participants free from CVD at baseline, we examined hazard ratios and population-attributable risk percentages (PAR%s) for CVD and all-cause mortality attributable to 12 modifiable socioeconomic, psychosocial, lifestyle, and metabolic risk factors by four age groups (40-<55 years, 55-<65 years, 65-<75 years, and ≥75 years).

Findings

Metabolic risk factors accounted for 52·4%, 47·2%, and 37·8% of the PAR% for CVD events in participants aged 40-<55 years, 55-<65 years, and 65-<75 years, respectively, with hypertension being the largest risk factor. While in participants aged ≥75 years, lifestyle risk factors contributed to 34·0% of the PAR% for CVD, with inappropriate sleep duration being the predominant risk factor. Most deaths were attributed to metabolic risk factors (PAR% 25·3%) and lifestyle risk factors (PAR% 24·6%) in participants aged 40-<55 years, with unhealthy diet and diabetes being the main risk factors. While in participants aged ≥55 years, most deaths were attributed to lifestyle risk factors (PAR% 26·6%-41·0%) and socioeconomic and psychosocial risk factors (PAR% 26·1%-27·7%). In participants aged ≥75 years, lifestyle risk factors accounted for 41·0% of the PAR% for mortality, with inappropriate sleep duration being the leading risk factor.

Interpretation

We identified age-specific modifiable risk profiles for CVD and all-cause mortality in Chinese adults, with remarkable differences between adults aged ≥75 years and their younger counterparts.

Funding

National Natural Science Foundation of China.

Systolic Blood Pressure and Mortality in Community-Dwelling Older Adults: The Role of Frailty

OBJECTIVES

To investigate whether frailty modifies the association of systolic blood pressure (SBP) with cardiovascular mortality and all-cause mortality in community-dwelling older adults.

DESIGN

A prospective cohort study.

SETTING

A population-based study of nationally representative older Chinese adults in a community setting.

PARTICIPANTS

This study included participants aged 65 years or older from the Chinese Longitudinal Healthy Longevity Survey 2002-2014 and followed up to 2018.

MEASUREMENTS

Participants were divided into two groups according to a frailty index based on the accumulation of a 44-items deficits model. The association between SBP and mortality was analyzed using multivariable-adjusted Cox proportional hazards models.

RESULTS

Among 18,503 participants included, the mean age was 87.2 years and the overall median follow-up time was 42.7 months. We identified 7808 (42.2%) frail participants (mean frailty index=0.33), in which 7533 (96.5%) died during the follow-up. Effect modification by frailty was detected (P for interaction=0.032). Among frail participants, a U-shaped association was found with hazard ratios of 1.16 (95% CI, 1.02-1.32) for SBP < 100 mmHg, and 1.11 (95% CI, 1.00-1.24) for SBP ≥ 150 mmHg compared with SBP 120-130 mmHg. For non-frail older adults, a tendency toward higher risk among those with SBP ≥ 130 mmHg was observed. The analyses towards cardiovascular mortality showed similar results.

CONCLUSION

Our results suggest the presence of effect modification by frailty indicating a possible negative effect for elevated SBP in non-frail older adults and a U-shaped relationship of SBP in frail older adults with respect to mortality even after adjusting for diastolic blood pressure.

Integrating sex and gender in studies of cardiac resynchronization therapy: a systematic review

Aims

To examine the prevalence, temporal changes, and impact of the National Institute of Health (NIH) Sex as a Biological Variable (SABV) policy on sex and gender reporting and analysis in cardiac resynchronization therapy (CRT) cohort studies.

Methods and results

We searched MEDLINE, EMBASE, and Web of Science for cohort studies reporting the effectiveness and safety of CRT in heart failure patients from January 2000 to June 2020, with no language restrictions. Segmented regression analysis was used for policy analysis. We included 253 studies. Fourteen per cent considered sex in the study design. Outcome data disaggregated by sex were only reported in 17% of the studies. Of the studies with statistical models (n = 173), 57% were adjusted for sex. Sixty‐eight per cent of those reported an effect size for sex on the outcome. Sex‐stratified analyses were conducted in 13% of the studies. Temporal analysis shows an increase in sex reporting in background, statistical models, study design, and discussion. Besides statistical models, NIH SABV policy analysis showed no significant change in the reporting of sex in study sections. Gender was not reported or analysed in any study.

Conclusions

There is a need to improve the study design, analysis, and completeness of reporting of sex in CRT cohort studies. Inadequate sex integration in study design and analysis may potentially hinder progress in understanding sex disparities in CRT. Deficiencies in the integration of sex in studies could be overcome by implementing guidance that already exists.

Implementation of an Ask Me 3 ® education video to improve outcomes in post-myocardial infarction patients

Objective: The Advanced Practice Providers (APPs) in an adult cardiology practice in a large metropolitan city, provide hospital follow-up care to post-myocardial infarction (MI) patients. The APPs identified a problem: patients retained very little of the information they receive during their hospitalization. The purpose of this pilot project was to evaluate the impact of an Ask Me 3 ® post-MI education video on patients’ knowledge of self-care activities. The video was designed to promote secondary prevention of cardiovascular disease and support optimal cardiovascular health.

Methods: The project used a pre-test post-test quasi-experimental design to evaluate the feasibility and efficacy of a post-MI education video compared to the standard teaching methods.

Results: The sample consisted of 25 total participants, 12 in the control group and 13 in the intervention group. The increase in the intervention group's post- test scores was statistically significant (p value = 0.0056), showing a vast improvement in knowledge with the addition of an “Ask Me 3” education video.

Conclusion: An “Ask Me 3” post-MI education video may effectively improve cardiovascular secondary prevention when incorporated with the standard teaching methods. Patients may view the video multiple times, enhancing their knowledge of lifestyle modifications following hospitalization and their overall cardiovascular health.

Usefulness of a Novel Risk Score to Predict In-Hospital Mortality in Patients ≥ 60 Years of Age with ST Elevation Myocardial Infarction

Numerous algorithms are available to predict short-term mortality in ST elevation myocardial infarction (STEMI) but none are focused on elderly patients or include invasive hemodynamics. A simplified risk score (LASH score) including left ventricular end diastolic pressure > 20 mm Hg, age > 75 years, systolic blood pressure < 100 mm Hg and heart rate > 100 bpm was tested in a retrospective, single-center study of 346 patients ≥ 60 years old who underwent primary percutaneous coronary intervention (PPCI). The median age was 70 years [IQR: 64, 79], 60.1% were men, and 77.8% identified as White. In-hospital all-cause mortality was 10.1%. Patients with a LASH score ≥ 3 (n = 34) had an in-hospital mortality rate of 44.1% compared to 6.4% for LASH score ≤ 2 (p < 0.0001). The odds ratio for in-hospital mortality for patients with LASH score ≥ 3 was 13.2 (95% CI 5.3-33.1) compared to patients with a LASH score ≤ 2 when adjusted for sex, cardiac arrest, heart failure, and prior cerebrovascular event. The LASH score had an area under the ROC curve for predicting in-hospital mortality of 0.795 [CI 0.716-0.872], as compared to TIMI-STEMI (0.881, CI 0.829-0.931; p = 0.01), GRACE (0.849, CI 0.778-0.920; p = 0.19), shock index (0.769, CI 0.667-0.871; p = 0.51) and modified shock index (0.765, CI 0.716-0.873; p = 0.48). In summary, a simplified, easy to calculate risk score that incorporates age and invasive hemodynamics predicts in-hospital mortality in patients ≥ 60 years old undergoing PPCI for STEMI.

Very long-term outcomes of older adults with stable coronary artery disease (from the CORONOR study)

BACKGROUND

There are limited data on stable coronary artery disease (CAD) in the very elderly. The present study aimed to investigate incident cardiovascular events and mortality in older adults (≥85 years) included in a multicenter registry on stable CAD.

METHODS

A long-term follow-up was performed in 198 patients ≥85 years with stable CAD, free from myocardial infarction (MI) or coronary revascularization within the year. The median age was 87 years. Clinical events during the follow-up period [death, MI, ischemic stroke, coronary revascularization and hospitalization for heart failure (HF)] were centrally adjudicated.

RESULTS

There were 164 deaths during follow-up. The cumulative risk of all-cause death was 9.1% at 1 year, 53.9% at 5 years and 85.5% at 10 years. The cause of death was adjudicated as cardiovascular in 64 patients with death from HF in 36 patients. Male gender, previous hospitalization for HF and an estimated glomerular filtration rate <60 ml/min/1.73 m2 were independently associated with all-cause death. Ten-year cumulative incidences of MI, ischemic stroke and coronary revascularization were low (6.6, 7.7 and 6.6%, respectively). By contrast, the 10-year cumulative incidence of hospitalization for HF was high (27.8%).

CONCLUSION

The 10-year mortality of elderly patients with stable CAD is very high. While ischemic events are relatively unfrequent, HF events are frequent and represent the most common cause of cardiovascular death in this population. Prevention and management of HF are important goals for physicians in charge of older adults with stable CAD.

Revascularization versus medical therapy in patients aged 80 and older with stable ischemic heart disease

BACKGROUND

Older patients are underrepresented in landmark randomized trials for stable ischemic heart disease (SIHD). Therefore, we sought to evaluate the benefits of revascularization in patients ≥80 years old with SIHD.

METHODS

Retrospective study of patients undergoing invasive coronary angiography (ICA) for SIHD between 2009 and 2019. Patients were grouped according to treatment: revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) versus initial medical therapy alone. Inverse probability of treatment weighting (IPTW)-adjusted Cox proportional hazard regression analyses were performed. Outcomes evaluated were all-cause mortality, non-fatal myocardial infarction (MI), and repeat revascularization.

RESULTS

A total of 1015 patients (median age 83.0, interquartile range [IQR] 81.3-85.2 years; 29% female) underwent ICA for SIHD. Of these, 557 (55%) were treated with revascularization and 458 (45%) with initial medical therapy alone. Baseline characteristics were well balanced after IPTW adjustment. At median follow-up of 3.5 years (IQR 1.7-5.9 years), there were no differences in all-cause mortality and non-fatal MI between treatment groups; but there was an increased need for repeat revascularization (IPTW adjusted hazard ratio 2.22, 95% confidence interval 1.53-3.22) with revascularization. Separately comparing PCI or CABG alone versus medical therapy yielded similar results; as well as in subgroup analysis (except for patients ≥90 years old and those without prior CABG).

CONCLUSION

There were no differences in all-cause mortality and non-fatal MI with invasive revascularization (either PCI or CABG) versus medical therapy alone in patients ≥80 years old with SIHD. Large randomized trials focusing on older patients are warranted to guide clinical practice in this growing population.

Clinicians' and patients' experiences of managing heart failure during the COVID-19 pandemic

Background

Severe acute respiratory coronavirus 2 (SARS-CoV-2), also known as coronavirus disease 2019 (COVID-19), resulted in unprecedented societal and healthcare provision change, which has been implemented at pace. Little is known about the indirect impacts of these changes and what the future effects may be.

Aim

To explore patients’ and clinicians’ experiences of managing heart failure (HF) during the COVID-19 pandemic.

Design & setting

Qualitative study in three regions of the UK: Cambridgeshire, Greater Manchester, and the West Midlands.

Method

Semi-structured interviews (n = 30) were conducted with older adults with established HF and healthcare providers from primary and secondary health services involved in their care. Interviews were analysed thematically.

Results

Compliance with the government guidance ‘Stay at home, protect the NHS, and save lives’ during the COVID-19 pandemic, and perceptions relating to risk from COVID-19 and underlying morbidity, drove ‘being careful’ behaviours and organisational changes. Enacting behavioural change and implementing organisational change resulted in opportunities and challenges for health and healthcare practice.

Conclusion

Perception of risk led to significant behavioural and organisational change during the pandemic. Some changes described by both patients and clinicians, such as enhanced relationships and self-monitoring, present as opportunities, and consideration should be given as to how to maintain or develop these. Equally, indirect impacts of COVID-19 and the associated lockdown, such as disengagement and withdrawal, and the fallout from reluctance to access health services, should be acknowledged and interventions to address these challenges are needed.

Effects of aging on clinical outcomes in patients receiving genotype-guided P2Y12 inhibitor selection after percutaneous coronary intervention

STUDY OBJECTIVE

To compare the clinical effectiveness of genotype-guided P2Y12 inhibitor selection following PCI in older patients (≥70 years) and younger patients (<70 years).

DESIGN AND SETTING

Single-center, retrospective, cohort study. Risk of major adverse cardiovascular or cerebrovascular events (MACCE), defined as stent thrombosis, ischemic stroke, transient ischemic attack, non-fatal acute coronary syndrome, or cardiovascular death during 12 months after PCI, was compared across genotype and antiplatelet therapy groups by proportional hazards regression in patients ≥70 years and <70 years.

PATIENTS

1,469 patients who underwent PCI and had CYP2C19 genotype testing at a single academic medical center.

MEASUREMENTS AND MAIN RESULTS

The study population was comprised of 402 (27.4%) ≥70 years (older group) and 1067 (72.6%) <70 years (younger group). Alternative P2Y12 inhibitors (prasugrel or ticagrelor) were used less often in the older group than the younger group in patients with a CYP2C19 no function allele (55% vs. 67%; p = 0.02) and in patients without a no function allele (10% vs. 35%, p < 0.001). For patients treated with clopidogrel, MACCE was significantly higher in no function allele carriers compared to those without a no function allele in the older group (19.2% vs. 12.7%; adjusted HR 2.32; 95% CI 1.07-5.05; p = 0.03) and the younger group (17.4% vs. 10.4%; adjusted HR 2.01; 95% CI 1.17-3.46; p = 0.01). In patients without a no function allele, MACCE risk was similar with clopidogrel compared to prasugrel or ticagrelor in the older group (adjusted HR 0.99; 95% CI 0.44-2.21; p = 0.98) and the younger group (adjusted HR 1.12; 95% CI 0.72-1.74; p = 0.61).

CONCLUSION

This study suggests important clinical benefits of CYP2C19 genotype-guided antiplatelet therapy after PCI in both younger and older patients.

10-Year Follow-Up After Revascularization in Elderly Patients With Complex Coronary Artery Disease

BACKGROUND

The optimal revascularization strategy for the elderly with complex coronary artery disease remains unclear.

OBJECTIVES

The goal of this study was to investigate 10-year all-cause mortality, life expectancy, 5-year major adverse cardiac or cerebrovascular events (MACCE), and 5-year quality of life (QOL) after percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in elderly individuals (>70 years old) with 3-vessel disease (3VD) and/or left main disease (LMD).

METHODS

In the present pre-specified analysis on age of the SYNTAX Extended Survival study, 10-year all-cause death and 5-year MACCE were compared with Kaplan-Meier estimates and Cox proportional hazards models among elderly or nonelderly patients. Life expectancy was estimated by restricted mean survival time within 10 years, and QOL status according to the Seattle Angina Questionnaire up to 5 years was assessed by linear mixed-effects models.

RESULTS

Among 1,800 randomized patients, 575 patients (31.9%) were elderly. Ten-year mortality did not differ significantly between PCI and CABG in elderly (44.1% vs. 41.1%; hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 0.84 to 1.40) and nonelderly patients (21.1% vs. 16.6%; HR: 1.30; 95% CI: 1.00 to 1.69; p_interaction = 0.332). Among elderly patients, 5-year MACCE was comparable between PCI and CABG (39.4% vs. 35.1%; HR: 1.18; 95% CI: 0.90 to 1.56), whereas it was significantly higher in PCI over CABG among nonelderly patients (36.3% vs. 23.0%; HR: 1.69; 95% CI: 1.36 to 2.10; p_interaction = 0.043). There were no significant difference in life expectancy (mean difference: 0.2 years in favor of CABG; 95% CI: -0.4 to 0.7) and 5-year QOL status between PCI and CABG among elderly patients.

CONCLUSIONS

Elderly patients with 3VD and/or LMD had comparable 10-year all-cause death, life expectancy, 5-year MACCE, and 5-year QOL status irrespective of revascularization mode. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050) (SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).

Comprehensive geriatric assessment in elderly and senile patients with cardiovascular diseases. Expert opinion of the Russian Association of Gerontologists and Geriatricians

Senile asthenia syndrome (SAS) is a geriatric syndrome characterized by age-associated decline of the physiological reserve and function in multiple systems, which results in higher vulnerability to effects of endo- and exogenous factors and a high risk of unfavorable outcomes, loss of self-sufficiency, and death. Generally, SAS is observed in elderly patients with comorbidities. In cardiovascular diseases, SAS is associated with a poor prognosis, including a higher incidence of exacerbation and death both during acute events and in chronic disease. However, SAS is often not taken into account in developing diagnostic and therapeutic programs for managing elderly patients with cardiovascular diseases (CVD). This article analyzes available scientific information about SAS, algorithms for SAS diagnosis, and the scales that may be useful in developing individual plans for management of elderly patients with CVD.

Effect of alirocumab on cardiovascular outcomes after acute coronary syndromes according to age: an ODYSSEY OUTCOMES trial analysis

Aims

Lowering low-density lipoprotein cholesterol (LDL-C) reduces cardiovascular risk irrespective of age, but the evidence is less strong for older patients.

Methods and results

This prespecified analysis from ODYSSEY OUTCOMES compared the effect of alirocumab vs. placebo in 18 924 patients with recent acute coronary syndrome (ACS) according to age. We examined the effect of assigned treatment on occurrence of the primary study outcome, a composite of coronary heart disease death, myocardial infarction, ischaemic stroke, or unstable angina requiring hospitalization [major adverse cardiovascular event (MACE)] and all-cause death. Relative risk reductions were consistent for patients ≥65 vs. <65 years for MACE [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.68–0.91 vs. 0.89, 0.80–1.00; P_interaction = 0.19] and all-cause death [HR 0.77, 0.62–0.95 vs. 0.94, 0.77–1.15; P_interaction = 0.46], and consistent for MACE when dichotomizing at age 75 years (HR 0.85, 0.64–1.13 in ≥75 vs. 0.85, 0.78–0.93 in <75, P_interaction = 0.19). When considering age as a continuous variable in regression models, advancing age increased risk of MACE, as well as the absolute reduction in MACE with alirocumab, with numbers-needed-to-treat for MACE at 3 years of 43 (25–186) at age 45 years, 26 (15–97) at age 75 years, and 12 (6–81) for those at age 85 years. Although adverse events were more frequent in older patients, there were no differences between alirocumab and placebo.

Conclusion

In patients with recent ACS, alirocumab improves outcomes irrespective of age. Increasing absolute benefit but not harm with advancing age suggests that LDL-C lowering is an important preventive intervention for older patients after ACS.

Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality

BACKGROUND

Current cardiac intensive care unit (CICU) practice has seen an increase in patient complexity, including an increase in noncardiac organ failure, critical care therapies, and comorbidities. We sought to describe the changing epidemiology of noncardiac multimorbidity in the CICU population.

METHODS

We analyzed consecutive unique patient admissions to 2 geographically distant tertiary care CICUs (n = 16,390). We assessed for the prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities (diabetes, chronic lung, liver, and kidney disease, cancer, and stroke/transient ischemic attack) and their associations with hospital and postdischarge 1-year mortality using multivariable logistic regression.

RESULTS

The prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities was 37.7%, 31.4%, 19.9%, and 11.0%, respectively. Increasing noncardiac comorbidities were associated with a stepwise increase in mortality, length of stay, noncardiac indications for ICU admission, and increased utilization of critical care therapies. After multivariable adjustment, compared with those without noncardiac comorbidities, there was an increased hospital mortality for patients with 1 (odds ratio [OR] 1.30; 95% confidence interval [CI], 1.10-1.54, P = .002), 2 (OR 1.47; 95% CI, 1.22-1.77, P < .001), and ≥3 (OR 1.79; 95% CI, 1.44-2.22, P < .001) noncardiac comorbidities. Similar trends for each additional noncardiac comorbidity were seen for postdischarge 1-year mortality (P < .001, all).

CONCLUSIONS

In 2 large contemporary CICU populations, we found that noncardiac multimorbidity was highly prevalent and a strong predictor of short- and long-term adverse clinical outcomes. Further study is needed to define the best care pathways for CICU patients with acute cardiac illness complicated by noncardiac multimorbidity.

Statin Therapy for Primary Prevention in the Elderly and Its Association with New-Onset Diabetes, Cardiovascular Events, and All-Cause Mortality

PURPOSE

This study assessed associations of the use of statins for primary prevention with cardiovascular outcomes among adults ages ≥70 years.

METHODS

In a retrospective population-based cohort study, new users of statins without cardiovascular disease or diabetes mellitus were stratified by ages ≥70 years and <70 years. Using a time-dependent approach, adherence to statins was evaluated according to the proportion of days covered: <25%, 25%-50%, 50%-75%, and ≥75%. We assessed associations of statin therapy with increased risk of new-onset diabetes mellitus and with decreased risks of major adverse cardiovascular events and all-cause mortality.

RESULTS

Of 42,767 new users of statins, 5970 (14%) were ages ≥70 years. The incident rates of major adverse cardiovascular events, all-cause mortality, and new-onset diabetes mellitus in the highest to lowest proportion of days covered categories were 16.9%, 16.7%, and 9.4% and 6.3%, 1.7%, and 9.4%, respectively. For the older group, the adjusted hazard ratios of major adverse cardiovascular events and mortality were significantly decreased for the highest adherence group (proportion of days covered ≥75%): 0.71 (0.57-0.88) and 0.68 (0.54-0.84), respectively. The respective hazard ratios were less favorable for the younger group: 0.80 (0.68-0.93) and 0.74 (0.58-1.03). The risk of new-onset diabetes mellitus was increased for the younger but not the older group.

CONCLUSIONS

Statin use for primary prevention was associated with cardiovascular benefit in adults ages ≥70 years without a significant risk for the development of diabetes. These data may support the use of statin therapy for primary prevention in the elderly.

Yanyu Decoction for Aged Patients with Stable Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

There was limited evidence of treatments aiming at aged coronary artery disease (CAD) patients. Yanyu decoction (YD) has been used as adjuvant therapy in aged patients with stable CAD and might be a new treatment worthy of recommendation for CAD patients. This study was to evaluate the combined effects of YD plus conventional pharmaceutical treatment (CPT) on senile patients with stable CAD.

Methods

This review was designed according to the PRISMA (Preferred Reported Items for Systematic Reviews and Meta-Analysis) recommendations. A literature search was conducted in seven electronic databases from their inception until August 2020. Primary outcomes of interest were adverse cardiovascular events, including cardiac mortality, acute myocardial infarction (AMI), and unstable angina (UA). The secondary outcomes were blood lipids and hemorheology. Studies were pooled to calculate the risk ratio or weighted mean difference and corresponding 95% confidence interval.

Results

Five studies recruiting 848 aged patients with stable CAD were included. Patients receiving YD as an adjuvant have fewer adverse cardiovascular events, including cardiac mortality, AMI, and UA. Besides, YD plus CPT has a better effect on reducing triglycerides, low-density lipoprotein cholesterol, and improving high-density lipoprotein cholesterol. Moreover, significant effects of YD plus CPT for reducing blood viscosity, plasma viscosity, and platelet aggregation rate were found compared with CPT alone.

Conclusion

YD plus CPT showed better efficacy than CPT on reducing adverse cardiovascular events and improving hemorheology and blood lipids for aged patients with stable CAD. Our findings may suggest YD as an adjuvant natural-based treatment for CAD. However, more rigorous and larger trials are essential to validate our results, and further consideration of CAD studies specific to aged patients is needed.

Nonprofit Advocacy at the American Heart Association: Creating a Visionary Way Forward at Our 40th Anniversary: An American Heart Association Policy Statement

In 2021, the American Heart Association celebrates its 40th anniversary in advocacy. This policy statement details the arc of the organization's nonpartisan, evidence-based, equity-focused approach to advocating for public policy change, highlighting key milestones and describing the core components of the association's capacity and activity at all levels of government. This policy statement presents a vision and strategic imperative for future American Heart Association advocacy efforts to inform and influence policy changes that advance equitable, impactful societal solutions that transform and improve cardiovascular health for everyone. The American Heart Association maintains accountability by measuring and evaluating the totality of this work and its impact on equitable health outcomes. The American Heart Association will apply these lessons to constantly refine its own strategic policy focus and advocacy efforts. The association will also serve as a resource and catalyst to other organizations working to engage and educate policy makers, partners, the media, and funders about the important role and contribution of public policy change to achieve shared goals.

Predictors of Health-Related Quality-of-Life Status Among Elderly Patients With Cardiovascular Diseases

OBJECTIVES

Quality of life is an important patient-reported outcome in the care of older patients with chronic diseases owing to aging-associated limited physical activity and poor health status. The current study aimed to evaluate health-related quality of life and its predictors among elderly cardiac outpatients.

METHODS

A descriptive, nonexperimental, cross-sectional study was carried out from May 2018 to October 2018 in outpatient departments of a tertiary-care hospital. The population under study were patients aged ≥65 years with at least 1 cardiovascular condition. The EQ-5D-3L (Euro QOL) and Barthel index were used to measure the quality of life and performance of activities of daily living, respectively. Linear regression analysis was performed by using SPSS version 21.

RESULTS

Of a total of 386 patients, 198 patients (51.3%) reported impairment in the mobility domain, and 70.5% (n = 272) of patients indicated impairment in the depression domain. Mann-Whitney tests revealed EQ-5D scores, and visual analogue scale scores significantly differed by hospital admissions (P = .001), fall history (P < 0.001), and activities of daily living (P < .001). Kruskal-Wallis analysis revealed that EQ-5D index value and visual analogue scale score were significantly lower among patients who had comorbidities and who were exposed to polypharmacy (5-9 medications) (P < .001). In multivariate linear regression analysis, self-reported health (P = .006) and performance of activities of daily living (P < .001) were reported as influencing factors on health-related quality of life.

CONCLUSION

Findings indicated poor quality of life among older patients with cardiovascular diseaese or heart diseases in Pakistan. Measures should be taken to improve patients' perception and to enhance awareness regarding the importance of doing daily living activities as a predictor of good quality of life.

Presentation, Treatment, and Outcomes of the Oldest-Old Patients with Acute Myocardial Infarction: The SILVER-AMI Study

BACKGROUND

Oldest-old patients (≥85 years) constitute half the acute myocardial infarction hospitalizations among older adults and more commonly have atypical presentation, under-treatment, and functional impairments. Yet this group has not been well characterized. We characterized differences in presentation, functional impairments, treatments, health status, and mortality among middle-old (75-84 years) and oldest-old patients with myocardial infarction.

METHODS

We analyzed data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study that enrolled 3041 patients ≥75 years of age from 94 hospitals across the US between 2013 and 2016. We performed Cox proportional hazards regression to examine the association between the oldest-old (n = 831) and middle-old (n = 2210) age categories with postdischarge 6-month case fatality rate adjusting for sociodemographic and clinical variables, and mobility impairment.

RESULTS

The oldest-old were less likely to present with chest pain (52.7% vs 57.7%) as their primary symptom or to receive coronary revascularization (58.1% vs 71.8) (P < .01 for both). The oldest-old were more likely to have functional impairments and had higher 6-month mortality compared with the middle-old patients (hazard ratio 1.78, 95% confidence interval, 1.39-2.28). This association was substantially attenuated after adjusting for mobility impairment (hazard ratio 1.29, confidence interval, 0.99-1.68).

CONCLUSIONS

There is considerable heterogeneity in presentation, treatment, and outcomes among older patients with myocardial infarction. Mobility impairment, a marker for frailty, modifies the association between advanced age and treatments as well as outcomes.

Physiology-guided revascularization versus optimal medical therapy of nonculprit lesions in elderly patients with myocardial infarction: Rationale and design of the FIRE trial

BACKGROUND

Myocardial infarction (MI) in elderly patients is associated with unfavorable prognosis, and it is becoming an increasingly prevalent condition. The prognosis of elderly patients is equally impaired in ST-segment elevation (STE) or non-STE (NSTE), and it is markedly worsened by the common presence of multivessel disease (MVD). Given the limited evidence available for elderly patients, it has not yet been established whether, as for younger patients, a complete revascularization strategy in MI patients with MVD should be advocated. We present the design of a dedicated study that will address this research gap.

METHODS AND DESIGN

The FIRE trial is a prospective, randomized, international, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients aged 75 years and older, with MI (either STE or NSTE), MVD at coronary artery angiography, and a clear culprit lesion will be randomized to culprit-only treatment or to physiology-guided complete revascularization. The primary end point will be the patient-oriented composite end point of all-cause death, any MI, any stroke, and any revascularization at 1 year. The key secondary end point will be the composite of cardiovascular death and MI. Quality of life and physical performance will be evaluated as well. All components of the primary and key secondary outcome will be tested also at 3 and 5 years. The sample size for the study is 1,400 patients.

IMPLICATIONS

The FIRE trial will provide evidence on whether a specific revascularization strategy should be applied to elderly patients presenting MI and MVD to improve their clinical outcomes.

Inclusion of Performance Parameters and Patient Context in the Clinical Practice Guidelines for Heart Failure

BACKGROUND

To facilitate evidence-based medicine (EBM) on an individual level, it may be important for clinical practice guidelines (CPGs) to incorporate the performance parameters of diagnostic studies and therapeutic interventions (such as likelihood ratio and absolute benefit or harm), and to incorporate relevant patient contexts that may influence decision-making. We sought to determine the extent to which heart failure CPGs currently incorporate this information.

METHODS

We reviewed the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) 2013 Heart Failure CPG, the 2017 ACCF/AHA/HFSA update, and European Society of Cardiology (ESC) 2016 Heart Failure CPG. We abstracted variables for each CPG recommendation from the following domains: quality of evidence, strength of recommendation, diagnostic and therapeutic performance parameters, and patient context.

RESULTS

We examined 169 recommendations from the ACCF/AHA 2013 CPGs and 2017 update and 187 recommendations from the 2016 ESC CPGs. Performance parameters for diagnostic studies (2013 ACCF/AHA: 13%; 2017 ACCF/AHA/HFSA update: 0%; 2016 ESC: 0%) and therapeutic interventions (2013 ACCF/AHA: 65%; 2017 ACCF/AHA/HFSA update: 64%; 2016 ESC: 16%) were not commonly included in CPGs. Patient context was included in about half of ACCF/AHA recommendations and a quarter of ESC recommendations.

CONCLUSIONS

The majority of recommendations from heart failure CPGs lack information on diagnostic and therapeutic performance parameters and patient context. Given the importance of these components to effectively implement EBM, particularly for a heterogeneous heart failure population, innovative strategies are needed to optimize CPGs so they provide comprehensive yet succinct recommendations that can improve population-level outcomes and ensure optimal patient-centered care.

Blood pressure in frail older adults: associations with cardiovascular outcomes and all-cause mortality

Background

Blood pressure (BP) management in frail older people is challenging. An randomised controlled trial of largely non-frail older people found cardiovascular and mortality benefit with systolic (S) BP target <120 mmHg. However, all-cause mortality by attained BP in routine care in frail adults aged above 75 is unclear.

Objectives

To estimate observational associations between baseline BP and mortality/cardiovascular outcomes in a primary-care population aged above 75, stratified by frailty.

Methods

Prospective observational analysis using electronic health records (clinical practice research datalink, n = 415,980). We tested BP associations with cardiovascular events and mortality using competing and Cox proportional-hazards models respectively (follow-up ≤10 years), stratified by baseline electronic frailty index (eFI: fit (non-frail), mild, moderate, severe frailty), with sensitivity analyses on co-morbidity, cardiovascular risk and BP trajectory.

Results

Risks of cardiovascular outcomes increased with SBPs >150 mmHg. Associations with mortality varied between non-frail <85 and frail 75–84-year-olds and all above 85 years. SBPs above the 130–139-mmHg reference were associated with lower mortality risk, particularly in moderate to severe frailty or above 85 years (e.g. 75–84 years: 150–159 mmHg Hazard Ratio (HR) mortality compared to 130–139: non-frail HR = 0.94, 0.92–0.97; moderate/severe frailty HR = 0.84, 0.77–0.92). SBP <130 mmHg and Diastolic(D)BP <80 mmHg were consistently associated with excess mortality, independent of BP trajectory toward the end of life.

Conclusions

In representative primary-care patients aged ≥75, BP <130/80 was associated with excess mortality. Hypertension was not associated with increased mortality at ages above 85 or at ages 75–84 with moderate/severe frailty, perhaps due to complexities of co-existing morbidities. The priority given to aggressive BP reduction in frail older people requires further evaluation.