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Adachi T, Tsunekawa Y, Tanimura D. Cognitive decline assessed using a brief screening test and cardiovascular and non-cardiovascular events in older patients with heart failure. Aging Clin Exp Res 2023; 35:3233-3238. [PMID: 37921906 DOI: 10.1007/s40520-023-02591-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/10/2023] [Indexed: 11/05/2023]
Abstract
BACKGROUND Although cognitive decline is recognized as a prognostic factor of heart failure (HF), the association of cognitive decline with specific clinical outcomes in patients with HF remains unclear. AIM This study examines the relationship between cognitive decline using a brief test and cardiovascular and non-cardiovascular events in older patients with HF. METHODS This study included 146 hospitalised patients with HF (median age, 77 years; male, 56.8%). Cognitive decline was defined as a score of ≤ 9 points on the Rapid Dementia Screening Test at the time of discharge. RESULTS Cumulative incidence of cardiovascular events after discharge was twofold higher in patients with cognitive decline (Model 1 adjusted for basic characteristics, hazard ratio (HR) = 2.01, 95% confidence interval (CI): 0.94-4.31; Model 2 adjusted for potential confounders, HR = 2.30, 95% CI: 1.07-4.97). The association between cognitive decline and non-cardiovascular events decreased after adjusting for potential confounders. CONCLUSION The results of this study emphasize the clinical utility of cognitive assessment for risk stratification of worsening cardiovascular conditions, including HF.
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Affiliation(s)
- Takuji Adachi
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, 1-1-20 Daiko-Minami, Higashi-Ku, Nagoya, 461-8673, Japan.
- Department of Rehabilitation, Nagoya Ekisaikai Hospital, 4-66 Syonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan.
| | - Yuki Tsunekawa
- Department of Rehabilitation, Nagoya Ekisaikai Hospital, 4-66 Syonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan
| | - Daisuke Tanimura
- Department of Cardiology, Nagoya Ekisaikai Hospital, 4-66 Syonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan
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Patient, hospital and country-level risk factors of all-cause mortality among patients with chronic heart failure: Prospective international cohort study. PLoS One 2021; 16:e0250931. [PMID: 33970939 PMCID: PMC8109791 DOI: 10.1371/journal.pone.0250931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/19/2021] [Indexed: 11/19/2022] Open
Abstract
Background Although many studies have described patient-level risk factors for outcomes in heart failure (HF), health care structural determinants remain largely unexplored. This research reports patient-, hospital- and country-level characteristics associated with 1-year all-cause mortality among patients with chronic HF, and investigates geographic and hospital variation in mortality. Methods and findings We included 9,277 patients with chronic HF enrolled between May 2011 and November 2017 in the prospective cohort study European Society of Cardiology Heart Failure Long Term registry across 142 hospitals, located in 22 countries. Mean age of the selected outpatients was 65 years (sd 13.2) and 28% were female. The all-cause 1-year mortality rate per 100 person-years was 7.1 (95% confidence interval (CI) 6.6–7.7), and varied between countries (median 6.8, IQR 5.6–11.2) and hospitals (median 7.8, IQR 5.2–12.4). Mortality was associated with age (incidence rate ratio 1.03, 95% CI 1.02–1.04), diabetes mellitus (1.37, 1.15–1.63), peripheral artery disease (1.56, 1.27–1.92), New York Heart Association class III/IV (1.91, 1.60–2.30), treatment with angiotensin-converting enzyme inhibitor and angiotensin receptor antagonists (0.71, 0.57–0.87) and HF clinic (0.64, 0.46–0.89). No other hospital-level characteristics, and no country-level healthcare characteristics were associated with 1-year mortality, with case-mix standardised variance between countries being very low (1.83e-06) and higher for hospitals (0.372). Conclusions All-cause mortality at 1 year among outpatients with chronic HF varies between countries and hospitals, and is associated with patient characteristics and the availability of hospital HF clinics. After full adjustment for clinical, hospital and country variables, between-country variance was negligible while between-hospital variance was evident.
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Kawada K, Fukuda H, Kubo T, Ohta T, Ishida T, Morisawa S, Kawazoe T, Okamoto M, Fujita H, Jobu K, Morita Y, Ueba T, Kitaoka H, Miyamura M. Added value of anxiolytic benzodiazepines in predictive models on severe delirium in patients with acute decompensated heart failure: A retrospective analysis. PLoS One 2021; 16:e0250372. [PMID: 33886657 PMCID: PMC8062069 DOI: 10.1371/journal.pone.0250372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/06/2021] [Indexed: 11/21/2022] Open
Abstract
Background Delirium in patients with acute decompensated heart failure (ADHF) is associated with poor clinical outcomes. Although some medications have been reported as risk factors for delirium, their impact on patients with ADHF is still unclear. This study aimed to determine the association of specific medication use with delirium and their additive predictive value in models based on conventional risk factors. Methods and results In this single-center, retrospective study, 650 patients treated for ADHF were included. Fifty-nine patients (9.1%) had delirium. In multivariate analysis, anxiolytic benzodiazepines [odds ratio (OR): 6.4, 95% confidence interval (CI): 2.8–15], mechanical ventilation or noninvasive positive pressure ventilation (OR: 6.0, 95% CI: 2.9–12), depression (OR: 3.2, 95% CI: 1.5–6.5), intensive care or high care unit admission (OR: 2.9, 95% CI: 1.5–5.6), male sex (OR: 2.0, 95% CI: 1–3.7), and age (OR: 1.1, 95% CI: 1–1.1) were independently associated with severe delirium. The predictive model that included anxiolytic benzodiazepines had a significantly better discriminatory ability for the incidence of severe delirium than the conventional model. Conclusions The use of anxiolytic benzodiazepines was independently correlated with severe delirium, and their use in models based on conventional risk factors had an additive value for predicting delirium in patients with ADHF.
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Affiliation(s)
- Kei Kawada
- Graduate School of Integrated Arts and Sciences Kochi University, Oko town, Nankoku City, Kochi, Japan
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
- * E-mail:
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi Medical School Kochi University, Oko town, Nankoku City, Kochi, Japan
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School Kochi University, Oko town, Nankoku City, Kochi, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, National Cerebral and Cardiovascular Center Hospital, Suita City, Osaka, Japan
| | - Tomoaki Ishida
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
| | - Shumpei Morisawa
- Graduate School of Integrated Arts and Sciences Kochi University, Oko town, Nankoku City, Kochi, Japan
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
| | - Tetushi Kawazoe
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
| | - Manami Okamoto
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
| | - Hiroko Fujita
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
| | - Kohei Jobu
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
| | - Yasuyo Morita
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
| | - Tetsuya Ueba
- Department of Neurosurgery, Kochi Medical School Kochi University, Oko town, Nankoku City, Kochi, Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School Kochi University, Oko town, Nankoku City, Kochi, Japan
| | - Mitsuhiko Miyamura
- Graduate School of Integrated Arts and Sciences Kochi University, Oko town, Nankoku City, Kochi, Japan
- Department of Pharmacy, Kochi Medical School Hospital, Oko town, Nankoku City, Kochi, Japan
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Clinical impact of functional independent measure (FIM) on 180-day readmission and mortality in elderly patients hospitalized with acute decompensated heart failure. Heart Vessels 2021; 36:1536-1541. [PMID: 33834270 DOI: 10.1007/s00380-021-01841-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
Activities of daily living (ADL) are important prognostic factors for heart failure. The functional independent measure (FIM) has emerged as a comprehensive valid measure of ADL from both physical and cognitive perspectives. This study aimed to investigate the prognostic impact of the FIM score on clinical outcomes in hospitalized patients with acute decompensated heart failure (ADHF). We retrospectively analyzed 473 ADHF patients, with available pre-discharge FIM scores, admitted to our institution between May 2018 and May 2020. Primary outcome measures, defined as a composite of 180-day all-cause deaths and readmissions, were compared among three tertiles. The median FIM score was 102 (interquartile range: 85-115). Tertile 1 corresponded to an FIM score > 111 (n = 154), Tertile 2 to that of 90-111 (n = 167), and Tertile 3 to that of < 90 (n = 152). During follow-up, 28 deaths and 114 readmissions occurred. Patients with lower FIM scores were associated with a graded increase in the risk of primary outcome measure (p = 0.001). Even after multivariable adjustment, the results remained significant [Tertile 1 vs 3; adjusted hazard ratio: 3.28 (95% confidence interval: 1.72-6.56), p < 0.001; Tertile 2 vs 3; 2.32 (1.27-4.47), p = 0.006]. FIM scores were significantly associated with readmission or death within 180 days of discharge in hospitalized ADHF patients.
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Sarcopenia in patients after an episode of acute decompensated heart failure: An underdiagnosed problem with serious impact. Clin Nutr 2021; 40:4490-4499. [PMID: 33483182 DOI: 10.1016/j.clnu.2020.12.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/30/2020] [Accepted: 12/26/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND & AIMS Sarcopenia is a multifactorial syndrome resulting in a decrease in both muscle mass and function. Little is known about the prevalence and prognostic impact of sarcopenia in patients with acutely decompensated chronic heart failure (ADHF). We aimed to evaluate the prevalence (main endpoint) and impact of sarcopenia on ADHF patients. METHODS 140 ADHF patients were enrolled between November 2014 and September 2018 in a multicenter prospective longitudinal study. A similar, independent multi-departmental cross-sectional study in 165 ADHF patients was used for external validation of prevalence data. All subjects were assessed on the European Working Group on Sarcopenia criteria. RESULTS Ninety-one patients (65%) had sarcopenia (vs. 53.6% in the external replication regional cohort). Patients with sarcopenia were older and more likely to have eGFR <60 ml/min/1.73 m2 (p < 0.001 and p = 0.002). Sarcopenia was associated with impaired functional status [lower 6 min walking test (220 ± 108 vs. 279 ± 170, p = 0.03) and 4 m gait speed (0.56 ± 0.24 vs. 0.80 ± 0.37, p < 0.001)] and autonomy [Instrumental activities of daily living: 6.7 ± 1.4 vs. 7.3 ± 1.2, p = 0.005]. Over up to 4 years' follow-up, 30 cardiovascular (CV) deaths and 42 non-CV deaths occurred. In a multivariable analysis, sarcopenia was associated with time to first non-CV hospitalization (hazard ratio 1.93; 95% confidence interval 1.14-3.24; p = 0.014) but not with any other hospitalization, any mortality endpoint, or a composite endpoint of CV death and HF hospitalization. CONCLUSIONS The prevalence of sarcopenia in ADHF patients is high and associated with greater risk of non-CV hospitalizations, highlighting the importance of identifying and managing the condition in a multidisciplinary approach. CLINICAL TRIAL REGISTRATION NCT03153774.
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Okano T, Motoki H, Minamisawa M, Kimura K, Kanai M, Yoshie K, Higuchi S, Saigusa T, Ebisawa S, Okada A, Shoda M, Kuwahara K. Cardio-renal and cardio-hepatic interactions predict cardiovascular events in elderly patients with heart failure. PLoS One 2020; 15:e0241003. [PMID: 33095810 PMCID: PMC7584193 DOI: 10.1371/journal.pone.0241003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/07/2020] [Indexed: 12/28/2022] Open
Abstract
Background The composite Model for End-Stage Liver Disease Excluding International Normalized Ratio Score (MELD-XI) is a novel tool to evaluate cardio-renal and cardio-hepatic interactions in patients with advanced heart failure (HF). However, its prognostic ability remains unclear in elderly HF patients. Methods and results From July 2014 to July 2018, patients hospitalized for HF were prospectively recruited at 16 centers. Clinical features, laboratory findings, and echocardiography results were assessed prior to discharge. Cardiovascular (CV) death and HF re-hospitalization were recorded. Of the 676 patients enrolled, 264 (39.1%) experienced CV events throughout a 1-year median follow-up period. Patients with high MELD-XI were predominantly male and had a higher prevalence of NYHA III/IV, history of HF admission, hyperuricemia, ventricular tachycardia, anemia, and ischemic heart disease. In Kaplan-Meyer analysis, patients with higher MELD-XI (≥11) scores showed a worse prognosis than did those with lower (<11) scores (log-rank p≤0.001). Multivariate Cox proportional hazards testing revealed MELD-XI as an independent predictor of CV events (HR: 1.033, 95% CI: 1.006–1.061, p = 0.015) after adjusting for age, gender, body mass index, NYHA III/IV, prior HF hospitalization, systolic blood pressure, ischemic etiology, ventricular tachycardia, anemia, BNP, and left ventricular ejection fraction. Conclusions Cardio-renal and cardio-hepatic interactions predicted CV events in aged HF patients.
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Affiliation(s)
- Takahiro Okano
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
- * E-mail:
| | - Masatoshi Minamisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Kazuhiro Kimura
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Masafumi Kanai
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Koji Yoshie
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Satoko Higuchi
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Soichiro Ebisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Ayako Okada
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Morio Shoda
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Lelli D, Pedone C, Leosco D, Onder G, Antonelli Incalzi R. Management of heart failure: an Italian national survey on fellows/specialists in geriatrics. Aging Clin Exp Res 2020; 32:2049-2055. [PMID: 32383033 DOI: 10.1007/s40520-020-01577-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/25/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Heart failure (HF) is often managed by geriatricians. Few data are available on their knowledge and attitudes about this condition. AIMS To compare perceptions and knowledge on HF of specialists/fellows in geriatrics working in Italy. METHODS This nation-wide survey carried out by the Italian Society of Gerontology and Geriatrics in May-June 2019 enrolled 283 specialists/fellows in geriatrics in Italy. Results were stratified by qualification (specialist/fellow) and performance (lower/higher quartile of correct answers). RESULTS About half (55.5%) of the participants worked in acute care wards, 190 were residents, and 93 specialists. The overall proportion of correct answers was 70.8%, with no differences between specialists and fellows. There was a poor knowledge, with no differences between groups, about the target doses of ACE-inhibitors (36% of correct answers), the pharmacological treatment of HF with preserved ejection fraction (HFpEF) (37% of correct answers), and the inotropes indicated in acute HF (35% of correct answers). Compared to specialists, fellows performed better on indication (88% vs 76%, P = 0.019) and mechanism of action (93% vs 84%, P = 0.023) of sacubitril/valsartan, and on therapeutic indications of patients with atrial fibrillation (92% vs 75%, P < 0.001). CONCLUSIONS Globally, there was a good knowledge of the latest guidelines on the diagnosis and management of HF. However, for some important topics, such as HFpEF, that is the most common HF manifestation in older adults, the observed performance was relatively poor, indicating the need for focused educational campaigns.
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Affiliation(s)
- Diana Lelli
- Area di Geriatria, Università Campus Bio-Medico di Roma, via Alvaro del Portillo 21, 00128, Rome, Italy.
| | - Claudio Pedone
- Area di Geriatria, Università Campus Bio-Medico di Roma, via Alvaro del Portillo 21, 00128, Rome, Italy
| | - Dario Leosco
- Dipartimento di Scienze Mediche Traslazionali, Università Degli Studi di Napoli "Federico II", Via Pansini 5, 80131, Naples, Italy
| | - Graziano Onder
- Dipartimento di Malattie Cardiovascolari, endocrino-metaboliche ed invecchiamento, Istituto Superiore di Sanità, viale Regina Elena 299, 00161, Rome, Italy
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Huerta-Preciado J, Franco J, Formiga F, Iborra PL, Epelde F, Franco ÁG, Ormaechea G, Manzano L, Cepeda-Rodrigo JM, Montero-Pérez-Barquero M. Differential characteristics of acute heart failure in very elderly patients: the prospective RICA study. Aging Clin Exp Res 2020; 32:1789-1799. [PMID: 31621036 DOI: 10.1007/s40520-019-01363-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 09/21/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Acute heart failure (AHF) is a frequent epidemic in geriatrics. The main aim of this study was to evaluate the clinical and prognostic differences of very elderly patients with AHF compared to the rest, and evaluate the factors associated with 90-day mortality. METHODS We analyzed 3828 patients hospitalized for AHF with an age of ≥ 70 years. The population was divided into three groups: 70-79, 80-89 and ≥ 90 years old (nonagenarians). The baseline characteristics of patients nonagenarians were compared with the rest. In the group of nonagenarians, their clinical characteristics were analyzed according to the left ventricular ejection fraction (LVEF) and the factors associated with mortality at 90 days of follow-up. RESULTS Nonagenarians showed higher comorbidity and cognitive deterioration, worse basal functional status, and preserved LVEF. Alternatively, they presented a lower rate of diabetes mellitus, lower incidence of de novo AHF, and lower prescription of angiotensin-converting-enzyme inhibitors, aldosterone blockers, anticoagulants, and statins at hospital discharge. Of the total, 334 patients (9.3%) had died by 90 days. The 90-day mortality rate was highest in nonagenarians (7.1% vs 9.8% vs 17%; p = 0.001). Multivariate analysis showed that renal failure, New York Heart Association (NYHA) functional classifications of III-IV, and a more advanced functional deterioration at baseline are predictors of mortality within 90 days. CONCLUSIONS The AHF in patients nonagenarians has a different clinical profile compared to younger patients and a higher mortality. In this subgroup of patients having a worse baseline functional status, higher NYHA classification (III-IV), and renal failure are predictors of 90-day mortality.
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Affiliation(s)
- Jorge Huerta-Preciado
- Department of Internal Medicine, Hospital Universitario Quirón Dexeus, Barcelona, Spain.
| | - Jonathan Franco
- Department of Internal Medicine, Hospital Universitario Quirón Dexeus, Barcelona, Spain
| | - Francesc Formiga
- Department of Internal Medicine, Hospital Universitario Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Pau Llácer Iborra
- Department of Internal Medicine, Hospital de Manises, Manises, Spain
| | - Francisco Epelde
- Short-Stay Unit, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - Álvaro González Franco
- Department of Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Gabriela Ormaechea
- Multidisciplinary Unit on Heart Failure, Hospital de Clínicas Dr. Manuel Quintela, Montevideo, Uruguay
| | - Luis Manzano
- Department of Internal Medicine, Hospital Universitario Ramón y Cajal, Universidad de Alcalá/IRYCIS, Madrid, Spain
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Testa G, Curcio F, Liguori I, Basile C, Papillo M, Tocchetti CG, Galizia G, Della-Morte D, Gargiulo G, Cacciatore F, Bonaduce D, Abete P. Physical vs. multidimensional frailty in older adults with and without heart failure. ESC Heart Fail 2020; 7:1371-1380. [PMID: 32243099 PMCID: PMC7261566 DOI: 10.1002/ehf2.12688] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/08/2020] [Indexed: 12/27/2022] Open
Abstract
Aims The assessment of frailty in older adults with heart failure (HF) is still debated. Here, we compare the predictive role and the diagnostic accuracy of physical vs. multidimensional frailty assessment on mortality, disability, and hospitalization in older adults with and without HF. Methods and results A total of 1077 elderly (≥65 years) outpatients were evaluated with the physical (phy‐Fi) and multidimensional (m‐Fi) frailty scores and according to the presence or the absence of HF. Mortality, disability, and hospitalizations were assessed at baseline and after a 24 month follow‐up. Cox regression analysis demonstrated that, compared with phy‐Fi score, m‐Fi score was more predictive of mortality [hazard ratio (HR) = 1.05 vs. 0.66], disability (HR = 1.02 vs. 0.89), and hospitalization (HR = 1.03 vs. 0.96) in the absence and even more in the presence of HF (HR = 1.11 vs. 0.63, 1.06 vs. 0.98, and 1.14 vs. 1.03, respectively). The area under the curve indicated a better diagnostic accuracy with m‐Fi score than with phy‐Fi score for mortality, disability, and hospitalizations, both in absence (0.782 vs. 0.649, 0.763 vs. 0.695, and 0.732 vs. 0.666, respectively) and in presence of HF (0.824 vs. 0.625, 0.886 vs. 0.793, and 0.812 vs. 0.688, respectively). Conclusions The m‐Fi score is able to predict mortality, disability, and hospitalizations better than the phy‐Fi score, not only in absence but also in presence of HF. Our data also demonstrate that the m‐Fi score has better diagnostic accuracy than the phy‐Fi score. Thus, the use of the m‐FI score should be considered for the assessment of frailty in older HF adults.
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Affiliation(s)
- Gianluca Testa
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy.,Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Francesco Curcio
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy
| | - Ilaria Liguori
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy
| | - Claudia Basile
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy
| | - Martina Papillo
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy
| | - Gianlugi Galizia
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy.,IRCCS Salvatore Maugeri Foundation, Scientific Institute of Veruno, Novara, Italy
| | - David Della-Morte
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Department of Human Sciences and Quality of Life Promotion, San Raffaele Roma Open University, Rome, Italy
| | - Gaetano Gargiulo
- Division of Internal Medicine, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Francesco Cacciatore
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy
| | - Domenico Bonaduce
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 80131, Naples, Italy
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Kaufmann D, Szwoch M, Kwiatkowska J, Raczak G, Daniłowicz-Szymanowicz L. Global longitudinal strain can predict heart failure exacerbation in stable outpatients with ischemic left ventricular systolic dysfunction. PLoS One 2019; 14:e0225829. [PMID: 31790492 PMCID: PMC6886774 DOI: 10.1371/journal.pone.0225829] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022] Open
Abstract
Background Despite advancements in pharmacological and device-based treatment, heart failure (HF) continues to impose an enormous burden for health care system worldwide. Decompensation of HF is one of the main causes of hospitalization, therefore the identification of patients with the highest risk of such complication is still of great clinical importance. The prognostic significance and utility of global longitudinal strain (GLS) has been previously studied in patients with the broad spectrum of cardiovascular diseases in various endpoints, however its role in assessing the risk of hospitalization due to HF exacerbation of optimally treated outpatients has not been fully explored. Therefore, the aim of the study was to verify whether the GLS of the left ventricle (LV) derived by 2D speckle tracking echocardiography has, independently of other well-known clinical parameters, an additional impact on the risk of HF decompensation in stable patients with LV systolic dysfunction of ischemic origin. Methods In 193 clinically stable HF outpatients with LV ejection fraction (LVEF) ≤ 50%, GLS, additionally to other clinical parameters, was analyzed. During 34 (14–71) months of follow-up, 58 patients were hospitalized due to HF decompensation (EVENT). Results EVENT was significantly associated with age, QRS width, NYHA functional class, left atrium diameter, LV systolic and diastolic volume, LVEF, hemoglobin, brain natriuretic peptide, diuretic treatment, absence of beta-blockers, impaired renal function and history of diabetes in univariate Cox analyzes. GLS with pre-specified cut-off value of -9.4% was also significantly associated with the EVENT (HR 15.16; 95% CI 1.81–126.91). After adjusting for above-mentioned parameters GLS was still a significant predictor of hospitalization due to HF decompensation. Conclusions GLS measurement can provide incremental information on the risk of HF decompensation in stable outpatients with LV systolic dysfunction of ischemic origin.
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Affiliation(s)
- Damian Kaufmann
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdańsk, Poland
- * E-mail:
| | - Małgorzata Szwoch
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdańsk, Poland
| | - Joanna Kwiatkowska
- Department of Pediatric Cardiology and Congenital Heart Defect, Medical University of Gdansk, Gdańsk, Poland
| | - Grzegorz Raczak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdańsk, Poland
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Cacciatore F, Amarelli C, Ferrara N, Della Valle E, Curcio F, Liguori I, Bosco Q, Maiello C, Napoli C, Bonaduce D, Abete P. Protective effect of physical activity on mortality in older adults with advanced chronic heart failure: A prospective observational study. Eur J Prev Cardiol 2018; 26:481-488. [DOI: 10.1177/2047487318790822] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives The objective of this study was to evaluate the effect on mortality of self-reported physical activity evaluated by the physical activity scale for the elderly (PASE) in elderly patients with advanced heart failure enrolled in a cardiac rehabilitation unit after heart failure decompensation (NYHA class IIIB). Methods The study prospectively enrolled 314 elderly patients (≥65 years) with heart failure in NYHA class IIIB (symptomatic with a recent history of dyspnoea at rest) consecutively admitted to cardiac rehabilitation between January 2010 and July 2011. Comprehensive geriatric assessment was performed. Physical activity was evaluated by PASE and stratified in tertiles (0–15, 16–75 and >75). Mortality was collected from September to October 2015 in 300 patients. Results The mean age was 74.5 ± 6.1 (range 65–89); 74.7% were men, 132 patients (44.0%) died during the follow-up (44.1 ± 20.7 months). Univariate analysis shows that physical activity level conducted before heart failure decompensation was inversely related to mortality (from 76.0% to 8.2%, P = 0.000). Multivariate analysis confirms that the PASE score predicts mortality independently of several demographic and clinical variables (hazard rate 0.987, 95% confidence interval (CI) 0.980–0.994, P = 0.000). Notably, when considering PASE 0–15 versus 16–75 score and PASE 0–15 versus > 75 score, the hazard rate is 4.06 (95% CI 1.67–9.84, P < 0.001) and 7.25 (95% CI 2.7–19.5, P < 0.001), respectively. Conclusions Physical activity level evaluated by the PASE score is inversely related to mortality in elderly patients with advanced heart failure confirming the reduction of mortality exerted by moderate physical activity in such patients.
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Affiliation(s)
- Francesco Cacciatore
- Laboratory for the Assessment of Clinical Complexity, Istituti Clinici Scientifici Maugeri Spa SB, Italy
- Department of Translational Medical Sciences, University of Naples “Federico II”, Italy
- Division of Cardiac Transplantation and Mechanical Assistance, AORN Monaldi Hospital, Italy
| | - Cristiano Amarelli
- Division of Cardiac Transplantation and Mechanical Assistance, AORN Monaldi Hospital, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, University of Naples “Federico II”, Italy
| | | | - Francesco Curcio
- Department of Translational Medical Sciences, University of Naples “Federico II”, Italy
| | - Ilaria Liguori
- Department of Translational Medical Sciences, University of Naples “Federico II”, Italy
| | - Quirino Bosco
- Laboratory for the Assessment of Clinical Complexity, Istituti Clinici Scientifici Maugeri Spa SB, Italy
| | - Ciro Maiello
- Division of Cardiac Transplantation and Mechanical Assistance, AORN Monaldi Hospital, Italy
| | - Claudio Napoli
- Department of Medical, Surgical, Neurological, Aging and Metabolic Sciences, University of Campania “L. Vanvitelli”, Italy
- Istituto di Ricerca Diagnostica e Nucleare, IRCCS-SDN, Piazza Amedeo, 9-Naples, Italy
| | - Domenico Bonaduce
- Department of Translational Medical Sciences, University of Naples “Federico II”, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, University of Naples “Federico II”, Italy
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Acute care hospital at different levels of intensity: the role of Geriatrician. Aging Clin Exp Res 2018; 30:703-712. [PMID: 29468615 DOI: 10.1007/s40520-018-0920-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/15/2018] [Indexed: 10/18/2022]
Abstract
The traditional model of care is based on "disease-centered" management that requires the organization of the hospital in specialized wards, to which the patient is assigned for the main disease. The growing need to optimize economical and human resources and to promote a global approach to the patient has led to the setting up of the intensity of care model. It is a health system based on a "patient-centered" approach, where the hospital is organized in departments dedicated to patients with homogenous needs of care. In Italy, intensity of care model is currently being tested in the hospital organization, where three levels of intensity are proposed: low, medium and high. The purpose of the following review is to describe the role and importance of the Geriatrician in each of these care settings and to highlight the contradiction of a National Health System which promotes the geriatric approach to all types of patients, but does not invest in the formation and integration of the figure of the Geriatrician in clinical practice, condemning it to marginalization or even extinction.
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Frailty syndrome and rehospitalizations in elderly heart failure patients. Aging Clin Exp Res 2018; 30:617-623. [PMID: 28849550 PMCID: PMC5968054 DOI: 10.1007/s40520-017-0824-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/11/2017] [Indexed: 11/04/2022]
Abstract
Background Heart failure (HF) patients with frailty syndrome (FS) are at higher risk of falling, decreased mobility, ability to perform the basic activities of daily living, frequent hospitalizations, and death. Aims The purpose of this study was to evaluate the correlations between FS and hospital readmissions, and to assess which factors are associated with rehospitalizations. Methods The study included 330 patients with a mean age of 72.1 ± 7.9 years, diagnosed with HF. Frailty was measured using the Polish version of the Tilburg Frailty Indicator (TFI). Demographic, sociodemographic, and clinical data, such as the New York Heart Association (NYHA) functional class, ejection fraction (EF), number of rehospitalizations, and the medications taken, were obtained. Results Positive correlation was observed between the number of hospitalizations and FS. In the single-factor correlation analysis, treatment with diuretics, a higher NYHA class, and a lower left ventricular EF were predictors of a higher number of hospitalizations. Additionally, the physical and psychological components of the TFI, as well as the total TFI score, predisposed HF patients to more frequent hospitalizations. Discussion It seems that a deterioration of functional capabilities and an increase in symptom severity naturally lead to increased hospitalization frequency in HF. In the own study, regression analysis indicates that high NYHA classes and TFI social component scores are significant predictors of the number of hospitalizations in the studied group. Conclusions FS is highly prevalent among elderly HF patients. Higher frailty levels in elderly patients are a determinant of more frequent rehospitalizations in HF.
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Chronic obstructive pulmonary disease and long-term mortality in elderly subjects with chronic heart failure. Aging Clin Exp Res 2017; 29:1157-1164. [PMID: 28224475 DOI: 10.1007/s40520-016-0720-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/23/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are associated with high rates of mortality in elderly subjects. Concurrent CHF and COPD frequently occur, especially in with advancing age. This study examines long-term mortality in community-dwelling elderly subjects affected by CHF alone, COPD alone, and coexistent CHF and COPD. METHODS The study evaluated 12-years mortality in 1288 subjects stratified for the presence or absence of CHF or COPD alone, and for coexistence of CHF and COPD. RESULTS Mortality, at 12 year follow-up, was 46.7% overall, 68.6% in the presence of CHF alone (p < 0.001), 56.9% in the presence of COPD alone (p < 0.01); mortality was 86.2% where CHF and COPD coexisted (p < 0.001) and was significantly higher than in CHF or COPD alone (p < 0.05). Multivariate analysis indicates that CHF (Hazard risk = 1.67, 95% confidence interval 1.15-3.27, p < 0.031) and COPD (Hazard risk = 1.27, 95% confidence interval = 1.08-1.85, p < 0.042) were predictive of long-term mortality. When CHF and COPD simultaneously occurred, the risk dramatically increased up to 3.73 (95% confidence interval = 1.19-6.93, p < 0.001). CONCLUSIONS Long-term follow-up showed higher mortality among elderly subjects affected by CHF or COPD. Simultaneous presence of CHF and COPD significantly increased the risk of death. Therefore, the presence of COPD in CHF patients should be considered a relevant factor in predicting high risk of mortality.
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15
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Precipitating factors of heart failure admission: Differences related to age and left ventricular ejection fraction. Int J Cardiol 2016; 219:150-5. [DOI: 10.1016/j.ijcard.2016.06.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/12/2016] [Indexed: 11/18/2022]
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16
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Sarzani R, Spannella F, Giulietti F, Fedecostante M, Giordano P, Gattafoni P, Espinosa E, Busco F, Piccinini G, Dessì-Fulgheri P. NT-proBNP and Its Correlation with In-Hospital Mortality in the Very Elderly without an Admission Diagnosis of Heart Failure. PLoS One 2016; 11:e0153759. [PMID: 27077910 PMCID: PMC4831737 DOI: 10.1371/journal.pone.0153759] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 04/04/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The diagnosis of heart failure (HF) is often difficult and underestimated in very elderly comorbid patients, especially when an echocardiographic evaluation is not available or feasible. AIM to evaluate NT-proBNP values and their correlation with in-hospital mortality in a population of very elderly hospitalized for medical conditions other than HF. METHODS We performed a prospective observational study on 403 very elderly admitted to an Internal Medicine and Geriatrics Department. Exclusion criterion was an admission diagnosis of HF. Patients with at least one symptom or sign compatible with HF were tested for NT-proBNP. NT-proBNP values < 300 pg/ml were considered as an age-independent exclusion criterion for HF (high negative predictive value), while NT-proBNP values ≥ 1800 pg/ml were considered as a diagnostic criterion. Main comorbidities and laboratory parameters were considered to adjust regression analyses between NT-proBNP and in-hospital mortality. RESULTS NT-proBNP values ≥ 1800 pg/ml were present in 61.0% of patients and 32.8% of patients laid between 300 ≤ NT-proBNP < 1800 pg/ml values. NT-proBNP values were associated with the main indices of disease severity/organ failure considered such as reduced eGFR, reduced albumin and elevated CRP. NT-proBNP values ≥ 1800 pg/ml and ln(NT-proBNP) values were significantly associated with in-hospital mortality independently from the main comorbidities and lab parameters considered. The patients, who were already taking ACE inhibitors/Angiotensin Receptor Blockers before admission, showed lower in-hospital mortality. CONCLUSIONS Testing for NT-proBNP should be strongly recommended in the hospitalized very elderly, because of the very high prevalence of underlying HF and its impact on in-hospital mortality, to identify an underlying cardiac involvement that requires appropriate treatment.
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Affiliation(s)
- Riccardo Sarzani
- Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
- Internal Medicine and Geriatrics, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Francesco Spannella
- Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
- Internal Medicine and Geriatrics, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Federico Giulietti
- Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
- Internal Medicine and Geriatrics, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | | | - Piero Giordano
- Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
- Internal Medicine and Geriatrics, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Pisana Gattafoni
- Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
- Internal Medicine and Geriatrics, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Emma Espinosa
- Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
- Internal Medicine and Geriatrics, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Franco Busco
- Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
- Clinical Analysis Laboratory, Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
| | - Gina Piccinini
- Clinical Analysis Laboratory, Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
| | - Paolo Dessì-Fulgheri
- Italian National Research Centre on Aging “U.Sestilli”, IRCCS-INRCA, Ancona, Italy
- Internal Medicine and Geriatrics, Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
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Carraro S, Veronese N, De Rui M, Manzato E, Sergi G. Acute decompensated heart failure: Decision pathways for older people. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2015.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
Risk prediction in patients admitted with acute decompensated heart failure (ADHF) remains a challenge. Biomarkers may improve risk prediction, which in turn may help to better inform patients regarding short-term and long-term prognosis, therapy and care. Most data on biomarkers have been derived from patient cohorts with chronic heart failure. In ADHF, currently, risk tools largely rely on common clinical and biochemical parameters. However, ADHF is not a single disease. It presents in various manners and different etiologies may underlie ADHF, which are reflected by different biomarkers. In the last decade, many studies have reported the prognostic value of these biomarkers. These studies have attempted to describe a value for statistical modeling, e.g., reclassification indices, in an effort to report incremental value over a clinical model or the "gold standard". However, the overall incremental predictive value of biomarkers has been modest compared to already existing clinical models. Natriuretic peptides, e.g., (NTpro-)BNP, are the benchmark, but head-to-head comparisons show that there are novel biomarkers with comparable prognostic value. Multimarker strategies may provide superior risk stratification. Future studies should elucidate cost-effectiveness of single or combined biomarker testing. The purpose of this review was to provide an update on current biomarkers and to identify new promising biomarkers than can be used in prognostication of acute heart failure.
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Short- and long-term mortality and hospital readmissions among patients with new hospitalization for heart failure: A population-based investigation from Italy. Int J Cardiol 2015; 181:81-7. [DOI: 10.1016/j.ijcard.2014.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/28/2014] [Accepted: 12/01/2014] [Indexed: 11/21/2022]
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Cognitive impairment and cardiovascular diseases in the elderly. A heart-brain continuum hypothesis. Ageing Res Rev 2014; 18:41-52. [PMID: 25107566 DOI: 10.1016/j.arr.2014.07.003] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 07/09/2014] [Accepted: 07/17/2014] [Indexed: 12/30/2022]
Abstract
The aging population is increasing and, therefore, a higher prevalence of cardiac disease is emerging; including hypertension, coronary artery disease, atrial fibrillation and chronic heart failure. Large cohort studies have revealed a relationship among increased risk for cognitive impairment and dementia in cardiovascular diseases probably due to embolic stroke or chronic cerebral hypoperfusion. Thus, the aim of the present review is to overview the studies that investigate the presence and/or the development of cognitive impairments and dementia in patients with varied types of cardiovascular disease. Finally, a continuum among hypertension, coronary artery disease, atrial fibrillation and chronic heart failure with to the development of cognitive impairment and progression to dementia has been hypothesized.
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Heckman GA, Boscart VM, McKelvie RS. Management considerations in the care of elderly heart failure patients in long-term care facilities. Future Cardiol 2014; 10:563-77. [DOI: 10.2217/fca.14.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
ABSTRACT: Heart failure, a condition that affects up to 20% of older persons residing in long-term care facilities, is an important cause of morbidity, health service utilization and death. Effective and interprofessional heart failure care processes could potentially improve care, outcomes and quality of life and delay decline or hospital admission. This article reviews the clinical aspects of heart failure, and the challenges to the diagnosis and management of this condition in long-term care residents who are frail and are affected by multiple comorbidities.
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Affiliation(s)
- George A Heckman
- Research Institute on Aging, University of Waterloo, BMH 3734, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Veronique M Boscart
- Conestoga College, School for Health & Life Sciences & Community Services, 299 Doon Valley Drive, Kitchener, ON, N2G 4M4, Canada
| | - Robert S McKelvie
- McMaster University & Hamilton Health Sciences, David Braley Cardiac, Vascular & Stroke Research Institute, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada
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