Knowledge Gaps in Cardiovascular Care of the Older Adult Population

The association of inflammatory biomarkers and long-term clinical outcomes in older adults with non-ST elevation acute coronary syndrome

BACKGROUND

The prognostic significance of inflammatory markers on the long-term risk of major adverse cardiovascular and cerebrovascular events (MACCE) in older NSTEACS patients remains unclear.

METHODS

NSTEACS patients aged 75 and older were recruited to the multicentre cohort study Improve Cardiovascular Outcomes in High-Risk PatieNts with Acute Coronary Syndrome (ICON1). Inflammatory markers including interleukin-6 (IL-6), myeloperoxidase (MPO), high-sensitivity C-reactive protein (hsCRP), fibrinogen and tumor necrosis factor-alpha (TNF-α) were collected at baseline. Primary outcome was MACCE consisting of all-cause mortality, reinfarction, stroke/transient ischaemic attack, urgent revascularization, and significant bleeding at 5-year follow-up.

RESULTS

There were 230 patients with baseline IL-6 (median age 80.9 [interquartile range (IQR):78.2-83.9] years). High IL-6 was not associated with MACCE, but it was independently associated with all-cause mortality (adjusted hazard ratio [aHR]: 2.26 [95% Confidence Interval (CI):1.34-3.82]; P = 0.002). For patients with hsCRP (n = 260, median age 80.9 [IQR:77.9-84.1] years), higher levels were significantly associated with increased risk of MACCE (aHR:1.77 [95% CI:1.26-2.49], P = 0.001). In the cohort with MPO (230 patients, median age 80.9 [IQR:78.2-83.9] years), lower MPO was independently associated with the risk of MACCE (aHR: 0.67 [95%CI:0.46-0.96]; P = 0.029). There was no prognostic significance with fibrinogen and TNF-α.

CONCLUSION

Among older NSTEACS patients, elevated IL-6 and hsCRP were associated with increased risk of all-cause mortality and MACCE, respectively. Low MPO levels were associated with higher MACCE. Further studies are required to determine how these biomarkers should influence treatment strategy in this understudied subset.

CLINICAL TRIAL REGISTRATION

NCT01933581.

The impact of frailty on initiation, continuation and discontinuation of secondary prevention medications following myocardial infarction

AIM

To evaluate the association between frailty and initiating, continuing, or discontinuing secondary prevention medications following myocardial infarction (MI).

METHODS

We conducted a cohort study using linked health data, including all adults aged ≥65 years who discharged from hospital following MI from January 2013 to April 2018 in Victoria, Australia (N = 29,771). The Hospital Frailty Risk Score (HFRS) was used to assess frailty. Logistic regression was used to investigate associations of frailty with initiation, continuation, and discontinuation of secondary prevention medications (P2Y12 inhibitor antiplatelets, beta-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and lipid-lowering therapies) in the 90 days from discharge post-MI, by HFRS, adjusted for age, sex, and Charlson Comorbidity Index.

RESULTS

Increasing frailty was associated with lower probability of initiating and continuing P2Y12 inhibitors, RAAS inhibitors, and lipid-lowering therapies, but not beta-blockers. At at an HFRS of 0, the predicted probabiliy of having all four medications initiated or continued was 0.59 (95 %CI 0.57-0.62) for STEMI and 0.35 (0.34-0.36) for non-STEMI, compared to 0.38 (0.33-0.42) and 0.16 (0.14-0.18) at an HFRS of 15. Increasing frailty was associated with higher probability of discontinuing these medications post-MI. The predicted probability of discontinuing at least one secondary prevention medication post-MI at an HFRS of 0 was 0.10 (0.08-0.11) for STEMI and 0.14 (0.13-0.15) for non-STEMI, compared to 0.27 (0.22-0.32) and 0.34 (0.32-0.36) at an HFRS of 15.

CONCLUSION

People with higher levels of frailty were managed more conservatively following MI than people with lower levels of frailty. Whether this conservative treatment is justified warrants further study.

Comparison of clinical outcomes between family caregivers and professional caregivers in in-hospital patients with acute ischaemic stroke: A prospective cohort study

AIM

This study explored the impact of different care modes on the outcome of hospitalized patients with acute ischaemic stroke (AIS) during hospitalization and 3 months after discharge.

METHODS

This was a prospective cohort study comparing the outcomes at hospitalization, at discharge, and at 3 months post discharge among AIS patients with different caregiving arrangements from 9, December 2022 to 20, August 2023. The general information questionnaire, Modified Barthel Index, Shortened General Comfort Questionnaire, Perceived Social Support scale, Herth Hope Index, modified Rankin scale and EQ-5D-5L were utilized for the investigation.

RESULTS

The psychological evaluation scores during hospitalization, including comfort, perceived social support, and hope, did not significantly differ between the two groups of AIS patients (p > .05). Moreover, there were no significant impacts observed in terms of length of stay (LOS) at the hospital or hospitalization expense (p > .05). The proportion of patients with intact functionality was greater in the family caregiver group 3 months after discharge (16.5%). However, when stratified based on prognosis, the difference in outcomes between the two groups of patients did not reach statistical significance (p > .05). The analysis of ADL, quality of life and stroke recurrence in 276 surviving ischaemic stroke patients 3 months post discharge indicated no differences between the two groups across all three aspects (p > .05).

CONCLUSION

Older and divorced or widowed AIS patients tend to prefer professional caregivers. The psychological state during hospitalization, length of hospital stay and hospitalization expenses are not influenced by the caregiving model. Three months post discharge, a greater proportion of patients in the family caregiving group had intact mRS functionality, but this choice did not impact patient prognosis, stroke recurrence, quality of life or independence in ADL.

Complete versus partial revascularization for older adults with acute coronary syndrome: a meta-analysis and systematic review of randomized and multivariable adjusted data

BACKGROUND

Evidence from randomized studies support complete over culprit-only revascularization for patients with acute coronary artery syndrome (ACS) and multivessel coronary artery diseases (MVD). Whether these findings extend to elderly patients, however, has not been thoroughly explored.

METHODS

We conducted a systematic review and meta-analysis comparing clinical outcomes of elderly individuals (defined as age ≥75 years) with ACS and MVD submitted to complete vs partial-only percutaneous coronary intervention (PCI). PubMed, Embase, and Cochrane were searched. We computed pooled hazard ratios with 95% confidence intervals (CI) to preserve time time-to-event data.

RESULTS

We included 7 studies, of which 2 were RCT and 5 were multivariable adjusted cohorts, comprising a total 10 147, of whom 43.8% underwent complete revascularization. As compared with partial-only PCI, complete revascularization was associated with a lower all-cause mortality (hazard ratio 0.71; 95% CI 0.60-0.85; P < 0.01), cardiovascular mortality (hazard ratio 0.64; 95% CI 0.52-0.79; P < 0.01), and recurrent myocardial infarction (hazard ratio 0.65; 95% CI 0.50-0.85; P < 0.01). There was no significant difference between groups regarding the risk of revascularizations (hazard ratio 0.80; 95% CI 0.53-1.20; P = 0.28).

CONCLUSION

Among elderly patients with ACS and multivessel CAD, complete revascularization is associated with a lower risk of all-cause mortality, cardiovascular mortality, and recurrent myocardial infarction.

Prognostic value of geriatric nutritional risk index in patients with stable coronary artery disease undergoing percutaneous coronary intervention

BACKGROUND

Malnutrition increases the risk of poor prognosis in patients with cardiovascular disease, and our current research was designed to assess the predictive performance of the Geriatric Nutrition Risk Index (GNRI) for the occurrence of poor prognosis after percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (SCAD) and to explore possible thresholds for nutritional intervention.

METHODS

This study retrospectively enrolled newly diagnosed SCAD patients treated with elective PCI from 2014 to 2017 at Shinonoi General Hospital, with all-cause death as the main follow-up endpoint. Cox regression analysis and restricted cubic spline (RCS) regression analysis were used to explore the association of GNRI with all-cause death risk and its shape. Receiver operating characteristic curve (ROC) analysis and piecewise linear regression analysis were used to evaluate the predictive performance of GNRI level at admission on all-cause death in SCAD patients after PCI and to explore possible nutritional intervention threshold points.

RESULTS

The incidence of all-cause death was 40.47/1000 person-years after a mean follow-up of 2.18 years for 204 subjects. Kaplan-Meier curves revealed that subjects at risk of malnutrition had a higher all-cause death risk. In multivariate Cox regression analysis, each unit increase in GNRI reduced the all-cause death risk by 14% (HR 0.86, 95% CI 0.77, 0.95), and subjects in the GNRI > 98 group had a significantly lower risk of death compared to those in the GNRI < 98 group (HR 0.04, 95% CI 0.00, 0.89). ROC analysis showed that the baseline GNRI had a very high predictive performance for all-cause death (AUC = 0.8844), and the predictive threshold was 98.62; additionally, in the RCS regression analysis and piecewise linear regression analysis we found that the threshold point for the GNRI-related all-cause death risk was 98.28 and the risk will be significantly reduced when the subjects' baseline GNRI was greater than 98.28.

CONCLUSIONS

GNRI level at admission was an independent predictor of all-cause death in SCAD patients after PCI, and GNRI equal to 98.28 may be a useful threshold for nutritional intervention in SCAD patients treated with PCI.

Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association

Cardiogenic shock continues to portend poor outcomes, conferring short-term mortality rates of 30% to 50% despite recent scientific advances. Age is a nonmodifiable risk factor for mortality in patients with cardiogenic shock and is often considered in the decision-making process for eligibility for various therapies. Older adults have been largely excluded from analyses of therapeutic options in patients with cardiogenic shock. As a result, despite the association of advanced age with worse outcomes, focused strategies in the assessment and management of cardiogenic shock in this high-risk and growing population are lacking. Individual programs oftentimes develop upper age limits for various interventional strategies for their patients, including heart transplantation and durable left ventricular assist devices. However, age as a lone parameter should not be used to guide individual patient management decisions in cardiogenic shock. In the assessment of risk in older adults with cardiogenic shock, a comprehensive, interdisciplinary approach is central to developing best practices. In this American Heart Association scientific statement, we aim to summarize our contemporary understanding of the epidemiology, risk assessment, and in-hospital approach to management of cardiogenic shock, with a unique focus on older adults.

Comparative Analysis of Three Atherosclerotic Cardiovascular Disease Risk Prediction Models in Individuals Aged 75 and Older

Purpose

To evaluate the performance of the Framingham cardiovascular risk score (FRS)/pooled cohort equations (PCE)/China prediction for atherosclerotic cardiovascular disease (ASCVD) risk (China-PAR model) in a prospective cohort of Chinese older adults.

Patients and Methods

We assessed 717 older adults aged 75-85 years without ASCVD at the baseline from the Sichuan province of China. The participants were followed annually from 2011 to 2021. We obtained the participants' information through the medical records of physical examination and evaluated their 10-year ASCVD risk using FRS, PCE, and China-PAR. We further evaluated the predictive abilities of three assessment models.

Results

During the 10-year follow-up, 206 participants developed ASCVD, with an incidence rate of 28.73%. The FRS and China-PAR moderately underestimated the risk of ASCVD (22.1% and 12.4%, respectively), but while PCE overestimated the risk (36.1%). FRS and China-PAR were found to underestimate the risk of ASCVD (26% and 63%, respectively) for men, while PCE overestimated the risk by 8%; For women, FRS and China-PAR were found to underestimate the risk of ASCVD (14% and 35%, respectively), while PCE overestimated the risk by 88%.

Conclusion

The 10-year ASCVD risk was found to be overestimated by PCE. China-PAR had the most accurate predictions in women, while FRS was particularly well-calibrated in males. All three risk models have good discrimination, with FRS and PCE being well-calibrated in men and all three being well-calibrated in women. Therefore, accurate risk models are warranted to facilitate the prevention of ASCVD at the baseline among Chinese older adults.

Frailty in acute coronary syndromes. A systematic review and narrative synthesis of frailty assessment tools and interventions from randomised controlled trials

AIM

We aimed to review all randomised controlled trial (RCT) data to explore optimal identification and treatment strategies of frail patients with Acute Coronary Syndromes (ACS).

METHODS

The protocol was preregistered (PROSPERO - CRD42021250235). We performed a systematic review including RCT's that 1; used at least one frailty assessment tool to assess frailty and its impact on outcomes in patients diagnosed with ACS and 2; used at least one intervention where change in frailty was measured in patients diagnosed with ACS. The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched on the 1st April 2021 and updated on 4th July 2023. Owing to low search output results are presented as a narrative synthesis of available evidence.

RESULTS

A single RCT used a frailty assessment tool. A single RCT specifically targeted frailty with their intervention. This precluded further quantitative analysis. There was indication of selection bias against frail participants, and a signal of value for physical activity measurement in frail ACS patients. There was a high level of uncertainty and low level of robustness of this evidence.

CONCLUSIONS

Data from RCT's alone is inadequate in answering the reviews question. Future RCT's need to address ways to incorporate frail participants, whilst mitigating selection biases. Physical performance aspects of the frailty syndrome appear to be high yield modifiable targets that improve outcomes. Intervention trials should consider using change in frailty status as an outcome measure. Any trials that include frail participants should present data specifically attributable to this group.

Diabetes mellitus does not alter mortality or hospitalisation risk in patients with newly diagnosed heart failure with preserved ejection fraction: Time to rethink pathophysiological models of disease progression

INTRODUCTION

Type 2 diabetes is a common and adverse prognostic co-morbidity for patients with heart failure with reduced ejection fraction (HFrEF). The effect of diabetes on long-term outcomes for heart failure with preserved ejection fraction (HFpEF) is less established.

METHODS

Prospective cohort study of patients referred to a regional HF clinic with newly diagnosed with HFrEF and HFpEF according to the 2016 European Society of Cardiology guidelines. The association between diabetes, all-cause mortality and hospitalisation was quantified using Kaplan-Meier or Cox regression analysis.

RESULTS

Between 1st May 2012 and 1st May 2013, of 960 unselected consecutive patients referred with suspected HF, 464 and 314 patients met the criteria for HFpEF and HFrEF respectively. Within HFpEF and HFrEF groups, patients with diabetes were more frequently male and in both groups patients with diabetes were more likely to be treated with β-adrenoceptor antagonists and angiotensin converting enzyme inhibitors. After adjustment for age, sex, medical therapy and co-morbidities, diabetes was associated with increased mortality in individuals with HFrEF (HR 1.46 95% CI: 1.05-2.02; p = .023), but not in those with HFpEF (HR 1.26 95% CI 0.92-1.72; p = .146).

CONCLUSION

In unselected patients with newly diagnosed HF, diabetes is not an adverse prognostic marker in patients with HFpEF, but is in HFrEF.

'When age is not a barrier': an explorative study of nonagenarian patients' experiences of undergoing percutaneous coronary intervention

AIMS

The recent rise in the number of nonagenarians (age ≥ 90 years) undergoing percutaneous coronary intervention (PCI) has revealed gaps in research, in particular on patients' experiences. Therefore, the aim of the study was to explore and describe nonagenarians' internal resources and their experiences of the in-hospital pathway.

METHODS AND RESULTS

Nineteen nonagenarian patients (women n = 9), mean age 91 years, 9 acutely, and 10 electively treated, were consecutively enrolled from a tertiary university hospital from June 2021 to February 2023. In-depth interviews were conducted during hospitalization, audiotaped and transcribed. The interviews were analysed using qualitative content analysis. Three sub-themes emerged from the nonagenarians' experiences with the PCI treatment trajectory: (i) Taking lifelong responsibility for own physical and mental health describes a population striving to live a healthy life and to stay independent. Physical and mental activities including healthy food choices had been an integral aspect of their lives from early childhood. (ii) Individual internal resources influenced the PCI pathway describes how their internal resources were used, from actively engaging in the decision-making process to withstanding discomfort during the PCI procedure. (iii) The post-PCI pathway was multifaceted describes a short stay at the cardiac ward with individual post-procedural experiences, close monitoring, and preparation for discharge including cardiac rehabilitation.

CONCLUSION

Nonagenarians undergoing PCI demonstrated a personal incentive to stay healthy and independent. Their internal resources of independence, stoicism, and resilience were used during their in-hospital stay contributing to a successful PCI procedure. Individual cardiac rehabilitation strategies were highlighted after discharge from hospital.

Exploring postoperative atrial fibrillation after non-cardiac surgery: mechanisms, risk factors, and prevention strategies

Atrial fibrillation (AF) stands as the most prevalent persistent arrhythmia and a common complication after surgical procedures. Although the majority of non-cardiac surgery patients experience postoperative AF (POAF) and the condition is typically self-limited and asymptomatic, its detrimental impact on patient outcomes, prolonged hospitalization, and heightened risk of stroke and overall mortality has become increasingly evident. Of significant concern, POAF emerges as a noteworthy risk factor for stroke, myocardial infarction, and mortality in comparison to patients with non-surgical atrial fibrillation. Multiple studies have corroborated the association between POAF and an elevated risk of stroke and mortality. The development of postoperative atrial fibrillation is multifactorial, with the inflammatory response being a primary contributor; additionally, factors such as hypovolemia, intraoperative hypotension, anemia, trauma, and pain can trigger POAF. Risk factors for POAF in non-cardiac surgery primarily relate to age, hypertension, obesity, prior cardiac disease, obstructive sleep apnea, and male sex. Prophylactic treatment with β-blockers, amiodarone, or magnesium has demonstrated efficacy, but further trials are warranted, especially in high-risk populations. This review provides an account of the incidence rate, pathophysiology, and prognosis of atrial fibrillation after non-cardiac surgery, elucidates the underlying mechanisms of its occurrence, and explores various preventive strategies investigated in this domain.

Anxiety and depression in patients aged 80 years and older following aortic valve therapy. A six-month follow-up study

BACKGROUND

Little is known about mental health following advanced cardiac procedures in the oldest patients.

AIMS

To study changes in anxiety and depression from baseline to one- and six-month follow-up in older patients following transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).

METHODS

Prospective cohort study of patients ≥ 80 years undergoing elective TAVI or SAVR in a tertiary university hospital. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. Differences between TAVI/SAVR were analyzed using Welch's t test or chi-squared. Changes over time and group differences were established with longitudinal models using generalized least squares.

RESULTS

In 143 patients (83.5 ± 2.7 years), 46% (n = 65) received TAVI. Anxiety was identified in 11% of TAVI patients at baseline. One- and six-months later, percentages were 8% and 9%. In SAVR patients, 18% had baseline scores indicating anxiety. One and six-months later, percentages were 11% and 9%. Depression was identified in 15% of TAVI patients. One- and six-months later, percentages were 11% and 17%. At baseline, 11% of SAVR patients had scores indicating depression. One- and six-months after SAVR, percentages were 15% and 12%. Longitudinal analyses showed reductions (P < 0.001) in anxiety from baseline to one-month, and stable scores between one- and six-months for both treatment groups. There was no change over time for depression among treatment groups (P = 0.21).

DISCUSSION AND CONCLUSIONS

SAVR or TAVI in patients ≥ 80 years was associated with anxiety reduction between baseline and follow-up. For depression, there was no evidence of change over time in either treatment group.

Guideline concordant prescribing following myocardial infarction in people who are frail: A systematic review

AIMS

The risk-to-benefit ratio of cardioprotective medications in frail older adults is uncertain. The objective was to systematically review prescribing of guideline-recommended cardioprotective medications following myocardial infarction (MI) in people who are frail.

DATA SOURCES

Ovid Medline, PubMed and Cochrane were searched from inception to October 2022 for studies that reported prescribing of one or more cardioprotective medication classes post-MI or acute coronary syndromes in people with frailty.

STUDY SELECTION

We included observational studies that reported prescribing of cardioprotective medications post-MI stratified by frailty status.

RESULTS

Overall, 16 cohort studies published from 2013 to 2022 that used seven different frailty scales were included. Prescribing of all cardioprotective medication classes following MI was lower in frail compared to non-frail people, with absolute rates of prescribing varying substantially across studies. Median prescribing in frail and non-frail people, respectively, was 88.9% (IQR 81.5-96.2) and 93.1% (IQR 92.0-98.9) for aspirin; 68.1% (IQR 61.9-91.2) and 86.7% (IQR 79.5-92.8) for P2Y12-inhibitors; 83.1% (IQR 76.9-91.3) and 94.0% (IQR 87.1-95.9) for lipid-lowering therapy; 67.9% (IQR 60.6-74.0) and 74.7% (IQR 71.3-84.5) for angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers; and 74.1% (IQR 69.2-79) and 77.6% (IQR 71.8-85.9) for beta-blockers.

CONCLUSION

People who were frail were less likely to be prescribed guideline recommended medication classes post-MI than those who were non-frail. Further research is needed into treatment benefits and risks in frail people to avoid unnecessarily withholding treatment in this high-risk population, while also minimising potential for medication related harm.

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.

Prognostic Impact of Percutaneous Coronary Intervention in Older Patients Hospitalized with Acute Myocardial Infarction: Real-World Findings from the Lombardy Health Database

BACKGROUND

Older patients are less likely to receive percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) compared to younger patients. We investigated the prognostic impact of PCI in a large population of patients hospitalized with AMI in the period 2003-2018 by using the administrative Lombardy Health Database (Italy).

METHODS

We considered all patients aged ≥75 years hospitalized with AMI (either STEMI or NSTEMI) from 2003 to 2018 in Lombardy. Patients were grouped according to whether they were treated or not with PCI during the index hospitalization. The primary outcome was in-hospital mortality. The secondary endpoints were 1-year mortality and 1-year re-hospitalization for acute heart failure (AHF) or AMI.

RESULTS

116,063 patients aged ≥75 years (mean age 83 ± 6; 48% males; 46% STEMI) were hospitalized with a primary diagnosis of AMI. Thirty-seven percent of them (n = 42,912) underwent PCI. The in-hospital mortality rate was significantly lower in PCI-treated patients (6% vs. 15%; p < 0.0001). One-year mortality and 1-year re-hospitalization for AHF/AMI were less frequent in PCI-treated patients (16% vs. 41% and 15% vs. 21%, respectively; p < 0.0001). The adjusted risks of the study endpoints were lower in PCI-treated patients: OR 0.37 (95% CI 0.36-0.39) for in-hospital mortality; HR 0.37 (95% CI 0.36-0.38) for 1-year mortality; HR 0.74 (95% CI 0.71-0.77) for 1-year re-hospitalization for AHF/AMI. Similar results were found in STEMI and NSTEMI patients considered separately.

CONCLUSIONS

Our real-world data showed that in patients with AMI ≥ 75 years of age, PCI use is associated with lower in-hospital and 1-year mortality.

Frailty, Treatments, and Outcomes in Older Patients With Myocardial Infarction: A Nationwide Registry-Based Study

Background Guidelines recommend that patients with myocardial infarction (MI) receive equal care regardless of age. However, withholding treatment may be justified in elderly and frail patients. This study aimed to investigate trends in treatments and outcomes of older patients with MI according to frailty. Methods and Results All patients aged ≥75 years with first-time MI during 2002 to 2021 were identified through Danish nationwide registries. Frailty was categorized using the Hospital Frailty Risk Score. One-year risk and hazard ratios (HRs) for days 0 to 28 and 29 to 365 were calculated for all-cause death. A total of 51 022 patients with MI were included (median, 82 years; 50.2% women). Intermediate/high frailty increased from 26.7% in 2002 to 2006 to 37.1% in 2017 to 2021. Use of treatment increased substantially regardless of frailty: for example, 28.1% to 48.0% (statins), 21.8% to 33.7% (dual antiplatelet therapy), and 7.6% to 28.0% (percutaneous coronary intervention) for high frailty (all P-trend <0.001). One-year death decreased for low frailty (35.1%-17.9%), intermediate frailty (49.8%-31.0%), and high frailty (62.8%-45.6%), all P-trend <0.001. Age- and sex-adjusted 29- to 365-day HRs (2017-2021 versus 2002-2006) were 0.53 (0.48-0.59), 0.62 (0.55-0.70), and 0.62 (0.46-0.83) for low, intermediate, and high frailty, respectively (P-interaction=0.23). When additionally adjusted for treatment, HRs attenuated to 0.74 (0.67-0.83), 0.83 (0.74-0.94), and 0.78 (0.58-1.05), respectively, indicating that increased use of treatment may account partially for the observed improvements. Conclusions Use of guideline-based treatments and outcomes improved concomitantly in older patients with MI, irrespective of frailty. These results indicate that guideline-based management of MI may be reasonable in the elderly and frail.

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.

Proxy Decision-Making for Clinical Research in Nursing Home Residents With Dementia: A Qualitative Analysis

OBJECTIVES

The benefit-risk ratio of many interventions remains unclear in older adults with dementia. Efforts for more representative trial inclusion are made; however, recruiting and particularly gaining informed consent remains complex. For research participation, dementia compels the designation of a legal guardian (LG) to give proxy consent. To advance future trial development, we aimed to provide more insights into the factors that affect the proxy decision-making process in dementia research.

DESIGN

A qualitative analysis of semi-structured interviews about proxy decision-making on participation in dementia research.

SETTING AND PARTICIPANTS

LGs of nursing home residents that gave (n = 19) and refrained from giving (n = 18) proxy consent for a clinical trial (the ∗∗∗BLINDED∗∗∗ study) in the Netherlands.

METHODS

Verbatim transcripts were thematically analyzed by using a preliminary deductive framework with room for induction of additional emerging themes, being an overall abductive approach. Based on that theme list, related factors of the decision-making process were grouped into overarching levels and merged into a step-by-step process.

RESULTS

When discussing proxy decision-making on the participation of an older adult with dementia in a clinical trial, LGs described interconnected factors on the level of the study and patient. Past experiences and attitudes of the LG influenced the weighing of these study- and patient-related factors, leading to a preliminary decision. Other proxies and treating health care professionals (HCPs) were named as important other stakeholders of the decision-making process.

CONCLUSIONS AND IMPLICATIONS

When giving proxy consent for research participation, LGs weigh study- and patient-related factors, leading to an initial benefit-risk evaluation. This weighing process is influenced by LG-related factors and can be modulated by other proxies or treating HCPs, leading to a definitive decision. Although insights into these underlying mechanisms could facilitate the proxy decision-making process for both LGs and researchers, treating HCPs could act as an independent party.

Sex Differences in 10-Year Outcomes After Percutaneous Coronary Intervention With Drug-Eluting Stents: Insights From the DECADE Cooperation

BACKGROUND

Although some studies have investigated sex-related outcomes up to 5 years after percutaneous coronary intervention (PCI), analyses at longer follow-up (ie, to 10 years) in large cohorts treated exclusively with drug-eluting stent (DES) platforms are lacking. Therefore, this study aimed to define whether sex-related differences in long-term outcomes after PCI persist both in the DES era and at longer-term follow-up.

METHODS

Individual data of patients treated with DES in 5 randomized controlled trials with 10-year follow-up were pooled. Patients were divided into 2 groups by sex. The analysis of individual participant data was performed using a 1-stage approach by entering a clustering effect by parent study in all univariable and multivariable models focusing on sex. The main outcomes of interest for this analysis included cardiovascular death, myocardial infarction, repeat revascularization, and definite stent thrombosis to 10 years after PCI. Survival was analyzed by the Kaplan-Meier method to estimate the time to first event, and differences between the 2 groups were tested with the log-rank test. Hazard ratios (HRs) and 95% CIs were calculated with a Cox proportional hazards model. Conventional multivariable analyses with adjustment for relevant variables were performed.

RESULTS

Among 9700 patients undergoing PCI with DES implantation included in the present analysis, 2296 were women and 7404 were men. Through to 10 years, cardiovascular death occurred in 407 of the 2296 female patients and 1012 of the 7404 male patients (adjusted HR [HR_adj], 0.94 [95% CI, 0.80-1.11]). Female sex was associated with a lower risk of repeat revascularization of the target lesion (HR_adj, 0.80 [95% CI, 0.74-0.87]), target vessel (HR_adj, 0.81 [95% CI, 0.76-0.87]), and nontarget vessels (HR_adj, 0.69 [95% CI, 0.62-0.77]). Compared with male patients, female patients displayed an increased risk of myocardial infarction in the first 30 days after PCI with DES (HR_adj, 1.65 [95% CI, 1.24-2.19]) but a comparable risk of myocardial infarction thereafter. The risk of definite stent thrombosis was not significantly different between female and male patients (HR_adj, 1.14 [95% CI, 0.89-1.47]).

CONCLUSIONS

Through to 10-year follow-up after PCI with DES, female patients are at increased risk of early myocardial infarction, receive fewer repeat revascularizations, and have no difference in cardiovascular mortality compared with male patients.

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.

Anxiety and Depressive Symptoms, Frailty and Quality of Life in Atrial Fibrillation

Introduction: Symptoms of atrial fibrillation (AF) can significantly affect functioning in daily life and reduce patients’ quality of life (QoL). The severity and type of AF symptoms affects not only patient’s QoL, but can be a cause of the development of emotional and psychological disorders. In addition, frailty syndrome (FS) plays important role from the point of view of developing disability and dependence on others, as well as reducing QoL. Aim: To assess the symptoms of anxiety and depression, to evaluate the co-occurrence of frailty syndrome and the impact of these factors on the quality of life of patients with AF. Methods: The study used a Polish adaptation of the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia part III (ASTA part III), the Tilburg Frailty Indicator (TFI) and the Hospital Anxiety Depression Scale (HADS). Results: Analysis showed that anxiety symptoms and depressive symptoms correlate significantly (p < 0.05) and positively with the physical (r = 0.24; p < 0.001, r = 0.29, p = 0.002, respectively), psychological (r = 0.34, p < 0.001, r = 0.49 p < 0.001, respectively) and total quality of life (r = 0.31, p = 0.001, r = 0.414; p < 0.001, respectively) ASTA III domains. A significant (p < 0.05) positive correlation was observed between the TFI total score and the physical (r = 0.34, p < 0.001), psychological (r = 0.36, p < 0.001) and overall quality of life (r = 0.38, p < 0.001) in ASTA III domains. Conclusions: Both FS and depressive and anxiety symptoms significantly affect QoL. Understanding the relationship between anxiety and depressive symptoms, FS and QoL may allow for a more targeted approach to the treatment and care of patients with AF.

Primary prevention statin therapy in older adults

PURPOSE OF REVIEW

The purpose of this review is to assess the evidence for primary prevention statin treatment in older adults, within the context of the most recent guideline recommendations, while also highlighting important considerations for shared decision-making.

RECENT FINDINGS

As the average lifespan increases and the older adult population grows, the opportunity for prevention of morbidity and mortality from cardiovascular disease is magnified. Randomized trials and meta-analyses have demonstrated a clear benefit for primary prevention statin use through age 75, with uncertainty beyond that age. Despite these data supporting their use, current guidelines conflict in their statin treatment recommendations in those aged 70-75 years. Reflecting the paucity of evidence, the same guidelines are equivocal around primary prevention statins in those beyond age 75. Two large ongoing randomized trials (STAREE and PREVENTABLE) will provide additional insights into the treatment benefits and risks of primary prevention statins in the older adult population. In the meantime, a holistic approach in treatment decisions remains paramount for older patients.

SUMMARY

The benefits of primary prevention statin treatment are apparent through age 75, which is reflected in the current ACC/AHA and USPSTF recommendations. Ongoing trials will clarify the utility in those beyond age 75.

The Aging Heart: A Molecular and Clinical Challenge

Aging is associated with an increasing burden of morbidity, especially for cardiovascular diseases (CVDs). General cardiovascular risk factors, ischemic heart diseases, heart failure, arrhythmias, and cardiomyopathies present a significant prevalence in older people, and are characterized by peculiar clinical manifestations that have distinct features compared with the same conditions in a younger population. Remarkably, the aging heart phenotype in both healthy individuals and patients with CVD reflects modifications at the cellular level. An improvement in the knowledge of the physiological and pathological molecular mechanisms underlying cardiac aging could improve clinical management of older patients and offer new therapeutic targets.

Sarcopenia and Frailty in Heart Failure: Is There a Biomarker Signature?

PURPOSE OF REVIEW

Sarcopenia and frailty are common in patients with heart failure (HF) and are strongly associated with prognosis. This review aims to examine promising biomarkers that can guide physicians in identifying sarcopenia and frailty in HF.

RECENT FINDINGS

Traditional biomarkers including C-reactive protein, aminotransaminase, myostatin, and urinary creatinine as well as novel biomarkers including microRNAs, suppression of tumorigenicity 2 (ST2), galectin-3, and procollagen type III N-terminal peptide may help in predicting the development of sarcopenia and frailty in HF patients. Among those biomarkers, aminotransferase, urinary creatinine, and ST2 predicted the prognosis in HF patients with sarcopenia and frailty. This review outlines the current knowledge of biomarkers that are considered promising for diagnosing sarcopenia and frailty in HF. The listed biomarkers might support the diagnosis, prognosis, and therapeutic decisions for sarcopenia and frailty in HF patients.

Sex-related differences in clinical outcomes and predictive factors in the very elderly patients with ACS undergoing PCI

Background

As shown in previous studies, there may be sex-related differences in clinical outcomes in patients with acute coronary syndromes (ACS) after percutaneous coronary intervention (PCI). However, the benefits of PCI in very elderly ACS patients and the gender differences were poorly described and understood. We investigated the clinical characteristics and outcomes after PCI by sex stratification, and the predictive factors of major adverse cardiovascular and cerebrovascular events (MACCE) in this very elderly ACS cohort.

Methods

A total of 1,676 consecutive ACS patients (50.2% women) aged ≥80 years old between January 2013 and May 2020 were recruited in this study. All patients were divided into four groups according to gender and treatment: male PCI (n = 321) and conservative management groups (n = 513), and female PCI (n = 283) and conservative management groups (n = 559). Clinical and coronary lesion characteristics were compared among four groups, also the clinical outcomes. MACCE and their predictive factors were assessed using Kaplan–Meier curve and Cox regression analysis.

Results

PCI procedures were conducted in 604 patients, and 1,072 were conservative management. Men were most likely to present with prior myocardial infarction (MI), peripheral artery disease, and chronic total occlusion (CTO); women had a higher prevalence of hypertension and dyslipidemia. The proportion of men receiving PCI procedures was significantly higher than that of women (38.5 vs. 33.6%, p = 0.038). Compared to conservative management, successful PCI significantly improved composite MACCE in both men (33.9 vs. 18.4%, p < 0.001) and women (27.9 vs. 20.8%, p = 0.026). There were no differences between sex in the improvement of clinical outcomes after PCI. In addition, age, ST-segment elevation myocardial infarction (STEMI), log N-terminal pro-brain natriuretic peptide (NT-proBNP), P2Y12 receptor antagonist, and β-blocker were independently associated with the incidence of MACCE after PCI tested by the Cox regression model, but not gender (male: hazard ratio (HR) 1.275, 95% confidence interval (CI) 0.853–1.905, p = 0.236).

Conclusion

In this very elderly ACS cohort, men presented with more complex clinical conditions, and women were less likely to receive PCI treatment. Both women and men had similar benefits from the PCI procedure in the decrease of MACCE.

Elderly aortic stenosis patients' perspectives on treatment goals in transcatheter aortic valvular replacement

Aims

Transcatheter aortic valvular replacement (TAVR) is increasingly being performed for elderly patients with aortic stenosis (AS), and current guidelines acknowledge the importance of shared decision‐making in their management. This study aimed to evaluate elderly symptomatic severe AS patients' perspectives on their treatment goals and identify factors that influence their treatment choice.

Methods and Results

We performed a pre‐procedural cross‐sectional survey using a questionnaire at a single university hospital. The questionnaire included three primary domains: (i) symptom burden, (ii) goals and important factors related to treatment, and (iii) preferred place of residence after treatment. We investigated 98 symptomatic severe AS patients who underwent TAVR (median age 86 years, 26% men). None of the patients died during hospitalization, and most of them (94%) were discharged home. Prior to TAVR, the three most common symptom burdens were poor mobility (52%), shortness of breath (52%), and weakness (44%). The reported preferred treatment goals were symptom burden reduction (78%), independence maintenance (68%), ability to perform a specific activity/hobby (62%), and improvement in prognosis (58%). In total, 54% of the patients rated ‘in alignment with my values’ as the factor that affected their decision to undergo TAVR. Nearly all patients (95%) stated that they preferred to live at home after TAVR.

Conclusions

Among elderly AS patients with varying symptoms who underwent TAVR, symptom burden reduction was the most cited patient‐reported goal. Nearly all the patients preferred to live at home after the procedure. Encouraging patients to define their specific goals may improve the quality of shared decision‐making in such settings.

Conventional medical therapy in heart failure patients eligible for the PARADIGM-HF, DAPA-HF, and SHIFT trials

BACKGROUND

Recent trials on novel heart failure (HF) treatments (angiotensin receptor-neprilysin inhibitor, sodium-glucose cotransporter 2 inhibitor, and ivabradine) emphasize the use of conventional medical therapy (angiotensin-converting enzyme inhibitors, beta-blockers [BB], and mineral corticosteroid receptor antagonists). We aimed to evaluate the prescription rate of conventional medical therapy and its association with long-term outcomes in patients eligible for recent trials.

METHODS

We examined 1295 consecutive patients with HF with reduced ejection fraction (HFrEF) from a multicenter registry (WET-HF registry). We assessed conventional medical therapy implementation among patients meeting the PARADIGM-HF/DAPA-HF and SHIFT enrollment criteria. We also examined the association between conventional medical therapy use and long-term outcomes within each enrollment criterion.

RESULTS

Overall, 62.2% and 35.3% of HFrEF patients met the enrollment criteria of the PARADIGM-HF/DAPA-HF and SHIFT trials. Only 33.9% and 31.9% received full conventional medical therapy within each patient subset. Notably, 84.2% of patients who met the SHIFT enrollment criteria were on BB, and only 23.0% and 4.4% were on ≥50% or the full recommended dose, respectively. Implementation of full conventional medical therapy use was associated with lower 2-year mortality and HF readmission rates in the PARADIGM-HF/ DAPA-HF eligible group (HR 0.68, 95% CI 0.50-0.92). The use of BB at ≥50% of the recommended dose was associated with lower 2-year mortality and HF readmission rates in the SHIFT-eligible group (HR 0.50, 95% CI 0.30-0.84).

CONCLUSIONS

Conventional medical therapy was underutilized among patients eligible for novel trials within a Japanese HF registry. Further efforts to optimize conventional medical therapy are needed.

Randomized Controlled Trial Comparing a Multidisciplinary Intervention by a Geriatrician and a Cardiologist to Usual Care after a Heart Failure Hospitalization in Older Patients: The SENECOR Study

Background: The prognosis of older patients after a heart failure (HF) hospitalization is poor. Methods: In this randomized trial, we consecutively assigned 150 patients 75 years old or older with a recent heart failure hospitalization to follow-up by a cardiologist (control) or follow-up by a cardiologist and a geriatrician (intervention). The primary outcome was all-cause hospitalization at a one-year follow-up. Results: All-cause hospitalization occurred in 47 of 75 patients (62.7%) in the intervention group and in 58 of 75 patients (77.3%) in the control group (hazard ratio, 0.67; 95% confidence interval, 0.46 to 0.99; p = 0.046). The number of patients with at least one HF hospitalization was similar in both groups (34.7% in the intervention group vs. 40% in the control group, p = 0.5). There were a total of 236 hospitalizations during the study period. The main reasons for hospitalization were heart failure (38.1%) and infection (14.8%). Mortality was 24.7%. Heart failure was the leading cause of mortality (54.1% of all deaths), without differences between groups. Conclusions: A follow-up by a cardiologist and geriatrician in older patients after an HF hospitalization was superior to a cardiologist’s follow-up in reducing all-cause hospitalization in older patients. (Funded by Beca Primitivo de la Vega, Fundación MAPFRE. ClinicalTrials.gov number, NCT03555318).

In-Hospital Bleeding in Elderly Patients With Acute Coronary Syndrome: Are Potent Antiplatelet Agents Safe?

Despite implementation of new interventional techniques and therapeutic advances, elderly patients with acute coronary syndrome (ACS) continue to be susceptible to in-hospital bleeding compared with younger ones. Thus, we investigated the incidence of in-hospital bleeding events and associated risk factors in elderly (≥ 75°years) ACS patients. We also wanted to define the bleeding sites, characteristics, and associated mortality. Bleeding Academic Research Consortium (BARC) classification type 2, 3, or 5 was used to define bleeding events. Overall, 539 patients were included in the study (mean age: 82.5 ± 4.8°years; 282 (52.3%) females). Of these patients, 69 (12.8%) developed in-hospital bleeding. Factors that were independently related with in-hospital bleeding were age (odds ratio (OR): 1.08; 95% confidence interval (CI): 1.011.14, P = .01), acute kidney injury (OR: 3.66; 95% CI: 2.016.69; P < .01), tirofiban (OR: 4.43; 95% CI: 1.7810.99; P < .01), and ticagrelor (OR: 1.93; 95% CI: 1.013.73; P = .04) administration. The urinary tract was the most frequent bleeding site, followed by femoral arteries. In conclusion, ticagrelor and tirofiban should be used with caution in elderly ACS patients.

All-cause mortality and cardiovascular events in a Spanish nonagenarian cohort according to type 2 diabetes mellitus status and established cardiovascular disease

Background

Despite the progressive aging of the population in industrialized countries, few studies have focused on the natural history of cardiovascular disease in the very old, and recommendations on prevention of cardiovascular disease in this population are lacking. We aimed to analyze all-cause mortality and cardiovascular events according to prevalent type 2 diabetes mellitus and established cardiovascular disease in nonagenarians from a Mediterranean population.

Methods

We analyzed the primary health records of all nonagenarians living in the Community of Madrid (N = 59,423) and collected data for 4 groups: Group 1, individuals without T2DM or established CVD (T2DM-, CVD-); Group 2, individuals without T2DM but with established CVD (T2DM-, CVD +); Group 3, individuals with T2DM but without established CVD (T2DM + , CVD-); and Group 4, individuals with both T2DM and established CVD (T2DM + , CVD +), taking into account the influence of sex on the outcomes. Follow-up was 2.5 years. The primary outcomes were cumulative incidence and incidence density rates for all-cause mortality, non-fatal myocardial infarction, non-fatal stroke (the first composite primary outcome [CPO1]), combined with heart failure (CPO2). We evaluated the adjusted effect of each group on all-cause mortality (Cox regression).

Results

Mean age was 93.3 ± 2.8 years (74.2% women). Hypertension, dyslipidemia, heart failure, albuminuria, and estimated glomerular filtration rate < 60 mL/min/1.73 m2 were significantly more prevalent in G4 than in the other groups (all p values < 0.001). We observed significantly higher cumulative incidence rates for all-cause mortality, CPO1, and CPO2 in participants belonging to G4 (all p values ≤ 0.001). People in G2 presented higher rates of all-cause mortality, heart failure, CPO1, and CPO2 than people in G3 (all p values ≤ 0.001). In the fully adjusted model, G4 independently predicted all-cause mortality (HR = 1.48 [95% CI, 1.40 to 1.57] vs reference G1 [p < 0.01]). In addition, significant HRs were recorded for cardiovascular disease alone (G2) and type 2 diabetes mellitus alone (G3) (1.13 and 1.14, respectively; both p values < 0.01).

Conclusions

In Spanish nonagenarians, established cardiovascular disease and type 2 diabetes mellitus conferred a modest risk of all-cause mortality. However, the simultaneous presence of both conditions conferred the highest risk of all-cause mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02893-z.

Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research?

Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.

Non-vitamin K antagonist oral anticoagulants in older and frail patients with atrial fibrillation

Elderly and frail patients with atrial fibrillation (AF) are at increased risk of thrombotic events, bleeding, and death compared to their counterparts, making their management challenging. With the introduction of non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) in the past decade, the risk:benefit balance in such high-risk patients with AF has tipped in favor of treating these patients with anticoagulation, and in most cases with a NOAC instead of a VKA. In patients ≥75 years of age with AF, each of the 4 approved NOACs reduced stroke or systemic embolism and vs warfarin in their landmark clinical trial and lowered mortality. However, only apixaban and edoxaban significantly reduced major bleeding vs warfarin. A similar pattern was seen in even older cohorts (≥80 and ≥85 years). Among patients age ≥80 who are not candidates for oral anticoagulants at the approved dose, edoxaban 15 mg may be a reasonable alternative. In elderly or frail individuals who are on multiple comedications (particularly if ≥1 moderate or strong cytochrome P-450 inhibitor), only edoxaban consistently reduced major bleeding compared to warfarin. Regardless of the specific OAC selected, appropriate dosing in the elderly (who frequently qualify for dose reduction per the prescribing label) is critical. In elderly and frail patients with AF, factors that may modify the efficacy-safety profile of specific oral OACs should be carefully considered to permit the optimal selection and dosing in these vulnerable patients.

Aging Impairs Reverse Remodeling and Recovery of Ventricular Function after Isoproterenol-Induced Cardiomyopathy

Information about heart failure with reduced ejection fraction (HFrEF) in women and the potential effects of aging in the female heart is scarce. We investigated the vulnerability to develop HFrEF in female elderly mice compared to young animals, as well as potential differences in reverse remodeling. First, HF was induced by isoproterenol infusion (30 mg/kg/day, 28 days) in young (10-week-old) and elderly (22-month-old) female mice. In a second set of animals, mice underwent isoproterenol infusion followed by no treatment during 28 additional days. Cardiac remodeling was assessed by echocardiography, histology and gene expression of collagen-I and collagen-III. Following isoproterenol infusion, elderly mice developed similar HFrEF features compared to young animals, except for greater cell hypertrophy and tissue fibrosis. After beta-adrenergic withdrawal, young female mice experienced complete reversal of the HFrEF phenotype. Conversely, reversed remodeling was impaired in elderly animals, with no significant recovery of LV ejection fraction, cardiomyocyte hypertrophy and collagen deposition. In conclusion, chronic isoproterenol infusion is a valid HF model for elderly and young female mice and induces a similar HF phenotype in both. Elderly animals, unlike young, show impaired reverse remodeling, with persistent tissue fibrosis and cardiac dysfunction even after beta-adrenergic withdrawal.

Sex Differences in Cardiovascular Outcomes of Older Adults After Myocardial Infarction

Background Evidence on the impact of sex on prognoses after myocardial infarction (MI) among older adults is limited. We evaluated sex differences in long-term cardiovascular outcomes after MI in older adults. Methods and Results All patients with MI ≥70 years admitted to 20 Finnish hospitals during a 10-year period and discharged alive were studied retrospectively using a combination of national registries (n=31 578, 51% men, mean age 79). The primary outcome was combined major adverse cardiovascular event within 10-year follow-up. Sex differences in baseline features were equalized using inverse probability weighting adjustment. Women were older, with different comorbidity profiles and rarer ST-segment-elevation MI and revascularization, compared with men. Adenosine diphosphate inhibitors, anticoagulation, statins, and high-dose statins were more frequently used by men, and renin-angiotensin-aldosterone inhibitors and beta blockers by women. After balancing these differences by inverse probability weighting, the cumulative 10-year incidence of major adverse cardiovascular events was 67.7% in men, 62.0% in women (hazard ratio [HR], 1.17; CI, 1.13-1.21; P<0.0001). New MI (37.0% in men, 33.1% in women; HR, 1.16; P<0.0001), ischemic stroke (21.1% versus 19.5%; HR, 1.10; P=0.004), and cardiovascular death (56.0% versus 51.1%; HR, 1.18; P<0.0001) were more frequent in men during long-term follow-up after MI. Sex differences in major adverse cardiovascular events were similar in subgroups of revascularized and non-revascularized patients, and in patients 70 to 79 and ≥80 years. Conclusions Older men had higher long-term risk of major adverse cardiovascular events after MI, compared with older women with similar baseline features and evidence-based medications. Our results highlight the importance of accounting for confounding factors when studying sex differences in cardiovascular outcomes.

Special Considerations for Healthy Lifestyle Promotion Across the Life Span in Clinical Settings: A Science Advisory From the American Heart Association

At a population level, engagement in healthy lifestyle behaviors is suboptimal in the United States. Moreover, marked disparities exist in healthy lifestyle behaviors and cardiovascular risk factors as a result of social determinants of health. In addition, there are specific challenges to engaging in healthy lifestyle behaviors related to age, developmental stage, or major life circumstances. Key components of a healthy lifestyle are consuming a healthy dietary pattern, engaging in regular physical activity, avoiding use of tobacco products, habitually attaining adequate sleep, and managing stress. For these health behaviors, there are guidelines and recommendations; however, promotion in clinical settings can be challenging, particularly in certain population groups. These challenges must be overcome to facilitate greater promotion of healthy lifestyle practices in clinical settings. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with consideration for the demands of clinical settings. In this science advisory, we summarize specific considerations for lifestyle-related behavior change counseling using the 5A Model for patients across the life span. In all life stages, social determinants of health and unmet social-related health needs, as well as overweight and obesity, are associated with increased risk of cardiovascular disease, and there is the potential to modify this risk with lifestyle-related behavior changes. In addition, specific considerations for lifestyle-related behavior change counseling in life stages in which lifestyle behaviors significantly affect cardiovascular disease risk are outlined. Greater attention to healthy lifestyle behaviors during every clinician visit will contribute to improved cardiovascular health.

Burden of cardiovascular diseases in older adults using aged care services

OBJECTIVE

To quantify the burden of cardiovascular diseases (CVD) in older adults using community and residential care services.

METHODS

The study population comprised people aged 45+ from the 45 and Up Study (2006-09, n = 266,942) in Australia linked with records for hospital stays, aged care service and deaths for the period 2006-14. Follow-up time for each person was allocated to three categories of service use: no aged care, community care and residential care, with censoring at date of death. We calculated the prevalence at baseline and entry to aged care, and incidence rates for major CVD and six cardiovascular diagnoses, seven cardiovascular interventions (collectively CV interventions), cardiovascular-related intensive care unit stays and cardiovascular death.

RESULTS

The prevalence of major CVD at entry into community care and residential care was 41% and 58% respectively. Incidence per 1,000 person-years of all major CVD hospitalisations and CV interventions, respectively, was 182.8 (95% CI: 180.0-185.8) and 37.0 (95% CI: 35.6-38.4) for people using community care, and 280.7 (95% CI: 272.2-289.4) and 11.7 (95% CI: 9.8-13.9) for people using residential care. Similar trends were observed for each of the CVD diagnoses and interventions. Crude incidence rates for cardiovascular deaths per 1,000 person-years were 1.4 (95% CI: 1.3-1.5) in no aged care, 13.3 (95% CI: 12.6-14.1) in community care, and 149.7 (95% CI: 144.4-155.2) in residential care.

CONCLUSION

Our findings demonstrate the significant burden of CVD in people using both community-based and residential aged care services and highlights the importance of optimising cardiovascular care for older adults.

Cardiovascular care of older adults

Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.

Perioperative cardiovascular outcomes among older adults undergoing in-hospital noncardiac surgery

BACKGROUND

Older adults undergoing noncardiac surgery have a high risk of major adverse cardiovascular events (MACE). This study aims to estimate the magnitude of increased perioperative risk, and examine national trends in perioperative MACE following in-hospital noncardiac surgery in older adults compared to middle-aged adults.

DESIGN

Time-series analysis of retrospective longitudinal data.

SETTING

The United States Agency for Healthcare Research and Quality National Inpatient Sample (NIS).

PARTICIPANTS

Hospitalizations for major noncardiac surgery among adults age ≥45 years between January 2004 and December 2014.

MEASUREMENTS

Inpatient perioperative MACE was defined as a composite of in-hospital death, myocardial infarction (MI), and ischemic stroke. In hospital death was determined from the NIS discharge disposition. MI and ischemic stroke were defined by International Classification of Diseases, Ninth Revision codes.

RESULTS

Of an estimated 55,349,978 surgical hospitalizations, 26,423,039 (47.7%) were for adults age 45-64, 14,231,386 (25.7%) age 65-74, 10,621,029 (19.2%) age 75-84 years, and 4,074,523 (7.4%) age ≥85 years. MACE occurred in 1,601,022 surgical hospitalizations (2.9%). Adults 65-74 (2.8%; aOR 1.16, 95% CI 1.14-1.17), 75-84 years (4.5%; aOR 1.30, 95% CI 1.28-1.32), and ≥85 years (6.9%; aOR 1.55, 95% CI 1.52-1.57) had greater risk of MACE than those 45-64 years (1.7%). From 2004 to 2014, MACE declined among adults 65-74 (3.1-2.5%, p < 0.001), 75-85 years (4.9-3.9%, p < 0.001), and ≥85 years (7.7-6.1%, p < 0.001), but was unchanged for adults age 45-64. Declines in MACE were driven by decreased MI and mortality despite increased stroke.

CONCLUSION

Older adults accounted for half of hospitalizations, but experienced the majority of MACE. Older adults had greater adjusted odds of MACE than younger individuals. The proportion of perioperative MACE declined over time, despite increases in ischemic stroke. These data highlight risks of noncardiac surgery in older adults that warrant increased attention to improve perioperative outcomes.

Association between frailty and ischemic heart disease: a systematic review and meta-analysis

Background

Frailty is increasingly reported among older adults with cardiovascular diseases and it has been demonstrated to increase negative health outcomes and mortality. To date, no systematic review of the evidence is available regarding the association between frailty and ischemic heart disease (IHD). We performed a systematic review of literature and a meta-analysis to assess the association between frailty and IHD.

Methods

We selected all the studies that provided information on the association between frailty and IHD, regardless of the study setting, study design, or definition of IHD and frailty. PubMed, Web of Science and Embase were searched for relevant papers. Studies that adopted the Fried definition for frailty were included in the meta-analyses. For each measure of interest (proportions and estimates of associations), a meta-analysis was performed if at least three studies used the same definition of frailty. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting.

Results

Thirty-seven studies were included. Of these, 22 adopted the Fried criteria to define frailty and provided estimates of prevalence and therefore they were included in meta-analyses. The pooled prevalence of IHD in frail individuals was 17% (95% Confidence Interval [95%CI] 11–23%) and the pooled prevalence of frailty in individuals with IHD was 19% (95% CI 15–24%). The prevalence of frailty among IHD patients ranged from 4 to 61%. Insufficient data were found to assess longitudinal association between frailty and IHD.

Conclusions

Frailty is quite common in older persons with IHD. The identification of frailty among older adults with IHD should be considered relevant to provide individualized strategies of cardiovascular prevention and care. Further research should specifically explore the association between frailty and IHD and investigate the potential common biological ground.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02304-9.

Older patients' perspectives toward lifestyle-related secondary cardiovascular prevention after a hospital admission-a qualitative study

BACKGROUND

lifestyle-related secondary prevention reduces cardiac events and is recommended irrespective of age. However, motivation may be influenced by age and disease progression.

OBJECTIVE

to explore older cardiac patients' perspectives toward lifestyle-related secondary prevention after a hospital admission.

METHODS

a generic qualitative design was used. Semi-structured interviews were performed with cardiac patients ≥ 70 years within 3 months after a hospital admission. The interview guide was based on the Attitudes, Social influence and self-Efficacy (ASE) model. All interviews were analysed using thematic analysis.

RESULTS

eight themes emerged which were linked to the determinants of the ASE-model. The three themes (i) Perspectives are determined by general health and habits, (ii) feeling the threat as a motivator and (iii) balancing between health benefits and quality of life (QoL), were linked to attitude. Regarding social influence, the themes (iv) feeling both encouraged and hindered by family members, and (v) the healthcare professional says so, were identified. For the self-efficacy determinant, (vi) experiences from previous lifestyle changes, (vii) integrating advice in daily life and (viii) feeling limited by functional impairments, emerged as themes.

CONCLUSION

most older cardiac patients made no lifestyle modifications after the last hospital admission and balanced possible benefits against their QoL. Functional impairments frequently limit implementation, in particular of physical activity. Patients' preferences and patient-centred outcomes focusing on QoL and functional independence may be the starting point when healthcare professionals discuss lifestyle modification in older patients. The involvement of family members may help patients to integrate lifestyle-related secondary prevention in daily life.

Very Elderly Patients With Acute Coronary Syndromes Treated With Percutaneous Coronary Intervention

BACKGROUND

The rates of very elderly patients (≥85 years old) undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) are rapidly increasing. They are under-represented in clinical trials, and those who are included may not reflect the real-world population. We aim to review the clinical characteristics of very elderly patients undergoing PCI for ACS and identify factors associated with adverse outcomes.

METHOD

All very elderly patients undergoing PCI for ACS in the Auckland region between January 2014 to December 2016 were included. Baseline clinical and procedural details were obtained, and the primary endpoint was all-cause mortality measured up to a maximum of 4 years. Secondary endpoints include recurrent myocardial infarction, unplanned revascularisation, stroke and major bleeding.

RESULTS

A total of 186 patients were included for analysis (mean age 87.6±2.8 years, 51.6% male). Indications for PCI were ST-elevation myocardial infarction (STEMI) in 74 (39.8%), non-ST elevation myocardial infarction (NSTEMI) in 97 (52.2%) and unstable angina in 15 patients (8.1%). Successful PCI was completed in 180 patients. At a maximal follow-up of 4 years (mean 23.4 mo), the rates of all-cause mortality and recurrent myocardial infarction were 22.0% and 14.0% respectively. The risk of mortality was increased by the presence of diabetes (44.8% vs 17.8%, HR=3.0, 95%CI: 1.6-5.9, p=0.001), STEMI (33.8% vs 13.5%, HR=3.1, 95%CI: 1.6-5.9, p=0.001), and reduced eGFR (every -10 mL/min/1.73m², HR=1.7, 95%CI: 1.3-2.1, p<0.0001). Major bleeding events while on dual antiplatelet therapy as defined by Bleeding Academic Research Consortium score ≥3 occurred in 14 patients (7.5%; 8 on ticagrelor, 6 on clopidogrel).

CONCLUSION

Very elderly patients who undergo PCI for ACS have acceptable survival outcomes. STEMI, diabetes and impaired renal function were predictive of mortality in this elderly cohort.

Psychosocial Syndemics and Multimorbidity in Patients with Heart Failure †

Heart failure (HF) is a common cause of hospitalization and mortality in older adults. HF is almost always embedded within a larger pattern of multimorbidity, yet many studies exclude patients with complex psychiatric and medical comorbidities or cognitive impairment. This has left significant gaps in research on the problems and treatment of patients with HF. In addition, HF is only one of multiple challenges facing patients with multimorbidity, stressful socioeconomic circumstances, and psychosocial problems. The purpose of this study is to identify combinations of comorbidities and health disparities that may affect HF outcomes and require different mixtures of medical, psychological, and social services to address. The syndemics framework has yielded important insights into other disorders such as HIV/AIDS, but it has not been applied to the complex psychosocial problems of patients with HF. The multimorbidity framework is an alternative approach for investigating the effects of multiple comorbidities on health outcomes. The specific aims are: (1) to determine the coprevalence of psychiatric and medical comorbidities in patients with HF (n = 535); (2) to determine whether coprevalent comorbidities have synergistic effects on readmissions, mortality, self-care, and global health; (3) to identify vulnerable subpopulations of patients with HF who have high coprevalences of syndemic comorbidities; (4) to determine the extent to which syndemic comorbidities explain adverse HF outcomes in vulnerable subgroups of patients with HF; and (5) to determine the effects of multimorbidity on readmissions, mortality, self-care, and global health.

High-Sensitivity Cardiac Troponin I for Risk Stratification in Older Adults

BACKGROUND/OBJECTIVES

Traditional cardiovascular risk factors are less predictive in older age. High-sensitivity cardiac troponin I (hs-cTnI) is a marker of subclinical cardiomyocyte damage associated with cardiovascular risk in middle-aged adults. We hypothesized hs-cTnI would be indicative of mortality and cardiovascular risk beyond traditional cardiovascular risk factors in older adults and may be more discriminatory compared to hs-troponin T (hs-cTnT).

DESIGN

Prospective cohort study.

SETTING

Population-based Atherosclerosis Risk in Communities (ARIC) Study.

PARTICIPANTS

We included 5,876 ARIC participants at Visit 5 (2011-2013).

OUTCOMES AND MEASURES

We used Cox regression for the association of hs-cTnI categories (women: <4, 4-<10, ≥10 ng/ml; men: <6, 6-<12, ≥12 ng/ml, prevalent cardiovascular disease (CVD)) with mortality and incident CVD (atherosclerotic CVD [ASCVD]: coronary heart disease or stroke, or heart failure).

RESULTS

Participants were ages 66 to 90, 23% black, 42% male, and 24% had prevalent CVD. There were 1,053 (321 CVD) deaths (median follow-up 6.3 years). Participants with elevated hs-cTnI and no CVD (7% of participants) had mortality risk similar to those with a history of CVD (55.6 vs 55.7 deaths/1,000 person-years, P = .99). After adjustment, elevated hs-cTnI and no CVD (hazard ratio (HR) = 2.38, 95% confidence interval (CI) = 1.85-3.06) and prevalent CVD (HR = 2.21, 95% CI = 1.90-2.57) remained associated with mortality, compared to low hs-cTnI and no CVD. Elevated hs-cTnI was independently associated with incident CVD (HR = 3.41, 95% CI = 2.58-4.51), ASCVD (HR = 2.02, 95% CI = 1.36-2.98), and heart failure (HR = 6.16, 95% CI = 4.24-8.95). The addition of hs-cTnI significantly improved C-statistics for all outcomes and added greater discrimination than hs-cTnT for cardiovascular mortality and incident heart failure.

CONCLUSIONS

Hs-cTnI improves mortality and CVD risk stratification in older adults beyond traditional risk factors and improved model discrimination more than hs-cTnT for certain outcomes. Elevated hs-cTnI without CVD identifies a high-risk group with comparable mortality risk as those with a history of clinical CVD.

Impact of age on catheter ablation of premature ventricular contractions

INTRODUCTION

Catheter ablation (CA) of frequent premature ventricular contractions (PVC) is increasingly performed in older patients as the population ages. The aim of this study was to assess the impact of age on procedural characteristics, safety and efficacy on PVC ablations.

METHODS

Consecutive patients with symptomatic PVCs undergoing CA between 2015 and 2020 were evaluated. Acute ablation success was defined as the elimination of PVCs at the end of the procedure. Sustained success was defined as an elimination of symptoms, and ≥80% reduction of PVC burden determined by Holter-electrocardiogram during long-term follow. Patients were sub-grouped based on age (<65 vs. ≥65 years).

RESULTS

A total of 114 patients were enrolled (median age 64 years, 71% males) and followed up for a median duration of 228 days. Baseline and procedural data were similar in both age groups. A left-sided origin of PVCs was more frequently observed in the elderly patient group compared to younger patients (83% vs. 67%; p = .04). The median procedure time was significantly shorter in elderly patients (160 vs. 193 min; p = .02). The rates of both acute (86% vs. 92%; p = .32) and sustained success (70% vs. 71%; p = .90) were similar between groups. Complications rates (3.7%) did not differ between the two groups.

CONCLUSION

In a large series of patients with a variety of underlying arrhythmia substrates, similar rates of acute procedural success, complications, and ventricular arrhythmia-free-survival were observed after CA of PVCs. Older age alone should not be a reason to withhold CA of PVCs.

Frailty in heart transplantation: Report from the heart workgroup of a consensus conference on frailty

A consensus conference on frailty in solid organ transplantation took place on February 11, 2018, to discuss the latest developments in frailty, adopt a standardized approach to assessment, and generate ideas for future research. The findings and consensus of the Frailty Heart Workgroup (American Society of Transplantation's Thoracic and Critical Care Community of Practice) are presented here. Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised. Frailty is increasingly recognized as a distinct biologic entity that can adversely affect outcomes before and after heart transplantation. A greater proportion of patients referred for heart transplantation are older and have more complex comorbidities. However, outcomes data in the pretransplant setting, particularly for younger patients, are limited. Therefore, there is a need to develop objective frailty assessment tools for risk stratification in patients with advanced heart disease. These tools will help to determine appropriate recipient selection for advanced heart disease therapies including heart transplantation and mechanical circulatory support, improve overall outcomes, and help distinguish frailty phenotypes amenable to intervention.