Coexisting Frailty With Heart Failure

Associations of individual chronic diseases and multimorbidity with multidimensional frailty

OBJECTIVE

To examine the associations between individual chronic diseases and multidimensional frailty comprising physical, psychological, and social frailty.

METHODS

Dutch individuals (N = 47,768) age ≥ 65 years completed a general health questionnaire sent by the Public Health Services (response rate of 58.5 %), including data concerning self-reported chronic diseases, multidimensional frailty, and sociodemographic characteristics. Multidimensional frailty was assessed with the Tilburg Frailty Indicator (TFI). Total frailty and each frailty domain were regressed onto background characteristics and the six most prevalent chronic diseases: diabetes mellitus, cancer, hypertension, arthrosis, urinary incontinence, and severe back disorder. Multimorbidity was defined as the presence of combinations of these six diseases.

RESULTS

The six chronic diseases had medium and strong associations with total ((f2 = 0.122) and physical frailty (f2 = 0.170), respectively, and weak associations with psychological (f2 = 0.023) and social frailty (f2 = 0.008). The effects of the six diseases on the frailty variables differed strongly across diseases, with urinary incontinence and severe back disorder impairing frailty most. No synergetic effects were found; the effects of a disease on frailty did not get noteworthy stronger in the presence of another disease.

CONCLUSIONS

Chronic diseases, in particular urinary incontinence and severe back disorder, were associated with frailty. We thus recommend assigning different weights to individual chronic diseases in a measure of multimorbidity that aims to examine effects of multimorbidity on multidimensional frailty. Because there were no synergetic effects of chronic diseases, the measure does not need to include interactions between diseases.

Changes in Cardiovascular Spending, Care Utilization, and Clinical Outcomes Associated With Participation in Bundled Payments for Care Improvement - Advanced

BACKGROUND

Bundled Payments for Care Improvement - Advanced (BPCI-A) is a Medicare initiative that aims to incentivize reductions in spending for episodes of care that start with a hospitalization and end 90 days after discharge. Cardiovascular disease, an important driver of Medicare spending, is one of the areas of focus BPCI-A. It is unknown whether BPCI-A is associated with spending reductions or quality improvements for the 3 cardiovascular medical events or 5 cardiovascular procedures in the model.

METHODS

In this retrospective cohort study, we conducted difference-in-differences analyses using Medicare claims for patients discharged between January 1, 2017, and September 30, 2019, to assess differences between BPCI-A hospitals and matched nonparticipating control hospitals. Our primary outcomes were the differential changes in spending, before versus after implementation of BPCI-A, for cardiac medical and procedural conditions at BPCI-A hospitals compared with controls. Secondary outcomes included changes in patient complexity, care utilization, healthy days at home, readmissions, and mortality.

RESULTS

Baseline spending for cardiac medical episodes at BPCI-A hospitals was $25 606. The differential change in spending for cardiac medical episodes at BPCI-A versus control hospitals was $16 (95% CI, -$228 to $261; P=0.90). Baseline spending for cardiac procedural episodes at BPCI-A hospitals was $37 961. The differential change in spending for cardiac procedural episodes was $171 (95% CI, -$429 to $772; P=0.58). There were minimal differential changes in physicians' care patterns such as the complexity of treated patients or in their care utilization. At BPCI-A versus control hospitals, there were no significant differential changes in rates of 90-day readmissions (differential change, 0.27% [95% CI, -0.25% to 0.80%] for medical episodes; differential change, 0.31% [95% CI, -0.98% to 1.60%] for procedural episodes) or mortality (differential change, -0.14% [95% CI, -0.50% to 0.23%] for medical episodes; differential change, -0.36% [95% CI, -1.25% to 0.54%] for procedural episodes).

CONCLUSIONS

Participation in BPCI-A was not associated with spending reductions, changes in care utilization, or quality improvements for the cardiovascular medical events or procedures offered in the model.

Association Between Frailty, 30-day Unplanned Readmission and Mortality After Hospitalization for Heart Failure: Results From the Nationwide Readmissions Database

Objectives: This study examined how frailty in traditional risk-adjusted models could improve the predictability of unplanned 30-day readmission and mortality among heart failure patients. Methods: This study was a retrospective analysis of Nationwide Readmissions Database data collected during the years 2010-2018. All patients ≥65 years who had a principal diagnosis of heart failure were included in the analysis. The Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator was used to identify frail patients. Results: There was a total of 819,854 patients admitted for heart failure during the study period. Among them, 63,302 (7.7%) were frail. In the regression analysis, the risk of all-cause 30-day readmission (OR, 1.18; 95% CI, 1.14-1.22) and in-hospital mortality (OR, 1.52; 95% CI, 1.40-1.66) were higher in patients with frailty. Discussion: Inclusion of frailty in comorbidity-based risk-prediction models significantly improved the predictability of unplanned 30-day readmission and in-hospital mortality.

Bidirectional Association Between Frailty and Cardiac Structure and Function: The Atherosclerosis Risk in Communities Study

Background Frailty and heart failure frequently coexist in late life. Limited data exist regarding the longitudinal associations of frailty and subclinical cardiac dysfunction. We aim to quantify the association of frailty with longitudinal changes in cardiac function and of cardiac function with progression in frailty status in older adults. Methods and Results Participants in the Atherosclerosis Risk in Communities cohort underwent frailty assessments at Visit 5 (V5; 2011-2013), V6 (2016-2017), and V7 (2018-2019), and echocardiographic assessments at V5 and V7. We assessed the association between frailty status at V5 and changes in frailty status from V5 to V7 and changes in cardiac function over 6 years. We then evaluated the association of cardiac function measured at Visit 5 with progression in frailty status over 4 years. Multivariable regression models adjusted for demographics and comorbidities. Among 2574 participants free of heart failure at V5 and V7 (age 74±4 years at V5 and 81±4 years at V7), 3% (n=83) were frail. Frailty at V5 was associated with greater left atrial volume index and E/e' ratio at V5 and 7. Participants who transitioned from robust at V5 to frail at V7 demonstrated greater increases in left ventricular mass index, left atrial volume index, and E/e' over the same period. Among 1648 robust participants at Visit 5, greater left ventricular mass index and mean wall thickness, lower tissue Doppler imaging e', and higher E/e' ratio at Visit 5 were associated with progression in frailty status. Conclusions Among robust, older adults free of heart failure, progression in frailty and subclinical left ventricular remodeling and diastolic dysfunction are interrelated.

Telerehabilitation in patients with recent hospitalisation due to acute decompensated heart failure: protocol for the Tele-ADHF randomised controlled trial

BACKGROUND

Cardiac rehabilitation in patients with chronic heart failure (CHF) has favourable effects on exercise capacity, the risk at hospital (re-)admission and quality of life. Although cardiac rehabilitation is generally recommended it is still under-utilised in daily clinical practice, particularly in frail elderly patients after hospital admission, mainly due to low referral and patient-related barriers. Cardiac telerehabilitation (CTR) has the potential to partially solve these barriers. The purpose of this study is to evaluate the effects of CTR as compared to standard remote care after hospital admission on physical functional capacity in CHF patients.

METHODS

In this randomised controlled trial, 64 CHF patients will be recruited during hospitalisation for acute decompensated heart failure, and randomised to CTR combined with remote patient management (RPM) or RPM alone (1:1). All participants will start with RPM after hospital discharge for early detection of deterioration, and will be up titrated to optimal medical therapy before being randomised. CTR will start after randomisation and consists of an 18-week multidisciplinary programme with exercise training by physical and occupational therapists, supported by a (remote) technology-assisted dietary intervention and mental health guiding by a physiologist. The training programme consists of three centre-based and two home-based video exercise training sessions followed by weekly video coaching. The mental health and dietary programme are executed using individual and group video sessions. A wrist-worn device enables remote coaching by the physical therapist. The web application is used for promoting self-management by the following modules: 1) goal setting, 2) progress tracking, 3) education, and 4) video and chat communication. The primary outcome measure is physical functional capacity evaluated by the Short Physical Performance Battery (SPPB) score. Secondary outcome measures include frailty scoring, recovery after submaximal exercise, subjective health status, compliance and acceptance to the rehabilitation programme, and readmission rate.

DISCUSSION

The Tele-ADHF trial is the first prospective randomised controlled trial designed for evaluating the effects of a comprehensive combined RPM and CTR programme in recently hospitalised CHF patients. We hypothesize that this intervention has superior effects on physical functional capacity than RPM alone.

TRIAL REGISTRATION

Netherlands Trial Registry (NTR) NL9619, registered 21 July 2021.

A Prospective Case-Control Study Examining the Relationship Between Frailty and Serum Myostatin in Older Persons with Chronic Heart Failure

Background

Frailty affects the prognosis and management of patients with heart failure, and is often related with sarcopenia. Also, the serum myostatin (MSTN) involved in the development of sarcopenia and frailty. This study aimed to determine the connection between MSTN level and frailty in older adults with chronic heart failure (CHF).

Methods

This prospective case-control study enrolled older adult patients with CHF between May 2019 and May 2021, and analyzed their clinical data.

Results

In this study 75 older adults with CHF were included, 29 of whom were frail. The B-type natriuretic peptide (BNP) levels were significantly higher in frail older adults with CHF than in older adults with CHF who were not frail (316.82 ± 235.64 pg/mL vs 198.61 ± 112.58 pg/mL; P = 0.016). The MSTN levels were significantly higher in frail participants than in participants who were not frail (2.93 ± 1.35 ng/mL vs 2.24 ± 0.84 ng/mL; P = 0.018). Based on multivariable analysis the BNP (odds ratio [OR] = 1.004, 95% confidence interval [CI] = 1 0.001-1.008; P = 0.018) and MSTN (OR = 1.772, 95% CI = 1.079-2.912; P =0 0.024) levels were independently associated with frailty in older adults with CHF.

Conclusion

MSTN is a promising biomarker of frailty in elderly patients with CHF.

Fast systematic geriatric assessment in acute heart failure patients admitted in Cardiology

BACKGROUND

Heart failure prevalence is increasing in elder adults. These patients usually present geriatric syndromes, especially frailty. The effect of frailty on heart failure is under discussion but there are few data about the clinical characterization of frail patients who are admitted for acute heart failure decompensation.

OBJECTIVE

The purpose of this study was to study the differences in clinical baseline variables and geriatric scales between frail and non-frail patients admitted to the Cardiology unit via the Emergency Department for acute heart failure.

METHODS

We enrolled all patients with acute heart failure who were admitted to the Cardiology unit from the Emergency Department of our hospital from July 2020 through May 2021. A multidimensional and comprehensive geriatric assessment was performed at the moment of admission. We studied differences in baseline variables and geriatric scales according to the frailty status determined by the FRAIL scale.

RESULTS

A total of 202 patients were included. In the whole population, 68 (33.7%) patients presented frailty defined by a FRAIL score ≥ 3. The frail patients were older (80±9 vs. 69±12 years; p<0.001), and had a worse quality of life (58.31±12.18 vs.39.26±13.71 points; p<0.001) according to the Minnesota scale, presented high comorbidity (47 (69.1%) vs. 67 (50.4%) patients; p = 0.011) defined as ≥3 points according to the Charlson scale and were more dependent (40 (58.8%) vs. 25 (18.8%) patients; p<0.001) according to the Barthel scale. The frail patients presented higher MAGGIC risk scores (24.09±4.99 vs. 18.89±6.26; p<0.001). Despite this adverse profile, the treatments prescribed during the admission and at the hospital discharge were similar.

CONCLUSIONS

The prevalence of geriatric syndromes, especially frailty, is very high in patients admitted for acute heart failure. Frail patients with acute heart failure had an adverse clinical profile with more prevalence of concomitant geriatric syndromes. Therefore, we consider that a geriatric assessment should be performed during the admission of acute heart failure patients to improve care and attention.

Developing a Parsimonious Frailty Index for Older, Multimorbid Adults With Heart Failure Using Machine Learning

Frailty is associated with adverse outcomes in heart failure (HF). A parsimonious frailty index (FI) that predicts outcomes of older, multimorbid patients with HF could be a useful resource for clinicians. A retrospective study of veterans hospitalized from October 2015 to October 2018 with HF, aged ≥50 years, and discharged home developed a 10-item parsimonious FI using machine learning from diagnostic codes, laboratory results, vital signs, and ejection fraction (EF) from outpatient encounters. An unsupervised clustering technique identified 5 FI strata: severely frail, moderately frail, mildly frail, prefrail, and robust. We report hazard ratios (HRs) of mortality, adjusting for age, gender, race, and EF and odds ratios (ORs) for 30-day and 1-year emergency department visits and all-cause hospitalizations after discharge. We identified 37,431 veterans (age, 73 ± 10 years; co-morbidity index, 5 ± 3; 43.5% with EF ≤40%). All frailty groups had a higher mortality than the robust group: severely frail (HR 2.63, 95% confidence interval [CI] 2.42 to 2.86), moderately frail (HR 2.04, 95% CI 1.87 to 2.22), mildly frail (HR 1.60, 95% CI 1.47 to 1.74), and prefrail (HR 1.18, 95% CI: 1.07 to 1.29). The associations between frailty and mortality remained unchanged in the stratified analysis by age or EF. The combined (severely, moderately, and mildly) frail group had higher odds of 30-day emergency visits (OR 1.62, 95% CI 1.43 to 1.83), all-cause readmission (OR, 1.75, 95% CI 1.52 to 2.02), 1-year emergency visits (OR 1.70, 95% CI 1.53 to 1.89), rehospitalization (OR 2.18, 95% CI 1.97 to 2.41) than the robust group. In conclusion, a 10-item FI is associated with postdischarge outcomes among patients discharged home after a hospitalization for HF. A parsimonious FI may aid clinical prediction at the point of care.

Pathophysiology and Management of Heart Failure in the Elderly

The population of elderly adults is increasing globally. It has been projected that the population of adults aged 65 years will increase by approximately 80% by 2050 in the United States. Similarly, the elderly population is rising in other countries; a notable example being Japan where approximately 30% of the population are aged above 65 years. The pathophysiology and management of heart failure (HF) in this age group tend to have more intricacies than in younger age groups owing to the presence of multiple comorbidities. The normal aging biology includes progressive disruption at cellular and genetic levels and changes in molecular signaling and mechanical activities that contribute to myocardial abnormalities. Older adults with HF secondary to ischemic or valvular heart disease may benefit from surgical therapy, valve replacement or repair for valvular heart disease and coronary artery bypass grafting for coronary artery disease. While referring these patients for surgery, patient and family expectations and life expectations should be taken into account. In this review, we will cover the pathophysiology and the management of HF in the elderly, specifically discussing important geriatric domains such as frailty, cognitive impairment, delirium, polypharmacy, and multimorbidity.

Factors Predicting Frailty Among Postoperative Brain Tumor Patients

ABSTRACT

BACKGROUND: Surgical frailty is a condition in which patients are weak with varied recovery of various organ functions after surgery resulting in unpleasant outcomes. Frailty studies have been conducted in several populations with a limited knowledge on postoperative brain tumor patients. This study aimed to examine factors predicting frailty in brain tumor patients after craniotomy. METHODS: This study was a cross-sectional predictive study. The sample included 85 patients who were 18 years or older and underwent craniotomy with tumor removal from 1 university hospital in Bangkok, Thailand, between February and October 2021. Data were analyzed using descriptive statistic, Pearson correlation, and multiple linear regression, which determined significance level at .05. RESULTS: The prevalence of frailty among participants was 50.6%. Postoperative symptom and mood state were positively associated with frailty (r = 0.410 and r = 0.448, respectively; P < .01). Postoperative symptom, mood state, age, tumor type, and income could explain the variance of frailty in brain tumor patients after craniotomy by 40.3% (R2 = 0.403, P < .01). CONCLUSION: Healthcare providers should plan for discharge planning including assessment and develop the intervention for managing postoperative symptoms and psychological symptoms to promote recovery from frailty that generally occurs after brain tumor surgery.

Machine Learning Approaches for the Frailty Screening: A Narrative Review

Frailty characterizes a state of impairments that increases the risk of adverse health outcomes such as physical limitation, lower quality of life, and premature death. Frailty prevention, early screening, and management of potential existing conditions are essential and impact the elderly population positively and on society. Advanced machine learning (ML) processing methods are one of healthcare’s fastest developing scientific and technical areas. Although research studies are being conducted in a controlled environment, their translation into the real world (clinical setting, which is often dynamic) is challenging. This paper presents a narrative review of the procedures for the frailty screening applied to the innovative tools, focusing on indicators and ML approaches. It results in six selected studies. Support vector machine was the most often used ML method. These methods apparently can identify several risk factors to predict pre-frail or frailty. Even so, there are some limitations (e.g., quality data), but they have enormous potential to detect frailty early.

Employing the Multivariate Edmonton Scale in the Assessment of Frailty Syndrome in Heart Failure

Background: Frailty syndrome (FS) is a syndrome characterized by a reduction in the body’s physiological reserves as a result of the accumulation of reduced efficiency of many organs and systems. Experts of the Heart Failure Association of the European Society of Cardiology (ECS) emphasize the need to assess frailty in all patients with heart failure (HF). There is no specific scale dedicated to this group of patients. The aim of the study was to assess the occurrence of the frailty syndrome in heart failure using the multidimensional Edmonton Frailty Scale (EFS). Methods: The study included 106 patients diagnosed with heart failure with reduced left ventricular ejection fraction (LVEF < 40%). The average age was 62.6 ± 9.7 years. Most of the patients (84%) studied were men. In 70 people (66%), the cause of heart failure was coronary artery disease. The study group included patients admitted to hospital on a scheduled basis and with exacerbation of heart failure. Frailty was measured using the EFS before discharge from the hospital. Demographic, sociodemographic and clinical data were obtained. A 12-month follow-up period was included in the project. The number of readmissions after 6 and 12 months was assessed. Results: A correlation was observed between the New York Heart Association (NYHA) functional class and the occurrence of frailty—this applies to the assessment at the beginning and at the end of hospitalization. When analyzing the age of the patients in relation to frailty, a statistically significant difference was obtained. The youngest group in terms of age were non-frail patients. Hospitalization of people prone to development of the frailty syndrome and diagnosed with the FS was significantly more often associated with the occurrence of complications during hospital stays. Rehospitalizations for exacerbation of heart failure were much more frequent in patients with frailty. Conclusions: Assessment and monitoring of the state of increased sensitivity to the development of frailty or FS in patients with heart failure should influence the differentiation of clinical management. The Edmonton Questionnaire may be a helpful tool for the assessment of frailty in hospitalized patients with HF.

Chinese expert consensus on the diagnosis and treatment of chronic heart failure in elderly patients (2021)

Heart failure is a clinical syndrome caused by ventricular insufficiency, which results in decreased activity tolerance and repeated hospitalization, seriously affecting quality of life, and it is the main cause of death in elderly people. In recent years, great progress has been made in the treatment of heart failure, but the prevalence, mortality, and readmission rate among elderly patients with heart failure remain high. Because elderly patients have multiple cardiovascular disease risk factors, coexistence of multiple diseases accompanied by multiple syndromes, multiple medications, and natural decline of body functions, the clinical diagnosis, treatment, rehabilitation, and long‐term management of these patients differ from those in other populations. To facilitate clinical practice and application of clinical geriatric medicine, especially among community physicians, experts from the Cardiovascular Group, Geriatrics Branch of the Chinese Medical Association have drafted this consensus to summarize the diagnosis and treatment regimens for elderly patients with chronic heart failure and provide guidance for its clinical diagnosis and treatment in China.

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).

Adherence to Medication in Older Adults with Type 2 Diabetes Living in Lubuskie Voivodeship in Poland: Association with Frailty Syndrome

Purpose: Diabetic patients aged 65 years or older are more likely to be frail than non-diabetic older adults. Adherence to therapeutic recommendations in the elderly suffering from diabetes and co-existent frailty syndrome may prevent complications such as micro- or macroangiopathy, as well as significantly affect prevention and reversibility of frailty. The study aimed at assessing the impact of frailty syndrome (FS) on the level of adherence to medication in elderly patients with type 2 diabetes (DM2). Patients and Methods: The research was carried out among 175 DM2 patients (87; 49.71% women and 88; 50.29% men) whose average age amounted to 70.25 ± 6.7. Standardized research instruments included Tilburg frailty indicator (TFI) to assess FS and adherence in chronic disease scale questionnaire (ACDS) to measure adherence to medications. Results: The group of 101 (57.71%) patients displayed medium, 39 (22.29%)—low, and 35 (20.00%)—high adherence. As many as 140 of them (80.00%) were diagnosed with frailty syndrome. The median of the average result of TFI was significantly higher in the low adherence group (p ˂ 0.001) (Mdn = 9, Q1–Q3; 7–10 pt.) than in the medium (Mdn = 6, Q1–Q3; 5–9 pt.) or high adherence (Mdn = 6.00, Q1–Q3; 4.5–8 pt.) ones. The independent predictors of the chance to be qualified to the non-adherence group included three indicators: TFI (OR 1.558, 95% CI 1.245–1.95), male gender (OR 2.954, 95% CI 1.044–8.353), and the number of all medications taken daily (each extra pill decreased the chance of being qualified to the non-adherence group by 15.3% (95% CI 0.728–0.954). Conclusion: Frailty syndrome in elderly DM2 patients influenced medical adherence in this group. The low adhesion group had higher overall TFI scores and separately higher scores in the physical and psychological domains compared to the medium and high adhesion groups.

Physical, Psychological and Social Frailty Are Predictive of Heart Failure: A Cross-Sectional Study

Background: Little is known about frailty among patients hospitalized with heart failure (HF). To date, the limited information on frailty in HF is based on a unidimensional view of frailty, in which only physical aspects are considered when determining frailty. The aims of this study were to study different dimensions of frailty (physical, psychological and social) in patients with HF and the effect of different dimensions of frailty on the incidence of heart failure. Methods: The study used a cross-sectional design and included 965 patients hospitalized for heart failure and 164 healthy controls. HF was defined according to the ESC guidelines. The Tilburg Frailty Indicator (TFI) was used to assess frailty. Probit regression analyses and chi-square statistics were used to examine associations between the occurrence of heart failure and TFI domains of frailty. Results: Patients diagnosed with frailty were 15.3% more likely to develop HF compared to those not diagnosed with frailty (p < 0.001). An increase in physical, psychological and social frailty corresponded to an increased risk of HF of 2.9% (p < 0.001), 4.4% (p < 0.001) and 6.6% (p < 0.001), respectively. Conclusions: We found evidence of the association between different dimensions of frailty and incidence of HF.

Apocynum venetum leaf extract alleviated doxorubicin-induced cardiotoxicity through the AKT/Bcl-2 signaling pathway

BACKGROUND

Doxorubicin (DOX) is a broad-spectrum anti-tumor drug that has been associated with cardiotoxicity. Plant extracts have been shown to confer protection against DOX-induced cardiotoxicity. Apocynum venetum L. belongs to the Apocynaceae family. Flavonoid extracted from Apocynum venetum L. possess various biological effects, such as lowering blood pressure levels, sedation, diuresis, anti-aging, and improving immunity.

PURPOSE

This study investigated the mechanism by which dry leaf extract of Apocynum venetum L. (AVLE) alleviates DOX-induced cardiomyocyte apoptosis.

METHODS

HPLC-MS/MS and HPLC methods were used to analyze the components of AVLE. The effects of DOX and AVLE on apoptosis of H9c2 and HMC cells were assessed using the MTT assay. Calcein AM/PI, TUNEL, and flow cytometry were carried out to determine the effects of AVLE on DOX-induced apoptosis. The effect of AVLE on DOX-induced oxidative stress in cardiomyocytes was investigated using ELISA test. Mito-Tracker Red CMXRos, JC-1, and RT-qPCR assays were performed to evaluate the impact of AVLE on DOX-induced cardiomyocyte mitochondrial activity and membrane permeability. Western blot assay was carried out to determine the activation of multiple signaling molecules, including phosphorylated-protein kinase B (p-AKT), Cytochrome c, Bcl-2 family, and caspase family in the apoptosis pathway. The AKT inhibitor was used to block AKT/Bcl-2 signaling pathway to investigate the role of AKT in the protection conferred by AVLE against DOX-induced cardiotoxicity.

RESULTS

A total of 8 compounds, including rutin, hyperoside, isoquercetin, unidentified compounds, myricetin, quercetin, quercetin-3-O-glucuronide and kaempferol, were detected in AVLE. Of note, DOX suppressed lactate dehydrogenase (LDH) levels, aggravated oxidative stress, and promoted cardiomyocyte apoptosis. It also upregulated the mRNA expression levels of voltage-dependent anion channel 1 (VDAC1), adenosine nucleotide transporter 1 (ANT1), and cyclophilin D (CYPD), while suppressing mitochondrial activity and mitochondrial membrane permeability. Treatment with DOX altered the expression levels of apoptosis-associated proteins, Bcl-2 and Bax. However, AVLE treatment alleviated DOX-induced effects on cardiomyocytes. In addition, application of AKT inhibitors promoted DOX-induced apoptosis and reversed the inhibitory effects of AVLE on DOX-induced apoptosis.

CONCLUSIONS

AVLE confer cardio protection by suppressing oxidative stress and apoptosis of cardiomyocytes via AKT/Bcl-2 signaling pathway.

Implementation of Rehabilitation and Patient Outcomes During the Initial COVID-19 Pandemic

Objectives:

This study investigated the impact of the initial outbreak of coronavirus disease (COVID-19) on rehabilitation and functional outcomes of patients in Japanese hospitals.

Methods:

The study subjects were hospitals belonging to Japan’s National Hospital Organization that provided inpatient care for patients with coronavirus COVID-19 during March–May 2020. We specifically focused on patients who were hospitalized for acute diseases, such as stroke, hip fracture, acute myocardial infarction, congestive heart failure, or chronic obstructive pulmonary disease, and received rehabilitation during hospitalization. Data were sourced from Japanese administrative data. The primary outcome was rehabilitation provision time in the target hospitals. The secondary outcomes were patient outcomes: rehabilitation participation time, length of hospital stay, 30-day readmission rate, and improvement of activities of daily living. Interrupted time series analysis was performed to evaluate the trend of rehabilitation provision time. Patient outcomes were compared with those for 2019.

Results:

The rehabilitation provision time for outpatients declined by 62% during the pandemic, while that for inpatients declined temporarily, and then increased. Compared with 2019 outcomes, rehabilitation participation time was longer and hospital stay length was shorter for stroke and hip-fracture patients, the 30-day readmission rate was increased for hip-fracture patients, and improvement of activities in daily living was less for patients with congestive heart failure who were totally dependent at admission. Other outcomes did not change.

Conclusions:

The findings suggest that during the initial COVID-19 pandemic, resources for rehabilitation were quickly reallocated to inpatient care, and the impact on inpatient outcomes was minimized.

Association of frailty with in-hospital outcomes in elderly patients with heart failure

BACKGROUND

Frailty is prevalent in elderly patients with cardiovascular diseases. However, the association between frailty and in-hospital outcomes for elderly patients with heart failure and reduced ejection (HFrEF) remains unknown.

AIM

To evaluate the predictive efficacy of frailty, compared with pre-frailty, for adverse events in these patients.

METHODS

Elderly patients (≥ 60 years) with HFrEF were assessed. Frailty was evaluated with the Fried phenotype criteria, and physical performance was evaluated based on handgrip strength and the short physical performance battery (SPPB). The composite incidence of adverse events, including all-cause death, multiple organ failure, cardiac shock, and malignant arrhythmia, during hospitalization was recorded.

RESULTS

Overall, 252 elderly individuals with HFrEF [mean age: 69.4 ± 6.7 years, male: 169 (67.0%)] were included. One hundred and thirty-five (53.6%) patients were frail and 93 (36.9%) were pre-frail. Frail patients were older, more likely to be female, to have a lower blood pressure, and to present with left ventricular thrombosis (P all < 0.05). Frail patients with HFrEF had a higher incidence of in-hospital mortality (11.9% vs 4.3%, P = 0.048). Multivariate analyses showed that female gender (OR = 0.422), aging (OR = 1.090), poor cardiac functional class (OR = 2.167), frailty (OR = 2.379), and lower handgrip strength (OR = 1.106) were independent predictors of in-hospital adverse events (P all < 0.05).

CONCLUSION

Frailty may be associated with poor in-hospital outcomes for elderly patients with HFrEF. The influence of frailty on long-term prognosis in these patients deserves further investigation.

The Association between Peripheral Blood Cells and the Frailty Syndrome in Patients with Cardiovascular Diseases

Background

Frailty syndrome is characterized by multisystem dysregulation frequently found in older individuals or even in younger patients with chronic disabling diseases such as cardiovascular diseases.

Objective

To determine whether peripheral blood cell count, and its subpopulations, red blood cell and platelets, morphology and different ratios (neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and red blood distribution width-to-platelet ratio) are associated with cardiac frail patients, and through this to improve the prediction of frailty status in patients with cardiovascular diseases.

Methods

An observational, retrospective, cohort study enrolling 179 patients with cardiovascular disease divided into two groups: non-frail group (100 pts) and frail group (79 pts), a cohort detached from the Frail.RO study. The frailty was evaluated based on the Fried criteria; haematological markers, sociodemographic data, and variables related to cardiovascular diseases and comorbidities were also recorded.

Results

Lower lymphocytes, platelet count, and neutrophil-to-lymphocyte ratio were significantly associated with a more severe frailty syndrome. Regarding red blood cells, haemoglobin concentration and red cell distribution width significantly correlated with the severity of the frailty syndrome. Receiver operating characteristic curve analysis for these markers associated with the frailty syndrome revealed an acceptable sensitivity of 66% and specificity of 65% to identify frail individuals. Malnutrition and hypercholesterolemia are relevant predictors for identifying frailty in hospitalized cardiovascular patients.

Conclusion

The evaluation of peripheral blood cell composition routinely measured in clinical practice can represent a valuable, but limited indicator, to diagnose frailty syndrome and eventually, the effects of interventions in frail patients with cardiovascular diseases.

Physical frailty and long-term mortality in older people with chronic heart failure with preserved and reduced ejection fraction: a retrospective longitudinal study

BACKGROUND

Frailty, a syndrome characterized by a decline in function reserve, is common in older patients with heart failure (HF) and is associated with prognosis. This study aimed to evaluate the impact of frailty on outcomes in older patients with preserved and reduced cardiac function.

METHODS

In total, 811 adults aged ≥65 years were consecutively enrolled from 2009 to 2018. HF was diagnosed according to the ICD9 code and a 2D echocardiogram was categorized by reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). The index date was registered at the time of HF. All patients received a comprehensive geriatric assessment, and clinical outcomes were examined with adjustment of the other prognostic variables.

RESULTS

Mean age was 80.5 ± 7.1 years. The prevalence of HF, HFpEF, HFrEF, Fried, and Rockwood frailty indicators was 28.5, 10.4, 9.7, 52.5, and 74.9%, respectively. At baseline, scores in the Timed Up and Go test was closely associated with the severity of HF, either with HFpEF or HFrEF. After a mean follow-up of 3.2 ± 2.0 years, we found that HF patients with low handgrip strength (HGS) had the poorest survival, followed by non-HF patients with decreased HGS, and HF with fair HGS in comparison with non-HF with fair HGS (p = 0.008) if participants were arbitrarily divided into two HGS groups. In all patients, a high Rockwood frailty index was independently associated with increased mortality (adjusted hazard ratio [aHR] = 1.05; 95% confidence interval [CI]: 1.0004 to 1.10). In addition, the adjusted mortality HR was 3.42 with decreased HGS (95% CI: 1.03 to 11.40), 7.65 with use of mineralocorticoid receptor antagonist (95% CI: 2.22 to 26.32), and 1.26 with associated multi-comorbidities assessed by Charlson comorbidity index (95% CI: 1.05 to 1.51).

CONCLUSIONS

Our study results indicate that frailty and decreased physical functions were associated with HF. Besides, frailty and HGS predicted prognosis in the patients, and there was a combined effect of HF and low HGS on survival.

[Frailty in older adults with chronic heart failure in a hospital from Lima]

Objective

To determine the prevalence of frailty in older adults with heart failure and to examine the association between frailty and socio-demographic and clinical characteristics in patients in the Chronic Heart Failure program of the Guillermo Almenara Irigoyen National Hospital in the period 2018-2020.

Materials and methods

Observational, cross-sectional, correlational study with quantitative approach in patients older than 60 years who had a frailty assessment using the Edmonton scale; as non-frail (0-4), apparently vulnerable (5-6), mildly frail (7-8), moderately frail (9-10) and severely frail (11-17). The association of frailty and patient characteristics was assessed using Pearson's Chi-Square test, values of p<0.05 and with a 95% confidence interval were considered significant.

Results

The prevalence of frailty was 58.8%, most patients were male (71.8%) and the average age was 72.9 years. Age and number of comorbidities were statistically significant factors associated with frailty with p=0.004 and p<0.001 respectively.

Conclusions

The prevalence of frailty was high in patients older than 60 years in the chronic heart failure program. Older patients with more comorbidities were at higher risk of frailty, highlighting the need for comprehensive assessment and screening for frailty in order to design secondary prevention programs in a timely manner.

Developing and Validating a Primary Care EMR-based Frailty Definition using Machine Learning

Introduction

Individuals who have been identified as frail have an increased state of vulnerability, often leading to adverse health events, increased health spending, and potentially detrimental outcomes.

Objective

The objective of this work is to develop and validate a case definition for frailty that can be used in a primary care electronic medical record database.

Methods

This is a cross-sectional validation study using data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) in Southern Alberta. 52 CPCSSN sentinels assessed a random sample of their own patients using the Rockwood Clinical Frailty scale, resulting in a total of 875 patients to be used as reference standard. Patients must be over the age of 65 and have had a clinic visit within the last 24 months. The case definition for frailty was developed using machine learning methods using CPCSSN records for the 875 patients.

Results

Of the 875 patients, 155 (17.7%) were frail and 720 (84.2%) were not frail. Validation metrics of the case definition were: sensitivity and specificity of 0.28, 95% CI (0.21 to 0.36) and 0.94, 95% CI (0.93 to 0.96), respectively; PPV and NPV of 0.53, 95% CI (0.42 to 0.64) and 0.86, 95% CI (0.83 to 0.88), respectively.

Conclusions

The low sensitivity and specificity results could be because frailty as a construct remains under-developed and relatively poorly understood due to its complex nature. These results contribute to the literature by demonstrating that case definitions for frailty require expert consensus and potentially more sophisticated algorithms to be successful.

Simultaneous Employment of the FRAIL Scale and the Tilburg Frailty Indicator May Identify Elderly People Who Require Different Interventional Strategies

Purpose

Frailty is a geriatric syndrome that is usually considered as a set of physical deficits (unidimensional concept); however, it can also concern the psychological and social domains of human functioning (multidimensional concept). The FRAIL scale is a diagnostic tool which ascertains only physical frailty, whereas the Tilburg Frailty Indicator (TFI) is a diagnostic instrument for multidimensional frailty. The study investigates if non-robust physical status and multidimensional frailty affect the same individuals and whether simultaneous employment of the FRAIL scale and TFI identifies specific subgroups of elderly people which require different interventions.

Patients and Methods

In this cross-sectional study, 1024 community dwelling elderly individuals at the age of 65 years or older (mean age 72.6 ± 6.3 years; range 65-93 years) were evaluated with the FRAIL scale and TFI.

Results

According to the FRAIL scale, 52.9% of the subjects were physically non-robust, but according to TFI, 54.6% presented multidimensional frailty. These two diagnostic tools were concordant in their outcomes in 77.1% (ie, 42.3% of individuals were physically and multidimensionally frail but 34.8% were robust according to both two instruments); however, in 22.9% the outcomes were discordant. Consequently, by simultaneous employment of the FRAIL scale and TFI, four distinct functional categories have been distinguished: (i) non-robust physical status with multidimensional frailty, (ii) exclusive non-robust physical status, (iii) exclusive multidimensional frailty, and (iv) full robust status.

Conclusion

By applying simple physical and multidimensional frailty diagnostic tools, subgroups of elderly people may be identified that require specific management strategies to improve their functional status.

Assessment of HF Outcomes Using a Claims-Based Frailty Index

OBJECTIVES

This study used a claims-based frailty index to investigate outcomes of frail patients with heart failure (HF).

BACKGROUND

Medicare value-based payment programs financially reward and penalize hospitals based on HF patients' outcomes. Although programs adjust risks for comorbidities, they do not adjust for frailty. Hospitals caring for high proportions of frail patients may be unfairly penalized. Understanding frail HF patients' outcomes may allow improved risk adjustment and more equitable assessment of health care systems.

METHODS

Adapting a claims-based frailty index, the study assigned a frailty score to each adult in the National in-patient Sample (NIS) from 2012 through September 2015 with a primary diagnosis of HF and dichotomized frailty by using a cutoff value established in the general NIS population. Multivariate regression models were estimated, controlling for comorbidities and hospital characteristics, to investigate relationships between frailty and outcomes.

RESULTS

Of 732,932 patients, 369,298 were frail. Frail patients were more likely than nonfrail patients to die during hospital stay (3.57% vs. 2.37%, respectively; adjusted odds ratio [aOR]: 1.67; 95% confidence interval [CI]: 1.61 to 1.72; p < 0.001); were less likely to be discharged to home (66.5% vs. 79.3%, respectively; aOR: 0.58; 95% CI: 0.57 to 0.58; p < 0.001); were hospitalized for more days (5.89 vs. 4.63 days, respectively; adjusted coefficient: 0.21 days; 95% CI: 0.21 to 0.22; p < 0.001); and incurred higher charges ($47,651 vs. $40,173, respectively; adjusted difference = $9,006; 95% CI: $8,596 to $9,416; p < 0.001).

CONCLUSIONS

Frail patients with HF had significantly poorer outcomes than nonfrail patients after accounting for comorbidities. Clinicians should screen for frailty to identify high-risk patients who could benefit from targeted intervention. Policymakers should perform risk adjustments for frailty for more equitable quality measurement and financial incentive allocation.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Cardiac tissue engineering therapeutic products to enhance myocardial contractility

Researchers continue to develop therapeutic products for the repair and replacement of myocardial tissue that demonstrates contractility equivalent to normal physiologic states. As clinical trials focused on pure adult stem cell populations undergo meta-analysis for preclinical through clinical design, the field of tissue engineering is emerging as a new clinical frontier to repair the myocardium and improve cardiac output. This review will first discuss the three primary tissue engineering product themes that are advancing in preclinical to clinical models: (1) cell-free scaffolds, (2) scaffold-free cellular, and (3) hybrid cell and scaffold products. The review will then focus on the products that have advanced from preclinical models to clinical trials. In advancing the cardiac regenerative medicine field, long-term gains towards discovering an optimal product to generate functional myocardial tissue and eliminate heart failure may be achieved.

Predictors and prognosis of delirium among older subjects in cardiac intensive care unit: focus on potentially preventable forms

BACKGROUND

Delirium is a common and potentially preventable condition in older individuals admitted to acute and intensive care wards, associated with negative prognostic effects. Its clinical relevance is being increasingly recognised also in cardiology settings. The aim of the present study was to assess the prevalence, incidence, predictors and prognostic role of delirium in older individuals admitted to two cardiology intensive care units.

METHODS

All patients aged over 65 years consecutively admitted to the two participating cardiology intensive care units were enrolled. Assessment on admission included acute physiological derangement (modified rapid emergency medicine score, REMS), chronic comorbidity, premorbid disability and dementia. The Confusion Assessment Method-Intensive Care Unit was applied daily for delirium detection.

RESULTS

Of 497 patients (40% women, mean age 79 years), 18% had delirium over the entire cardiology intensive care unit course, half of whom more than 24 hours after admission (incident delirium). Advanced age, a main diagnosis of ST-segment elevation myocardial infarction or acute respiratory failure, modified REMS, comorbidity and dementia were independent predictors of delirium. Adjusting for patient's features on admission, incident delirium was predicted by invasive procedures (insertion of peripheral arterial catheter, urinary catheter, central venous catheter, naso-gastric tube and intra-aortic balloon pump). In a logistic regression model, delirium was an independent predictor of inhospital mortality (odds ratio 3.18, 95% confidence interval 1.02, 9.93).

CONCLUSIONS

Eighteen per cent of older cardiology intensive care unit patients had delirium, with half of the cases being incident, thus potentially preventable. Invasive procedures were independently associated with incident delirium. Delirium was an independent predictor of inhospital mortality. Awareness of delirium should be increased in the cardiology intensive care unit setting and prevention studies are warranted.