Heart failure in the elderly: A geriatric syndrome. Picture of the modern situation

Among the older patients’ cohort, the aetiology of heart failure is peculiar and differs in many ways from the younger one, both in its epidemiology, diagnostic work-up and clinical presentation. Focusing on this population, we could assume that heart failure is a real geriatric syndrome, characterized by several features, which coexist with other comorbidities and require specific and targeted cares. It is therefore necessary to examine the global burden of heart failure and the patient’s history rather than the causal cardiomyopathy - frequently more than one in the elderly - facing with the condition, bearing in mind the quality of life even before its duration

Hyperinsulinism, Insulin Resistance and Impaired Fasting Glucose Revealing an Insulin Autoimmune Syndrome

We report a case of a 55-year-old woman who was evaluated for multiple episodes of late postprandial hypoglycaemia. We diagnosed her condition as insulin autoimmune syndrome (Hirata disease) because of a high insulin autoantibody (IAA) titre in association with high levels of plasmatic insulin and hypoglycaemia in a patient with no history of exogenous insulin administration and the exclusion of other causes of late postprandial hypoglycaemia

Dietary nitrate prevents progression of carotid subclinical atherosclerosis through blood pressure-independent mechanisms in patients with or at risk of type 2 diabetes mellitus

Aims To test if 6 months' intervention with dietary nitrate and spironolactone could affect carotid subclinical atherosclerosis and stiffness, respectively, vs. placebo/doxazosin, to control for blood pressure (BP). Methods A subgroup of participants in our double-blind, randomized-controlled, factorial VaSera trial had carotid imaging. Patients with hypertension and with/at risk of type 2 diabetes were randomized to active nitrate-containing beetroot juice or placebo nitrate-depleted juice, and spironolactone or doxazosin. Vascular ultrasound for carotid diameter (CD, mm) and intima–media thickness (CIMT, mm) was performed at baseline, 3- and 6-months. Carotid local stiffness (CS, m/s) was estimated from aortic pulse pressure (Arteriograph) and carotid lumen area. Data were analysed by modified intention to treat and using mixed-model effect, adjusted for confounders. Results In total, 93 subjects had a baseline evaluation and 86% had follow-up data. No statistical interactions occurred between the juice and drug arms and BP was similar between the juices and between the drugs. Nitrate-containing vs. placebo juice significantly lowered CIMT (−0.06 [95% confidence interval −0.12, −0.01], P = .034), an overall difference of ~8% relative to baseline; but had no effect on CD or CS. Doxazosin appeared to reduce CS from baseline (−0.34 [−0.62, −0.06]) however, no difference was detected vs. spironolactone (−0.15 [−0.46, 0.16]). No differences were detected between spironolactone or doxazosin on CIMT and CD. Conclusions Our results show that 6 months' intervention with dietary nitrate influences vascular remodelling, but not carotid stiffness or diameter. Neither spironolactone nor doxazosin had a BP-independent effect on carotid structure and function

Beta-Blocker Use in Older Hospitalized Patients Affected by Heart Failure and Chronic Obstructive Pulmonary Disease: An Italian Survey From the REPOSI Register

Beta (β)-blockers (BB) are useful in reducing morbidity and mortality in patients with heart failure (HF) and concomitant chronic obstructive pulmonary disease (COPD). Nevertheless, the use of BBs could induce bronchoconstriction due to β2-blockade. For this reason, both the ESC and GOLD guidelines strongly suggest the use of selective β1-BB in patients with HF and COPD. However, low adherence to guidelines was observed in multiple clinical settings. The aim of the study was to investigate the BBs use in older patients affected by HF and COPD, recorded in the REPOSI register. Of 942 patients affected by HF, 47.1% were treated with BBs. The use of BBs was significantly lower in patients with HF and COPD than in patients affected by HF alone, both at admission and at discharge (admission, 36.9% vs. 51.3%; discharge, 38.0% vs. 51.7%). In addition, no further BB users were found at discharge. The probability to being treated with a BB was significantly lower in patients with HF also affected by COPD (adj. OR, 95% CI: 0.50, 0.37-0.67), while the diagnosis of COPD was not associated with the choice of selective β1-BB (adj. OR, 95% CI: 1.33, 0.76-2.34). Despite clear recommendations by clinical guidelines, a significant underuse of BBs was also observed after hospital discharge. In COPD affected patients, physicians unreasonably reject BBs use, rather than choosing a β1-BB. The expected improvement of the BB prescriptions after hospitalization was not observed. A multidisciplinary approach among hospital physicians, general practitioners, and pharmacologists should be carried out for better drug management and adherence to guideline recommendations

Heart failure in the elderly: A geriatric syndrome. Picture of the modern situation

Among the older patients’ cohort, the aetiology of heart failure is peculiar and differs in many ways from the younger one, both in its epidemiology, diagnostic work-up and clinical presentation. Focusing on this population, we could assume that heart failure is a real geriatric syndrome, characterized by several features, which coexist with other comorbidities and require specific and targeted cares. It is therefore necessary to examine the global burden of heart failure and the patient’s history rather than the causal cardiomyopathy - frequently more than one in the elderly - facing with the condition, bearing in mind the quality of life even before its duration

Correlazioni clinico-prognostiche del diabete mellito in pazienti con arteriopatia degli arti inferiori sintomatica:dati preliminari

CORRELAZIONI CLINICO-PROGNOSTICHE DEL DIABETE MELLITO IN PAZIENTI CON ARTERIOPATIA DEGLI ARTI INFERIORI SINTOMATICA: DATI PRELIMINARI M. Nardi1 M. Pellegrinet1 D. Gasparini2 L. A. Sechi1 A. Cavarape1 1Clinica Medica AOU S.Maria della Misericordia-Udine 2SOC Radiodiagnostica AOU S.Maria della Misericordia-Udine BACKGROUND: Scopo dello studio \ue8 valutare le correlazioni cliniche e l\u2019impatto prognostico sulla mortalit\ue0 del diabete mellito in pazienti con arteriopatia periferica (PAD) sintomatica residenti in Friuli-Venezia Giulia. CASISTICA E METODI: Sono stati raccolti dati clinici e bioumorali in 366 pazienti con PAD sintomatica (193 diabetici, 52,7%) in occasione di rivascolarizzazione endovascolare. Al termine del follow-up (media 6 anni) i pazienti sono stati ricontattati e per i deceduti \ue8 stata considerata la scheda di morte ISTAT. Le variabili sono state comparate con metodi chi-quadrato e t di Student. L\u2019analisi di sopravvivenza \ue8 stata effettuata con metodo Kaplan-Meier. RISULTATI: Rispetto ai pazienti non diabetici, i pazienti affetti da diabete presentavano una PAD pi\uf9 severa (p<0,0001), con una maggior frequenza di ischemia critica (p=0,0003) e amputazione (p=0,002); presentavano inoltre pi\uf9 frequentemente cardiopatia ischemica (p=0,05), storia di fibrillazione atriale (p=0,05), storia di ictus (p=0,01), insufficienza renale cronica (p=0,0002) e, a livello laboratoristico, livelli di colesterolo HDL inferiori (p=0,002) e maggior prevalenza di proteinuria (P=0,0004). E\u2019 stato rilevato un trend associativo tra diabete mellito e mortalit\ue0 totale, che tuttavia non ha raggiunto la significativit\ue0 statistica (p=0,06). La mortalit\ue0 totale \ue8 risultata invece significativamente maggiore nei pazienti diabetici con livelli di HbA1c pi\uf9 elevati (p=0,02). Tale associazione \ue8 stata confermata dall\u2019analisi di sopravvivenza (p=0,01). CONCLUSIONI: Il diabete mellito rappresenta un fattore prognostico negativo nei pazienti affetti da PAD sintomatica, determinando una pi\uf9 rapida progressione a stadi clinici avanzati, fino all\u2019ischemia critica e all\u2019amputazione. Tuttavia nella popolazione con vasculopatia nota da noi esaminata il diabete mellito non sembra determinare un incremento statisticamente significativo di mortalit\ue0 totale, per quanto valori pi\uf9 elevati di HbA1c risultino associati a maggiore mortalit\ue0

Insulin receptors and renal sodium handling in hypertensive fructose-fed rats

Background. Insulin resistance and hypertension are present in Sprague-Dawley rats fed a fructose-enriched diet. In these rats, insulin might elevate blood pressure via an antinatriuretic action. Methods. To investigate the sodium-insulin interaction in fructose-fed rats, we compared insulin sensitivity, insulin receptor binding, and insulin receptor mRNA levels in the kidney and skeletal muscle of rats that were fed standard rat chow or a fructose-enriched diet (66%) with either low (0.07%), normal (0.3%), or high (7.5%) NaCl concentrations for 3 weeks. Results. Systolic blood pressure increased in the fructose-fed rats receiving the normal and high-salt diet, but not the low-salt diet.When the rats were fed the low-salt diet, the rate of glucose infusion required to maintain euglycemia during a hyperinsulinemic clamp and insulin receptor number and mRNA levels in skeletal muscle were lower in fructose-fed than control rats. High-salt diet decreased significantly the rate of glucose disposal during the clamp and muscular insulin receptor number and mRNA levels in control, but not fructose-fed rats. During the low-salt diet, renal insulin receptor number and mRNA levels were comparable in fructose-fed and control rats and hyperinsulinemia had comparable acute antinatriuretic effects in the two groups; when the rats were maintained on the high-salt diet, the expected decrease in renal insulin receptor number and mRNA levels occurred in control but not fructose-fed rats and, consistent with this finding, the antinatriuretic response to hyperinsulinemia was blunted only in controls. An inverse relationship between dietary NaCl content and renal insulin receptor mRNA levels was observed in control but not fructose-fed rats. Conclusion. Fructose-fed rats appear to have lost the feedback mechanism that limits insulin-induced sodium retention through a down-regulation of the renal insulin receptor when the dietary NaCl content is increased. This abnormality might possibly contribute to the elevation of blood pressure in these rats