Clinical and economic aspects of the use of nebivolol in the treatment of elderly patients with heart failure

Heart failure is a common and disabling condition with morbidity and mortality that increase dramatically with advancing age. Large observational studies, retrospective subgroup analyses and meta-analyses of clinical trials in systolic heart failure, and recently published randomized studies have provided data supporting the use of beta-blockers as a baseline therapy in heart failure in the elderly. Despite the available evidence about beta-blockers, this therapy is still less frequently used in elderly compared to younger patients. Nebivolol is a third-generation cardioselective beta-blocker with L-arginine/nitric oxide-induced vasodilatory properties, approved in Europe and several other countries for the treatment of essential hypertension, and in Europe for the treatment of stable, mild, or moderate chronic heart failure, in addition to standard therapies in elderly patients aged 70 years old or older. The effects of nebivolol on left ventricular function in elderly patients with chronic heart failure (ENECA) and the study of effects of nebivolol intervention on outcomes and rehospitalization in seniors with heart failure (SENIORS) have been specifically aimed to assess the efficacy of beta-blockade in elderly heart failure patients. The results of these two trials demonstrate that nebivolol is well tolerated and effective in reducing mortality and morbidity in older patients, and that the beneficial clinical effect is present also in patients with mildly reduced ejection fraction. Moreover, nebivolol appears to be significantly cost-effective when prescribed in these patients. However, further targeted studies are needed to better define the efficacy as well as safety profile in frail and older patients with comorbid diseases

Cardiac rehabilitation is safe and effective also in the elderly, but don't forget about drugs!

In the setting of heart failure (HF) pharmacotherapy demonstrates a quantifiable improvement in exercise tolerance also in HF with preserved ejection fraction (HFpEF). For patients with HFpEF, often older, with higher prevalence of hypertension, diabetes mellitus, atrial fibrillation and other comorbidities, endpoints such as quality of life and functional capacity may be more clinically relevant. However several study show as the use of ACE-I and B-blocker were lesser than expected. Beta-blocker therapy is the keystone of pharmacotherapy of HF patients and exercise training is the essential core of rehabilitation programs, it is important to elucidate the relationship between these therapies. Exercise training improves the clinical status of HF, improving left ventricular ejection fraction and improving quality of life, but it is possible that b-blocker may attenuate exercise training adaptations. Despite this, possible adverse b-blocker effects are just presumed and not confirmed by published randomized clinical trials. Metanalysis suggests that b-blocker compared with placebo enhances improvements in cardiorespiratory performance in exercise training intervention. Despite these evidences, prescription of gold standard therapy and adherence are still suboptimal and should be a priority goal for all CR program.  Riassunto Nell’ambito dei pazienti con scompenso cardiaco (SC) la terapia farmacologica permette di ottenere un miglioramento della tolleranza all’esercizio fisico anche nei pazienti con frazione di eiezione conservata. Questi pazienti spesso più anziani, con una più elevata incidenza di ipertensione, diabete mellito, fibrillazione atriale e comorbidità, endpoints quali qualità della vita e capacità funzionale dovrebbero risultare più clinicamente rilevanti. Tuttavia molti studi mostrano come l’utilizzo di ACE-I e Beta-bloccanti sia minore di quanto ci si aspetterebbe. Va evidenziato comunque come la terapia beta-bloccante costituisca il cardine della terapia farmacologica dello SC e come l’esercizio fisico sia il cuore dei programmi di riabilitazione, pertanto è importante valutarne le possibili interazioni. L’esercizio fisico migliora lo stato clinico dei pazienti con SC, ma è possibile che la terapia con Beta-bloccanti possa attenuare questi vantaggi. Tale assunto tuttavia rimane solo presunto e non confermato dai risultati dei trial pubblicati. Infatti una metanalisi suggerisce che la terapia Beta-bloccante, confrontata con il placebo, migliori la performance cardiorespiratoria nel gruppo sottoposto ad esercizio fisico. Malgrado tali evidenze, la prescrizione di una terapia medica ottimale e l’aderenza alla stessa rimangono ancora non ottimali e dovrebbe rappresentare un obiettivo primario per tutti i programmi di riabilitazione.

Barriers to cardiac rehabilitation access of older heart failure patients and strategies for better implementation

In heart failure (HF), cardiac rehabilitation (CR) may reduce decompensations, hospitalization, and ultimately mortality in long term. Many studies over the past decade have demonstrated that aerobic exercise training is effective and safe in stable patients with HF. Exercise CR resulted in a clinically important improvement in the QOL. Several clinical and psychosocial factors are associated with decreased participation in CR programs of elderly HF patients, such as perception of exercise as tiring or painful, comorbidities, lack of physician encouragement, and opinion that CR will not improve their health status. Besides low functional capacity, and chronic deconditioning may also deter patients from participating in CR programs.  Recent data suggest that current smoking, a BMI ≥30 kg/m2, diabetes mellitus, and cognitive dysfunction are associated with failure to enroll in outpatient CR in older age group. Moreover the lack of availability of CR facilities or the absence of financial refunds for enrolment of CHF patients in cardiac rehabilitation programs can play a crucial role. Many of this factors are modifiable through patient education and self care strategy instruction, health providers sensibilization, and implementing economic measures in order to make CR affordable.  Riassunto Numerosi studi hanno dimostrato come la riabilitazione cardiovascolare (RC) con esercizio aerobico sia risultato efficace e sicuro nei pazienti con scompenso cardiaco (SC), nel ridurre ospedalizzazioni, mortalità ed indurre un miglioramento della qualità di vita. Tuttavia numerosi fattori clinici e psicosociali, come la bassa capacità funzionale, le comorbidità, la percezione dell’esercizio fisico come noioso o doloroso, sono associati a ridotta partecipazione a RC da parte di pazienti anziani con SC.  Inoltre dati recenti mostrano come l’abitudine tabagica, un BMI ≥30 kg/m2, il diabete mellito ed il deterioramento cognitivo siano associati con il mancato arruolamento di pazienti anziani in programmi di RC.  In aggiunta la mancanza di disponibilità di strutture per la RC o l'assenza di rimborsi finanziari per l'iscrizione dei pazienti con SC in programmi di riabilitazione cardiaca possono svolgere un ruolo cruciale. Molti di questi fattori risultano modificabili attraverso programmi di educazione sanitaria del paziente, sensibilizzazione del personale sanitario ed attraverso un’implementazione delle misure economiche al fine di rendere accessibile la RC

Atrial fibrillation management in older heart failure patients: a complex clinical problem

BackgroundAtrial fibrillation (AF) and heart failure (HF), two problems of growing prevalence as a consequence of the ageing population, are associated with high morbidity, mortality, and healthcare costs. AF and HF also share common risk factors and pathophysiologic processes such as hypertension, diabetes mellitus, ischemic heart disease, and valvular heart disease often occur together. Although elderly patients with both HF and AF are affected by worse symptoms and poorer prognosis, there is a paucity of data on appropriate management of these patients.MethodsPubMed was searched for studies on AF and older patients using the terms atrial fibrillation, elderly, heart failure, cognitive impairment, frailty, stroke, and anticoagulants.ResultsThe clinical picture of HF patients with AF is complex and heterogeneous with a higher prevalence of frailty, cognitive impairment, and disability. Because of the association of mental and physical impairment to non-administration of oral anticoagulants (OACs), screening for these simple variables in clinical practice may allow better strategies for intervention in this high-risk population. Since novel direct OACs (NOACs) have a more favorable risk-benefit profile, they may be preferable to vitamin K antagonists (VKAs) in many frail elderly patients, especially those at higher risk of falls. Moreover, NOACs are simple to administer and monitor and may be associated with better adherence and safety in patients with cognitive deficits and mobility impairments.ConclusionsLarge multicenter longitudinal studies are needed to examine the effects of VKAs and NOACs on long-term cognitive function and frailty; future studies should include geriatric conditions

Exercise: a "new drug" for elderly patients with chronic heart failure

Patients with chronic heart failure (CHF) experience progressive deterioration of functional capacity and quality of life (QoL). This prospective, randomized, controlled trial assesses the effect of exercise training (ET) protocol on functional capacity, rehospitalization, and QoL in CHF patients older than 70 years compared with a control group. A total of 343 elderly patients with stable CHF (age, 76.90±5.67, men, 195, 56.9%) were randomized to ET (TCG, n=170) or usual care (UCG, n=173). The ET protocol involved supervised training sessions for 3 months in the hospital followed by home-telemonitored sessions for 3 months. Assessments, performed at baseline and at 3 and 6 months, included: ECG, resting echocardiography, NT-proBNP, 6-minute walk test (6MWT), Minnesota Living with Heart Failure Questionnaire, and comprehensive geriatric assessment with the InterRAI-HC instrument. As compared to UCG, ET patients at 6 months showed: i) significantly increased 6MWT distance (450±83 vs. 290±97 m, p=0.001); ii) increased ADL scores (5.00±2.49 vs. 6.94±5.66, p=0.037); iii) 40% reduced risk of rehospitalisation (hazard ratio=0.558, 95%CI, 0.326-0.954, p=0.033); and iv) significantly improved perceived QoL (28.6±12.3 vs. 44.5±12.3, p=0.001). In hospital and home-based telemonitored exercise confer significant benefits on the oldest CHF patients, improving functional capacity and subjective QoL and reducing risk of rehospitalisation

Early Doppler-echocardiography evaluation of Carpentier-Edwards Standard and Carpentier-Edwards Magna aortic prosthetic valve: comparison of hemodynamic performance

OBJECTIVES: This study was designed to describe Doppler-echocardiography values of Carpentier-Edwards Perimount Standard (CEPS) and Carpentier-Edwards Perimount Magna (CEPM) aortic prosthetic valves, evaluated by a single, experienced echo-laboratory, early in the postoperative phase. METHODS: Three-hundred-seventy-seven consecutive patients, who had had a CEPS or a CEPM implanted in our Hospital due to aortic stenosis and/or insufficiency, underwent baseline Doppler echocardiography evaluation within 7 days after surgery. Hemodynamic performances of CEPS and CEPM were accurately described, evaluating flow-dependent (transprosthetic velocities and gradients) and flow-independent (effective orifice area, indexed effective orifice area and Doppler velocity index) Doppler-echocardiography parameters. RESULTS: Out of the 377 patients 48.8% were men (n = 184), mean age was 74.63 ± 6.77 years, mean BSA was 1.78 ± 0.18 m2, mean ejection fraction was 57.78 ± 8%. Two-hundred and sixty two CEPS and 115 CEPM were implanted. Comparing size-by-size CEPS with CEPM, both prostheses showed a good hemodynamic profile, with fairly similar values of pressure gradients (PGmax and mean, in mmHg, = 37,18 ± 11.57 and 20.81 ± 7.44 in CEPS n°19 compared to 32,47 ± 7,76 and 17,67 ± 4.63 in CEPM n°19 and progressively lower in higher sized prostheses, having PGmax and mean 15 ± 3,16 and 9.15 ± 1,29 in CEPS n°29 compared to 15,67 ± 1,53 and 9 ± 1 in CEPM n°29) and EOAi (being 0,65 ± 0,33 cm²/m² in CEPS n°19 compared to 0,77 ± 0,29 cm²/m² in CEPM n°19 and progressively higher in higher sized prostheses, being 1,28 ± 0,59 cm²/m² in CEPS n°29 compared to 1,07 ± 0,18 cm²/m² in CEPM n°29), the latter resulting, however, basically less flow obstructive. CONCLUSIONS: Our data confirm the good hemodynamic performance of both aortic bioprostheses and the more favourable hemodynamic profile of CEPM compared to CEPS, pointing out the need to perform routinely an accurate baseline Doppler-echocardiography evaluation early after surgery to allow an adequate interpretation of data at follow-up