New horizons in management of heart failure in older patients

Heart failure has a high prevalence in older populations, is a common and growing cause for hospital admission and carries a high risk of morbidity and mortality. Important co-morbidities in older patients with heart failure include atrial fibrillation, renal impairment, hypertension and anaemia. Diagnosing and managing heart failure in older patients are complicated due to atypical presentations, co-morbidities and a relative lack of evidence for commonly used treatments in younger patients. The growing epidemic of heart failure is also under-recognised and resourced in most health systems. Despite potential differences, we recommend that the basic approach to manage heart failure patients with an ejection fraction (EF) of <40% should be the same in older and younger. These treatments need to be started at low doses and titrated slowly along with the management of co-morbidities. Older patients with EF 40–49% can be treated in a similar manner to those with <40%, while the treatment of those with EF ≥50% is pragmatic in nature based on symptom control and management of co-morbidities although the evidence base for these recommendations is lacking. Overall management must be holistic and continuous based on the patient’s social circumstances and ongoing needs. Finally, there is an urgent need for more research, evidence and resources directed towards older populations with heart failure to improve their care and the quality of life

Validación del Münchner Alkoholismus Test Subjektiv para el diagnóstico de alcoholismo en población adulta

ResumenObjetivoValidar la parte subjetiva del cuestionario MALT (Münchner Alkoholismus Test) para el diagnóstico de alcoholismo en población adulta.DiseñoEstudio descriptivo de validación de un instrumento diagnóstico.EmplazamientoDos centros de atención primaria, un centro de drogodependencias y un centro de atención a alcohólicos, ubicados en la provincia de Córdoba, España.ParticipantesSeiscientos catorce pacientes con edades de entre 18 y 80 años.Mediciones principalesMediante entrevista personal se realizaron los cuestionarios MALT, AUDIT (Alcohol Use Disorders Identification Test) y el SCAN (Schedules for clinical assessment in Neuropsychiatry). Se analizó la fiabilidad interna, la reproducibilidad, la validez criterial (patrón de referencia: criterios del Manual Diagnóstico y Estadístico de los Trastornos Mentales IV [DSM-IV]) y la validez convergente.ResultadosLa edad media de la población fue de 43 años (desviación estándar de 1,43). El 17,4% presentó síndrome de dependencia alcohólica. Los coeficientes kappa de los ítems del test oscilaban entre 0,568 y 0,969. El alfa de Cronbach del MALT completo fue de 0,919; el alfa de Cronbach del MALT subjetivo fue de 0,939, y el alfa de Cronbach del MALT objetivo fue de 0,737. El área bajo la curva de eficacia diagnóstica para el MALT-S fue de 0,946 y para el MALT completo fue de 0,953. Para un punto de corte de 4, la sensibilidad del MALT-S fue del 92,6% y la especificidad fue del 90,8%. El coeficiente de correlación del MALT-S y del AUDIT fue de 0,86 (p<0,001).ConclusionesEl MALT subjetivo es un cuestionario tan válido y fiable como el MALT completo, por lo que puede ser utilizado aisladamente para la detección y el diagnóstico de alcoholismo.AbstractObjectiveTo validate the subjective part of the MALT questionnaire (MALT-S) for the detection of alcoholism among the adult population.DesignA descriptive study on the validation of a diagnostic tool.SettingTwo primary health care centres, a centre for drug addicts and a centre for alcoholics in Cordoba (Spain).Participants614 patients, between 18 and 80 years.MeasurementsThrough personal interviews the MALT, AUDIT and SCAN questionnaires were given. The internal reliability, stability and both the criterion and convergent validity were analysed.ResultsThe mean age of the population’ was 43±1.43 (SD) years and 17.4% of them showed Alcohol Dependence Syndrome. The Kappa coefficients of the test items ranged from 0.568 to 0.969. The Cronbach alpha of the complete MALT was 0.919, of the MALT-S, 0.939 and of the MALT-O, 0.737. The area under the ROC curve of the MALT-S was 0.946 and that of the complete MALT was 0.953. For a cut-off point of four, the sensitivity of the MALT-S is 92.7% while its specificity was 90.9%. The correlation coefficient of the MALT-S and AUDIT was 0.86 (P<0.001).ConclusionsThe MALT-S questionnaire is as valid and reliable as the complete MALT; therefore, it can be used on its own for the diagnosis of alcoholism

Combining heart rate and systolic blood pressure to improve risk stratification in older patients with heart failure: Findings from the RICA Registry

Objectives: Heart rate (HR) and systolic blood pressure (SBP) are independent prognostic variables in patients with heart failure (HF). We evaluated if combining HR and SBP could improve prognostic assessment in older patients. Methods: Variables associated with all-cause mortality and readmission for HF during 9 months of follow-up were analyzed from the Spanish Heart Failure Registry (RICA). HR and SBP values were stratified in three combined groups. Results: We evaluated 1551 patients, 82 years and 56% women. Using HR strata of < 70 and ≥ 70 bpm we found mortality rates of 9.8 and 13.6%, respectively (hazard ratio 1.0 and 1.35). For SBP ≥ 140, 120–140 and < 120 mm Hg, mortality rates were 8.2, 10.4 and 20.3%. respectively (hazard ratio 1.0, 1.34 and 2.76). Using combined strata of HR < 70 bpm and SBP ≥ 140 mm Hg (n = 176; low-risk), HR < 70 and SBP < 140 + HR ≥ 70 and SBP < 120 (n = 1089; moderate-risk) and HR ≥ 70 and SBP < 120 (n = 286; high-risk) we found mortality rates of 4.5%, 11.0% and 24.0%, respectively. Multivariate Cox regression for all-cause mortality shows for low-, middle- and high-risk groups was 1 (reference), 1.93 (95% CI: 0.93–3.99, p = 0.077) and 4.32 (95% CI: 2.04–9.14, p < 0.001). BMI, NYHA, MDRD, hypertension and sodium were also independent prognostic factors. Conclusions: The combination provides better risk discrimination than use of HR and SBP alone and may provide a simple and reliable tool for risk assessment for older HF patients in clinical practice

Prognostic significance of the PROFUND index on one year mortality in acute heart failure: results from the RICA registry

Background: Heart failure (HF) is a syndrome with high prevalence, mainly affecting elderly patients, where the presence of associated comorbidities is of great importance. Methods: An observational study from a prospective registry was conducted. Patients identified from the National Registry of Heart Failure (RICA), which belongs to theWorking Group on Heart Failure and Atrial Fibrillation of the Spanish Society of Internal Medicine (SEMI), were included. The latter is a prospective, multicenter registry that has been active since 2008. It includes individual consecutive patients over 50 years of age with a diagnosis of HF at hospital discharge (acute decompensated or new-onset HF). Results: In total, 5424 patients were identified from the registry. Forty-seven percent were men and mean left ventricular ejection fraction (LVEF) was 51.4%; 1132 had a score of 0 to 2 according to the PROFUND index, 3087 had a score of 3 to 6, and 952 patients had a score of 7 to 10 points. In the sample, 252 patients had a score above 11 points. At the end of the year of follow-up, 61% of the patients died. This mortality increased proportionally as the PROFUND index increased, specifically 75% for patients with PROFUND greater than 11. The Kaplan-Meier survival curve shows that survival at one year progressively decreases as the PROFUND index value increases. Thus, subjects with scores greater than seven (intermediate-high and high-risk) presented the worst survival with a log rank of 0.96 and a p < 0.05. In the regression analysis, we found a higher risk of death from any cause at one year in the group with the highest risk according to the PROFUND index (score greater than 11 points (HR 1.838 (1.410-2.396)). Conclusions: The PROFUND index is a good index for predicting mortality in patients admitted for acute HF, especially in those subjects at intermediate to high risk with scores above seven. Future studies should seek to determine whether the PROFUND index score is simply a prognostic marker or whether it can also be used to make therapeutic decisions for those subjects with very high short-term mortality

Consenso para la mejora de la atención integral a los pacientes con insuficiencia cardiaca aguda

[eng] Acute heart failure (AHF) requires considerable use of resources, is an economic burden, and is associated with high complication and mortality rates in emergency departments, on hospital wards, or outpatient care settings. Diagnosis, treatment, and continuity of care are variable at present, leading 3 medical associations (for cardiology, internal medicine, and emergency medicine) to undertake discussions and arrive at a consensus on clinical practice guidelines to support those who manage AHF and encourage standardized decision making. These guidelines, based on a review of the literature and clinical experience with AHF, focus on critical points in the care pathway. Regarding emergency care, the expert participants considered the initial evaluation of patients with signs and symptoms that suggest AHF, the initial diagnosis, first decisions about therapy, monitoring, assessment of prognosis, and referral criteria. For care of the hospitalized patient, the group developed a protocol for essential treatment. Objectives for the management and treatment of AHF on discharge were also covered through the creation or improvement of multidisciplinary care systems to provide continuity of care.[spa] La insuficiencia cardiaca aguda (ICA) supone un elevado uso de recursos, carga económica y morbimortalidad, tanto en los servicios de urgencias como durante la hospitalización o durante su control ambulatorio. La variabilidad actual existente en el diagnóstico, tratamiento y la continuidad asistencial ha inducido que diferentes sociedades científicas (cardiología, medicina interna y urgencias) redacten este documento de consenso sobre recomendaciones prácticas que den soporte a todos los profesionales intervinientes en el manejo de la ICA y permita homogeneizar la toma de decisiones. El enfoque de estas recomendaciones, basadas en la revisión de la literatura y la experiencia clínica, se ha realizado abarcando diferentes puntos críticos del proceso asistencial de los pacientes con ICA: en el servicio de urgencias, en cuanto a la evaluación inicial del paciente con clínica sugestiva de ICA, orientación diagnóstica, primeras decisiones terapéuticas, monitorización, evaluación del pronóstico y criterios de derivación; durante la hospitalización, con el desarrollo de un protocolo básico terapéutico; tras el alta, con la definición de objetivos de manejo y tratamiento de la ICA al alta del paciente; y de forma global, mediante la mejora o creación de una organización en la atención multidisciplinar y la continuidad asistencial en la ICA

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group