Impacto Pronóstico de los Síndromes Geriátricos en Pacientes Ancianos con Síndrome Coronario Agudo

Los síndromes geriátricos pueden predecir eventos adversos en el contexto del síndrome coronario agudo más allá de la propia edad y de los clásicos factores de riesgo cardiovascular. El objetivo de la presente tesis doctoral fue cuantificar y evaluar un amplio espectro de síndromes geriátricos en pacientes supervivientes a la fase aguda de un síndrome coronario. Se incluyeron un total de 342 pacientes mayores de 65 años que ingresaron de forma consecutiva en el servicio de Cardiología de un único hospital terciario. Al alta hospitalaria, se evaluaron 5 síndromes geriátricos: la fragilidad (Fried y Green), la dependencia física (Escala de Barthel), la dependencia instrumental (Escala de Lawton y Brody), el deterioro cognitivo (Cuestionario de Pfeiffer) y la comorbilidad (Índices de Charlsos y los índices de comorbilidad simples). Se analizó el impacto pronóstico de dichos síndromes geriátricos sobre la mortalidad por todas las causas durante el seguimiento ambulatorio, así como sobre la aparición del evento combinado (muerte/ infarto) y el evento cardiovascular mayor (muerte/infarto/insuficiencia cardiaca).Geriatric conditions can predict adverse events in the context of acute coronary syndrome beyond age and classic cardiovascular risk factors. The objetive of the present thesis was to quantify and evaluate a big spectrum of geriatric conditions in older patients survivors to an acute coronary syndrome. A total of 342 patients older than 65 years admitted consecutevely in the Cardiology department of a unique tertiary hospital were included. At discharge, 5 geriatric conditions were evaluated: frailty (Fried and Green scores), physical disability (Barthel index), instrumental disability (Lawton-Brody scale), cognitive impairment (Pfeiffer questionnaire) and comorbidity (Charlson and simple comorbidity index). The prognostic impact of geriatric conditions on total mortality during follow-up was analysed, as well as the the appearance of the combined event (death/myocardial infarction) and major cardiovascular events (death/myocardial infarction /heart failure)

Oral anticoagulant use and appropriateness in elderly patients with atrial fibrillation in complex clinical conditions: CONVENIENCE study

Non-valvular atrial fibrillation (NVAF) is the most common arrhythmia in older patients. Although direct-acting oral anticoagulants (DOAC) are the antithrombotic treatment of choice, irrespective of age, certain factors may limit their use. The aim of the ACONVENIENCE study was to consult the opinion of a multidisciplinary panel of experts on the appropriateness of using OACs in elderly patients (>75 years) with NVAF associated with certain complex clinical conditions. A consensus project was performed on the basis of a systematic review of the literature, and application of a two-round Delphi survey. The agreement of 79 panellists on 30 Delphi-type statements was evaluated, and their opinion on the appropriateness of different oral anticoagulants in 16 complex clinical scenarios was assessed. A total of 27 consensus statements were agreed upon, including all statements addressing anticoagulation in older patients and in patients at high risk of bleeding complications, and most of those addressing frailty, dementia, risk of falling, and complex cardiac situations. It was almost unanimously agreed upon that advanced age should not influence the anticoagulation decision. Apixaban was the highest-rated therapeutic option in 14/16 situations, followed by edoxaban. There is a high degree of agreement on anticoagulation in older patients with NVAF. Age should not be the single limiting factor when prescribing OACs, and the decision should be made based on net clinical benefit and a comprehensive geriatric assessment. Apixaban, followed by edoxaban, was considered the most appropriate treatment in the various complex clinical situations examined

Oxigenoterapia y cuidados paliativos en pacientes con insuficiencia cardiaca. Respuesta

Letter to the Edito

Ethical considerations in elderly patients with acute coronary syndrome

Acute coronary syndrome (ACS) is one of the main causes of mortality and morbidity in the elderly. The prevalence of ACS increases with age and patients with advanced age have some co-morbidities that require an individualized approach, which includes a comprehensive geriatric assessment. Ageism is a matter of great concern. In this scenario, some ethical conflicts may arise which should be anticipated, considered, and solved. Clinicians will need to prioritize and allocate resources, to avoid futility/proportionality, which is not always easy to assess in these patients. This review aims to summarize the evidence regarding ethical conflicts that may arise in the management of patients with ACS and advanced age. We will discuss how to choose the best option (which frequently is not the only one) with the lowest risk for harm, considering and respecting the patients' decision. The four basic principles of bioethics (beneficence, non-maleficence, autonomy, and justice) are thoroughly reviewed, and discussed, regarding their role in the decision making process

Extended use of dual antiplatelet therapy among older adults with acute coronary syndromes and associated variables: a cohort study

Acute coronary syndromes; Dual antiplatelet therapy; ElderlySíndromes coronàries agudes; Teràpia antiplaquetària dual; Gent granSíndromes coronarios agudos; Terapia antiplaquetaria dual; Personas mayoresBackground Current guidelines recommend extending the use of dual antiplatelet therapy (DAPT) beyond 1 year in patients with an acute coronary syndrome (ACS) and a high risk of ischaemia and low risk of bleeding. No data exist about the implementation of this strategy in older adults from routine clinical practice. Methods We conducted a Spanish multicentre, retrospective, observational registry-based study that included patients with ACS but no thrombotic or bleeding events during the first year of DAPT after discharge and no indication for oral anticoagulants. High bleeding risk was defined according to the Academic Research Consortium definition. We assessed the proportion of cases of extended DAPT among patients 65 ≥ years that went beyond 1 year after hospitalisation for ACS and the variables associated with the strategy. Results We found that 48.1% (928/1,928) of patients were aged ≥ 65 years. DAPT was continued beyond 1 year in 32.1% (298/928) of patients ≥ 65; which was a similar proportion as with their younger counterparts. There was no significant correlation between a high bleeding risk and DAPT duration. Contrastingly, there was a strong correlation between the extent of coronary disease and DAPT duration (p < 0.001). Other variables associated with extended DAPT were a higher left ventricle ejection fraction, a history of heart failure and a prior stent thrombosis. Conclusion There was no correlation between age and extended use of DAPT beyond 1 year in older patients with ACS. DAPT was extended in about one-third of patients ≥ 65 years. The severity of the coronary disease, prior heart failure, left ventricle ejection fraction and prior stent thrombosis all correlated with extended DAPT.This work was supported by the “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” [grant numbers JR/21/00041, PI20/00637 and CIBERCV16/11/00486] and by Conselleria de Educación – Generalitat Valenciana (PROMETEO/2021/008)

Evaluation of the Use of Dual Antiplatelet Therapy beyond the First Year after Acute Coronary Syndrome

Acute coronary syndrome; Dual antiplatelet therapy; Ischemic riskSíndrome coronario agudo; Terapia antiplaquetaria dual; Riesgo isquémicoSíndrome coronària aguda; Teràpia antiplaquetària dual; Risc isquèmicClinical practice guidelines recommend extending dual antiplatelet therapy (DAPT) beyond 1 year after acute coronary syndrome (ACS) in patients with high ischemic risk and without high bleeding risk. The aim of this study was to identify variables associated with DAPT prolongation in a cohort of 1967 consecutive patients discharged after ACS without thrombotic or hemorrhagic events during the following year. The sample was stratified according to whether DAPT was extended beyond 1 year, and the factors associated with this strategy were analyzed. In 32.2% of the patients, DAPT was extended beyond 1 year. Overall, 770 patients (39.1%) were considered candidates for extended treatment based on PEGASUS criteria and absence of high bleeding risk, and DAPT was extended in 34.4% of them. The presence of a PEGASUS criterion was associated with extended DAPT in the univariate analysis, but not history of bleeding or a high bleeding risk. In the multivariate analysis, a history of percutaneous coronary intervention (odds ratio (OR) = 1.8, 95% confidence interval (CI) 1.4–2.4), stent thrombosis (OR = 3.8, 95% CI 1.7–8.9), coronary artery disease complexity (OR = 1.3, 95% CI 1.1–1.5), reinfarction (OR = 4.1, 95% CI 1.6–10.4), and clopidogrel use (OR = 1.3, 95% CI 1.1–1.6) were significantly associated with extended use. DAPT was extended in 32.2% of patients who survived ACS without thrombotic or hemorrhagic events. This percentage was 34.4% when the candidates were analyzed according to clinical guidelines. Neither the PEGASUS criteria nor the bleeding risk was independently associated with this strategy.This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” [grant numbers JR/21/00041, PI20/00637 and CIBERCV16/11/00486] and by Conselleria de Educación – Generalitat Valenciana (PROMETEO/2021/008)

Acute Coronary Syndrome in the Older Patient

Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making

Extended use of dual antiplatelet therapy among older adults with acute coronary syndromes and associated variables: a cohort study

Current guidelines recommend extending the use of dual antiplatelet therapy (DAPT) beyond 1 year in patients with an acute coronary syndrome (ACS) and a high risk of ischaemia and low risk of bleeding. No data exist about the implementation of this strategy in older adults from routine clinical practice. Methods We conducted a Spanish multicentre, retrospective, observational registry-based study that included patients with ACS but no thrombotic or bleeding events during the first year of DAPT after discharge and no indication for oral anticoagulants. High bleeding risk was defined according to the Academic Research Consortium definition. We assessed the proportion of cases of extended DAPT among patients 65≥years that went beyond 1 year after hospitalisation for ACS and the variables associated with the strategy. Results We found that 48.1% (928/1,928) of patients were aged≥65 years. DAPT was continued beyond 1 year in 32.1% (298/928) of patients≥65; which was a similar proportion as with their younger counterparts. There was no significant correlation between a high bleeding risk and DAPT duration. Contrastingly, there was a strong correlation between the extent of coronary disease and DAPT duration (p<0.001). Other variables associated with extended DAPT were a higher left ventricle ejection fraction, a history of heart failure and a prior stent thrombosis. Conclusion: There was no correlation between age and extended use of DAPT beyond 1 year in older patients with ACS. DAPT was extended in about one-third of patients≥65 years. The severity of the coronary disease, prior heart failure, left ventricle ejection fraction and prior stent thrombosis all correlated with extended DAPT

Risk score for early risk prediction by cardiac magnetic resonance after acute myocardial infarction

[EN] Background: Cardiac magnetic resonance (CMR) performed early after ST-segment elevation myocardial infarction (STEMI) can improve major adverse cardiac event (MACE) risk prediction. We aimed to create a simple clinical-CMR risk score for early MACE risk stratification in STEMI patients. Methods: We performed a multicenter prospective registry of reperfused STEMI patients (n = 1118) in whom early (1-week) CMR-derived left ventricular ejection fraction (LVEF), infarct size and microvascular obstruction (MVO) were quantified. MACE was defined as a combined clinical endpoint of cardiovascular (CV) death, nonfatal myocardial infarction (NF-MI) or re-admission for acute decompensated heart failure (HF). Results: During a median follow-up of 5.52 [2.63-7.44] years, 216 first MACE (58 CV deaths, 71 NF-MI and 87 HF) were registered. Mean age was 59.3 +/- 12.3 years and most patients (82.8%) were male. Based on the four variables independently associated with MACE, we computed an 8-point risk score: time to reperfusion >4.15 h (1 point), GRACE risk score > 155 (3 points), CMR-LVEF 1.5 segments (1 point). This score permitted MACE risk stratification: MACE per 100 person-years was 1.96 in the low-risk category (0-2 points), 5.44 in the intermediate-risk category (3-5 points), and 19.7 in the high-risk category (6-8 points): p 4.15 h and GRACE risk score > 155) and CMR (LVEF 1.5 segments) variables allows for simple and straightforward MACE risk stratification early after STEMI. External validation should confirm the applicability of the risk score.This work was supported by the Instituto de Salud Carlos III and cofunded by Fondo Europeo de Desarrollo Regional (FEDER) (grants PI20/00637 and CIBERCV16/11/00486), "Marató TV3" [grant number 20153030-31-32], the Catalonian Society of Cardiology 2015, La Caixa Foundation [HR17-00527], and by Sociedad Española de Cardiología (grant SEC/FECINV-CLI 21/024). D.M. acknowledges financial support from the Conselleria d'Educació, Investigació, Cultura i Esport, Generalitat Valenciana (grants AEST/ 2019/037 and AEST/2020/029). J. G. acknowledges financial support from the Agencia Estatal de Investigación (grant FJC2020-043981-I / AEI/10.13039/501100011033).Marcos-Garcés, V.; Perez, N.; Gavara-Doñate, J.; Lopez-Lereu, MP.; Monmeneu, JV.; Rios-Navarro, C.; De Dios, E.... (2022). Risk score for early risk prediction by cardiac magnetic resonance after acute myocardial infarction. International Journal of Cardiology. 349:150-154. https://doi.org/10.1016/j.ijcard.2021.11.05015015434

Sex differences in the impact of frailty in elderly outpatients with heart failure

Introduction: Frailty is common among patients with heart failure (HF). Our aim was to address the role of frailty in the management and prognosis of elderly men and women with HF. Methods and results: Prospective multicenter registry that included 499 HF outpatients ≥75 years old. Mean age was 81.4 ± 4.3 years, and 193 (38%) were women. Compared with men, women were older (81.9 ± 4.3 vs. 81.0 ± 4.2 years, p = 0.03) and had higher left ventricular ejection fraction (46 vs. 40%, p < 0.001) and less ischemic heart disease (30 vs. 57%, p < 0.001). Women had a higher prevalence of frailty (22 vs. 10% with Clinical Frailty Scale, 34 vs. 15% with FRAIL, and 67% vs. 46% with the mobility visual scale, all p-values < 0.001) and other geriatric conditions (Barthel index ≤90: 14.9 vs. 6.2%, p = 0.003; malnutrition according to Mini Nutritional Assessment Short Formulary ≤11: 55% vs. 42%, p = 0.007; Pfeiffer cognitive test's errors: 1.6 ± 1.7 vs. 1.0 ± 1.6, p < 0.001; depression according to Yesavage test; p < 0.001) and lower comorbidity (Charlson index ≥4: 14.1% vs. 22.1%, p = 0.038). Women also showed worse self-reported quality of life (6.5 ± 2.1 vs. 6.9 ± 1.9, on a scale from 0 to 10, p = 0.012). In the univariate analysis, frailty was an independent predictor of mortality in men [Hazard ratio (HR) 3.18, 95% confidence interval (CI) 1.29-7.83, p = 0.012; HR 4.53, 95% CI 2.08-9.89, p < 0.001; and HR 2.61, 95% CI 1.23-5.43, p = 0.010, according to FRAIL, Clinical Frailty Scale, and visual mobility scale, respectively], but not in women. In the multivariable analysis, frailty identified by the visual mobility scale was an independent predictor of mortality (HR 1.95, 95% CI 1.04-3.67, p = 0.03) and mortality/readmission (HR 2.06, 95% CI 1.05-4.04, p = 0.03) in men. Conclusions: In elderly outpatients with HF frailty is more common in women than in men. However, frailty is only associated with mortality in men