2006 Vol. 3, No. 4
Good morning, ladies and gentlemen, In the golden autumn of Beijing, on behalf of the Organizing Committee of the Great Wall International Congress of Cardiology, and the Institute of Geriatric Cardiology at Chinese PLA General Hospital, I am very delighted to extend my warmest welcome to the representatives, colleagues and distinguished guests, both domestic and abroad, to the 5th International Forum on Geriatric Cardiology.
Heart Failure (HP) is a major source of morbidity and mortality worldwide. In the United States, five million people carry this diagnosis. It accounts for in excess of one million hospitalizations and costs approximately $30 billion to treat. The elderly population is particularly affected since more than 80% of those hospitalized for HF are over age 65 years. Despite the development of evidence-based therapy and guidelines in the management of chronic HF for use by physicians and other health care providers, the mortality remains high.
Chronic heart failure (CHF) is a clinical syndrome as a common pathway at the end stage of cardiac diseases of different etiologies, and it is currently the only cardiovas-cular disease with an increasing prevalence in the devel-oped countries. In the United States, the prevalence of CHF at age 50 years is 1.0%, whereas it reaches 7.5% at age 80 years. In the United Kingdom, the prevalence of CHF is 5.0% at age 60-70 years, and 10-20% at age 80 years. The situation is similar in Italy and Portugal. Despite being a developing country in Asia, China has experienced rapid progress in acquiring medical knowledge and advancing techniques in recent years. Due to the markedly declined mortality of acute myocardial infarction (AMI) as well as the aging of Chinese population, about four million Chi-nese have CHF with a prevalence of 0.9%, most of whom are 60 years of age and older.
Each year, there are over one million hospitalizations for acute heart failure syndrome (AHFS) in the United States alone, with a similar number in Western Europe. These patients have very high short-term (2-6 months) mortality and readmission rates, while the healthcare system incurs substantial costs. Until recently, the clinical characteristics, management patterns, and outcomes of these patients have been poorly understood and, in consequence, risk stratification for these patients has not been well defined. Several risk prediction models that can accurately identify high-risk patients have been developed in the last year using data from clinical trials, large registries or administrative databases. Use of multi-variable risk models at the time of hospital admission or discharge offers better risk stratification and should be encouraged, as it allows for appropriate allocation of existing resources and development of clinical trials testing new treatment strategies for patients admitted with AHFS. The emerging observation that the prognosis for the ensuing three to six months may be obtained at presentation for AHFS has major implications for development of future therapies.
Heart failure with preserved left ventricular function is a common problem among elderly patients. Given that diastolic heart failure (DHF) occurs in up to 50% of all heart failure admissions, and that incidence increases with age, knowledge of current recommendations for its diagnosis and treatment are extremely important for the elderly population. Causes of DHF include the aging process itself, hypertension, left ventricular hypertrophy, aortic stenosis, and hypertrophic obstructive cardiomyopathy. The patient with DHF may present with signs and symptoms similar to those observed in systolic heart failure. Treatment goals for the patient with DHF include achieving normal volume status, improving relaxation of the left ventricle, regression of hypertrophy if possible, and management of any co-morbidities that may aggravate the clinical status of patients with DHF. Hopefully, in the future, further data from randomized clinical trials will allow a more defined approach to care in these patients.
Although surgical options exist, treatment for heart failure remains dominated by medical therapy. Even with optimal medical therapy, the mortality of heart failure continues to be high. Conventional wisdom in heart failure treatment leads many practitioners to believe that the patient is "too sick" for further operative procedures such as revascularization, valve repair or replacement and ventricular reconstruction. Improvements in intra and peri-operative care over the last 20 years have allowed for more complex procedures to be performed, and have improved the mortality rates of the more traditional surgeries. As the complexity of the operative procedure and morbidity of the patient has elevated so has the importance of a multidisciplinary approach in choosing treatment plans for patients. As the age of the population increases and acute management of ischemic heart disease improves, the prevalence of heart failure will likely increase. Improving access and changing treatment algorithms to include operative procedures can improve the treatment of heart failure patients.
Quality of life (QOL), as a relevant area of research in the understanding of heart failure (HP) patient outcomes, has been increasingly studied during the last two decades. The purposes of this review article are to (1) describe QOL in older adults with HF, (2) identify and critique research designed to test interventions to improve QOL, (3) identify gaps in the literature, and (4) provide recommendations for future research. Seventeen studies describing QOL in older adults with HF were identified. Elderly HF patient QOL has been reported to be fair to poor and is worse as compared to a healthy control group. Furthermore, there is some evidence that suggests that QOL is better in older adults than younger adults and worse in women (both older and younger) than in men, although these findings are not consistent across studies. Predictors of QOL and its dimensions in older HF patients included demographic, clinical, and psychosocial variables. Sixteen interventional studies were identified that reported QOL as an outcome in older adults. Findings among randomized clinical trials (RCTs) to improve QOL outcomes in elderly HF patients do not allow strong conclusions about the benefits of the interventions. It must be noted, though, that while not all studies reported improvements in QOL (either significant or as a trend), no studies reported deterioration in QOL with randomization to an intervention versus control. These studies were limited by several methodological issues. While there has been some research of QOL in this elderly cohort, it is paramount that we address methodological issues and thereby improve the scientific rigor of our research, continue to explore QOL in elderly HF patients, and design intervention trials for elders at risk for poor QOL.
Because decompensated heart failure (HF) patients present primarily with symptoms of congestion, the assessment of volume status is of paramount importance. Despite the addition of new technologies that can predict intracardiac filling pressures, the physical exam (PE) remains the most accessible and cost-effective tool available to clinicians. An elevated jugular venous pressure (JVP) is considered the most sensitive sign of volume overload, although the commonly used 'method of Lewis' has several limitations. A useful cutoff is that if the JVP is greater than 3 cm in vertical distance above the sternal angle, the central venous pressure is elevated. In addition to assessment of volume status, the PE in HF can reveal adverse prognostic signs, namely: elevated JVP, presence of third heart sound, elevated heart rate, low systolic BP, and low proportional pulse pressure (< 25%). This article will review the evidence for the diagnostic and prognostic utility of common PE findings in HF.
Objectives To evaluate the effect of thyroid hormone therapy with low dose of thyroxin on cardiac function in elderly patients with heart failure and sick euthyroid syndrome. Methods Forty-seven patients (33 males and 14 females, mean age 85.9±4.6 years, ranging from 80 to 99 years) with chronic heart failure (NYHA II-IV) and low triiodothyronine (T ) state were randomly allocated to the treatment group or control group. The treatment group patients received oral administration of levothyroxine sodium (Euthyrox) 25-50 mg/d in addition to conventional therapy of heart failure, whereas patients in control group were given conventional therapy only. Serum level of total T3 (TT3), free T3 (FT3), total thyroxine (TT4), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) were determined. For both groups, left ventricular ejection fraction (LVEF) and stroke volume (SV) were assessed by two-dimensional echocardiography before and at 8 weeks after treatment. The changes of these parameters after the treatment were evaluated by adjusting heart rate in the two groups. Results The reduced serum T3 level in the treatment group was corrected after thyroid hormone therapy, and these patients had a significant improvement in cardiac function after treatment. By contrast, in the control group only changes of serum TT3 and TT4 levels and S V and LVEF after treatment were statistically significant. The heart rate-adjusted mean SV and LVEF in both groups were also increased, which was significantly greater in the treatment group than in the control group. Conclusion In the elderly patients with heart failure and sick euthyroid syndrome, addition of thyroxine at a low dosage to the conventional treatment could effectively improve the low T3 state and cardiac function independent of changes of heart rate.
Heart failure (HF) affects 5 million Americans, of whom three-fourths are over age 65 and half are over age 75.' HF is currently the leading cause of hospitalization among older adults in the U.S., and it is the most costly medical illness by a factor of almost two.2 In addition, it is anticipated that the number of older people with HF will double over the next 20-25 years due to the progressive aging of the U.S. population.
Congestive heart failure (HF) is a major and growing public health problem. The therapeutic approach includes non-pharmacological measures, pharmacological therapy, mechanical devices, and surgery. Despite the benefits of optimal pharmacologic therapy, the prognosis is still not ideal. At this time, cardiac resynchronization therapy (CRT) has gained wide acceptance as an alternative treatment for HF patients with conduction delay.
Objectives Intra-atrial re-entrant tachycardias (lARTs) are common late after heart surgery. Conventional mapping and ablation is relatively difficult because of the complicated anatomy and multiple potential re-entry loops. In this study we aimed to evaluate the electrophysiological characteristics and radiofrequency catheter ablation of atrial tachycardia (AT) induced by myocardial scar or incision. Methods In 6 patients (three male and three female, aged 33.3±11.8 years) who had AT related to myocardial scar or incision, electrophysiological study and radiofrequency catheter ablation (RFCA) were performed. Earliest activation combined with entrain-ment mapping was adopted to determine a critical isthmus. Results Re-entry related to the lateral atriotomy scar was inducible in 5 of 6 patients. With entrainment mapping, the PPI (post-pacing interval)-TCL (tachycardia cycle length) difference was <30 ms when pacing at the inferior margins of the right lateral atriotomy scar. Among them, 3 patients had successful linear ablation between scar area to inferior vena cava, and 2 patients between scar area to tricuspid annulus. Re-entry involving an ASD patch was demonstrated in 1 of 6 patients. PPI-TCL differences <30 ms were observed when entraining tachycardia at sites near the septal patch. But linear ablation failed in terminating AT. There was no complication during procedure. No recurrence of AT related to incision was observed during follow-up except for the failed patient. Conclusion Under conventional electrophysiological mapping, adopting linear ablation from scar area to anatomic barrier, successful ablation can be obtained in patients with IRATs related to myocardial scar or incision.
The Fourth Pivotal Research in Cardiology in the Elderly (PRICE-IV) symposium, entitled "Electrophysiology and Heart Rhythm Disorders in the Elderly: Mechanisms and Management", was held on November 11, 2006 in Chicago. The program, sponsored by the Society of Geriatric Cardiology and supported by a conference grant from the National Institute on Aging (NIA), featured a distinguished cadre of over 25 internationally acclaimed experts on all aspects of heart rhythm disorders in the elderly, ranging from basic mechanisms to clinical features and management to end-of-life care. Dr. Michael W. Rich, from Washington University in St. Louis, and Dr. Anne B. Curtis, from the University of South Florida in Tampa, served as co-chairs. Meeting participants uniformly praised the superb faculty, the excellent blend of basic and clinical sciences, and the outstanding quality of the overall program.
Presented on November 4-6, 2006, Wenzhou Medical College, China