2016 Vol. 13, No. 7
Background Medication adherence is an integral part of the comprehensive care of patients with atrial fibrillation (AF) receiving oral anticoagulation (OACs) therapy. Many patients with AF are elderly and may suffer from some form of cognitive impairment. This study was conducted to investigate whether cognitive impairment affects the level of adherence to anticoagulation treatment in AF patients. Methods The study involved 111 AF patients (mean age, 73.5 ± 8.3 years) treated with OAC. Cognitive function was assessed using the Mini Mental State Examination (MMSE). The level of adherence was assessed by the 8-item Morisky Medication Adherence Scale (MMAS-8). Scores on the MMAS-8 range from 0 to 8, with scores Results 46.9% of AF patients had low adherence, 18.8% had moderate adherence, and 33.3% had high adherence to OAC. Patients with lower adherence were older than those with moderate or high adherence (76.6 ± 8.7 vs. 71.3 ± 6.4 vs. 71.1 ± 6.7 years) and obtained low MMSE scores, indicating cognitive disorders or dementia (MMSE = 22.3 ± 4.2). Patients with moderate or high adherence obtained high MMSE test results (27.5 ± 1.7 and 27.5 ± 3.6). According to Spearman’s rank correlation, worse adherence to treatment with OAC was determined by older age (rS = －0.372) and lower MMSE scores (rS = 0.717). According to multivariate regression analysis, the level of cognitive function was a significant independent predictor of adherence (b = 1.139). Conclusions Cognitive impairment is an independent determinant of compliance with pharmacological therapy in elderly patients with AF. Lower adherence, beyond the assessment of cognitive function, is related to the age of patients.
Dyspnea is a common and disabling symptom of respiratory and heart diseases, which is growing in incidence. During hospital admission, breathlessness is under-diagnosed and under-treated, although there are treatments available for controlling the symptom. We have developed a tailored implementation strategy directed to medical staff to promote the application of these pharmacological and non-pharmacological tools in dealing with dyspnea. The primary aim is to decrease the rate of patients that do not receive an adequate relief of dyspnea. This is a four-stage quasi-experimental study. The intervention consists in two teaching talks that will be taught in Cardiology and Respiratory Medicine Departments. The contents will be prepared by Palliative Care specialists, based on available tools for management of dyspnea and patients’ needs. A cross-sectional study of dyspnea in hospitalized patients will be performed before and after the intervention to ascertain an improvement in dyspnea intensity due to changes in medical practices. The last phase consists in the creation of consensus protocols for dyspnea management based in our experience. The results of this study are expected to be of great value and may change clinical practice in the near future and promote a changing for the better of dyspnea care.
Background Acute myocardial infarction (AMI) is the most serious type of coronary heart disease. However, less than 30% of these patients have been treated effectively in China. Delayed treatment is a leading cause. This study aimed to evaluate a new regional cooperative model for improving the first medical contact-to-device time and the therapeutic effects on AMI patients. Methods A retrospective analysis of 458 ST-elevation myocardial infarction (STEMI) patients was performed. Patients were divided into two groups in terms of before or after the model were implemented. First medical contact-to-device time (FMC2D), Door to device time (D2D), referral time, cardiac functions, mean cost, days of hospitalization, and major adverse cardiac events (MACE) were analyzed. Results The mean FMC2D time, D2D time and referral time of the model group were significantly lower than the control group. The left ventricular ejection fraction of the model group increased but the left ventricular end-diastolic dimension decreased compared with the control group at 6 months after discharge. These results also showed that mean costs and days of hospitalization were reduced. The MACE rate was reduced in the model group. Conclusions These results suggested that the new model decreased the FMC2D time, which could improve the cardiac function and therapeutic effect of STEMI patients as well as decreased the financial burden.
Background A considerable proportion of elderly patients with symptomatic severe heart valve disease are treated conservatively despite clear indications for surgical intervention. However, little is known about how advanced age and comorbidities affect treatment decision-making and therapeutic outcomes. Methods Patients (n = 234, mean age: 78.5 ± 3.7 years) with symptomatic severe heart valve disease hospitalized in our center were included. One hundred and fifty-one patients (65%) were treated surgically (surgical group) and 83 (35%) were treated conservatively (conservative group). Factors that affected therapeutic decision-making and treatment outcomes were investigated and long-term survival was explored. Results Isolated aortic valve disease, female sex, chronic renal insufficiency, aged ≥ 80 years, pneumonia, and emergent status were independent factors associated with therapeutic decision-making. In-hospital mortality for the surgical group was 5.3% (8/151). Three patients (3.6%) in the conservative group died during initial hospitalization. Low cardiac output syndrome and chronic renal insufficiency were identified as predictors of in-hospital mortality in the surgical group. Conservative treatment was identified as the single risk factor for late death in the entire study population. The surgical group had better 5-year (77.2% vs. 45.4%, P vs. 8.9%, P Conclusions Advanced age and geriatric comorbidities profoundly affect treatment decision-making for severe heart valve disease. Valve surgery in the elderly was not only safe but was also associated with good long-term survival while conservative treatment was unfavorable for patients with symptomatic severe valve disease.
We describe a rare case of a 60-year-old woman suffering from intramyocardial dissection and left ventricular aneurysm secondary to acute myocardial infarction. A rare form of ventricular septal rupture resulted from intramyocardial dissection deterioration, which was identified during echocardiographic follow-up. Surgical repair under beating-heart cardiopulmonary bypass was successful.
Background End-of-life care is not usually a priority in cardiology departments. We sought to evaluate the changes in end-of-life care after the introduction of a do-not-resuscitate (DNR) order protocol. Methods & Results Retrospective analysis of all deaths in a cardiology department in two periods, before and after the introduction of the protocol. Comparison of demographic characteristics, use of DNR orders, and end-of-life care issues between both periods, according to the presence in the second period of the new DNR sheet (Group A), a conventional DNR order (Group B) or the absence of any DNR order (Group C). The number of deaths was similar in both periods (n = 198 vs. n = 197). The rate of patients dying with a DNR order increased significantly (57.1% vs. 68.5%; P = 0.02). Only 4% of patients in both periods were aware of the decision taken about cardiopulmonary resuscitation. Patients in Group A received the DNR order one day earlier, and 24.5% received it within the first 24 h of admission (vs. 2.6% in the first period; P vs. 25.0% in the first period; P = 0.02). Conclusions The introduction of a DNR order protocol may improve end-of-life care in cardiac patients by increasing the use and shortening the time of registration of DNR orders. It may also contribute to increase ICD deactivation in patients with these orders in place. However, the introduction of the sheet in late stages of the disease failed to improve patient participation.
Background The efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in Asian octogenarian atrial fibrillation (AF) patients have not been established in a real-world setting. We aimed to evaluate the efficacy and safety of NOACs and warfarin in Korean octogenarian patients. Methods A total of 293 consecutive patients aged ≥ 80 years with non-valvular AF who had taken either NOACs (148 cases, 50.5%) or warfarin (145 cases, 49.5%) were retrospectively reviewed. The efficacy outcome was the composite of stroke or systemic embolism. The safety outcome was major bleeding. Results The follow-up duration was 375 patient-years (172 patient-years with NOACs and 203 patient-years with warfarin). Patients on NOACs were slightly older (P = 0.006) and had slightly higher HAS-BLED scores (P = 0.034). The efficacy of both anticoagulants was high (1.16% for NOACs vs. 2.98% for warfarin per 100 patient-years, P = 0.46). The safety outcome was relatively high in both NOACs and warfarin groups (8.96% vs. 12.46%, P = 0.29). The efficacy and safety outcomes tended to decrease non-significantly in low dose NOACs than in common dose NOACs or warfarin (0.85% vs. 1.84% vs. 2.98% in efficacy outcome, P = 0.69; and 6.97% vs. 13.29% vs. 12.46% in safety outcome, P = 0.34). Conclusions NOACs were highly effective for prevention of stroke or systemic embolism in Asian octogenarian AF patients. However, major bleeding occurred excessively high in both anticoagulant groups. Further study is required on the optimal anticoagulant regimen in octogenarian population.
Background Elevated resting heart rate and hypertension independently increase the risk of mortality. However, their combined effect on mortality in stages of hypertension according to updated clinical guidelines among elderly population is unclear. Methods We followed a cohort of 6100 residents (2600 males and 3500 females) of Kangwha County, Korea, ranging from 55 to 99 year-olds as of March 1985, for all-cause and cardiovascular mortality for 20.8 years until December 31, 2005. Mortality data were collected through telephone calls and visits (to 1991), and were confirmed by death record matching with the National Statistical Office (1992–2005). Hazard ratios were calculated for all-cause and cardiovascular mortality by resting heart rate and hypertension defined by Eighth Joint National Committee criteria using the Cox proportional hazard model after controlling for confounding factors. Results The hazard ratios associated with resting heart rate > 80 beats/min were higher in hypertensive men compared with normotensives with heart rate of 61–79 beats/min, with hazard ratios values of 1.43 (95% CI: 1.00–1.92) on all-cause mortality for prehypertension, 3.01 (95% CI: 1.07–8.28) on cardiovascular mortality for prehypertension, and 8.34 (95% CI: 2.52–28.19) for stage 2 hypertension. Increased risk (HR: 3.54, 95% CI: 1.16–9.21) was observed among those with both a resting heart rate ≥ 80 beats/min and prehypertension on cardiovascular mortality in women. Conclusions Individuals with coexisting elevated resting heart rate and hypertension, even in prehypertension, have a greater risk for all-cause and cardiovascular mortality compared to those with elevated resting heart rate or hypertension alone. These findings suggest that elevated heart rate should not be regarded as a less serious risk factor in elderly hypertensive patients.
Chronic heart failure (CHF) is a highly prevalent condition among the elderly and is associated with considerable morbidity, institutionalization and mortality. In its advanced stages, CHF is often accompanied by the loss of muscle mass and strength. Sarcopenia is a geriatric syndrome that has been actively studied in recent years due to its association with a wide range of adverse health outcomes. The goal of this review is to discuss the relationship between CHF and sarcopenia, with a focus on shared pathophysiological pathways and treatments. Malnutrition, systemic inflammation, endocrine imbalances, and oxidative stress appear to connect sarcopenia and CHF. At the muscular level, alterations of the ubiquitin proteasome system, myostatin signaling, and apoptosis have been described in both sarcopenia and CHF and could play a role in the loss of muscle mass and function. Possible therapeutic strategies to impede the progression of muscle wasting in CHF patients include protein and vitamin D supplementation, structured physical exercise, and the administration of angiotensin-converting enzyme inhibitors and β-blockers. Hormonal supplementation with growth hormone, testosterone, and ghrelin is also discussed as a potential treatment.
Objective To determine the association between plasma brain natriuretic peptide (BNP) level in patients with heart failure (HF) and physical frailty as well as with each domain of physical frailty. Methods Two hundred and six outpatients of cardiovascular medicine aged 60 years and older who had been hospitalized for HF or had been given a prescription medication for HF were included. Physical frailty was assessed using the following five domains: slowness, weakness, exhaustion, low activity, and shrinking, according to the Cardiovascular Health Study. Patients were divided into nonfrailty and frailty groups according to frailty scores. Plasma BNP level was measured. The 6-min walk test was performed to measure endurance. Results Plasma BNP was significantly different between the two groups (frailty group: 158.0 ± 214.7 pg/mL, nonfrailty group: 65.2 ± 88.0 pg/mL, P P P Conclusions Plasma BNP level was related to physical frailty, especially in the slowness domain. Endurance may intervene in the associations between plasma BNP level and walking speed.
Background Hypertension is a common chronic disease among older adults, and is associated with medical complications and mortality. This study aimed to examine the effects of social network characteristics on the prevalence, awareness, and control of hypertension among older adults. Methods The Korean Social Life, Health, and Aging Project (KSHAP) interviewed 814 ≥ 60-year-old residents and their spouses from a rural township between December 2011 and March 2012 (response rate: 95%). We evaluated the data from 595 participants. Multivariate logistic regression models were used to assess the effects of network characteristics on hypertension. Results We observed strong sex-specific network effects on the prevalence, awareness, and control of hypertension. Among older women, network density was associated with hypertension awareness [odds ratio (OR): 2.63, 95% confidence interval (CI): 1.03–5.37] and control (OR: 1.72; 95% CI: 0.94–3.13). Among older men, large networks were associated with a lower prevalence of hypertension (OR: 0.75; 95% CI: 0.58–0.96). Compared to older women, older men with coarse networks exhibited better hypertension awareness (OR: 0.37; 95% CI: 0.14–0.95) and control (OR: 0.42; 95% CI: 0.19–0.91). Network size interacted with density for hypertension control (P = 0.051), with controlled hypertension being associated with large and course networks. Conclusions A large network was associated with a lower risk for hypertension, and a coarse network was associated with hypertension awareness and control among older men. Older women with dense networks were most likely to exhibit hypertension awareness and control.