Abstract Background Elderly patients represent a large proportion of patients admitted for Acute Coronary Syndrome (ACS). Whether frailty, defined as a biological syndrome that reflects a state of ...decreased physiological reserve and vulnerability to stressors, may impact the clinical outcomes in this population remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted for ACS. Methods This prospective observational study was conducted among patients aged 80 or older admitted in a tertiary hospital for ACS. Frailty was assessed using the Edmonton Frail Scale (EFS) which provides a score ranging from 0 (not frail) to 17 (very frail). Population was divided into 3 classes: 0-3 EFS-score, 4-6 EFS-score, and >7 EFS-score. Results 236 patients were included with a mean follow-up duration of 470 days. The mean age was 85.9 years. 75 patients died during follow-up period.119 subjects (50.4%) had a 0-3 EFS-score, 68 patients (28.8%) had a 4-6 EFS-score and 49 patients (20.8%) had a ≥ 7 EFS-score. All-cause mortality rate was 17.7% in the 0-3 EFS-score group, 35.3% in the 4-6 EFS-score group and 61.2% in the ≥ 7 EFS-score group, (p<0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: HR was 1.53 (95% CI 0.74 - 3.16) within the 4-6 EFS-score group, and HR was 3.60 (95% CI 1.70 - 7.63) within the ≥ 7 EFS-score group. Conclusion Frailty is a strong and independent prognosis factor of midterm all-cause mortality in elderly patients presenting with ACS.
The aim of this multicenter observational study conducted in France was to determine the prevalence of memory impairment in ambulatory patients aged ≥70 years with chronic heart failure (HF). Two ...hundred ninety-one cardiologists recruited 912 ambulatory patients with HF (mean age 79.2 ± 5.8 years) from January to November 2009. Memory was evaluated by the delayed-recall Memory Impairment Screen (MIS-D). Memory impairment was defined as MIS-D score ≤6 and severe memory impairment as MIS-D score ≤4. HF was diagnosed 4.4 ± 4.8 years earlier and mean left ventricular ejection fraction was 43.6 ± 12.0%. Memory impairment was found in 416 subjects (45.6%, 95% confidence interval 42.4 to 48.8) and severe memory impairment in 213 subjects (23.4%, 95% confidence interval 20.6 to 26.1), whereas cardiologists only suspected memory impairment in 109 patients (12%; before evaluation by MIS). Determinants of memory disorders included older age, lower education level, depression, history of stroke, renal failure, and less regular physical activity. The severity of memory impairment increased with increasing severity of HF (New York Heart Association classification; p <0.00001). In conclusion, memory impairment in older patients with HF is common. The use of a simple-to-use tool such as the MIS-D may identify patients at risk and enable implementation of management strategies to improve therapeutic compliance.
Early Aldosterone Blockade in Acute Myocardial Infarction Beygui, Farzin, MD, PhD; Cayla, Guillaume, MD, PhD; Roule, Vincent, MD ...
Journal of the American College of Cardiology,
04/2016, Letnik:
67, Številka:
16
Journal Article
Recenzirano
Odprti dostop
Abstract Background Mineralocorticoid receptor antagonists (MRA) improve outcome in the setting of post–myocardial infarction (MI) heart failure (HF). Objectives The study sought to assess the ...benefit of an early MRA regimen in acute MI irrespective of the presence of HF or left ventricular (LV) dysfunction. Methods We randomized 1,603 patients to receive an MRA regimen with a single intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) for 6 months in addition to standard therapy or standard therapy alone. The primary outcome of the study was the composite of death, resuscitated cardiac arrest, significant ventricular arrhythmia, indication for implantable defibrillator, or new or worsening HF at 6-month follow-up. Key secondary/safety outcomes included death and other individual components of the primary outcome and rates of hyperkalemia at 6 months. Results The primary outcome occurred in 95 (11.8%) and 98 (12.2%) patients in the treatment and control groups, respectively (hazard ratio HR: 0.97; 95% confidence interval CI: 0.73 to 1.28). Death occurred in 11 (1.4%) and 17 (2.1%) patients in the treatment and control groups, respectively (HR: 0.65; 95% CI: 0.30 to 1.38). In a non–pre-specified exploratory analysis, the odds of death were reduced in the treatment group (3 0.5% vs. 15 2.4%; HR: 0.20; 95% CI: 0.06 to 0.70) in the subgroup of ST-segment elevation MI (n = 1,229), but not in non–ST-segment elevation MI (p for interaction = 0.01). Hyperkalemia >5.5 mmol/l–1 occurred in 3% and 0.2% of patients in the treatment and standard therapy groups, respectively (p < 0.0001). Conclusions The study failed to show the benefit of early MRA use in addition to standard therapy in patients admitted for MI. (Aldosterone Lethal effects Blockade in Acute myocardial infarction Treated with or without Reperfusion to improve Outcome and Survival at Six months follow-up; NCT01059136 ).
Objectives This study sought to measure muscle sympathetic nerve activity (MSNA) in patients with aortic stenosis (AS) before and after transcatheter aortic valve implantation (TAVI) and to compare ...MSNA with that of control patients. Background TAVI is an emerging therapeutic option in patients with severe AS at high risk of open heart surgery. Whether patients with AS have increased sympathetic activity remains to be established, and the effects of TAVI on the sympathetic nervous system are also unknown. Methods We prospectively enrolled 14 patients with severe symptomatic AS treated by TAVI. Fourteen control patients matched for age, body mass index, and unscathed of AS were also included. All patients underwent MSNA and arterial baroreflex gain assessment at baseline and 1 week after TAVI for AS patients. Results Patients with AS had lower blood pressure (BP) levels, a significant increase in MSNA (61.0 ± 1.7 burst/min vs. 55.4 ± 1.4 burst/min; p < 0.05), and a decrease in arterial baroreflex gain (2.13 ± 0.14% burst/mm Hg vs. 3.32 ± 0.19% burst/mm Hg; p < 0.01) compared with matched control patients. The TAVI procedures induced an increase in BP associated with a significant decrease in MSNA (from 61.0 ± 1.7 burst/min to 54.1 ± 1.0 burst/min; p < 0.01) and was associated with a significant increase in arterial baroreflex gain (from 2.13 ± 0.14% burst/mm Hg to 3.49 ± 0.33% burst/mm Hg; p < 0.01). Conclusions We report for the first time, through direct measurement of nerve activity, that patients with AS have increased sympathetic nervous system activity associated with a decrease in sympathetic baroreflex gain and that TAVI normalizes these parameters. This study provides evidence of a new beneficial effect of TAVI, namely, normalization of sympathetic nervous system hyperactivity.
Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the outcomes of elderly patients admitted to a ...cardiac intensive care unit (CICU) remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted to a CICU.
This prospective single-centre observational study was conducted among patients aged ≥ 80 years admitted to a CICU in a tertiary centre. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS-score of 0-3, EFS-score of 4-6, and EFS-score > 7.
A total of 199 patients were included, and median follow-up duration was 365 days. The mean age was 84.8 years, and 50 patients (25.1%) died during the follow-up period. In all, 45 (22.6%), 60 (30.2%), and 94 patients (47.2%) had an EFS-score of 0-3, 4-6, and ≥ 7, respectively. The all-cause mortality rate was 4.4%, 27.1%, and 37.2% in the 0-3, 4-6, and ≥ 7 EFS-score groups, respectively (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: hazard ratio was 2.60 (95% confidence interval 0.54-12.45) within the 4-6 EFS-score group, and 5.46 (95% confidence interval 1.23-24.08) within the ≥ 7 EFS-score group.
Frailty is highly prevalent in older adults admitted to the population hospitalized in a CICU and represents a strong prognostic factor for 1-year all-cause mortality.
On ignore si la fragilité, définie comme un syndrome biologique reflétant une diminution des réserves physiologique et une vulnérabilité au stress, impacte le pronostic des sujets âgés admis en unité de soins intensifs cardiologiques (USIC). Notre objectif était de déterminer la prévalence de la fragilité et son impact sur la mortalité chez les sujets âgés de 80 ans ou plus admis en USIC.
Il s'agit d'une étude prospective monocentrique observationnelle conduite sur les patients de 80 ans ou plus admis en USIC dans un centre tertiaire. La fragilité a été évaluée par l’échelle de fragilité d'Edmonton (EFS) qui donne un score allant de 0 (pas fragile) à 17 (très fragile). La population a été divisé en 3 classes : score EFS de 0 à 3, score EFS de 4 à 6, et score EFS de > 7.
Cent quatre-vingt-dix-neuf patients ont été inclus avec un suivi médian de 365 jours. L’âge moyen était de 84,8 ans. Cinquante patients (25,1 %) sont décédés au cours de la période de suivi. Quarante-cinq patients (22,6 %) avaient un score EFS de 0 à 3, 60 patients (30,2 %) avaient un score EFS de 4 à 6 et 94 patients (47,2 %) avaient un score EFS de ≥ 7. Les taux de mortalité toutes causes étaient de 4,4 % dans la classe de score EFS de 0 à 3, 27,1 % dans la classe de score EFS de 4 à 6 et 37,2 % dans la classe de score EFS de ≥ 7, (p < 0.001). En analyse multivariée, la fragilité demeurait associée avec la mortalité toutes causes : le rapport de risques instantanés (RRI) était à 2,60 (intervalle de confiance IC à 95 % 0,54 - 12,45) dans la classe de score EFS de 4 à 6, et le RRI était à 5,46 (IC à 95 % 1,23 - 24,08) dans la classe de score EFS de ≥ 7.
La fragilité est fortement prévalente dans la population des sujets âgés admis en USIC et constitue un facteur pronostique fort de mortalité toutes causes à un an.
The prognostic value of symptomatic peripheral arterial disease (PAD) in patients with coronary heart disease (CHD) is well documented, but few reports differentiating between symptomatic and ...asymptomatic forms of PAD are available. We investigated the respective prognostic effect of clinical and subclinical PAD on long-term all-cause mortality in patients with stable CHD. We analyzed 710 patients with stable CHD referred for hospitalization for CHD evaluation and management. As a part of the study, they completed questionnaires on medical history, underwent a standardized clinical examination, including ankle-brachial index (ABI) measurement, and provided a fasting blood sample. Three groups of patients were individualized: no PAD (no history of PAD and ABI >0.9 but ≤1.4); subclinical PAD (no history of PAD but abnormal ABI i.e., ≤0.9 or >1.4); and clinical PAD (history of claudication, peripheral arterial surgery, or amputation due to PAD). Clinical and subclinical PAD was present in 83 (11.7%) and 181 (25.5%) patients, respectively. After a median follow-up of 7.2 years, 130 patients died. On multivariate analysis adjusted for age, hypertension, diabetes, dyslipidemia, smoking, left ventricular ejection fraction, CHD duration, heart rate, history of stroke or transient ischemic attack, and coronary revascularization, previous clinical PAD (hazard ratio 2.11, 95% confidence interval 1.28 to 3.47) and subclinical PAD (hazard ratio 1.65, 95% confidence interval 1.11 to 2.44) were significantly associated with increased all-cause mortality. In conclusion, our study has demonstrated that the detection of subclinical PAD by ABI in patients with stable CHD provides additional information for long-term mortality risk evaluation.
Plasma Brain Natriuretic Peptide-Guided Therapy to Improve Outcome in Heart Failure: The STARS-BNP Multicenter Study Patrick Jourdain, Guillaume Jondeau, François Funck, Pascal Gueffet, Alain Le ...Helloco, Erwan Donal, Jean F. Aupetit, Marie C. Aumont, Michel Galinier, Jean C. Eicher, Alain Cohen-Solal, Yves Juillière A total of 220 New York Heart Association functional class II to III patients optimally treated by chronic heart failure (CHF) specialists were randomized into a clinical group (normal care without brain natriuretic peptide BNP measurement) and a BNP group (target BNP plasma levels of <100 pg/ml). Outpatient visits were monthly for 3 months and every 3 months thereafter. Groups were similar at baseline, except a slightly lower left ventricular ejection fraction in the BNP group (29.9 ± 7.7% vs. 31.8 ± 8.4%, p = 0.05). After a mean follow-up of 15 months, significantly fewer patients reached the combined end point (CHF-related death or hospital stay) in the BNP group (24% vs. 52%, p < 0.001). This was mainly obtained through an increase in angiotensin-converting enzyme inhibitor and beta-blocker dosages.
We report on a 62-year-old man referred to the cardiac intensive care unit less than 24 hours after anterior ST-segment elevated myocardial infarction. The patient developed cardiogenic shock ...requiring elective intubation, vasopressor, and inotropic support. Emergency coronary angiography, revascularization, and insertion of an intraaortic balloon pump were performed. Nevertheless, the hemodynamic situation remained unstable, and a left ventricular assist device (LVAD) was inserted. Severe hypoxemia occurred several minutes after initiating the Impella Recover LD/LP 5.0 (Abiomed, Danvers, MA). Transesophageal echocardiography allowed diagnosis of patent foramen ovale. The shunt resulted from abnormal left-to-right pressure gradient due to left ventricular unloading and increased right ventricular afterload induced by mechanical ventilation. Transesophageal echocardiography was used to regulate both LVAD output and positive end-expiratory pressure settings to optimize oxygen transport. Because patent foramen ovale is common in humans, transesophageal echocardiography should be performed systematically after LVAD insertion.
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