Background
There is scarce information on the prognostic role of frailty and atrial fibrillation (AF) in elderly patients with acute coronary syndrome (ACS).
Methods
The aim was to analyse the ...management of elderly patients with frailty and AF who suffered an ACS using data of the prospective multicentre LONGEVO‐SCA registry. We evaluated the predictive performance of FRAIL, Charlson scores and AF status for adverse events at 6‐month follow‐up.
Results
A total of 531 unselected patients with ACS and above 80 years old mean age 84.4 (SD = 3.6) years; 322 (60.6%) male were enrolled, of whom 128 (24.1%) with AF and 145 (27.3%) with frailty. Mutually exclusive number of patients were as follows: non‐frail and sinus rhythm (SR) 304 (57.2%); frail and SR 99 (18.6%); non‐frail and AF 82 (15.4%); and frail and AF 46 (8.7%). Frail and AF patients compared with non‐frail and SR patients had higher risk of all‐cause mortality HR 2.61, (95% CI 1.28‐5.31; P = .008), readmissions HR 2.28, (95%CI 1.37‐3.80); P = .002) and its composite HR 2.28, (95% CI 1.44‐3.60); P < .001). After multivariate adjustment, FRAIL score HR 1.41, (95% CI 1.02‐1.97); P = .040 and Charlson index HR 1.32, (95% CI 1.09‐1.59); P = .003 were significantly associated with mortality. AF status was not independently related with adverse events.
Conclusions
Frailty but not AF status was independently associated with follow‐up adverse events. Frailty status and high Charlson index were independent conditions associated with adverse events during the follow‐up. The impact of functional status has a bigger prognostic role over AF status in elderly patients with ACS.
Abstract
Background
Cardiac arrest is a major public health issue in Europe. Cardiac arrest seems to be associated with a large socioeconomic burden in terms of resource utilization and health care ...costs. The aim of this study is the analysis of the economic burden of cardiac arrest in Spain and a cost-effectiveness analysis of the key intervention identified, especially in relation to neurological outcome at discharge.
Methods
The data comes from the information provided by 115 intensive care and cardiology units from Spain, including information on the care of patients with out-of-hospital cardiac arrest who had a return of spontaneous circulation. The information reported by theses 115 units was collected by a nationwide survey conducted between March and September 2020. Along with number of patients (2631), we also collect information about the structure of the units, temperature management, and prognostication assessments. In this study we analyze the potential association of several factors with neurological outcome at discharge, and the cost associated with the different factors. The cost-effectiveness of using servo-control for temperature management is analyzed by means of a decision model, based on the results of the survey and data collected in the literature, for a one-year and a lifetime time horizon.
Results
A total of 109 cardiology units provided results on neurological outcome at discharge as evaluated with the cerebral performance category (CPC). The most relevant factor associated with neurological outcome at discharge was ‘servo-control use’, showing a 12.8% decrease in patients with unfavorable neurological outcomes (i.e., CPC3-4 vs. CPC1-2). The total cost per patient (2020 Euros) was €73,502. Only “servo-control use” was associated with an increased mean total cost per hospital. Patients treated with servo-control for temperature management gained in the short term (1 year) an average of 0.039 QALYs over those who were treated with other methods at an increased cost of €70.8, leading to an incremental cost-effectiveness ratio of 1,808 euros. For a lifetime time horizon, the use of servo-control is both more effective and less costly than the alternative.
Conclusions
Our results suggest the implementation of servo-control techniques in all the units that are involved in managing the cardiac arrest patient from admission until discharge from hospital to minimize the neurological damage to patients and to reduce costs to the health and social security system.
Background Current electrocardiographic algorithms lack sensitivity to diagnose acute myocardial infarction (AMI) in the presence of left bundle branch block. Methods and Results A multicenter ...retrospective cohort study including consecutive patients with suspected AMI and left bundle branch block, referred for primary percutaneous coronary intervention between 2009 and 2018. Pre-2015 patients formed the derivation cohort (n=163, 61 with AMI); patients between 2015 and 2018 formed the validation cohort (n=107, 40 with AMI). A control group of patients without suspected AMI was also studied (n=214). Different electrocardiographic criteria were tested. A total of 484 patients were studied. A new electrocardiographic algorithm (BARCELONA algorithm) was derived and validated. The algorithm is positive in the presence of ST deviation ≥1 mm (0.1 mV) concordant with QRS polarity, in any lead, or ST deviation ≥1 mm (0.1 mV) discordant with the QRS, in leads with max (R|S) voltage (the voltage of the largest deflection of the QRS, ie, R or S wave) ≤6 mm (0.6 mV). In both the derivation and the validation cohort, the BARCELONA algorithm achieved the highest sensitivity (93%-95%), negative predictive value (96%-97%), efficiency (91%-94%) and area under the receiver operating characteristic curve (0.92-0.93), significantly higher than previous electrocardiographic rules (
<0.01); the specificity was good in both groups (89%-94%) as well as the control group (90%). Conclusions In patients with left bundle branch block referred for primary percutaneous coronary intervention, the BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI, leading to a diagnostic accuracy comparable to that obtained by ECG in patients without left bundle branch block.
Introduction
Clinical guidelines recommend extended treatment with dual antiplatelet therapy (DAPT) with ticagrelor 60 mg (twice daily) beyond 12 months in high‐risk patients with a history of ...myocardial infarction (MI) who have previously tolerated DAPT and are not at heightened bleeding risk. However, evidence on patterns of use and associated clinical outcomes in routine clinical practice is limited.
Methods
ALETHEIA is an observational, multi‐country study, designed to describe characteristics, treatment persistence, and bleeding and cardiovascular (CV) outcomes in post‐MI patients who initiate ticagrelor 60 mg in routine clinical practice (NCT04568083). The study will include electronic health data in the United States (US; Medicare, commercial claims) and Europe (Sweden, Italy, United Kingdom, Germany). Characteristics will be described among patients with and without ticagrelor 60 mg ≥1 year post‐MI. Assuming an a priori threshold of 5000 person‐years on‐treatment is met, to ensure sufficient precision, clinical outcomes (bleeding and CV events) among patients treated with ticagrelor 60 mg will be assessed. Risk factors for clinical outcomes and treatment discontinuation will be assessed in patients with ticagrelor 60 mg and meta‐analysis used to combine estimates across databases. Cohort selection will initiate from the ticagrelor 60 mg US and European approval dates and end February 2020. An estimated total of 7250 patients prescribed ticagrelor 60 mg are expected to be included.
Discussion
An increased understanding of patterns of ticagrelor 60 mg use and associated clinical outcomes among high‐risk patients with a prior MI is needed. The a priori specified stepwise approach adapted in this observational study is expected to generate useful evidence for clinical decision‐making and treatment optimization.
Although a significant association between renal function and outcomes in patients with acute coronary syndromes (ACS) has been consistently described, little information exists about the magnitude ...of this association in patients at older ages. No study assessed the prognostic role of renal function according to frailty in patients with ACS. The LONGEVO-SCA registry included unselected ACS patients aged ≥80 years. Frailty was asessesed by the FRAIL scale, and baseline creatinine clearance was calculated by the Cockroff-Gault formula. We evaluated the impact of renal function on mortality or readmission at 6-months according to frailty status by the Cox regression method. A total of 473 patients were assessed, with a mean age of 84.2 years. The distribution of patients across estimated glomerular filtration rate (eGFR) subgroups was as follows: (1) <30 ml/min: n = 76 (16.1%); (2) 30 to 44 ml/min: n = 147 (31.1%); (3) 45 to 60 ml/min: n = 136 (28.8%); and (4) >60 ml/min: n = 114 (24.1%). Patients with lower eGFR values were older, had a higher proportion of comorbidities and other geriatric syndromes (p = 0.001) and underwent less often an invasive management during admission (p < 0.001). The incidence of mortality or readmission at 6 months progressively increased across renal function subgroups (p = 0.001). After adjusting for potential confounders, this association became nonsignificant (p = 0.802). The association between eGFR and outcomes was only significant in patients without frailty (p = 0.001). In conclusion, most patients aged ≥80 years with NSTEACS had renal function impairment at admission. The association between renal function and outcomes was different according to frailty status.
Background/Objetctives
Mitral regurgitation (MR)after an acute coronary syndrome is associated with a poor prognosis. However,the prognostic impact of MR in elderly patients with non‐ST‐segment ...elevation myocardialinfarction (NSTEMI) has not been well addressed.
Design
Prospective registry.
Setting and participants
The multicenter LONGEVO‐SCA prospective registry included 532 unselected NSTEMI patients aged ≥80 years.
Measurements
MR was quantified using echocardiography during admission in 497 patients. They were classified in two groups: significant (moderate or severe) or not significant MR (absent or mild). We evaluated the impact of MR status on mortality or readmission at 6 months.
Results
Mean age was 84.3±4.1 years, and 308 (61.9%) were males. A total of 108 patients (21.7%) had significant MR. Compared with those without significant MR, they were older and showed worse baseline clinical status, with higher frailty, disability, and risk of malnutrition. They also had lower systolic blood pressure, higher heart rate, worse Killip class, lower left ventricular ejection fraction, and higher pulmonary pressure on admission, as well as more often new onset atrial fibrillation (all p values = 0.001). Patients with significant MR also had higher in‐hospital mortality (4.6% vs. 1.3%, p = 0.04), longer hospital stay (median 8 5‐12 vs. 6 4‐10 days, p = 0.002), and higher mortality/readmission at 6 months (hazard ratio 1.54, 95% confidence interval 1.09‐2.18, p = 0.015). However, after adjusting for potential confounders, this last association was not significant.
Conclusions
Significant MR is seen in one fifth of octogenarians with NSTEMI. Patients with significant MR have a poor prognosis, mainly determined by their baseline clinical characteristics. J Am Geriatr Soc 67:1641–1648, 2019
Background The clinical significance of conduction disturbances after transcatheter aortic valve implantation has been described; however, little is known about the influence of baseline ECGs in the ...prognosis of these patients. Our aim was to study the influence of baseline ECG parameters, including interatrial block (IAB), in the prognosis of patients treated with transcatheter aortic valve implantation. Methods and Results The BIT (Baseline Interatrial Block and Transcatheter Aortic Valve Implantation) registry included 2527 patients with aortic stenosis treated with transcatheter aortic valve implantation. A centralized analysis of baseline ECGs was performed. Patients were divided into 4 groups: normal P wave duration (<120 ms); partial IAB (P wave duration ≥120 ms, positive in the inferior leads); advanced IAB (P wave duration ≥120 ms, biphasic +/- morphology in the inferior leads); and nonsinus rhythm (atrial fibrillation/flutter and paced rhythm). The mean age of patients was 82.6±9.8 years and 1397 (55.3%) were women. A total of 960 patients (38.0%) had a normal P wave, 582 (23.0%) had partial IAB, 300 (11.9%) had advanced IAB, and 685 (27.1%) presented with nonsinus rhythm. Mean follow-up duration was 465±171 days. Advanced IAB was the only independent predictor of all-cause mortality (hazard ratio HR, 1.48; 95% CI, 1.10-1.98
=0.010) and of the composite end point (death/stroke/new atrial fibrillation) (HR, 1.51; 95% CI, 1.17-1.94
=0.001). Conclusions Baseline ECG characteristics influence the prognosis of patients with aortic stenosis treated with transcatheter aortic valve implantation. Advanced IAB is present in about an eighth of patients and is associated with all-cause death and the composite end point of death, stroke, and new atrial fibrillation during follow-up.
To assess whether 1-year mortality in older patients experiencing a first admission for acute heart failure was related to sex, and to explore differential characteristics according to sex.
We ...reviewed the medical records of 1132 patients aged >70 years of age admitted within a 3-year period because of a first episode of acute heart failure. We analyzed sex differences. Mortality was assessed using multivariate Cox analysis.
There were 648 (57.2%) women (mean age 82.1 years) and 484 men (mean age 80.1 years). There were some differences in risk factors: women more often had hypertension, and less frequently had coronary heart disease and comorbidities (women more often had dementia, and men more often had chronic obstructive pulmonary disease, chronic kidney disease and stroke). Women were treated more frequently with spironolactone. The 1-year all-cause mortality rate was 30.2% (30.7% women and 29.5% men). Multivariate Cox analysis identified an association between reduced heart failure (hazard ratio HR 0.35, 95% confidence interval 95% CI 0.21-0.59), hemoglobin <10 g/dL (HR 1.99, 95% CI 1.16-3.40), systolic blood pressure (HR 0.98, 95% CI 0.97-0.99), previous diagnosis of dementia (HR 2.07, 95% CI 1.12-3.85), number of chronic therapies (HR 1.12, 95% CI 1.05-1.19) and 1-year mortality in women. In men, an association with mortality was found for low systolic blood pressure (HR 0.97, 95% CI 0.97-0.98) and higher potassium values (HR 1.42, 95% CI 1.01-2.00).
Among older patients hospitalized for the first acute heart failure episode, there is a slightly higher predominance of women. There are sex differences in risk factors and comorbidities. Although the mortality rate is similar, the factors associated with it according to sex are different. Geriatr Gerontol Int 2019; 19: 184-188.
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