Donatella Del Sindaco

Two-year outcome of a prospective, controlled study of a disease management programme for elderly patients with heart failure.

Objective Elderly heart failure patients are at high risk of events. Available studies and systematic reviews suggest that elderly patients benefit from disease management programmes (DMPs). However, important questions remain open, including the optimal follow-up intensity and duration and whether such interventions are cost-effective during long-term follow-up and in different healthcare systems. The aim of this study was to determine the long-term efficacy of a hybrid DMP in consecutive older outpatients. Methods Intervention consisted in combined hospital-based (cardiologists and nurse-coordinators from two heart failure clinics) and home-based (patients general practitioner visits) care. The components of the DMP were the following: discharge planning, education, therapy optimisation, improved communication, early attention to signs and symptoms. Intensive follow-up was based on scheduled hospital visits (starting within 14 days of discharge), nurses phone call and home general practitioner visits. Results A group of 173 patients aged ≥70 years (mean age 77 ± 6 years, 48% women) was randomly assigned to DMP (n = 86) or usual care (n = 87). At 2-year follow-up, a 36% reduction in all-cause death and heart failure hospital admissions was observed in DMP vs. usual care. All-cause and heart failure admissions as well as the length of hospital stay were also reduced. DMP patients reported, compared to baseline, significant improvements in functional status, quality of life and β-blocker prescription rate. The intervention was cost-effective with a mean saving of &U20AC; 982.04 per patient enrolled. Conclusions A hybrid DMP for elderly heart failure patients improves outcomes and is cost-effective over a long-term follow-up.

Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure.

Mitral regurgitation (MR) has been demonstrated to be a powerful predictor of adverse outcome in middle‐aged patients with chronic heart failure (CHF). In this study, we sought to define the prognostic impact of functional mitral regurgitation in a population of elderly patients with systolic CHF.

Programme to improve the use of beta‐blockers for heart failure in the elderly and in those with severe symptoms: Results of the BRING‐UP 2 Study

Beta‐blockers are underused in HF patients, thus strategies to implement their use are needed.

Prevalence, predictors and prognostic value of acute impairment in renal function during intensive unloading therapy in a community population hospitalized for decompensated heart failure.

Background and Methods Chronic heart failure (CHF) is often associated with impaired renal function. Diuretics and vasodilators may lead to aggravated renal dysfunction (ARD), particularly among patients with decompensated CHF. Although the prevalence of ARD has been evaluated in patients awaiting heart transplantation, little is known about ARD in the community sample of CHF patients. Accordingly, we prospectively assessed the prevalence, predictors and prognostic value of ARD in 79 consecutive patients admitted to our general community hospital for decompensated CHF undergoing intensive unloading therapy (intravenous nitroprusside and furosemide). ARD was defined as a ≥ 25% increase in serum creatinine between admission and maximal value of ≥ 2 mg/dl. Results Sixteen patients (20%) developed ARD with a mean increase in serum creatinine of 31% (from 1.74 ± 0.6 to 2.27 ± 0.9 mg/dl). ARD persisted at 8-day evaluation in seven of 16 subjects (44%) whereas it was reversible in nine (56%). Lower creatinine clearance at baseline [exp β = 0.93, 95% confidence interval (CI) = 0.87–0.99] and the higher dose of furosemide (exp β = 1.02, 95% CI = 1.01–1.03) emerged as independent predictors of ARD. During a follow-up of 11 ± 8 months, death and hospitalization for worsening CHF occurred more frequently in ARD than non-ARD patients (69% versus 17%, P = 0.0001; 69% versus 29%, P = 0.003, respectively). Persistent ARD was a powerful independent predictor of long-term adverse outcome (odds ratio = 11.1; 95% CI = 1.12–36.1; P = 0.04). Conclusions Intensive unloading therapy is associated with the development of ARD in one-fifth of the community population hospitalized for decompensated CHF. The magnitude of this phenomenon is not greater than that observed in younger selected populations with advanced CHF, and depends on baseline renal function and increased diuretic dosage. ARD persisting after 8 days from starting intensive unloading is a powerful predictor of subsequent worsened clinical outcome.

Incremental Value of Gait Speed in Predicting Prognosis of Older Adults With Heart Failure: Insights From the IMAGE-HF Study.

OBJECTIVES The aim of this study was to assess the relationship between gait speed and the risk for death and/or hospital admission in older patients with heart failure (HF). BACKGROUND Gait speed is a reliable single marker of frailty in older people and can predict falls, disability, hospital admissions, and mortality. METHODS In total, 331 community-living patients ≥70 years of age (mean age 78 ± 6 years, 43% women, mean ejection fraction 35 ± 11%, mean New York Heart Association functional class 2.7 ± 0.6) in stable condition and receiving optimized therapy for chronic HF were prospectively enrolled and followed for 1 year. Gait speed was measured at the usual pace over 4 m, and cutoffs were defined by tertiles: ≤0.65, 0.66 to 0.99, and ≥1.0 m/s. RESULTS There was a significant association between gait speed tertiles and 1-year mortality: 38.3%, 21.9%, and 9.1% (p < 0.001), respectively. On multivariate analysis, gait speed was associated with a lower risk for all-cause death (hazard ratio: 0.62; 95% confidence interval: 0.43 to 0.88) independently of age, ejection fraction <20%, systolic blood pressure, anemia, and absence of beta-blocker therapy. Gait speed was also associated with a lower risk for hospitalization for HF and all-cause hospitalization. When gait speed was added to the multiparametric Cardiac and Comorbid Conditions Heart Failure risk score, it improved the accuracy of risk stratification for all-cause death (net reclassification improvement 0.49; 95% confidence interval: 0.26 to 0.73, p < 0.001) and HF admissions (net reclassification improvement 0.37; 95% confidence interval: 0.15 to 0.58; p < 0.001). CONCLUSIONS Gait speed is independently associated with death, hospitalization for HF, and all-cause hospitalization and improves risk stratification in older patients with HF evaluated using the Cardiac and Comorbid Conditions Heart Failure score. Assessment of frailty using gait speed is simple and should be part of the clinical evaluation process.

Pharmacological left ventricular reverse remodeling in elderly patients receiving optimal therapy for chronic heart failure.

In recent years, reversal of established left ventricular (LV) dilatation has been increasingly recognized in middle‐aged patients with dilated cardiomyopathy receiving angiotensin‐converting enzyme (ACE) inhibitors and/or beta‐blockers. We performed this prospective study to evaluate whether optimized therapy for heart failure also induces LV reverse remodeling in older patients.

Translation and validation of the Italian version of the European Heart Failure Self-care Behaviour Scale.

Background Heart failure (HF) patients can benefit from management programmes that include education, discharge planning and structured follow-up. Therefore, it is important to evaluate the improvement of self-care as a result of these interventions. The European Heart Failure Self-care Behaviour Scale (EHFScBS) was developed as a reliable and valid instrument for self-care evaluation. Objectives The aims were to translate and validate the Italian version of the EHFScBS and to evaluate factors related to self-care. Methods The translation and validation were performed as follows: translation and back-translation; evaluation by four bilingual cardiologists; administration to healthy individuals of different ages and education to test language comprehension; final correction by cardiologists experienced in cognitive assessment; and administration in HF patients to test validity and internal consistency. Results A sample of 93 HF patients (mean age 77 ± 6 years, 53% women) was considered for the validation procedure. Fifty-four (58%) patients were already followed in the HF clinic (HFC), with previous HF education, and 39 (42%) were evaluated at baseline. The reliability analysis showed a Cronbachs alpha of 0.82. At multivariate analysis, age, not already followed in HFC and female sex were associated to worse self-care behaviour. When HFC patients were considered separately, an association between self-care and cognitive dysfunction was observed. Conclusion The EHFScBS appears to be a valid and reliable instrument in the Italian version also. Self-care behaviour appears to depend on age and sex and a previous HF education. Mild to moderately impaired cognitive function seems to influence self-care in patients who have already received HF education.

Chronic renal dysfunction and anaemia are associated with cognitive impairment in older patients with heart failure.

Aims Cognitive impairment, anaemia and chronic kidney disease (CKD) are associated with mortality and disability in chronic heart failure patients. We hypothesized that anaemia and CKD are independent predictors of cognitive impairment in older patients with heart failure. Methods One hundred and ninety community-living elderly patients aged at least 70 years, treated with optimized therapy for heart failure in stable clinical conditions, were prospectively studied. They underwent clinical and multidimensional assessment. Cognitive status was assessed by the Mini Mental State Examination. Cognitive impairment was defined as the Mini Mental State Examination score adjusted by age and educational level below 24. CKD was defined as the Cockcroft–Gault glomerular filtration rate below 60 ml/min and anaemia as haemoglobin below 12 g/dl. Results Cognitive impairment was diagnosed in 38.9% of patients, CKD in 85.7% and anaemia in 42.6%. Age, female sex, BMI, education less than 5 years, depressive symptoms, anaemia, CKD, disability and worse quality of life were significantly associated with cognitive impairment. Cognitive impairment involved primarily global cognitive deficit, memory, mental speed, attention, calculation and language. A significant relationship between haemoglobin levels and cognitive impairment was found, with the range of 15–16.5 g/dl having the lower prevalence of cognitive impairment (19.4%). At multivariate analysis, advanced age, low education level, anaemia and CKD were independently associated with cognitive impairment. Cox analysis showed that cognitive impairment was an independent predictor of hospitalization for worsening heart failure alone and combined with all-cause death. Conclusion Cognitive impairment is common in elderly heart failure patients and is independently associated with anaemia and renal dysfunction. Further studies are needed to assess whether optimal treatment of anaemia and CKD may prevent the development of cognitive impairment in heart failure patients.

The evolving care of the elderly with heart failure: from the 'high-tech' to the 'high-touch' approach.

It is well known that congestive heart failure (HF) shows an age-related increasing prevalence [1–3]. In the community and in unselected hospitalized patients, the mean age is above 70 years and, despite recent advances in pharmacotherapy, HF represents a major cause of death and hospitalization for elderly people [4–6]. Thus, in developed countries HF appears to be principally a cardiogeriatric syndrome and it has become a growing public health problem [7]. Because elderly persons represent an increasing proportion of our population and require a major burden of the acute and chronic medical care delivered in our country, this epidemiological trend will raise implications for the evolution of care in the cardiology clinical practice.

Safety and efficacy of carvedilol in very elderly diabetic patients with heart failure.

Objective β-Blockers are often cautiously prescribed to older heart failure diabetics because of the paucity of published data and their perceived unfavourable effects on glucose metabolism, in spite of the evidence of their effectiveness and safety in middle-aged diabetic patients. The aim of this study was to compare the safety, tolerability and efficacy of long-term administration of carvedilol in a group of elderly patients with chronic heart failure, with and without concomitant diabetes. Methods Two hundred and fifty-two patients aged ≥70 years with heart failure and left ventricular ejection fraction ≤40% were followed in specialised heart failure clinics. Diabetes was present in 29.7%. Carvedilol was associated with conventional optimised treatment in 64% of diabetics and 65% of non-diabetics (P = NS). Results At baseline, diabetics presented with a longer duration of symptoms, higher Charlson comorbidity index, more frequent renal dysfunction and smaller left ventricular volumes than non-diabetics. New York Heart Association functional class and ejection fraction were similar in the two groups. At 1-year follow-up, tolerability (93.7 vs. 92.2%) and mean daily dose (24 ± 17 vs. 23 ± 14 mg/day) of carvedilol were similar in diabetics and non-diabetics. No worsening of fasting glucose, glycosylated haemoglobin and creatinine levels as well as the incidence of deaths and hospitalisations was observed in diabetics treated with carvedilol. Similar improvements in New York Heart Association class and mitral regurgitation severity were observed in diabetic and non-diabetic patients taking carvedilol. Ejection fraction showed a significant improvement, more pronounced in non-diabetics than in diabetics (+10 vs. +7 points; improvement of at least 10 points: 15 vs. 36%, P = 0.03). Conclusions Similarly to younger ones, also in older patients, diabetes does not negatively influence the safety, tolerability and efficacy of carvedilol. However, diabetes remains a strong prognostic factor limiting the reversibility of left ventricular systolic dysfunction and the effect of treatment on subsequent outcome.