Linda G. Jones

Update on diastolic heart failure or heart failure with preserved ejection fraction in the older adults

Nearly half of all heart failure (HF) patients have diastolic HF (DHF) or clinical HF with normal or near-normal left ventricular ejection fraction (LVEF). Although the terminology has not been clearly defined, it is increasingly being referred to as HF with preserved ejection fraction (HFPEF). The prevalence of HFPEF increases with age, especially among older women. Identifying HFPEF is important because the etiology, pathogenesis, prognosis, and optimal management may differ from that for systolic HF (SHF) or HF with reduced ejection fraction. The clinical presentation of HF is similar for both SHF and HFPEF. As in SHF, HFPEF is a clinical diagnosis. Once a clinical diagnosis of HF has been made, the presence of HFPEF can be established by confirming a normal or near-normal LVEF, often by an echocardiogram. HFPEF is often associated with a history of hypertension, concentric left ventricular hypertrophy, vascular stiffness, and left ventricular diastolic dysfunction. As in SHF, HFPEF is also associated with poor outcomes. While therapies with angiotensin-converting enzyme inhibitors and beta-blockers improve outcomes in SHF, there is currently no such evidence of their benefits in older HFPEF patients. In this review recent advances in the diagnosis and management of HFPEF in older adults are discussed.

The meaning of hypokalemia in heart failure

Maintenance of normal potassium (K(+)) homeostasis has become an increasingly important limiting factor in the therapy of heart failure (HF). With the application of loop diuretics and digoxin, hypokalemia has become a frequent and feared side effect of treatment. Low serum K(+) in HF may be also a marker of increased neurohormonal activity and disease progression. To gain the maximum benefit from treatment, we need to individualize drug use and carefully monitor electrolytes. Symptomatic HF patients (New York Heart Association class III-IV) should be prescribed the lowest dose of diuretic necessary to maintain euvolemia. Mild hypokalemia may be corrected by the use of aldosterone receptor antagonists such as spironolactone or eplerenone. However, a more severe hypokalemia should preferably be corrected using K(+) supplement. Serum K levels should be frequently checked and maintained between 4.0 and 5.5 mEq/l (mmol/l).

DEFEAT Heart Failure: Assessment and Management of Heart Failure in Nursing Homes Made Easy

Heart failure (HF) in older adults presents challenges that are different in many ways than those for younger adults. Diagnosis of HF in older adults can be delayed due to attributing early symptoms to normal changes of aging or, in the setting of a normal ejection fraction, failing to appreciate diastolic heart failure. Moreover, treatment of HF in the elderly is often complicated by comorbidities and polypharmacy. The long-term care setting can present even more challenges, yet can be made easy by following a simple mnemonic DEFEAT-HF. After making a clinical Diagnosis and determining the Etiology, Fluid volume must be assessed to achieve euvolemia, and Ejection frAction must be determined to guide Therapy.

Effect of Warfarin on Outcomes in Septuagenarian Patients With Atrial Fibrillation

Anticoagulation has been shown to decrease ischemic stroke in atrial fibrillation (AF). However, concerns remain regarding their safety and efficacy in those ≥70 years of age who constitute most patients with AF. Of the 4,060 patients (mean age 65 years, range 49 to 80) in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 2,248 (55% of 4,060) were 70 to 80 years of age, 1,901 of whom were receiving warfarin. Propensity score for warfarin use, estimated for each of the 2,248 patients, was used to match 227 of the 347 patients not on warfarin (in 1:1, 1:2, or 1:3 sets) to 616 patients on warfarin who were balanced in 45 baseline characteristics. All-cause mortality occurred in 18% and 33% of matched patients receiving and not receiving warfarin, respectively, during up to 6 years (mean 3.4) of follow-up (hazard ratio [HR] when warfarin use was compared to its nonuse 0.58, 95% confidence interval [CI] 0.43 to 0.77, p <0.001). All-cause hospitalization occurred in 64% and 67% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.93, 95% CI 0.77 to 1.12, p = 0.423). Ischemic stroke occurred in 4% and 8% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.57, 95% CI 0.31 to 1.04, p = 0.068). Major bleeding occurred in 7% and 10% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.73, 95% CI 0.44 to 1.22, p = 0.229). In conclusion, warfarin use was associated with decreased mortality in septuagenarian patients with AF but had no association with hospitalization or major bleeding.

Association between smoking and outcomes in older adults with atrial fibrillation

Tobacco smoking is a risk factor for atrial fibrillation (AF), but little is known about the impact of smoking in patients with AF. Of the 4060 patients with recurrent AF in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 496 (12%) reported having smoked during the past two years. Propensity scores for smoking were estimated for each of the 4060 patients using a multivariable logistic regression model and were used to assemble a matched cohort of 487 pairs of smokers and nonsmokers, who were balanced on 46 baseline characteristics. Cox and logistic regression models were used to estimate the associations of smoking with all-cause mortality and all-cause hospitalization, respectively, during over 5 years of follow-up. Matched participants had a mean age of 70 ± 9 years (± S.D.), 39% were women, and 11% were non-white. All-cause mortality occurred in 21% and 16% of matched smokers and nonsmokers, respectively (when smokers were compared with nonsmokers, hazard ratio=HR=1.35; 95% confidence interval=95%CI=1.01-1.81; p=0.046). Unadjusted, multivariable-adjusted and propensity-adjusted HR (95% CI) for all-cause mortality associated with smoking in the pre-match cohort were: 1.40 (1.13-1.72; p=0.002), 1.45 (1.16-1.81; p=0.001), and 1.39 (1.12-1.74; p=0.003), respectively. Smoking had no association with all-cause hospitalization (when smokers were compared with nonsmokers, odds ratio=OR=1.21; 95%CI=0.94-1.57, p=0.146). Among patients with AF, a recent history of smoking was associated with an increased risk of all-cause mortality, but had no association with all-cause hospitalization.

Understanding the reasons for the underuse of pneumococcal vaccination by community-dwelling older African Americans.

OBJECTIVES: To understand the potential roles of various patient and provider factors in the underuse of pneumococcal vaccination in Medicare‐eligible older African Americans.

In-Hospital Cardiology Consultation and Evidence-Based Care for Nursing Home Residents With Heart Failure

OBJECTIVES To determine the association between cardiology consultation and evidence-based care for nursing home (NH) residents with heart failure (HF). PARTICIPANTS Hospitalized NH residents (n = 646) discharged from 106 Alabama hospitals with a primary discharge diagnosis of HF during 1998-2001. DESIGN Observational. MEASUREMENTS OF EVIDENCE-BASED CARE: Preadmission estimation of left ventricular ejection fraction (LVEF) for patients with known HF (n = 494), in-hospital LVEF estimation for HF patients without known LVEF (n = 452), and discharge prescriptions of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs or ARBs) to systolic HF (LVEF <45%) patients discharged alive who were eligible to receive those drugs (n = 83). Eligibility for ACEIs or ARBs was defined as lack of prior allergy or adverse effect, serum creatinine lower than 2.5 mg/dL, serum potassium lower than 5.5 mEq/L, and systolic blood pressure higher than 100 mm Hg. RESULTS Preadmission LVEF was estimated in 38% and 12% of patients receiving and not receiving cardiology consultation, respectively (adjusted odds ratio [AOR], 3.49; 95% CI, 2.16-5.66; P < .001). In-hospital LVEF was estimated in 71% and 28% of patients receiving and not receiving cardiology consultation, respectively (AOR, 6.01; 95% CI, 3.69-9.79; P < .001). ACEIs or ARBs were prescribed to 62% and 82% of patients receiving and not receiving cardiology consultation, respectively (AOR, 0.24; 95% CI, 0.07-0.81; P = .022). CONCLUSION In-hospital cardiology consultation was associated with significantly higher odds of LVEF estimation among NH residents with HF; however, it did not translate into higher odds of discharge prescriptions for ACEIs or ARBs to NH residents with systolic HF who were eligible for the receipt of these drugs.

Characteristics and Outcomes of Patients With Advanced Chronic Systolic Heart Failure Receiving Care at the Veterans Affairs Versus Other Hospitals Insights From the Beta-blocker Evaluation of Survival Trial (BEST)

Background—Characteristics and outcomes of patients with heart failure and reduced ejection fraction receiving care at Veterans Affairs (VA) versus non-VA hospitals have not been previously reported. Methods and Results—In the randomized controlled Beta-blocker Evaluation of Survival Trial (BEST; 1995-1999), of the 2707 (bucindolol=1353; placebo=1354) patients with heart failure and left ventricular ejection fraction ⩽35%, 918 received care at VA hospitals, of which 98% (n=898) were male. Of the 1789 receiving care at non-VA hospitals, 68% (n=1216) were male. Our analyses were restricted to these 2114 male patients. VA patients were older with higher symptom and comorbidity burdens. There was no significant between-group difference in unadjusted primary end point of 2-year all-cause mortality (35% VA versus 32% non-VA; hazard ratio associated with VA hospitals, 1.09; 95% confidence interval, 0.94–1.26), which remained unchanged after adjustment for age and race (hazard ratio, 1.00; 95% confidence interval, 0.86–1.16) or multivariable adjustment, including cardiovascular morbidities (hazard ratio, 0.94; 95% confidence interval, 0.80–1.10). There was no between-group difference in cause-specific mortalities or hospitalizations. Chronic kidney disease, pulmonary edema, left ventricular ejection fraction <20%, and peripheral arterial disease were significant predictors of mortality for both groups. African America race, New York Heart Association class IV symptoms, atrial fibrillation, and right ventricular ejection fraction <20% were associated with higher mortality among non-VA hospital patients only; however, these differences from VA patients were not significant. Conclusions—Patients with heart failure and reduced ejection fraction receiving care at VA hospitals were older and sicker; yet their risk of mortality and hospitalization was similar to younger and healthier patients receiving care at non-VA hospitals. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000560.

Intrinsic Association of Widowhood With Mortality in Community-Dwelling Older Women and Men: Findings From a Prospective Propensity-Matched Population Study

OBJECTIVES Widowhood is associated with increased mortality. However, to what extent this association is independent of other risk factors remains unclear. In the current study, we used propensity score matching to design a study to examine the independent association of widowhood with outcomes in a balanced cohort of older adults in the United States. METHODS We used public-use copies of the Cardiovascular Health Study data obtained from the National Heart, Lung, and Blood Institute. Of the 5,795 community-dwelling older men and women aged 65 years and older in Cardiovascular Health Study, 3,820 were married and 1,436 were widows or widowers. Propensity scores for widowhood, estimated for each of the 5,256 participants, were used to assemble a cohort of 819 pairs of widowed and married participants who were balanced on 74 baseline characteristics. The 1,638 matched participants had a mean (± standard deviation) age of 75 (± 6) years, 78% were women, and 16% African American. RESULTS All-cause mortality occurred in 46% (374/819) and 51% (415/819) of matched married and widowed participants, respectively, during more than 11 years of median follow-up (hazard ratio associated with widowhood, 1.18; 95% confidence interval, 1.03-1.36; p = .018). Hazard ratios (95% confidence intervals) for cardiovascular and noncardiovascular mortalities were 1.07 (0.87-1.32; p = .517) and 1.28 (1.06-1.55; p = .011), respectively. Widowhood had no independent association with all-cause or heart failure hospitalization or incident cardiovascular events. CONCLUSIONS Among community-dwelling older adults, widowhood was associated with increased mortality, which was independent of confounding by baseline characteristics and largely driven by an increased noncardiovascular mortality. Widowhood had no independent association with hospitalizations or incident cardiovascular events.

Characteristics and Outcomes of Patients With Advanced Chronic Systolic Heart Failure Receiving Care at the Veterans Affairs Versus Other HospitalsCLINICAL PERSPECTIVE

Background—Characteristics and outcomes of patients with heart failure and reduced ejection fraction receiving care at Veterans Affairs (VA) versus non-VA hospitals have not been previously reported. Methods and Results—In the randomized controlled Beta-blocker Evaluation of Survival Trial (BEST; 1995-1999), of the 2707 (bucindolol=1353; placebo=1354) patients with heart failure and left ventricular ejection fraction ⩽35%, 918 received care at VA hospitals, of which 98% (n=898) were male. Of the 1789 receiving care at non-VA hospitals, 68% (n=1216) were male. Our analyses were restricted to these 2114 male patients. VA patients were older with higher symptom and comorbidity burdens. There was no significant between-group difference in unadjusted primary end point of 2-year all-cause mortality (35% VA versus 32% non-VA; hazard ratio associated with VA hospitals, 1.09; 95% confidence interval, 0.94–1.26), which remained unchanged after adjustment for age and race (hazard ratio, 1.00; 95% confidence interval, 0.86–1.16) or multivariable adjustment, including cardiovascular morbidities (hazard ratio, 0.94; 95% confidence interval, 0.80–1.10). There was no between-group difference in cause-specific mortalities or hospitalizations. Chronic kidney disease, pulmonary edema, left ventricular ejection fraction <20%, and peripheral arterial disease were significant predictors of mortality for both groups. African America race, New York Heart Association class IV symptoms, atrial fibrillation, and right ventricular ejection fraction <20% were associated with higher mortality among non-VA hospital patients only; however, these differences from VA patients were not significant. Conclusions—Patients with heart failure and reduced ejection fraction receiving care at VA hospitals were older and sicker; yet their risk of mortality and hospitalization was similar to younger and healthier patients receiving care at non-VA hospitals. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000560.