Małgorzata Fedyk-Łukasik

Age-related gap in the management of heart failure patients. The National Project of Prevention and Treatment of Cardiovascular Diseases--POLKARD.

BACKGROUND Heart failure (HF) is strongly associated with aging. It affects 10-12% of patients older than 80 years, with five-year overall mortality after first hospitalization for HF being as high as 81%. The main objective of this study was to assess the diagnosis and treatment of HF in hospitalized octogenarians compared to younger subjects. METHODS The survey was performed among a random sample of all Polish hospitals and in all academic centers, as part of the National Project of Prevention and Treatment of Cardiovascular Diseases in Poland -- POLKARD. Using a questionnaire-based method, hospital documentation of the last five patients with diagnosed HF was reviewed. Eventually, in 2005, HF patients of 259 internal medicine and cardiology hospital wards, including 260 very elderly patients, were selected to the study. RESULTS The mean age of the 1,289 studied patients was 69.8 ± 11.4 years (age range: 26-96 years), 57.8% were males, and 80.1% were in NYHA class III or IV. Echocardiography was performed in 41.7% of octogenarians in comparison with 58.7% of those categorized as younger elderly, i.e. 60-79 years, and 75.2% of patients aged below 60 years (p < 0.0001). The most prescribed drugs in very elderly patients were diuretics (86.9%, p = 0.005) and ACE-I (81.9%), while only 61.5% used beta-blockers (p < 0.0001). In stepwise logistic regression analysis, hypertension, history of myocardial infarction and admission to cardiology ward were positively associated with beta-blocker and ACE-I (or ARB) therapy, while older age and pulmonary diseases (COPD or asthma) were related to their non-prescription. CONCLUSIONS Despite significant progress in HF management, there is still a need for an improvement in the medical care of very elderly patients. The major obstacles seem to be advanced age and the presence of coexistent pulmonary diseases. Therefore, the participation of geriatricians and pulmonologists should be recommended in caring for octogenarians with HF.

Heart failure and atrial fibrillation — Does practice meet the anticoagulation guidelines?

Angiographyof IndividualsUndergoing Invasive CoronaryAngiography) trial. J AmColl Cardiol 2008;52:1724–32. [4] Meijboom WB, Meijs MFL, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 2008;52:2135–44. [5] Chow BJ, FreemanMR, Bowen JM, et al. Ontario multidetector computed tomographic coronary angiography study: field evaluation of diagnostic accuracy. Arch Intern Med 2011;171:1021–9.

Chronic heart failure management in primary healthcare in Poland: Results of a nationwide cross-sectional study

Abstract Background: Organizational and educational activities in primary care in Poland have been introduced to improve the chronic heart failure (CHF) management. Objectives: To assess the use of diagnostic procedures, pharmacotherapy and referrals of CHF in primary care in Poland. Methods: The cross-sectional survey was conducted in 2013, involving 390 primary care centres randomly selected from a national database. Trained nurses contacted primary care physicians who retrospectively filled out the study questionnaires on the previous year’s CHF management in the last five patients who had recently visited their office. The data on diagnostic and treatment procedures were collected. Results: The mean age ± SD of the 2006 patients was 72 ± 11 years, 45% were female, and 56% had left ventricular ejection fraction <50%. The percentage of the CHF patients diagnosed based on echocardiography was 67% and significantly increased during the last decade. Echocardiography was still less frequently performed in older patients (≥80 years) than in the younger ones (respectively 50% versus 72%, Ρ <0.001) and in women than in men (62% versus 71%, P <0.001). The percentage of the patients treated with β-blocker alone was 88%, but those with a combination of angiotensin inhibition 71%. The decade before, these percentages were 68% and 57%, respectively. Moreover, an age-related gap observed in the use of the above-mentioned therapy has disappeared. Conclusion: The use of echocardiography in CHF diagnostics has significantly improved in primary care in Poland but a noticeable inequality in the geriatric patients and women remains. Most CHF patients received drug classes in accordance with guidelines.

Should the malnutrition risk be assessed in older patients with an elevated aminoterminal pro-brain natriuretic peptide?

Introduction An inverse relationship between natriuretic peptides (N‑terminal fragment of the prohormone brain natriuretic peptide [NT‑proBNP]) and body mass index (BMI) among healthy people and patients with chronic heart failure (CHF) was observed. Objectives The aim of the study was to assess the relationship between nutritional status and NT‑proBNP concentrations in older persons. Patients and methods NT‑proBNP concentrations, medical histories, and malnutrition risk using Mini Nutritional Assessment were evaluated. Body composition was measured with dual energy X‑ray absorptiometry. The relationship of nutritional status with NT‑proBNP concentrations (in tertiles) was assessed. Results The mean (SD) age of 106 participants was 72.16 (9.38) years. Heart failure was diagnosed in 72.6% of patients. The risk of malnutrition was recognized in 28.3%, and the percentage of patients at risk increased in subsequent NT‑proBNP tertiles: from 16.7% in the first tertile to 48.6% in the third tertile (P = 0.005). The risk of malnutrition was associated with an increase in NT‑proBNP concentrations per tertile (odds ratio [OR], 2.30; 95% CI, 1.30-4.07; P = 0.004). Based on a multivariable logistic model, the NT‑proBNP concentration in the third tertile was associated with an over 9‑fold higher risk of malnutrition (OR, 9.80; 95% CI, 2.00-48.17; P = 0.005) as compared with the lowest concentration. Among patients with CHF, the relationship between NT‑proBNP and nutritional status was even stronger. Conclusions High NT‑proBNP levels contribute to increased risk of malnutrition in older patients with heart failure. In patients with elevated NT‑proBNP levels, the risk of malnutrition should be assessed.

Is the Clock Drawing Test useful in the screening assessment of aged patients with chronic heart failure

PURPOSE Cognitive impairment is one of the most common geriatric deficits in old patients with heart failure (HF), but there has been a lack of study on the utility of the Clock Drawing Test (CDT) when used with this group of patients. The aim of the study was to assess the usefulness of the CDT in the geriatric assessment of aged outpatients with chronic HF. PATIENTS AND METHODS A cross-sectional analysis of the results of the comprehensive geriatric assessment (CGA), including the CDT, of 92 aged outpatients with heart failure was conducted. RESULTS We found a high prevalence of five examined geriatric problems. The majority of the patients presented signs of cognitive deterioration of different patterns and severity on the Clock Drawing Test. All the CDT scoring systems correlated significantly with the Mini-Mental Test Examination results. CONCLUSIONS It seems reasonable to perform the routine CGA with the CDT examination in all aged heart failure patients.

Physical performance and inflammatory markers in relation to nutritional status in older subjects

Introduction.– The aim of the study was to assess the correlates of poor nutritional status of elderly subjects. Methods.– Comprehensive geriatric assessment (Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS), Mini Nutritional Assessment (MNA), Katz’s Index, Lawton scale) was performed in 89 subjects aged 60 years and older. Physical performance was assessed using 6-Minute Walk Test (6MWT), walking speed (V) and handgrip strength. Markers of inflammation: hsCRP, TNFalfa-soluble receptor2 (STNFR2), IL-6, IL-8, IL-18, pentraxin (PTX) and osteoprotegerin (OPG) were measured. Using dual energy Xray absorptiometry (DXA) lean body mass total (LBM) and appendicular (aLM)weremeasured, aLM indexwas calculated: aLMIx= aLM(kg)/height(m2). Results.– Out of 89 patients (mean age 72.8±7,6) MNA<24 had 30.3%. Subjects in good nutritional status and at risk of malnutrition did not differ in age, but had lower MMSE (P=0.025), handgrip strength (14.0±7.9 vs 22.79±10.97kg, P=0.0019), lower hemoglobin (12.82±1.5 vs 14.07±1.5 g/dl, P=0.0006), and albumin level (41.82±3.6 vs 43.48±2.7, P=0.026). Patients with lower MNA had lower LBM (41.51±7.71 vs 48.67±7.24kg, P=0.001), aLM (16.85±3.5 vs 20.68±3.4 kg; P=0.0003) and aLMIx (6.64±0.99vs7.52±0.86kg/m2, P=0.001), and performed worse physical tests: had shorter 6-MWT distance (308.89±7682 vs 362.55±107.5m; P=0.03), lowerV (0.761±0.23 vs 0.935±0.3m/s; P=0.03). MNA<24 was associated with higher OPG (9.851±3.45 vs 8.094±2.5, P=0.013), and STNFR2 (P=0.039). MNA correlated positively with 6MWT (r=0.3, P=0.04), V (r=0.44, P=0.002), handgrip strength (r=0.42, P=0.003), LBM (r=0.29, P=0.04), aLM (r=0.32,P=0.03), aLMIx (r=0.20, P=0.047) and negatively with age (r=–0.33,P=0.02). In multiple regression analysis MNAwas influenced by MMSE positively and negatively by hsCRP, IL-8 and number of diseases. Conclusions.– Risk of malnutrition in elderly was associated with worse physical performance, cognitive impairment, comorbidity, higher osteoprotegerin and inflammatory markers.