María Teresa Vidán

Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006.

CONTEXT Whether decreases in the length of stay during the past decade for patients with heart failure (HF) may be associated with changes in outcomes is unknown. OBJECTIVE To describe the temporal changes in length of stay, discharge disposition, and short-term outcomes among older patients hospitalized for HF. DESIGN, SETTING, AND PARTICIPANTS An observational study of 6,955,461 Medicare fee-for-service hospitalizations for HF between 1993 and 2006, with a 30-day follow-up. MAIN OUTCOME MEASURES Length of hospital stay, in-patient and 30-day mortality, and 30-day readmission rates. RESULTS Between 1993 and 2006, mean length of stay decreased from 8.81 days (95% confidence interval [CI], 8.79-8.83 days) to 6.33 days (95% CI, 6.32-6.34 days). In-hospital mortality decreased from 8.5% (95% CI, 8.4%-8.6%) in 1993 to 4.3% (95% CI, 4.2%-4.4%) in 2006, whereas 30-day mortality decreased from 12.8% (95% CI, 12.8%-12.9%) to 10.7% (95% CI, 10.7%-10.8%). Discharges to home or under home care service decreased from 74.0% to 66.9% and discharges to skilled nursing facilities increased from 13.0% to 19.9%. Thirty-day readmission rates increased from 17.2% (95% CI, 17.1%-17.3%) to 20.1% (95% CI, 20.0%-20.2%; all P < .001). Consistent with the unadjusted analyses, the 2005-2006 risk-adjusted 30-day mortality risk ratio was 0.92 (95% CI, 0.91-0.93) compared with 1993-1994, and the 30-day readmission risk ratio was 1.11 (95% CI, 1.10-1.11). CONCLUSION For patients admitted with HF during the past 14 years, reductions in length of stay and in-hospital mortality, less marked reductions in 30-day mortality, and changes in discharge disposition accompanied by increases in 30-day readmission rates were observed.

An Intervention Integrated into Daily Clinical Practice Reduces the Incidence of Delirium During Hospitalization in Elderly Patients

OBJECTIVES: To analyze the effectiveness of a multicomponent intervention integrated into daily practice for the prevention of in‐hospital delirium in elderly patients.

Prevalence of geriatric syndromes and impact on clinical and functional outcomes in older patients with acute cardiac diseases

Objective To assess the prevalence of major geriatric syndromes (MGSs)―frailty, cognitive impairment, severe dependence and depression―and their influence on outcomes in unselected patients with acute cardiac diseases. Design Observational prospective study with 12-month clinical and functional follow-up. Setting Clinical cardiology unit of a university hospital in Madrid, Spain. Patients Consecutive patients ≥75 years old urgently admitted to the cardiology unit. Intervention Systematic comprehensive geriatric assessment. Main outcome measures 12-month rates of mortality, readmission, functional decline and need for new social help. Results Among the 211 patients studied, 127 (60.2%) presented at least one MGS on admission: 86 frailty (40.8%), 67 cognitive impairment (31.8%), 31 severe dependency (14.7%) and 9 depression (4.3%). Patients with MGSs were slightly older (82±5 vs 81±4 years, p=0.02) but did not show greater disease severity or comorbidity. The presence of MGSs was associated with a higher incidence of functional decline during hospitalisation (35.7% vs 8.6%, p=0.002) and higher 12-month age-, comorbidity- and diagnosis-adjusted risks of readmission (OR, 2.1.92; 95% CI 0.98 to 3.7), functional decline (OR, 2.86; 95% CI 1.41 to 5.79) and need for new social help (OR, 3.10; 95% CI 1.45 to 6.60). MGSs were also associated with a higher 12-month mortality rate, which was only obvious in patients hospitalised for heart failure but not for other reasons. Conclusions A majority of older patients hospitalised for acute cardiac conditions in a cardiology department show at least one MGS on admission. MGSs are associated with poorer inhospital and postdischarge functional and clinical outcomes, particularly in patients with heart failure.

Prevalence and prognostic impact of frailty and its components in non‐dependent elderly patients with heart failure

The aim of this study was to evaluate the prevalence, clinical features, and the independent impact of frailty—a geriatric syndrome characterized by the decline of physiological systems—and its components, on prognosis after heart failure (HF) hospitalization.

El anciano con cardiopatía terminal

El objetivo de este documento del Grupo de Estudio «El anciano con cardiopatia terminal», de la Seccion de Cardiologia Geriatrica de la Sociedad Espanola de Cardiologia, es aportar un punto de vista experto que permita un mejor conocimiento de la situacion y una mejora en el manejo y la toma de decisiones en los ultimos dias de vida del paciente de edad avanzada que sufre una cardiopatia. Los cardiopatas ancianos constituyen un grupo heterogeneo y es necesaria una valoracion exhaustiva, especialmente de los factores que condicionan el pronostico (cardiopatia, comorbilidad, situacion funcional y datos de fragilidad) antes de tomar decisiones, sobre todo aquellas que conlleven limitacion del esfuerzo terapeutico como las ordenes de no reanimar o la desactivacion de desfibriladores automaticos implantables. Los ancianos con cardiopatias terminales tienen derecho a disponer de una serie de cuidados y atenciones, entre ellos no sufrir inutilmente, respeto a su libertad de conciencia, conocer su situacion, opinar sobre posibles intervenciones y recibir asistencia psicoespiritual. Los cuidados paliativos deben dirigirse al control de los sintomas tras el diagnostico de la enfermedad incurable y no iniciarse unicamente en la fase de agonia. Estos cuidados estan poco desarrollados en las cardiopatias y deben de tenerse presentes en los ancianos con insuficiencia cardiaca avanzada. Su objetivo es conseguir el maximo bienestar para el paciente desde un punto de vista integral, mejorar su calidad de vida antes del fallecimiento y evitar el empleo de tratamientos agresivos que consumen recursos sin resultados.

FRAIL‐HF, a Study to Evaluate the Clinical Complexity of Heart Failure in Nondependent Older Patients: Rationale, Methods and Baseline Characteristics

The clinical scenario of heart failure (HF) in older hospitalized patients is complex and influenced by acute and chronic comorbidities, coexistent geriatric syndromes, the patients ability for self‐care after discharge, and degree of social support. The impact of all these factors on clinical outcomes or disability evolution is not sufficiently known. FRAIL‐HF is a prospective observational cohort study designed to evaluate clinical outcomes (mortality and readmission), functional evolution, quality of life, and use of social resources at 1, 3, 6, and 12 months after admission in nondependent elderly patients hospitalized for HF. Clinical features, medical treatment, self‐care ability, and health literacy were prospectively evaluated and a comprehensive geriatric assessment with special focus on frailty was systematically performed in hospital to assess interactions and relationships with postdischarge outcomes. Between May 2009 and May 2011, 450 consecutive patients with a mean age of 80 ± 6 years were enrolled. Comorbidity was high (mean Charlson index, 3.4 ± 2.9). Despite being nondependent, 118 (26%) had minor disability for basic activities of daily living, only 76 (16.2%) had no difficulty in walking 400 meters, and 340 (75.5%) were living alone or with another elderly person. In addition, 316 patients (70.2%) fulfilled frailty criteria. Even nondependent older patients hospitalized for HF show a high prevalence of clinical and nonclinical factors that may influence prognosis and are usually not considered in routine clinical practice. The results of FRAIL‐HF will provide important information about the relationship between these factors and different postdischarge clinical, functional, and quality‐of‐life outcomes.

The relationship between systolic blood pressure on admission and mortality in older patients with heart failure.

To determine the relationship between admission systolic blood pressure (SBP) and mortality in older patients hospitalized for heart failure (HF) and among various subgroups.

Interatrial block and atrial arrhythmias in centenarians: Prevalence, associations, and clinical implications

BACKGROUND Data are lacking on the characteristics of atrial activity in centenarians, including interatrial block (IAB). OBJECTIVE The aim of this study was to describe the prevalence of IAB and auricular arrhythmias in subjects older than 100 years and to elucidate their clinical implications. METHODS We studied 80 centenarians (mean age 101.4 ± 1.5 years; 21 men) with follow-ups of 6-34 months. Of these 80 centenarians, 71 subjects (88.8%) underwent echocardiography. The control group comprised 269 septuagenarians. RESULTS A total of 23 subjects (28.8%) had normal P wave, 16 (20%) had partial IAB, 21 (26%) had advanced IAB, and 20 (25.0%) had atrial fibrillation/flutter. The IAB groups exhibited premature atrial beats more frequently than did the normal P wave group (35.1% vs 17.4%; P < .001); also, other measurements in the IAB groups frequently fell between values observed in the normal P wave and the atrial fibrillation/flutter groups. These measurements included sex preponderance, mental status and dementia, perceived health status, significant mitral regurgitation, and mortality. The IAB group had a higher previous stroke rate (24.3%) than did other groups. Compared with septuagenarians, centenarians less frequently presented a normal P wave (28.8% vs 53.5%) and more frequently presented advanced IAB (26.3% vs 8.2%), atrial fibrillation/flutter (25.0% vs 10.0%), and premature atrial beats (28.3 vs 7.0%) (P < .01). CONCLUSION Relatively few centenarians (<30%) had a normal P wave, and nearly half had IAB. Our data suggested that IAB, particularly advanced IAB, is a pre-atrial fibrillation condition associated with premature atrial beats. Atrial arrhythmias and IAB occurred more frequently in centenarians than in septuagenarians.

Impact of Frailty and Functional Status on Outcomes in Elderly Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Angioplasty: Rationale and Design of the IFFANIAM Study

The IFFANIAM study (Impact of frailty and functional status in elderly patients with ST segment elevation myocardial infarction undergoing primary angioplasty) is an observational multicenter registry to assess the impact of frailty and functional status on outcomes of elderly patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. STEMI patients age 75 years or older undergoing primary angioplasty will be extensively studied during admission in 4 tertiary care Hospitals in Spain, assessing their baseline functional status (Barthel index, Lawton‐Brody index), frailty (Fried criteria, FRAIL scale [fatigue, resistance, ambulation, illnesses, and loss of weight]), comorbidities (Charlson index), nutritional status (Mini Nutritional Assessment–Short Form), and quality of life (Seattle Angina Questionnaire). Participants will be managed according current recommendations. The primary outcome will be the description of 1‐year mortality, its causes, and associated factors. Secondary outcomes will be functional capacity and quality of life. Results will help to better understand the impact of frailty and functional ability on outcomes in elderly STEMI patients undergoing primary angioplasty, thus potentially contributing to improving their clinical management. Higher life expectancy has resulted in a large segment of elderly population and an increase in myocardial infarction in these patients. This calls attention to healthcare systems to focus on promoting methods to improve the clinical management of this population.

Centenarians and their hearts: A prospective registry with comprehensive geriatric assessment, electrocardiogram, echocardiography, and follow-up.

BACKGROUND Data on the cardiac characteristics of centenarians are scarce. Our aim was to describe electrocardiogram (ECG) and echocardiography in a cohort of centenarians and to correlate them with clinical data. METHODS We used prospective multicenter registry of 118 centenarians (28 men) with a mean age of 101.5±1.7 years. Electrocardiogram was performed in 103 subjects (87.3%) and echocardiography in 100 (84.7%). All subjects underwent a follow-up for at least 6 months. RESULTS Centenarians with abnormal ECG were less frequently females (72% vs 93%), had higher rates of previous consumption of tobacco (14% vs 0) and alcohol (24% vs 12%), and scored lower in the perception of health status (6.8±2.0 vs 8.3±6.8). Centenarians with significant abnormalities in echocardiography were less frequently able to walk 6 m (33% vs 54%). Atrial fibrillation/flutter was found in 27 subjects (26%). Mean left ventricular (LV) ejection fraction was 60.0±10.5%. Moderate or severe aortic valve stenosis was found in 16%, mitral valve regurgitation in 15%, and aortic valve regurgitation in 13%. Diastolic dysfunction was assessed in 79 subjects and was present in 55 (69.6%). Katz index and LV dilation were independently associated with the ability to walk 6 m. Age, Charlson and Katz indexes, and the presence of significant abnormalities in echocardiography were associated with mortality. CONCLUSIONS Centenarians have frequent ECG alterations and abnormalities in echocardiography. More than one fifth has atrial fibrillation, and most have diastolic dysfunction. Left ventricular dilation was associated with the ability to walk 6 m. Significant abnormalities in echocardiography were associated with mortality.