Olivier Toulza

Blood pressure and pulse wave velocity values in the institutionalized elderly aged 80 and over: baseline of the PARTAGE study.

Objective The aim of the longitudinal study PARTAGE (predictive values of blood pressure and arterial stiffness in institutionalized very aged population) was to determine the predictive value of blood pressure (BP) and arterial stiffness for overall mortality, major cardiovascular events and cognitive decline in a large population of institutionalized patients aged 80 and over. In the study herein, we present the baseline data values of this study. Methods A total of 1130 patients were recruited (878 women), living in French and Italian nursing homes. Clinical and 3-day self-measurements of BP were conducted. Aortic and upper limb pulse wave velocity were obtained using a PulsePen tonometer. Results Of this population, 76% of women and 60% of men had a known hypertension and over 91% of the patients were under antihypertensive treatment; 51% of the treated hypertensive patients were well controlled (systolic BP <140 mmHg). No significant differences were found between clinical and self-measured BP. With age, there was an increase in pulse pressure (P < 0.001) due to a decrease in diastolic BP (P < 0.001), without any increase in systolic BP. Aortic but not peripheral pulse wave velocity significantly increased with age (P < 0.005). Conclusion Baseline values obtained herein demonstrate that elderly patients living in nursing homes present hemodynamic characteristics which are different to those described in community-living elderly populations, and indicate the interest of assessing, in longitudinal studies, the role of BP and arterial stiffness in morbidity and mortality in this population.

Predictive Factors of Attrition in a Cohort of Alzheimer Disease Patients

Background: Attrition, i.e. patient dropout, can threaten the validity of results in longitudinal studies. The aim of this study was to identify patient and caregiver factors predictive of attrition in a cohort of Alzheimer disease (AD) patients. Methods: 686 patients with mild to moderate AD were included in the multicenter prospective REAL.FR study. Standardized gerontological evaluations were carried out twice yearly. Factors associated with attrition were assessed by survival analysis using a Cox proportional hazard model. Results: After 2 years, 278 (40.5%) patients had dropped out. Causes of attrition included refusal (20.9%), death (20.1%), institutionalization (19.8%), and loss to follow-up (19.8%). Attrition rates between each 6-month wave were constant at 12%. After adjustment, several independent factors remained associated with attrition: patients cared for by an unrelated caregiver [HR 1.7; 95% CI (1.08–2.59)], loss of autonomy [HR = 1.37; (1.03–1.82)], increasing caregiver burden [HR = 1.014; (1.005–1.022)], use of cholinesterase inhibitors [HR = 0.40; (0.27–0.59)], use of 1 to 3 other types of medication [HR = 0.57; (0.36–0.89)]. Conclusions: The identification of both patient and caregiver factors predictive of attrition is of particular interest for the development and targeting of attrition prevention strategies. In patients with chronic diseases, particular attention should be paid to caregiver well-being to limit attrition.

Health-Related Quality of Life After Transcatheter Aortic Valve Implantation in Elderly Patients With Severe Aortic Stenosis

BACKGROUND Severe aortic stenosis may affect both normal daily living and survival. Transcatheter aortic valve implantation (TAVI) has become an appropriate alternative to surgery for elderly patients with high surgical risk, and it results in improved survival in this population. OBJECTIVE To describe health-related quality of life (QoL) before, and at 1 and 6 months after TAVI. SETTING Cardiovascular Department, Toulouse University Hospital, France. METHODS One hundred sixty-four consecutive patients with at least 6 months follow-up who underwent TAVI in our institution between February 2009 and June 2011 were enrolled in the study. Of this population, 73 (mean age: 82.3 ± 7.3 years, 56% men) completed QoL assessment using the EuroQOL Five Dimensions (EQ-5D) questionnaire and a visual analogue scale at baseline, and at 1 and 6 months. At each visit, medical data and New York Heart Association functional class were collected. RESULTS The median preprocedure EQ-5D index value (interquartile range) was 0.66 (range, 0.36-0.78) showing severely impaired QoL in almost all patients. Significant improvement occurred from baseline to 1 month of follow-up in EQ-5D index value [0.73 (range, 0.59-0.79)] and this was maintained at 0.73 (range, 0.62-0.81) at 6 months. The improvement was significant for 3 dimensions of the EQ-5D score at the 6-month follow-up: usual activities in 43.8% of patients (P < .001); anxiety/depression in 37% (P < .001) and pain/discomfort in 28.8% (P < .05). Mean New York Heart Association class improved significantly from 3.24 at baseline to 2.04 at 1 month and 1.89 at 6 months. CONCLUSIONS In high-risk patients with severe aortic stenosis, QoL and health status improved substantially at 1 month and improvement persisted 6 months after TAVI.

Sensory alien hand syndrome in corticobasal degeneration: A cerebral blood flow study

The presence of alien hand syndrome (AHS) is suggestive of the diagnosis of corticobasal degeneration when it develops in a progressive way. Sensory AHS (sAHS) should be distinguished from the motor form described more commonly. The physiopathology of sAHS remains unclear. The aim of this study is to determine cerebral regions involved in sAHS. We compared perfusion single photon emission computer tomography scans of patients with sAHS (n = 3) and without (n = 4). We observed significant decrease of regional cerebral blood flow over the nondominant thalamus in sAHS+ compared to sAHS− patients. This result suggests the involvement of the nondominant thalamus in sAHS.

Interest of Combined Blood Pressure Measurements in Very Old Frail Subjects: The PARTAGE Study

BACKGROUND Several clinical studies have shown that blood pressure (BP) measurements in very old frail individuals are of limited interest due to the fact that several age-related alterations and geriatric syndromes may modify BP. We studied in persons over 80-year old living in nursing homes the combined effects of 3 BP patterns on total mortality and major cardiovascular (CV) events: (i) low pulse pressure amplification (L-PPA) between carotid and brachial artery, (ii) systolic BP (SBP) <130 mm Hg (L-SBP), under >1 antihypertensive drugs, and (iii) changes in SBP between supine and upright position of >20 mm Hg in both directions (hypotension/hypertension, orthostatic SBP [O-SBP]). METHODS This analysis was performed in subjects of the PARTAGE study presenting all these 3 measurements (n = 883). The combined effects of L-PPA, L-SBP, and O-SBP were studied during the 2 years followed-up period. RESULTS After adjusting for age, sex, and history of CV events, all 3 BP patterns were independent determinants of major CV events (L-PPA, (P = 0.023); L-SBP, (P = 0.050); O-SBP, (P = 0.015)), whereas L-PPA (P = 0.012) and L-SBP (P = 0.006) were also independent determinants of total mortality. Compared with the subjects without any BP pattern, the presence of 2 or 3 BP patterns was associated with an increase in total mortality and major CV events greater than 2 and 2.5 times, respectively. CONCLUSIONS In very old frail subjects, there is a particular interest for using different BP measurement approaches, than in younger populations, in order to evaluate the risks related to the BP levels. CLINICAL TRIALS REGISTRATION Trial Number: NCT00901355 (Clinical Trials.gov).

[OP.2C.05] THE ROLE OF ARTERIAL STIFFNESS AND BLOOD PRESSURE VARIATIONS IN MORBIDITY AND MORTALITY IN VERY OLD FRAIL SUBJECTS. THE PARTAGE STUDY

Objective: We have previously reported in persons over 80 years old living in nursing homes (PARTAGE study) that low pulse pressure amplification (PPA) an indicator of arterial stiffness, was associated with total mortality and the major cardiovascular (CV) events. In subsequent analyses we have shown that the group of subjects with systolic blood pressure (SBP) <130 mmHg, under >1 antihypertensive drugs, had a greater risk of mortality as compared to all other subjects. More recently, we have demonstrated that orthostatic changes in BP (orthostatic hypotension or orthostatic hypertension) were associated with higher risk for major CV events. The aim of the present analysis was to study the combined effects of all these 3 arterial parameters on total mortality and major CV events. Design and method: This analysis was performed in the subjects of the PARTAGE study with follow-up for 2 years. The parameters were studied by using the cutoff points which according to the results of the previous analyses in this cohort: PPA<18.8% (LowPPA); SBP<130 mmHg under >1 antihypertensive drug (TtSBP<130); changes in systolic BP (both an increase or a decrease of >20 mmHg) between supine and upright position (DeltaSBP>20). Were included in the analysis the subjects (n = 883) with measurements of all these 3 arterial parameters. Age and gender were added in all multivariate models. Results: Low PPA, TtSBP<130 and DeltaSBP>20 were observed in 33%, 38% and 21% of patients respectively. “LowPPA” (HR 1.52 (1.13–2.05); p = 0.006) and “TtSBP<130”(HR 1.71 (1.24–2.35); p = 0.001) were independent determinants of total mortality and major CV events whereas “DeltaSBP>20” was a independent determinant for major CV events only (HR 1.40 (1.05–1.89); p = 0.02). In addition, combination of >1 of these arterial parameters significantly increases the risk of total mortality and major CV events (HR for 2 vs none, 2.12 (1.42–3.16); and HR for 3 vs 0, 2.90 (1.46–5.75). Conclusions: People presenting a vascular profile characterized by high arterial stiffness expressed by low PPA, low BP under combination anti-Htn treatment and significant variability in SBP between supine and upright position were at much higher risk for total mortality and major CV events.

ARTERIAL STIFFNESS AND BLOOD PRESSURE AMPLIFICATION IN THE PRESENCE OF CARDIAC DISEASE IN ELDERLY OVER 80 YEARS. THE PARTAGE STUDY: 6D.06

Objectives: PWV and PPA are independently predictors of cardiovascular risk, mainly in the elderly. The aim of the present research was to determine the influence of pulse pressure amplification (PPA) and pulse wave velocity (PWV), both manifestations of arterial stiffness, on heart disease in the elderly. Methods: The study population consisted of 1042 subjects (814 women) aged 80 and over who participated in the PARTAGE study. Carotid-femoral PWV was determined in order to assess aortic stiffness. Central aortic blood pressure values and central pulse wave analysis were obtained using the calibration method applied on the common carotid artery by a PulsePen tonometer. Amplification phenomenon was expressed as PPA i.e. the percentage of increase of pulse pressure in the brachial artery relative to central pulse pressure. Heart disease was defined as presence of heart failure, ischemic heart disease or atrial fibrillation. Results: PPA was significantly lower in patients with heart disease, independently of the presence of hypertension and/or diabetes. Heart disease was present in 61.8% of subjects with PPA < 10%, in 46.2% of subjects with PPA between 10% and 20% (p < 0.01), in 42.6% of subjects with PPA between 20% and 30% (p < 0.005), and in 32.5% of subjects with PPA >30% (p < 0.001). PWV, on the other hand, was not influenced by the presence of heart disease (12.3 ± 4.0 m/s vs. 13.5 ± 4.6 m/s) but significantly increased in presence of hypertension (14.4 ± 5.0 m/s, p < 0.001) or diabetes (16.1 ± 5.1 m/s, p < 0.001). Conclusions: In the very elderly, low brachial/aortic PPA is associated with higher prevalence of heart disease.