Richard Isnard

Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis

IntroductionOur objectives were to determine the causes of acute respiratory failure (ARF) in elderly patients and to assess the accuracy of the initial diagnosis by the emergency physician, and that of the prognosis.MethodIn this prospective observational study, patients were included if they were admitted to our emergency department, aged 65 years or more with dyspnea, and fulfilled at least one of the following criteria of ARF: respiratory rate at least 25 minute-1; arterial partial pressure of oxygen (PaO2) 70 mmHg or less, or peripheral oxygen saturation 92% or less in breathing room air; arterial partial pressure of CO2 (PaCO2) ≥ 45 mmHg, with pH ≤ 7.35. The final diagnoses were determined by an expert panel from the completed medical chart.ResultsA total of 514 patients (aged (mean ± standard deviation) 80 ± 9 years) were included. The main causes of ARF were cardiogenic pulmonary edema (43%), community-acquired pneumonia (35%), acute exacerbation of chronic respiratory disease (32%), pulmonary embolism (18%), and acute asthma (3%); 47% had more than two diagnoses. In-hospital mortality was 16%. A missed diagnosis in the emergency department was noted in 101 (20%) patients. The accuracy of the diagnosis of the emergency physician ranged from 0.76 for cardiogenic pulmonary edema to 0.96 for asthma. An inappropriate treatment occurred in 162 (32%) patients, and lead to a higher mortality (25% versus 11%; p < 0.001). In a multivariate analysis, inappropriate initial treatment (odds ratio 2.83, p < 0.002), hypercapnia > 45 mmHg (odds ratio 2.79, p < 0.004), clearance of creatinine < 50 ml minute-1 (odds ratio 2.37, p < 0.013), elevated NT-pro-B-type natriuretic peptide or B-type natriuretic peptide (odds ratio 2.06, p < 0.046), and clinical signs of acute ventilatory failure (odds ratio 1.98, p < 0.047) were predictive of death.ConclusionInappropriate initial treatment in the emergency room was associated with increased mortality in elderly patients with ARF.

Is the gap between guidelines and clinical practice in heart failure treatment being filled? Insights from the IMPACT RECO survey

Recent registries have shown that recommended drugs for the treatment of chronic heart failure (CHF) are under‐prescribed in daily practice.

Comparison of Brain Natriuretic Peptide and Probrain Natriuretic Peptide in the Diagnosis of Cardiogenic Pulmonary Edema in Patients Aged 65 and Older

Objectives: Differentiating cardiogenic pulmonary edema (CPE) from respiratory causes of dyspnea is difficult in elderly patients. The aim of this study was to compare the usefulness of B‐type natriuretic peptide (BNP) and amino‐terminal fragment BNP (proBNP), to diagnose CPE in patients aged 65 and older.

Improvement in the management of chronic heart failure since the publication of the updated guidelines of the European Society of Cardiology. The Impact-Reco Programme.

Recent studies have shown that prescription rates and doses of recommended drugs for chronic heart failure (CHF) are not optimal in daily practice. The aim of the Impact‐Reco programme was to analyse prescription rates of CHF drugs in stable outpatients with CHF related to left ventricular (LV) systolic dysfunction in two similar surveys in France.

Ultrasound-based teaching of cardiac anatomy and physiology to undergraduate medical students.

BACKGROUNDnUltrasonography is a non-invasive imaging modality that offers the opportunity to teach living cardiac anatomy and physiology.nnnAIMSnThe objectives of this study were to assess the feasibility of integrating an ultrasound-based course into the conventional undergraduate medical teaching programme and to analyse student and teacher feedback.nnnMETHODSnAn ultrasound-based teaching course was implemented and proposed to all second-year medical students (n=348) at the end of the academic year, after all the conventional modules at our faculty. After a brief theoretical and practical demonstration, students were allowed to take the probe and use the ultrasound machine. Students and teachers were asked to complete a survey and were given the opportunity to provide open feedback.nnnRESULTSnTwo months were required to implement the entire module; 330 (95%) students (divided into 39 groups) and 37 teachers participated in the course. Student feedback was very positive: 98% of students agreed that the course was useful; 85% and 74% considered that their understanding of cardiac anatomy and physiology, respectively, was improved. The majority of the teachers (97%) felt that the students were interested, 81% agreed that the course was appropriate for second-year medical students and 84% were willing to participate to future sessions.nnnCONCLUSIONSnCardiac anatomy and physiology teaching using ultrasound is feasible for undergraduate medical students and enhances their motivation to improve their knowledge. Student and teacher feedback on the course was very positive.

Cardiac asthma in elderly patients: incidence, clinical presentation and outcome

BackgroundCardiac asthma is common, but has been poorly investigated. The objective was to compare the characteristics and outcome of cardiac asthma with that of classical congestive heart failure (CHF) in elderly patients.MethodsProspective study in an 1,800-bed teaching hospital.ResultsTwo hundred and twelve consecutive patients aged ≥ 65 years presenting with dyspnea due to CHF (mean age of 82 ± 8 years) were included. Findings of cardiac echocardiography and natriuretic peptides levels were used to confirm CHF. Cardiac asthma patients were defined as a patient with CHF and wheezing reported by attending physician upon admission to the emergency department. The CHF group (n = 137) and the cardiac asthma group (n = 75), differed for tobacco use (34% vs. 59%, p < 0.05), history of chronic obstructive pulmonary disease (16% vs. 47%, p < 0.05), peripheral arterial disease (10% vs. 24%, p < 0.05). Patients with cardiac asthma had a significantly lower pH (7.38 ± 0.08 vs. 7.43 ± 0.06, p < 0.05), and a higher PaCO2 (47 ± 15 vs. 41 ± 11 mmHg, p < 0.05) at admission. In the cardiac asthma group, patients had greater distal airway obstruction: forced expiratory volume in 1 second of 1.09 vs. 1.33 Liter (p < 0.05), and a forced expiratory flow at 25% to 75% of vital capacity of 0.76 vs. 0.99 Liter (p < 0.05). The in-hospital (23% vs. 19%) and one year mortality (48% vs. 43%) rates were similar.ConclusionPatients with cardiac asthma represented one third of CHF in elderly patients. They were more hypercapnic and experienced more distal airway obstruction. However, outcomes were similar.

Findings of Cardiac Magnetic Resonance Imaging in Asymptomatic Myocardial Ischemic Disease in Takayasu Arteritis

Takayasu arteritis (TA) may affect myocardium and cause coronary stenosis. The aim of this study was to assess the prevalence and pattern of myocardial disease in patients with TA, using late gadolinium enhancement (LGE) of cardiac magnetic resonance imaging (CMRI). Twenty-seven consecutive patients with TA and 80 age- and gender-matched controls without known cardiovascular disease underwent CMRI. The prevalence of myocardial ischemic disease, as revealed by LGE, was compared between patients with TA and controls, and factors associated with myocardial disease were identified in patients with TA. Myocardial ischemic disease, as characterized by LGE on CMRI, was present in 7 (25.9%) of 27 patients with TA, and imaging with LGE showed a typical pattern of myocardial infarction in 6 patients (22.2%). Although both patients with TA and control subjects shared a similar risk of cardiovascular events, the prevalence of myocardial ischemia was >5× greater in patients with TA (p = 0.002 vs controls). No association was found between myocardial disease in patients with TA and cardiovascular atherosclerotic risk factors. The presence of myocardial scarring tended to be more closely associated with specific features of TA such as renovascular hypertension, older age at the onset of TA symptoms, male gender, aneurysmal dilatation, and Numano type V. In conclusion, finding of a significant and unexpectedly high prevalence of occult myocardial scarring in patients with TA indicates the usefulness of CMRI with LGE for the identification of occult myocardial disease in such patients.

Diagnosis and treatment of iron deficiency in patients with heart failure: Expert position paper from French cardiologists

The prevalence of iron deficiency is high -even in the absence of anaemia- in patients with chronic heart failure (HF). Although iron deficiency is easily diagnosed with two biomarkers (serum ferritin and transferrin saturation), it is underdiagnosed in patients with HF. Iron is not only necessary for red blood cells, but also for cells in tissues with high-energy demands (heart, muscle, brain). Even before the onset of anaemia, HF patients with iron deficiency have decreased physical and cognitive performances and a poorer quality of life. Moreover, iron deficiency is a risk factor, independent of anaemia, of unfavourable outcome (death or heart transplantation) in patients with chronic HF. Several randomized controlled studies have shown improvement in exercise capacity, New York Heart Association functional class and quality of life after correction of iron deficiency. The results of these clinical trials, which are supported by European guidelines, suggest considering iron deficiency in HF as a possible therapeutic target.

A 22-Year Follow-up Study of Long-term Cardiac Outcome and Predictors of Survival in Friedreich Ataxia

IMPORTANCEnFriedreich ataxia (FRDA) is the most common genetic sensory ataxia, and myocardial involvement is a major determinant of survival.nnnOBJECTIVEnTo assess FRDA survival and cardiac outcome to adapt future therapeutic trials.nnnDESIGN, SETTING, AND PARTICIPANTSnIn a longitudinal follow-up study, all patients with genetically confirmed FRDA seen in the reference center and referred for cardiac evaluation (standard 12-lead electrocardiogram and transthoracic echocardiography) to the cardiology department were enrolled and followed up from April 27, 1990, to July 31, 2013. The setting was the French National Reference Center for Rare Diseases and the Department of Cardiology, Salpêtrière University Hospital, Paris, France. In total, 138 patients with FRDA were followed up. Among 133 patients homozygous for expanded GAA repeats, the mean (SD) age was 31 (10) years (age range, 11-62 years), with a mean (SD) age at disease onset of 16 (8) years (age range, 3-50 years) and a mean (SD) age at first wheelchair use of 26 (9) years (age range, 11-64 years). Cardiac hypertrophy was present in 57.9% (77 of 133), and electrocardiography was normal in 6.8% (9 of 133).nnnMAIN OUTCOMES AND MEASURESnLong-term cardiac outcome and predictors of survival in FRDA.nnnRESULTSnAfter a mean (SD) follow-up of 10.5 (5.5) years (range, 0.6-23.0 years), the 10-year survival rate was 88.5%. In 80.0% of patients (12 of 15), death was due to cardiac causes. Predictors of survival were a shorter GAA repeat length on the smaller allele of the frataxin gene (hazard ratio [HR], 1.85; 95% CI, 1.28-2.69), left ventricular ejection fraction (HR, 0.42; 95% CI, 0.20-0.89), and left ventricular mass index (HR, 1.19; 95% CI, 1.04-1.36). Two cardiac evolutions were distinguished with a group-based trajectory model, including a low-risk cardiac group (78.6% [81 of 103] with normal ejection fraction at baseline that declined slightly over time but remained within the normal range) and a high-risk cardiac group (21.4% [22 of 103] in which the ejection fraction progressively declined during follow-up). The patients with the worse cardiac evolution had longer GAA repeats. Neurological impairment was not predictive of cardiac change over time.nnnCONCLUSIONS AND RELEVANCEnSurvival in FRDA is determined by cardiac complications, which are dependent on the mutation (ie, the size of the expanded GAA repeat). Patients with progressive decline of the left ventricular ejection fraction had a worse prognosis. This finding demonstrates that cardiac follow-up is important in FRDA to identify individuals at risk for further cardiac complications.

Prevalence of Memory Disorders in Ambulatory Patients Aged ≥70 Years With Chronic Heart Failure (from the EFICARE Study)

The aim of this multicenter observational study conducted in France was to determine the prevalence of memory impairment in ambulatory patients aged≥70 years with chronic heart failure (HF). Two hundred ninety-one cardiologists recruited 912 ambulatory patients with HF (mean age 79.2±5.8 years) from January to November 2009. Memory was evaluated by the delayed-recall Memory Impairment Screen (MIS-D). Memory impairment was defined as MIS-D score≤6 and severe memory impairment as MIS-D score≤4. HF was diagnosed 4.4±4.8 years earlier and mean left ventricular ejection fraction was 43.6±12.0%. Memory impairment was found in 416 subjects (45.6%, 95% confidence interval 42.4 to 48.8) and severe memory impairment in 213 subjects (23.4%, 95% confidence interval 20.6 to 26.1), whereas cardiologists only suspected memory impairment in 109 patients (12%; before evaluation by MIS). Determinants of memory disorders included older age, lower education level, depression, history of stroke, renal failure, and less regular physical activity. The severity of memory impairment increased with increasing severity of HF (New York Heart Association classification; p<0.00001). In conclusion, memory impairment in older patients with HF is common. The use of a simple-to-use tool such as the MIS-D may identify patients at risk and enable implementation of management strategies to improve therapeutic compliance.