Salvador Altimir

Prognostic Implication of Frailty and Depressive Symptoms in an Outpatient Population With Heart Failure

INTRODUCTION AND OBJECTIVES Heart failure patients have high levels of frailty and dependence. Our aim was to determine the impact of frailty and depressive symptoms on the 1-year mortality rate and the rate of hospitalization for heart failure during a follow-up period of 1 year. METHODS All patients underwent geriatric evaluation, and frailty and depressive symptoms were identified. The study included 622 patients (72.5% male; median age, 68 years; 92% in New York Heart Association class II or III; and median ejection fraction, 30%). RESULTS During follow-up, 60 patients (9.5%) died and 101 (16.2%) were hospitalized for heart failure. Overall, 39.9% of patients exhibited frailty, while 25.2% had depressive symptoms. There were significant associations between mortality at 1 year and the presence of frailty (16.9% vs. 4.8%; P< .001) and depressive symptoms (15.3% vs. 7.7%; P=.006). There was also a significant relationship between heart failure hospitalization and the presence of frailty (20.5% vs. 13.3%; P=.01). No relationship was found between heart failure hospitalization and depressive symptoms. Frailty was an independent predictor of mortality but not of hospitalization. CONCLUSIONS Univariate analysis demonstrated significant relationships between frailty and depressive symptoms and mortality at 1 year. In addition, there was a significant relationship between frailty and the need for heart failure hospitalization. However, only frailty showed prognostic value to predict mortality, which was independent of other variables strongly associated to outcome.

Sex and age differences in fragility in a heart failure population.

Heart failure (HF) patients have a high degree of fragility and dependence from physical, cognitive and psychological points of view, and are a mainly geriatric population.

Effectiveness of a geriatric intervention in primary care: a randomized clinical trial

OBJECTIVE To assess the effectiveness of an intervention after comprehensive geriatric assessment (CGA) in reducing morbidity and mortality in patients over 74 years in primary care. METHODS Randomized controlled trial with 18 months of follow-up. Patients in the control group (CG) followed usual care. Patients in the intervention group (IG) were classified as at risk or non-risk of frailty based on the CGA. Patients at non-risk of frailty in the IG were provided with recommendations about healthy habits and adherence to treatment in group sessions, while patients at risk of frailty were visited individually by a geriatrician. RESULTS Six hundred and twenty patients were randomized to the IG (49.7%) or to the CG (50.3%), 83.2% completed follow-up. Coxs proportional hazards model showed as covariates the study group (hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.28-1.22), risk of frailty (HR 1.33; 95% CI 0.71-2.51) and the interaction between both (HR 3.08; 95% CI 1.22-7.78). Forty-nine percent of the patients in the IG and 43% in the CG were at risk of frailty at baseline. At the end of the study, 27.9% of the IG and 13.5% of the CG had reversed their initial at risk of frailty status (P = 0.027). Multivariate predictors of reversible risk of frailty were younger age, not being at risk of depression, low consumption of medications and the intervention itself. CONCLUSIONS A specific intervention in patients over 74 years attended in primary care reduces morbidity and mortality in patients at risk of frailty and increases the proportion of patients that reversed their initial status at risk of frailty.

Statins in Heart Failure: The Paradox Between Large Randomized Clinical Trials and Real Life

OBJECTIVE To assess the relationship between statins and prognosis in ischemic and nonischemic patients with heart failure (HF) in a real-life cohort followed up for a long period. PATIENTS AND METHODS This prospective study included 960 patients with HF with preserved or depressed left ventricular ejection fraction (LVEF), irrespective of HF etiology, who were referred to the HF clinic of a university hospital between August 1, 2001, and December 31, 2008. The patients were followed up for a maximum of 9.1 years (median, 3.7 years), and survival in ischemic and nonischemic patients was determined. RESULTS Median age was 69 years, and median LVEF was 31%. Of the 960 patients, 532 (55.4%) had ischemic HF etiology, and most received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (846; 88.1%) and β-blockers (776; 80.8%). Patients with HF of ischemic origin were more often treated with statins (P<.001). During follow-up, 440 patients (45.8%) died. Statin therapy was associated with significantly improved survival (hazard ratio, 0.45 [95% confidence interval, 0.37-0.54]; P<.001). After adjustment for HF prognostic factors (age, sex, cholesterol level, New York Heart Association class, HF etiology, LVEF, body mass index, HF duration, atrial fibrillation, implantable cardioverter-defibrillator therapy, and medicines), statins remained significantly associated with lower mortality risk in both ischemic (P=.007) and nonischemic (P=.002) patients. CONCLUSION In contrast to results of large randomized trials, statins were independently and significantly associated with lower mortality risk in our real-life HF cohort, including patients with nonischemic HF etiology.

Significado pronóstico de los valores de hemoglobina en pacientes con insuficiencia cardíaca

Introduccion y objetivos Evaluar el valor pronostico de las concentraciones de hemoglobina (Hb) en relacion con la mortalidad y con los ingresos hospitalarios por insuficiencia cardiaca (IC) al ano de la primera visita a la Unidad de IC. Pacientes y metodo Conocemos la situacion vital y los ingresos por IC al ano en 337 pacientes admitidos entre agosto de 2001 y marzo de 2003. Las concentraciones de Hb se recogieron en la primera visita. Resultados Fallecieron 28 (8%) pacientes y hubo 158 ingresos por IC en 66 pacientes. Los valores de Hb se asociaron con la mortalidad a 1 ano (pacientes vivos, 13,0 ± 1,7 g/dl; pacientes fallecidos, 11,6 ± 1,7 g/dl; p Conclusiones Los valores de Hb se asocian inversamente con la mortalidad y los ingresos por IC en el primer ano de seguimiento. La prevalencia de anemia en nuestra poblacion con IC es elevada y tiene valor pronostico independiente.

Patient's education by nurse: what we really do achieve?

Aim: To evaluate what is really achieved with nurse education in an outpatient heart failure population. Method: The answers obtained in a nurse questionnaire performed at the first visit to the Unit and at 1 year of follow-up were compared. The questionnaire was addressed to know how compliant patients were and how much they knew about their disease and their treatment. Results: Two hundred and ninety eight patients (219 men and 79 women) were evaluated. Baseline mean age was 65 years (35–86). At first visit only 30% knew and understood the performance of the heart; 56% at 1 year (p < 0.001). Only 28% initially understood the disease; 55% at follow-up (p < 0.001). Awareness of more than 3 worsening signs increased from 66.5% to 86.5% (p < 0.001). Knowledge of the names of all the pills they were receiving increased from 33% to 44% (p < 0.001), of the action of these pills from 24% to 44% (p < 0.001), and of how to use nitroglycerine among patients with ischemic heart disease from 87% to 96% (p < 0.001). Initially 63% monitored their weight only at the medical visit and 21% monitored it at least once a week; at 1 year these percentages were 16% and 39% respectively (p < 0.001). At baseline 45% checked blood pressure only at the medical visit and 28.5% checked it at least once a week; at 1 year these percentages were 12% and 43% (p < 0.001). Whereas no significant differences were found in sodium restricted diet compliance, exercise performance increased slightly although statistically significantly (p = 0.01). The great majority of patients never or only very rarely smoked or drunk alcoholic beverages, both at first visit and at 1 year, although both habits increased slightly during follow-up. No significant differences in treatment compliance (92% vs. 88% were taking all the medications prescribed) were found. Conclusion: Nurse-guided education has changed self-care behaviour of patients with heart failure in several important aspects, as weight and blood monitoring, and has increased their knowledge and understanding of the disease and treatment. However, these improvements have not been reflected in a better compliance of treatment and sodium restricted diet. Such aspects need more and more work to obtain better results.

The obesity paradox in heart failure: is etiology a key factor?

BACKGROUND Obesity is paradoxically associated with survival in patients with heart failure (HF). Our objective was to assess whether the relationship between body mass index (BMI) and long-term survival is associated with HF etiology (ischemic vs. non-ischemic) in a cohort of ambulatory HF patients. METHODS BMI and survival status after a median follow-up of 6.1 years (IQR 2.2-7.8) were available for 504 patients (73% men; median age 68 years [IQR 58-74]). Fifty-nine percent of patients had ischemic etiology. Median left ventricular ejection fraction (LVEF) was 30% (IQR 23-39.7%). Most patients were in NYHA functional class II (51%) or III (42%). Patients were divided into four groups according to BMI: low weight (BMI < 20.5 kg/m(2)), normal weight (BMI 20.5 to < 25.5 kg/m(2)), overweight (BMI 25.5 to < 30 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)). RESULTS Mortality differed significantly across the BMI strata in non-ischemic patients (log-rank p < 0.0001) but not in ischemic patients. Using normal weight patients as a reference, hazard ratios for low weight, overweight, and obese patients were 2.08 (1.16-3.75, p = 0.014), 0.88 (0.54-1.43, p = 0.60), and 0.49 (0.28-0.86, p = 0.01), respectively, for non-ischemic patients and 1.19 (0.48-2.97, p = 0.71), 0.88 (0.61-1.27, p = 0.48), and 0.96 (0.66-1.41, p = 0.85), respectively, for ischemic patients. After adjusting for age, sex, NYHA functional class, LVEF, co-morbidities, and treatment, BMI remained an independent predictor of survival in non-ischemic patients. CONCLUSION Over long-term follow-up of ischemic and non-ischemic HF, the obesity paradox was only observed in patients with non-ischemic HF.

Mortalidad y causas de muerte en pacientes con insuficiencia cardiaca: experiencia de una unidad especializada multidisciplinaria

Introduccion y objetivos La mortalidad de la insuficiencia cardiaca es similar o incluso superior a la de muchos canceres. Suele ocurrir por progresion de la enfermedad, aunque la muerte subita se ha descrito como una causa frecuente. El objetivo es evaluar la mortalidad y sus causas en una poblacion ambulatoria de pacientes con insuficiencia cardiaca de etiologia diversa tratados en una unidad especializada multidisciplinaria y analizar los factores asociados con ellas. Metodos Estudio de seguimiento de cohorte (mediana, 36 meses) de 960 pacientes (el 70,9% varones; mediana de edad, 69 anos; mayoritariamente de etiologia isquemica, con fraccion de eyeccion del 31% y en clase funcional fundamentalmente II y III). Resultados Se registraron 351 fallecimientos (36,5%): 230 de causa cardiovascular (65,5%), fundamentalmente por insuficiencia cardiaca (33,2%) y muerte subita (16%), 94 de causa no cardiovascular (26,8%), fundamentalmente neoplasias (10,5%) y procesos septicos (6,8%), y 27 (7,7%) de causa desconocida. Mostraron relacion independiente con la mortalidad: edad, sexo, clase funcional, fraccion de eyeccion, tiempo de evolucion, etiologia isquemica, diabetes mellitus, aclaramiento de creatinina, vasculopatia periferica, fragilidad y ausencia de tratamiento con inhibidores de la enzima de conversion de angiotensina o antagonistas de los receptores de la angiotensina II, bloqueadores beta, estatinas y antiagregantes. El factor principal asociado a muerte cardiovascular fue la etiologia isquemica. No hallamos ningun factor predictor claramente determinante de muerte subita. Conclusiones Aunque la mortalidad de los pacientes atendidos en una unidad especializada de insuficiencia cardiaca no fue baja, una cuarta parte fallecio de causa no cardiovascular. El principal factor asociado a muerte cardiovascular fue la etiologia isquemica. La muerte subita afecto solo al 5,8% de la poblacion.

Depression, antidepressants, and long-term mortality in heart failure

BACKGROUND This study was designed to assess whether depression and the use of antidepressants were related to long-term mortality in heart failure. METHODS Heart failure outpatients (n=1017) from a specialized tertiary unit in Spain were prospectively studied for a median follow-up of 5.4 years (IQR 3.1-8.1). Depressive symptoms were assessed using an abbreviated version of the geriatric depression scale. Survival rates during the study period (August 2001 until December 2010) and hazard ratios (HR) for mortality were adjusted by several demographic and clinical variables. RESULTS Depressive symptoms were detected in 302 patients (29.7%) at baseline and 222 (21.8%) de novo during follow-up; 304 patients (29.9%) received at least one prescription of antidepressants, mainly selective serotonin reuptake inhibitors (92.8%); 441 patients (43.4%) died. In a multivariate Cox proportional hazard model, depression was associated with an increased all-cause (HR, 1.39; 95% CI, 1.15-1.68), but not cardiovascular, mortality risk after adjustment for several demographic and clinical confounders. The use of any antidepressant was not independently associated with mortality (HR, 0.89; 95% CI, 0.71-1.13), but benzodiazepines showed a protective role (HR, 0.70; 95% CI, 0.57-0.87). On the contrary, fluoxetine prescriptions, but not duration of fluoxetine treatment, were associated with increased mortality (HR, 1.66; 95% CI, 1.13-2.44). CONCLUSIONS Depressive symptoms are associated with long-term mortality, but the use of antidepressants and benzodiazepines is safe regarding survival in HF patients, although further research is needed considering individual antidepressants separately.

Use of the "Minnesota Living With Heart Failure" Quality of Life Questionnaire in Spain

INTRODUCTION AND OBJECTIVES Quality of life is an important end-point in heart failure studies, as well as mortality and hospitalization rates. The Minnesota Living With Heart Failure Questionnaire is the instrument used most widely to evaluate quality of life in research studies. We used this questionnaire to evaluate quality of life in a general population attended by a heart failure unit in Spain. PATIENTS AND METHOD 326 patients seen for the first time at the unit were evaluated. We analyzed the relationship between the questionnaire score and different clinical and demographic factors. RESULTS The median global score on the Minnesota Living With Heart Failure Questionnaire was relatively low (28). We found a strong correlation (P<.001) between the score and functional class, sex (women had higher scores), and diabetes. We also found a correlation between the score and number of hospital admissions in the previous year (P<.001), anemia (P<.001) and etiology (P=.01), and a weak trend toward higher scores with increasing age (P=.04). The highest scores were observed in patients with valve disease disorders (43), and the lowest were seen in patients with alcoholic cardiomyopathy (20) and ischemic heart disease (24). We found no correlation with time of evolution of heart failure or with left ventricular ejection fraction. CONCLUSIONS The scores on the Minnesota Living With Heart Failure Questionnaire in a general population attended by a heart failure unit in Spain were relatively low. However, we found a strong correlation between this score and functional class, and also between this score and number of admissions in the previous year. These results suggest that the questionnaire adequately reflects the severity of the disease.