Sofie Jansen

The Association of Cardiovascular Disorders and Falls: A Systematic Review

OBJECTIVE Cardiovascular disorders are recognized as risk factors for falls in older adults. The aim of this systematic review was to identify cardiovascular disorders that are associated with falls, thus providing angles for optimization of fall-preventive care. DESIGN Systematic review. DATA SOURCES Medline and Embase. ELIGIBILITY CRITERIA FOR SELECTING STUDIES studies addressing persons aged 50 years and older that described cardiovascular risk factors for falls. Key search terms for cardiovascular abnormalities included all synonyms for the following groups: structural cardiac abnormalities, cardiac arrhythmia, blood pressure abnormalities, carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), vasovagal syncope (VVS), postprandial hypotension (PPH), arterial stiffness, heart failure, and cardiovascular disease. Quality of studies was assed using the Newcastle-Ottawa Scale. RESULTS Eighty-six studies were included. Of studies that used a control group, most consistent associations with falls were observed for low blood pressure (BP) (4/5 studies showing a positive association), heart failure (4/5), and cardiac arrhythmia (4/6). Higher prevalences of CSH (4/6), VVS (2/2), and PPH (3/4) were reported in fallers compared with controls in most studies, but most of these studies failed to show clear association measures. Coronary artery disease (6/10), orthostatic hypotension (9/25), general cardiovascular disease (4/9), and hypertension (7/25) all showed inconsistent associations with falls. Arterial stiffness was identified as an independent predictor for falls in one study, as were several echocardiographic abnormalities. CONCLUSION Several cardiovascular associations with falls were identified, including low BP, heart failure, and arrhythmia. These results provide several angles for optimizing fall-preventive care, but further work on standard definitions, as well as the exact contribution of individual risk factors on fall incidence is now important to find potential areas for preventive interventions.

Prognostic Value of A Qualitative Brain MRI Scoring System After Cardiac Arrest

To develop a qualitative brain magnetic resonance imaging (MRI) scoring system for comatose cardiac arrest patients that can be used in clinical practice.

AF is associated with self-reported syncope and falls in a general population cohort

BACKGROUND syncope is an important, but underestimated clinical problem in older persons. It is often overlooked in clinical practice or mistaken for falls. Atrial fibrillation (AF) is the most common cardiac arrhythmia, but little evidence exists regarding the association between AF, falls and syncope in the general population. METHODS cross-sectional analyses within a population sample of people aged 50+, taken from The Irish Longitudinal Study on Ageing. Ten-minute electrocardiogram recordings (n = 4,885) were analysed to detect AF. Syncope (self-reported faints or blackouts) and falls in the past year, co-morbidities, health measures and medications were gathered through computer-aided personal interviews. Multivariable logistic regression was performed to study associations between AF, falls and syncope. RESULTS mean age was 62 years (range: 50-91), 54% were female. Prevalence of AF was 3%, increasing to 8% in participants aged 75+. Of participants, 5% (n = 223) reported syncope and 20% (n = 972) reported falls. After adjustment for confounders, AF was significantly associated with faints and blackouts (odds ratio (OR) 2.0 [95% confidence interval (CI) 1.0-3.9]). After stratification by age category, we found that this association was strongest and only significant in participants aged 50-64 years (OR 4.4 [1.5-12.6]). Stratified for age group, AF was significantly associated with falls in participants aged 65-74 years (OR 2.0 [1.0-4.1]). CONCLUSIONS adults aged 50+ with self-reported syncope and adults aged 65-74 years with falls are twice as likely to have AF at physical examination. These associations are independent of stroke, cardiovascular and psychotropic drugs and other confounders. Further longitudinal studies are needed to explore this association and potential causality further.

SSRIs Increase Risk of Blood Transfusion in Patients Admitted for Hip Surgery

Background Recent studies have shown that an increased bleeding tendency can be caused by Selective Serotonin Reuptake Inhibitors (SSRI) use. We aimed to investigate the occurrence and risk of blood transfusion in SSRI users compared to non-SSRI users in a cohort of patients admitted for hip-surgery. Methods We conducted a retrospective cohort study of patients who underwent planned or emergency hip surgery from 1996 to 2011 in the Academic Medical Center in Amsterdam. Primary outcome measure was risk of blood transfusion. Secondary outcome measures were pre- and postoperative hemoglobin level. Multivariate logistic regression was used to adjust for potential confounders. Results One-hundred and fourteen SSRI users were compared to 1773 non-SSRI users. Risk of blood transfusion during admission was increased for SSRI users in multivariate analyses (OR 1.7 [95% CI 1.1–2.5]). Also, pre-operative hemoglobin levels were lower in SSRI users (7.8±1.0 mmol/L) compared to non-SSRI users (8.0±1.0 mmol/L) (p = 0.042)), as were postoperative hemoglobin levels (6.2±1.0 mmol/L vs. 6.4±1.0 mmol/L respectively) (p = 0.017)). Conclusions SSRI users undergoing hip surgery have an increased risk for blood transfusion during admission, potentially explained by a lower hemoglobin level before surgery. SSRI use should be considered as a potential risk indicator for increased blood loss in patients admitted for hip surgery. These results need to be confirmed in a prospective study.

Atrial Fibrillation Is Associated With Impaired Mobility in Community-Dwelling Older Adults

OBJECTIVES To examine the independent associations between atrial fibrillation (AF) and objectively measured mobility in a nationally representative cohort. DESIGN Wave 1 of The Irish Longitudinal Study on Ageing (TILDA), a population-based study assessing health, economic, and social aspects of ageing. SETTING Community-dwelling adults completed a home-based interview and a center-based health assessment. PARTICIPANTS Participants aged 50 years or older, with Mini-Mental State Examination score of 24 or higher, and who completed at least 1 mobility test (n = 4525). MEASUREMENTS Mobility was assessed with the Timed Up-and-Go (TUG) test and usual and dual task gait speed obtained using a 4.88-m GAITRite® mat. AF was diagnosed using a 10-minute surface electrocardiogram recording. Linear regression analyses were performed to compare mobility in participants with and without AF, adjusting for confounders. RESULTS In this sample (mean age 62.3 years; range 51-89), overall prevalence of AF was 3.1%, increasing to 6.7% in the over 70s (11.8% men; 2.8% women). In multivariate analysis, AF was independently associated with slower TUG (β 0.37; 95% confidence interval [CI] 0.07-0.71; P = .043) and slower usual gait speed (β -3.59; 95% CI -7.05 to -0.12; P = .030). There was a significant age*AF interaction effect for usual gait speed (β -0.480, 95% CI -0.907 to -0.053, P = .028). Adults with AF walked 3.77 cm/s more slowly than adults without AF at age 70, declining by 4.8 cm/s for each additional decade. CONCLUSION AF is independently associated with lower usual gait speed in community-dwelling adults and this effect is magnified in those aged 70 and older. This may place them at increased risk of falls, hospitalization, cognitive decline, and mortality, as well as stroke and heart failure. Early recognition and treatment of AF is vital to improve physical function and reduce this risk.

Self-reported cardiovascular conditions are associated with falls and syncope in community-dwelling older adults

BACKGROUND with increasing age, causes of syncope are more often of cardiac origin. Syncope in older persons is often mistaken for falls. Data regarding the association between specific cardiovascular conditions, falls and syncope are limited. METHODS cross-sectional analyses within a population sample aged 50+ (n = 8,173). Syncope and falls in the past year, cardiovascular conditions and co-variates were gathered through personal interviews. Associations between cardiovascular conditions and (recurrent) falls and syncope were studied through multivariable logistic regression. RESULTS mean age was 64 years (range: 51-105); 54% was female. Four per cent reported syncope, 19% falls and 23% cardiovascular morbidity. Abnormal heart rhythm was associated with falls (odds ratio (OR) 1.3 [95% confidence interval (CI) 1.0-1.5]), syncope (OR 1.6 [1.2-2.3]) and recurrent syncope (OR 2.2 [1.3-3.6]). Heart murmur was associated with falls (OR 1.4 [1.1-1.8]), recurrent falls (OR 1.5 [1.0-2.0]) and syncope (OR 1.9 [1.3-2.7]). Angina was associated with recurrent falls (OR 1.4 [1.0-1.9]), syncope (OR 1.8 [1.2-2.6]) and recurrent syncope (OR 2.7 [1.6-4.6]). Heart failure was associated with recurrent falls (OR 1.9 [1.0-3.4]) and myocardial infarction with syncope (OR 1.5 [1.0-2.3]). CONCLUSION self-reported cardiovascular conditions are associated with falls and syncope in a general population cohort. This warrants additional cardiovascular evaluation in older patients with unexplained falls and syncope.

Effectiveness of a Cardiovascular Evaluation and Intervention in Older Fallers: A Pilot Study

To the Editor: Cardiovascular abnormalities are increasingly being recognized as important fall-risk factors in older persons because syncope in older persons is often mistaken for falls because they have retrograde amnesia. Despite recommendations of falls guidelines, cardiovascular examinations are still not routinely performed in the evaluation of older fallers. Furthermore, the effectiveness of treating these abnormalities on fall incidence is uncertain. The efficacy and feasibility of a comprehensive cardiovascular evaluation and intervention were therefore studied in a prospective pilot study of individuals aged 65 and older with one or more falls in the past year referred to a falls clinic. In addition to the routine multidisciplinary falls assessment, in which “traditional” modifiable fall-risk factors were identified, a comprehensive cardiovascular assessment was performed, including structured history taking, echocardiography, electrocardiography, and tilt-table testing with continuous blood pressure (BP) recording. A multidisciplinary evaluation followed this, and treatment advice (cardiologist and geriatrician) was provided. Main cardiovascular fall-risk factors under consideration were orthostatic hypotension (OH), carotid sinus syndrome (CSS), vasovagal syncope, structural cardiac abnormalities (ventricular dysfunction, heart valve abnormalities), and cardiac arrhythmia, diagnosed according to syncope guidelines. The intervention was aimed at optimizing cardiovascular function (drug interventions, specific advice, invasive diagnostics and treatment) to improve the effectiveness of the multifactorial intervention. The primary outcome measure was diagnosis of one or more additional cardiovascular conditions that contributed to the fall incident, followed by subsequent treatment. Secondary outcome measures included feasibility of the multidisciplinary intervention, fall incidents, and related injuries during 6 months of follow-up. Fifteen participants were included (mean age 75 7, 67% female). In 10 participants, a diagnosis was made upon comprehensive cardiovascular examination. These abnormalities were considered a cause or contributing factor to the fall incident in seven participants (47%): initial OH in four, delayed OH in one, CSS in one, and drug-induced hypotension in one (Table 1). Five participants (33%) fell during follow-up; one fall was injurious. The evaluation and intervention appeared to be feasible in current clinical practice. Cardiovascular conditions can lead to near-syncope, and thus falls, in those who already have other fall-risk factors, such as unstable gait, poor vision, or use of sedative medications, whereas this is not necessarily the case for younger and healthier individuals. The results of the pilot study show that, even in participants in whom falls were considered explained after multifactorial falls assessment, cardiovascular abnormalities that contributed to their fall incidents were found. For diagnosis of initial OH and CSS, continuous noninvasive BP measurement is required, which is not yet routinely performed in most fall clinics. Therefore, two important modifiable risk factors (CSS and initial OH) may be overlooked in current fall-prevention care, because important BP drops may be missed using intermittent measurements. Echocardiographic and electrocardiographic abnormalities were found in half of participants, none of which were considered a contribution to the fall in this sample, but recent studies have linked atrial fibrillation, poor left ventricular function, and valve abnormalities to falls. This suggests that greater awareness of atrial fibrillation and structural cardiac abnormalities may be necessary in older fallers, but this requires further study. These results confirm the multifactorial nature of fall incidents and emphasized the need for a broad assessment of fallers, including cardiovascular risk factors. This contrasts with current syncope guidelines, in which detailed history taking is considered the cornerstone of syncope assessment. In six participants in whom a cardiovascular cause of or contribution to their fall was found, the Table 1. Findings of a Comprehensive Cardiovascular Evaluation in Older Fallers (N = 15)

In-hospital haloperidol use and perioperative changes in QTc-duration

ObjectivesHaloperidol may prolong ECG QTc-duration but is often prescribed perioperatively to hip-fracture patients. We aimed to determine (1) how QTc-duration changes perioperatively, (2) whether low-dose haloperidol-use influences these changes, and (3) which clinical variables are associated with potentially dangerous perioperative QTc-prolongation (PD-QTc; increase >50 ms or to >500 ms).DesignProspective cohort study.SettingTertiary university teaching-hospital.ParticipantsPatients enrolled in a randomized controlled clinical trial of melatonin versus placebo on occurrence of delirium in hip-fracture patients.MeasurementsData from ECGs made before and after hip surgery (1–3 days and/or 4–6 days post-surgery) were analyzed. QTc-duration was measured by hand, blinded for haloperidol and pre/post-surgery status. Clinical variables were measured at baseline. Mixed model analysis was used to estimate changes in QTc-duration. Risk-factors for PD-QTc were estimated by logistic regression analysis.ResultsWe included 89 patients (mean age 84 years, 24% male); 39 were treated with haloperidol. Patients with normal pre-surgery QTc-duration (male ≤430 ms, female ≤450 ms) had a significant increase (mean 12 ms, SD 28) in QTc-duration. A significant decrease (mean 19 ms, SD 34) occurred in patients with prolonged pre-surgery QTc-duration (male >450ms, female >470 ms). Haloperidol-use did not influence the perioperative course of the QTc-interval (p=0.351). PD-QTc (n=8) was not associated with any of the measured risk-factors.ConclusionQTc-duration changed differentially, increasing in patients with normal, but decreasing in patients with abnormal baseline QTc-duration. PD-QTc was not associated with haloperidol-use or other risk-factors. Low-dose oral haloperidol did not affect perioperative QTc-interval.

Decreased left ventricular (LV) function is associated with hip-fractures

BACKGROUND Several risk factors for falls and hip-fractures have been recognized, but controversy still exists toward the importance of structural cardiac abnormalities as a potentially modifiable risk factor for recurrent falls. Aim of this study was to determine the association between echocardiographic abnormalities and hip-fractures. METHODS Design case-control study within consecutive patients undergoing hip-surgery in an academic hospital. CASES patients with traumatic hip-fractures. CONTROLS patients undergoing planned hip surgery (non-traumatic). INCLUSION CRITERIA age≥50 years, presence of pre-operative echocardiogram. EXCLUSION CRITERIA high energy trauma, pathological and/or previous hip-fracture. OUTCOME echocardiographic abnormalities (ventricular function, atrial enlargement, valve stenosis and/or regurgitation, pulmonary hypertension (pulmonary artery pressure (PAP) ≥35mmHg)). Multivariate logistic regression was performed to calculate odds ratios (OR) and to correct for confounders. RESULTS We included 197 patients (141 cases). Mean age was 77 years (SD), 65% female. After adjustment for potential confounders, decreased LV systolic function was associated with hip-fractures (OR 3.2 [95%CI 1.1-9.1]). Increasing severity of LV dysfunction was also associated with hip-fractures (p for trend=0.012). DISCUSSION In conclusion, patients with traumatic hip-fracture had greater risk of decreased LV function than patients who underwent planned hip-surgery. Possibly, decreased LV function is an underestimated risk factor for injurious falls.