Increased interleukin-6 but not tumour necrosis factor-alpha predicts mortality in the population of elderly heart failure patients

BACKGROUND: Increased proinflammatory cytokines have mainly been studied in younger patients with heart failure and are regarded as prognostic markers. However, whether this holds true in elderly patients with heart failure remains uncertain. OBJECTIVES: To determine whether inflammation is equally important in the progression of heart failure in the elderly as has been previously reported in younger patients, and whether cytokine level can predict mortality in this population of elderly heart failure patients. METHODS: The cytokine profile in an elderly patient group with severe heart failure (n=54, mean [+/- SD] age of 80.1+/-5.0 years, New York Heart Association class III or IV) was compared with that of age-matched healthy individuals (n=70). Of the 54 study patients, 46% were hypertensive, 54% had coronary artery disease, 43% had atrial fibrillation and 24% had a previous stroke. One-year mortality was 24%. RESULTS: The results showed increased levels of interleukin-6 (IL-6), tumour necrosis factor-alpha and epidermal growth factor in the heart failure patients compared with those in the control group. Moreover, IL-6, tumour necrosis factor-alpha and vascular endothelial growth factor were significantly increased in patients who died within one year. Further logistic regression analyses showed that IL-6 was the only significant predictor of one-year mortality. In a subgroup of heart failure patients with atrial fibrillation, there were significant cytokine activations, whereas in a subgroup with ischemia or diabetes, cytokines were less activated. CONCLUSIONS: In the present octogenarian group with heart failure, there were significant increases of inflammatory cytokines that were associated with mortality, and IL-6 was the only cytokine to predict one-year mortality. Cytokine activation was more pronounced in the subgroup of patients with heart failure and concomitant atrial fibrillation.     

Clinical trials update from the European Society of Cardiology Heart Failure meeting: COMET,COMPANION, Tezosentan and SHAPE

This article continues a series of reports on recent research developments in the field of heart failure. Key presentations made at the European Society of Cardiology Heart Failure Update meeting, held in Strasbourg, France are described. The COMET study showed a 17% relative risk reduction in all-cause mortality with carvedilol compared with metoprolol tartrate. The COMPANION study, as previously reported, showed encouraging results for the use of cardiac resynchronisation and implantable defibrillator therapy in patients with heart failure, but further evidence is awaited. The results of a study on tezosentan suggest that lower doses of this endothelin antagonist may be clinically more effective with fewer adverse effects compared with higher doses. The SHAPE survey of heart failure awareness in Europe identified a need for further heart failure education amongst the public, patients, their carers and primary care physicians.     

Clinical trials update from the European Society of Cardiology heart failure meeting 2009: CHANCE,B‐Convinced,CHAT, CIBIS‐ELD,and Signal‐HF

This paper provides information and a commentary on trials relevant to the pathophysiology, prevention, and treatment of heart failure presented at the annual meeting of the Heart Failure Association of the European Society of Cardiology held in Nice. The CHANCE study showed a substantial reduction in morbidity and mortality in a randomized controlled trial (RCT) of a multidisciplinary management programme for patients with chronic heart failure in Russia. Data from the B‐Convinced study, also an RCT, suggest that continuation of beta‐blocker (BB) therapy in patients hospitalized with worsening heart failure may be associated with improved outcomes when compared with treatment discontinuation. The CHAT study suggests that telephone support can improve prognosis in heart failure patients living in remote rural locations. CIBIS‐ELD showed that titration of BBs to target doses in older patients with heart failure is more difficult; but tolerance levels were similar for bisoprolol and carvedilol. Signal‐HF randomized elderly heart failure patients to treatment guided by NT‐proBNP levels or usual care, and showed no effect of NT‐proBNP‐guided treatment on outcomes.     

Clinical trials update and cumulative meta-analyses from the American College of Cardiology: WATCH, SCD-HeFT, DINAMIT, CASINO, INSPIRE, STRATUS-US, RIO-Lipids and cardiac resynchronisation therapy in heart failure

This article continues a series of reports on recent research developments in the field of heart failure. Key presentations made at the American College of Cardiology meeting, held in New Orleans, Louisiana, USA in March 2004 are reported. These new data have been added to existing data in cumulative meta-analyses. The WATCH study randomised 1587 patients with heart failure and left ventricular systolic dysfunction to warfarin, aspirin or clopidogrel. The study showed no difference between the effects of these agents on mortality or myocardial infarction, but hospitalisations for heart failure were higher on aspirin (22.2%) compared to warfarin (16.1%). The SCD-HeFT study showed that ICD therapy reduced all-cause mortality at 5 years by 23% in patients with predominantly NYHA class II heart failure and left ventricular systolic dysfunction, but amiodarone was ineffective. The DINAMIT study showed that ICD therapy was not beneficial in patients with left ventricular dysfunction after a recent MI, even in those with risk factors for arrhythmic death. In CASINO, levosimendan improved survival compared with dobutamine or placebo in patients with decompensated heart failure. INSPIRE showed that SPECT imaging can be used to assess risk early after acute MI safely and accurately. Rimonabant was shown to be safe and effective in treating the combined cardiovascular risk factors of smoking and obesity. An overview of new developments in cardiac resynchronisation therapy (CRT) in heart failure is also reported.     

Efficacy, safety and tolerability of beta-adrenergic blockade with metoprolol CR/XL in elderly patients with heart failure.

AIM: To study the efficacy and tolerability of beta-blockade in elderly patients with heart failure in the MERIT-HF study. METHODS AND RESULTS: Cox proportional hazards model was used to calculate hazard ratios (HR) with 95% confidence intervals (CI). Risk reduction was defined as (1-HR). In patients > or = 65 years total mortality was reduced by 37% (95% CI 17% to 52%; p=0.0008), sudden death by 43% (95% CI 17% to 61%; p=0.0032), and death from worsening heart failure by 61% (95% CI 32% to 77%; p=0.0005). Hospitalisations for worsening heart failure was reduced by 36% (p=0.0006). Elderly patients with severe heart failure (NYHA class III/IV with ejection fraction < 0.25; n=425, and patients above 75 years (n=490) showed similar risk reductions. Metoprolol CR/XL was safe and well tolerated both during initiating therapy and during long-term follow-up. CONCLUSIONS: Metoprolol CR/XL was easily instituted, safe and well tolerated in elderly patients with systolic heart failure. The data suggest that these are the patients in whom treatment will have the greatest impact as shown by number of lives saved and number of hospitalisations avoided. The time has come to overcome the barriers that physicians perceive to beta-blocker treatment, and to provide it to the large number of elderly patients with heart failure in need of this therapy.     

Clinical trials update from Heart Rhythm 2008 and Heart Failure 2008: ATHENA, URGENT, INH study, HEART and CK-1827452

This article provides information and a commentary on trials relevant to the pathophysiology, prevention and treatment of heart failure, presented at the Heart Rhythm Society meeting in San Francisco, USA and the Heart Failure Association meeting of the European Society of Cardiology which was held in Milan, Italy in June 2008. Unpublished reports should be considered as preliminary data, as analyses may change in the final publication. The ATHENA study showed that dronedarone reduced the incidence of the composite outcome of cardiovascular hospitalisation or death, in patients with atrial fibrillation or flutter, 29% of whom had a history of heart failure, compared with placebo. The URGENT study demonstrated that treatment of acute heart failure with standard therapy, including intravenous diuretics and nitrates, leads to a rapid resolution of breathlessness in the sitting position but that orthopnoea often persists. The INH study showed that a disease management programme could reduce mortality compared to usual care but not hospitalisation rates. The HEART study failed to recruit its planned number of patients, although it is the largest randomised trial of revascularisation in heart failure reported to date. At a median follow-up of 5 years no difference in mortality was observed but the study lacked power to provide a conclusive result. The selective myosin activator CK-1827452 produced a concentration dependent increase in systolic ejection time, stroke volume and fractional shortening in patients with heart failure compared to placebo.     

Clinical trials update from the American College of Cardiology meeting: CARE-HF and the remission of heart failure, Women's Health Study, TNT, COMPASS-HF, VERITAS, CANPAP, PEECH and PREMIER

This article provides information and a commentary on landmark trials presented at the American College of Cardiology meeting held in March 2005, relevant to the pathophysiology, prevention and treatment of heart failure. All reports should be considered as preliminary data, as analyses may change in the final publication. CARE-HF showed that Cardiac Re-synchronisation Therapy, administered in addition to expert pharmacological management, reduced all cause mortality and CV hospitalisation in patients with moderate or severe heart failure and cardiac dyssynchrony. The Women's Health Study showed no benefit of vitamin E supplementation or aspirin in the primary prevention of CV disease. The TNT study showed that reducing LDL cholesterol to levels lower than currently recommended, produced a 22% reduction in the incidence of major cardiovascular events. In COMPASS, an implantable device that continuously monitors intra-cardiac pressures was shown to be safe and to improve care in patients with chronic heart failure. Tezosentan failed to show benefit in patients with acute heart failure in the VERITAS study. The CANPAP study failed to show a benefit of continuous positive airway pressure on mortality and heart transplantation in heart failure patients with central sleep apnoea. EECP therapy improved exercise capacity but had no effect on peak VO2 in heart failure patients in the PEECH study. In the PREMIER study the matrix metalloproteinase inhibitor PG-116800 failed to prevent LV remodelling following myocardial infarction.     

Treatment of myocardial infarction in a community hospital coronary care unit. Experience with 1,246 patients

The hospital mortality in 1,246 consecutive acute myocardial infarction patients treated in a large community hospital coronary care unit was 14.4%. Of the total, 52.3% showed no evidence of heart failure, 25.8% had mild to moderate failure, 9.9% had pulmonary edema, and 12% developed cardiogenic shock; the mortality in these groups was 2.2%, 7.4%, 8.9%, and 87.2%, respectively. The mortalitiy in the 1,097 patints who did not have cardiogenic shock was 4.5%. Only one patient died as a result of primary ventricular fibrillation (0.08%). The mortality of complete heart block in the absence of cardiogenic shock (8.3%) was not significantly different from that of comparable patients who did not have complete heart block (4.3%). These results are lower than those generally reported.     

Clinical trials update from the American Heart Association meeting: Omega-3 fatty acids and arrhythmia risk in patients with an implantable defibrillator, ACTIV in CHF, VALIANT, the Hanover autologous bone marrow transplantation study, SPORTIF V, ORBIT and PAD and DEFINITE

The American Heart Association meeting reported the results of several clinical trials of particular interest to those who care for patients with heart failure. Omega-3 fatty acids were associated with a trend to increased recurrence of ventricular arrhythmias but not mortality in patients with an implantable debrillator. The ACTIV in CHF study provides more evidence of a therapeutic role for arginine vasopressin antagonists in the treatment of heart failure. The VALIANT study provides further evidence to suggest that a combination of angiotensin receptor antagonist and ACE inhibitor does not reduce mortality but may reduce morbidity in post-MI patients with heart failure or major LV systolic dysfunction. A study of autologous bone marrow cell transplantation into myocardial scar give gave encouraging results. SPORTIF V showed ximelagation to be as effective as warfarin but with improved safety. ORBIT and PAD showed public access defibrillators saved lives but questioned their cost effectiveness. DEFINITE supported a role for ICDs in patients with non-ischemic cardiomyopathy, although cost-effectiveness remains in doubt.     

Acute transmural myocardial infarction in elderly patients hospitalized in the coronary care unit versus the general medical ward

The hospital records of 126 patients over 75 years of age with transmural myocardial infarction initially treated in the coronary care unit were compared with a concurrent similar group of 94 patients admitted directly to the general medical wards. The in-hospital mortality rate for both groups together was 40%. The mortality rate within the coronary care unit was 24% as compared with 46% in the ward group (P less than 0.005). However, the mortality rate for the coronary care unit group as a whole (including those patients later transferred to the general ward) was 35 versus 46% in the ward group. Congestive heart failure and cardiogenic shock were the most frequent complications in both groups (47 and 30%, respectively), and they were the main cause of death. Patients with these complications were less likely to be successfully resuscitated, even in the coronary care unit. The overall incidence of serious ventricular arrhythmias and complete heart block was similar to that reported for younger patients. Eleven patients in the coronary care unit group were successfully resuscitated from these arrhythmias and eight survived to be discharged from hospital. In contrast, only two patients in the ward group were successfully resuscitated and eight (9%) patients died suddenly and the fatal event could not be diagnosed. We concluded that elderly patients with an acute myocardial infarction can benefit from early admission to a coronary care unit.     

Quality and outcomes of heart failure care in older adults: role of multidisciplinary disease-management programs

PURPOSE: To determine whether the management of heart failure by specialized multidisciplinary heart failure disease-management programs was associated with improved outcomes. BACKGROUND: The advent of angiotensin-converting enzyme inhibitors, beta-blockers, and spironolactone has revolutionized the management of heart failure. Randomized double-blind studies have demonstrated survival benefits of these drugs in heart failure patients. Nevertheless, in spite of these advances, heart failure continues to be a syndrome of poor outcomes.1-4 There is also evidence that a significant portion of heart failure patients does not receive this evidence-based therapy that reduces morbidity and mortality.5-7 Various disease-management programs have been proposed and tested to improve the quality of heart failure care. Most of these programs are specialized multidisciplinary heart failure clinics lead by cardiologists or heart failure specialists and conducted by nurses or nurse practitioners. Similar to the Department of Veterans Affairs (VA) multidisciplinary geriatric assessment clinics, these clinics also use many other services, including pharmacists, dietitians, physical therapists, and social workers. Some of these programs also have an affiliated home health service. Several observation studies, using mostly pre- and postcomparison designs, have demonstrated the effectiveness of these programs in the process of care, resource use, healthcare costs, and clinical outcomes in patients with heart failure.8 Risk of hospitalization was reduced by 50% to 85% in six of the studies.8 Subsequently, several randomized trials were conducted to determine the effectiveness of these programs. The purpose of this systematic review was to determine the effectiveness of these programs on mortality and hospitalization rates of heart failure patients. METHODS: Published articles on human randomized trials involving specialized heart failure disease-management programs in all languages were searched using Medline from 1966 to 1999 and other online databases using the following terms and Medical Subject Headings: case management (exp); comprehensive health care (exp); disease management (exp); health services research (exp); home care services (exp); clinical protocols (exp); patient care planning (exp); quality of health care (exp); nurse led clinics; special clinics; and heart failure, congestive (exp). In addition, a manual search of the bibliographies of searched articles was performed to identify articles otherwise missed in the above search. Personal communications were made with three authors to obtain further data on their studies. Using a data abstraction tool, two of the investigators separately abstracted data from the selected articles. Data from the selected studies were combined using the DerSimonian and Laird random effects model and the Mantel-Haenszel-Peto fixed effects model. Meta-Analyst 0.998 software (J. Lau, New England Medical Center, Boston, MA) was used to determine risk ratios (RRs) with 95% confidence intervals (CIs) of mortality and hospitalization for patients receiving care through these specialized programs compared with those receiving usual care. The Cochran Q test was used to test heterogeneity among the studies, and sensitivity analyses were performed to examine the effect of various covariates, such as duration of intervention, and other characteristics of the disease-management programs. RESULTS: The original search resulted in 416 published articles, of which 35 met preliminary selection criteria. Of these, 11 were randomized trials and were selected for the meta-analysis. Studies that were not randomized trials, did not involve heart failure patients or disease-management programs, or had missing outcomes were excluded. Of the 11 studies selected, nine involved specialized follow-up using multidisciplinary teams and the remaining two involved follow-up by primary care physicians and telephone. These studies involved 1,937 heart failure patients with a mean age of 74. The follow-up period ranged from no follorom no follow-up (one study) to 1 year (one study). Patients receiving care from specialized heart failure disease-management programs had a 13% lower risk of hospitalization than those receiving usual care (summary RR = 0.87; 95% CI = 0.79 -0.96), but the Cochran Q test demonstrated significant heterogeneity among the studies (P =.003). Subgroup analysis of the nine studies using specialized follow-up by a multidisciplinary team showed similar results (summary RR = 0.77, 95% CI = 0.68-0.86; test of heterogeneity, P>.50). Seven of the nine studies did not show any significant association between intervention and reduced hospitalization, but the two studies that used follow up by primary care physicians and telephone failed to show any significant reduction in hospitalization (summary RR = 0.94, 95% CI = 0.75-1.19). In fact, one of the studies demonstrated a higher risk of hospitalization for patients receiving intervention (RR = 1.26, 95% CI = 1.04-1.52). Of the 11 studies, only six reported mortality as an outcome. None of these studies found any association between intervention and mortality (summary RR = 1.15, 95% CI = 0.96-1.37; test of heterogeneity, P>.15). Five of the studies used quality of life or functional status as outcomes, and, of them, only one demonstrated significant positive association. The results of the sensitivity analyses were negative for any significant association with duration of intervention or follow-up or year of study. Eight studies performed cost analyses and seven demonstrated cost-effectiveness of the intervention. CONCLUSIONS: The authors concluded that specialized disease-management programs were cost-effective, and heart failure patients cared for by these programs were more likely to undergo fewer hospitalizations, but the study did not provide any conclusive association between these programs and quality of care or mortality. The authors recommend that disease-management programs involve patient education and specialized follow-up by a multidisciplinary team including home health care.     

Influence of age on the short- and medium-term prognosis in patients with acute myocardial infarct

Elderly patients with acute myocardial infarction (AMI) have a higher subsequent mortality than younger ones, yet the reasons for this adverse prognosis are poorly understood. We compared the clinical course and the prognosis of 163 patients aged 40 to 69 years with 112 patients older than 70 years. During hospitalization period 15.9% of younger and 37.5% of older patients died; at 1 year follow-up the cardiac mortality rate was 8.7% in younger and 12.9% in older patients. In elderly patients a greater prevalence of female gender, diabetes mellitus, anterior myocardial infarction, atrial fibrillation and a greater incidence of heart failure and shock were observed. Multivariate stepwise analysis identified shock and heart rate greater than or equal to 90 bpm at the time of admission as the most important prognostic variables for in-hospital mortality in both groups; heart failure (Killip class II and III) was significant in younger patients, while non Q wave myocardial infarction correlated with a better prognosis in elderly. In elderly patients who survived AMI, predischarge Holter monitoring showed higher frequency and complexity of ventricular arrhythmias, and radionuclide angiography lower left ventricular ejection fraction (E.F.) values. In these patients no difference was found in E.F. values despite myocardial infarction sites. At 1 year follow-up E.F. less than 40% and ventricular arrhythmias (3-4 Moss grading system) were significantly related to prognosis in younger patients, while E.F. less than 40% and clinical signs of heart failure in elderly. Therefore, low E.F. and heart failure account for a worse prognosis in elderly patients, while ventricular arrhythmias in younger ones. The results of this study support aggressive management even in elderly patients following AMI to preserve left ventricular function. In elderly patients a large use of antiarrhythmic drugs is not recommended because of low prognostic value of ventricular arrhythmias.     

Should β Blockers Be Used in the Treatment of Hypertension in the Elderly?

The lack of benefit and the potential negative side effects of β blockers are overstated, especially in the elderly. This emphasis has led to recommendations by some investigators that these agents not be used in the management of hypertension in this age group. There are numerous reasons why these recommendations should not be followed. The use of β blockers in the elderly hypertensive has resulted in a reduction in strokes and congestive heart failure. In addition, it should be emphasized that elderly patients are more likely to have silent coronary artery disease or sustain myocardial infarctions. There is abundant evidence that β blockers are effective therapy in reducing mortality once a myocardial infarction has occurred. In fact, there is a clear reduction in sudden cardiac death. Furthermore, national statistics document that elderly patients have a prevalence of congestive heart failure that varies from 6%–10%. Multiple studies have now documented that β blockers are additive to angiotensin-converting enzyme inhibitors in reducing mortality for congestive heart failure. Thus, elderly hypertensive patients may benefit from the use of β blockers, especially if there is evidence of ischemic heart disease, cardiac arrhythmias, or congestive heart failure.     

Congestive heart failure and cognitive impairment in the elderly

Congestive heart failure (CHF) represents the most frequent cause of death and disability in the elderly. The prevalence of impairment of cognitive abilities is very high in aging and several clinical studies have demonstrated high association between cardiovascular diseases (in particular CHF) and cognitive deterioration. However, little attention has been paid to the decline of cognitive functioning during congestive heart failure in elderly patients. In this paper an overview of studies investigating this association is offered, suggesting that hemodynamic alterations due to heart failure and cognitive deteriorations are very frequently associated in aging, increasing morbidity and mortality risks. Moreover, preliminary results of a prospective study on hospitalized elderly patients with heart disease are reported (CHF Italian Study). These data show that some psychosocial variables (illiteracy, depression, and particularly cognitive deterioration) determine a significant increase of the risk to develop heart failure. This paper confirms that a multidimensional approach is necessary to better characterize and treat elderly patients, in particular those with CHF. More attention should be paid to encourage mild physical activity, to provide emotional support to patients and also to assess their general cognitive abilities. Studies on large populations of patients with heart disease have to be designed to investigate psychosocial and cognitive status in these patients.     

Should β Blockers Be Used in the Treatment of Hypertension in the Elderly?

The lack of benefit and the potential negative side effects of beta blockers are overstated, especially in the elderly. This emphasis has led to recommendations by some investigators that these agents not be used in the management of hypertension in this age group. There are numerous reasons why these recommendations should not be followed. The use of beta blockers in the elderly hypertensive has resulted in a reduction in strokes and congestive heart failure. In addition, it should be emphasized that elderly patients are more likely to have silent coronary artery disease or sustain myocardial infarctions. There is abundant evidence that beta blockers are effective therapy in reducing mortality once a myocardial infarction has occurred. In fact, there is a clear reduction in sudden cardiac death. Furthermore, national statistics document that elderly patients have a prevalence of congestive heart failure that varies from 6%-10%. Multiple studies have now documented that beta blockers are additive to angiotensin-converting enzyme inhibitors in reducing mortality for congestive heart failure. Thus, elderly hypertensive patients may benefit from the use of beta blockers, especially if there is evidence of ischemic heart disease, cardiac arrhythmias, or congestive heart failure.     

A systematic review of telemonitoring for the management of heart failure

BACKGROUND: Telemonitoring allows a clinician to monitor, on a daily basis, physiological variables measured by patients at home. This provides a means to keep patients with heart failure under close supervision, which could reduce the rate of admission to hospital and accelerate discharge. OBJECTIVE: To review the literature on the application of telemedicine in the management of heart failure. METHODS: A literature search was conducted on studies involving telemonitoring and heart failure between 1966 and 2002 using Medline, Embase, Cochrane Library and Journal of Telemedicine and Telecare. RESULTS: Eighteen observational studies and six randomised controlled trials involving telemonitoring and heart failure were identified. Observational studies suggest that telemonitoring; used either alone or as part of a multidisciplinary care program, reduce hospital bed-days occupancy. Patient acceptance of and compliance with telemonitoring was high. Two randomised controlled trials suggest that telemonitoring of vital signs and symptoms facilitate early detection of deterioration and reduce readmission rates and length of hospital stay in patients with heart failure. One study also showed a reduction in readmission charges. One substantial randomised controlled study showed a significant reduction in mortality at 6 months by monitoring weight and symptoms in patients with heart failure; however, no difference was observed in readmission rates. Another randomised study comparing video-consultation performed as part of a home health care programme for patients with a variety of diagnoses, suggested a reduction in the costs of hospital care, which offset the cost of video-consultation. Patients with heart failure were not reported separately. One randomised study showed no difference in outcomes between the telemonitoring group and the standard care group. CONCLUSION: Telemonitoring might have an important role as part of a strategy for the delivery of effective health care for patients with heart failure. Adequately powered multicentre, randomised controlled trials are required to further evaluate the potential benefits and cost-effectiveness of this intervention.     

Pro–A-Type Natriuretic Peptide,Proadrenomedullin, and N-Terminal Pro–B-Type Natriuretic Peptide Used in a Multimarker Strategy in Primary Health Care in Risk Assessment of Patients With Symptoms of Heart Failure

ObjectiveUse of new biomarkers in the handling of heart failure patients has been advocated in the literature, but most often in hospital-based populations. Therefore, we wanted to evaluate whether plasma measurement of N-terminal pro–B-type natriuretic peptide (NT-proBNP), midregional pro–A-type natriuretic peptide (MR-proANP), and midregional proadrenomedullin (MR-proADM), individually or combined, gives prognostic information regarding cardiovascular and all-cause mortality that could motivate use in elderly patients presenting with symptoms suggestive of heart failure in primary health care.Methods and ResultsThe study included 470 elderly patients (mean age 73 years) with symptoms of heart failure in primary health care. All participants underwent clinical examination, 2-dimenstional echocardiography, and plasma measurement of the 3 propeptides and were followed for 13 years. All mortality was registered during the follow-up period. The 4th quartiles of the biomarkers were applied as cutoff values. NT-proBNP exhibited the strongest prognostic information with >4-fold increased risk for cardiovascular mortality within 5 years. For all-cause mortality MR-proADM exhibited almost 2-fold and NT-proBNP 3-fold increased risk within 5 years. In the 5–13-year perspective, NT-proBNP and MR-proANP showed significant and independent cardiovascular prognostic information. NT-proBNP and MR-proADM showed significant prognostic information regarding all-cause mortality during the same time. In those with ejection fraction (EF) <40%, MR-proADM exhibited almost 5-fold increased risk of cardiovascular mortality with 5 years, whereas in those with EF >50% NT-proBNP exhibited >3-fold increased risk if analyzed as the only biomarker in the model. If instead the biomarkers were all below the cutoff value, the patients had a highly reduced mortality risk, which also could influence the handling of patients.ConclusionsThe 3 biomarkers could be integrated in a multimarker strategy for use in primary health care.     

The role of hospitalists in the management of acute decompensated heart failure

Heart failure and episodes of acute decompensated heart failure have an important effect on the US health care system, especially the elderly Medicare population. Efforts to improve the quality of care for patients hospitalized with acute decompensated heart failure have focused on creating standardized treatment guidelines based on substantial clinical evidence, but inadequate implementation of these guidelines continues to result in excess morbidity and mortality from heart failure. Hospitalists specializing in inpatient treatment strategies may play an important role in implementing clinical guidelines because their main commitment is to overall clinical treatment of inpatients. This review focuses on current recommended guidelines for diagnosis, treatment, and long-term management of patients with acute decompensated heart failure and the hospitalist's role in providing the oversight needed to adhere to these guidelines and manage this complex disease state.     

Integrating palliative care into heart failure care

Heart failure is a condition for which both palliative care and hospice care can be appropriate. The disease's increasing prevalence and predilection for elderly patients with significant comorbidity underscore the need to integrate these modes of care with the acute care approach that has dominated heart failure treatment. We propose integration of a palliative care approach early in the course of heart failure treatment and a tiered process for selecting patients for hospice care. A transition of the focus to palliative care rather than mortality reduction should occur over time, when clinical status deteriorates and advanced therapeutic options become inappropriate or ineffective. Failure to respond to the need for palliative care puts at risk the mandate to treat the patient with heart failure during the entire course of illness.     

Unstable angina in the elderly: clinical, profile, management and mortality at three months. The PEPA Registry Data

INTRODUCTION AND OBJECTIVES: Few reports in the literature have studied the characteristics and management of unstable angina in the elderly in Spain. The aim of this study was to analyze the clinical characteristics and the use of diagnostic and therapeutic resources in patients > or = 70 years of age. PATIENTS AND METHODS: A total of 1,551 patients > or = 70 years of age were included out of 4,115 included in the PEPA registry with a follow up of 90 days. These patients were compared with 2,564 < 70 years. RESULTS. In comparison, the elderly (76 +/- 5 years) versus the younger group (58 +/- 8.5 years) included a higher proportion of women (43 vs 27%), diabetics (30 vs 23%)and hypertensive patients (60 vs 49%) with a lower proportion (p < 0.001) of hypercholesterolemia (33 vs 43%), smoking (40 vs 60%) or family history (9 vs 17%). A previous history of angina (49 vs 35%) or infarction (38 vs31%) and comorbidity was found to be significantly more frequent in the elderly, with a worse previous functional class (NYHA > 2 out of 34 vs 15%). The elderly were treated with fewer invasive procedures (25 vs 44%) or catheterization (26 vs 36%) and they were more frequently controlled with medical treatment (86 vs 83%) although with a lower use of beta blockers (45 vs 53%). The mortality at 3 months was greater in the elderly (7.4 vs 3.0%;p < 0.005) with age being an independent predictor of bad prognosis. Cox multivariate analysis showed the age, ST segment depression, diabetes and heart failure on admission to be predictors of bad prognosis in the elderly. CONCLUSIONS: A different pattern is observed in cardiovascular risk factors with a more unfavorable clinical profile in elderly patients with unstable angina. The management of these patients is less aggressive and the mortality is greater. Diabetes, heart failure and ST segment depression on admission are independent predictors of bad prognosis in elderly patients.