Acute liver failure; clinical features and management.

Acute liver failure (ALF) is uncommon and may be associated with a high mortality rate. Its aetiology shows considerable geographical variation, with viral hepatitis the most common worldwide, whilst acetaminophen (paracetamol) induced hepatotoxicity forms the most common precipitant in many developed countries. Its management requires meticulous intensive care and the effective management of haemodynamic, septic and cerebral complications. The early identification of patients unlikely to survive without emergency liver transplantation is important to maximize the possibility of an available graft. Survival in those patients who undergo transplantation may be in excess of 75%.     

Acute heart failure in elderly patients: a review of invasive and non-invasive management

Acute heart failure (AHF) is a major cause of unplanned hospitalisations in the elderly and is associated with high mortality. Its prevalence has grown in the last years due to population aging and longer life expectancy of chronic heart failure patients. Although international societies have provided guidelines for the management of AHF in the general population, scientific evidence for geriatric patients is often lacking, as these are underrepresented in clinical trials. Elderly have a different risk profile with more comorbidities, disability, and frailty, leading to increased morbidity, longer recovery time, higher readmission rates, and higher mortality. Furthermore, therapeutic options are often limited, due to unfeasibility of invasive strategies, mechanical circulatory support and cardiac transplantation. Thus, the in-hospital management of AHF should be tailored to each patient’s clinical situation, cardiopulmonary condition and geriatric assessment. Palliative care should be considered in some cases, in order to avoid unnecessary diagnostics and/or treatments. After discharge, a strict follow-up through outpatient clinic or telemedicine is can improve quality of life and reduce rehospitalisation rates. The aim of this review is to offer an insight on current literature and provide a clinically oriented, patient-tailored approach regarding assessment, treatment and follow-up of elderly patients admitted for AHF.

Heart failure (HF) is a growing health issue affecting around 2% of the adult population in developed countries.^[1] HF predominantly concerns elderly patients, since its incidence doubles in men and triples in women with each decade after the age of 65 years.^[2] HF is a common cause of hospitalisation, accounting for an estimated annual expense of at least 108 billion dollars in direct and indirect costs for health economies worldwide.^[3] This disease may develop insidiously or presenting in an emergent fashion with rapidly progressive signs and symptoms, in the constellation of acute HF (AHF). Depending on the clinical profile, patients hospitalised with AHF may require loop diuretics to treat congestion, vasodilators, inotropic or vasopressor therapy, and non-invasive ventilation. Advanced interventions such as mechanical ventilation or mechanical circulatory support necessitate admission to an intensive care unit.^[4,5] Since elderly patients with HF commonly differ from younger patients in terms of comorbidities, disability and drug therapy, they are often excluded from invasive and complex interventions, requiring tailored therapeutic pathways based on their clinical status and life expectancy. Furthermore, hospitalisation for AHF in the aged population is associated with higher rates of mortality, rehospitalisation, and decline in physical activity.^[6–8] Earlier data suggested a 1-year all-cause mortality of 56% in patients aged > 75 years. ^[9] Finally, these patients have a greater symptom burden and a worse quality of life (QoL) than age-matched individuals with stable HF.^[10]Several attempts to improve the outcomes of geriatric patients have been done in the last years, although they are often excluded from HF clinical trials and underrepresented in clinical registries.^[7,11] Thus, the information about the clinical profile and prognosis of patients hospitalised for AHF at extreme ranges of age is scarce. The purpose of this review is to offer an insight on current literature and provide a clinically oriented, patient-tailored approach regarding assessment, treatment and follow-up of elderly patients admitted for AHF.     

Conduct of clinical trials in acute heart failure: regional differences in heart failure clinical trials

Clinical trials are often conducted globally. Differences in standard of care, patient populations including genetic and phenotypic differences, disease etiologies, rates of comorbidities, ascertainment of endpoints, and differences in concomitant therapies and medical culture may influence subsequent outcomes. There has been little consensus on how clinical trial results should be evaluated. This article reviews the differences in cardiovascular trial results by geographic region, offers potential explanations for these differences, and suggests methods for standardization of trial results.     

Systolic heart failure in the elderly: optimizing medical management

The aging population with hypertension and coronary artery disease is rapidly increasing worldwide and develops heart failure (HF). A wide range of pharmacotherapeutic drugs are recommended in the HF management guidelines. For the most part, these recommendations are based on the results of studies in the younger population, and most drugs were not adequately tested in the elderly. However, many changes that occur during the aging process affect the response to several of the recommended therapeutic drugs. Physicians will be increasingly involved in managing the expanding elderly population with HF. It is therefore imperative that they recognize ways to use current pharmacotherapeutic agents and the increasing need for novel agents for optimizing the management of the elderly patient with HF.     

Office management of heart failure in the elderly

Heart failure is one of the most common conditions affecting older patients seen by clinicians in routine office practice. This article reviews the clinical features, diagnosis, and management of heart failure in elderly patients evaluated in the ambulatory care setting, and provides concise, practical information relevant to all major aspects of care. Specific topics include the role of diagnostic testing, such as echocardiography and B-type natriuretic peptide; principles of nonpharmacological management, including patient education, diet, exercise, and daily weights; drug therapy for systolic heart failure as well as heart failure with preserved left ventricular systolic function; end-of-life issues; and when to refer the patient to a specialist. Although heart failure in the elderly differs in many important respects from heart failure occurring in middle-aged patients, the general approach to diagnosis and management is similar in younger and older patients.     

Acute heart failure in the emergency department: short and long-term outcomes of elderly patients with heart failure

AIMS: Previous epidemiologic studies of acute heart failure (AHF) have involved patients admitted to hospital and fail to account for that unknown proportion discharged directly from the emergency department (ED). We examined discharge rates, and whether outcomes, including mortality, differed based on admission status in AHF. METHODS AND RESULTS: This population-based cohort included all patients > or =65 years presenting to an Alberta ED with HF (ICD9-CM 428.x; 1998 to 2001). Patients were either not admitted (Not-ADM) or directly admitted to hospital (ADM) and followed for one-year. Of 10,415 AHF patients evaluated in the ED, 35% were Not-ADM whereas 65% were ADM. Thirty days after ED presentation the rates of death, re-ED or initial/re-hospitalisation were 3.3%, 44% and 19% for Not-ADM, and 10.9%, 33% and 21% for the ADM patients, respectively (all p<0.0001). At one-year, the rates of death, re-ED or initial/re-hospitalisation were 20%, 82% and 58% for Not-ADM, and 34%, 72% and 60% for ADM, respectively (all p<0.0001). CONCLUSIONS: One third of AHF patients were not immediately admitted after an ED visit but most present again to the ED, two-thirds were hospitalised and 20% died within the first year. Our findings provide new impetus to undertake risk assessment and treatment strategies in the ED for AHF.     

Heart failure in the elderly: age-related differences in clinical profile and mortality

BACKGROUND: Age influence in the prognosis in unselected patients with heart failure has not been widely studied. AIMS: To evaluate possible differences in clinical profile and outcome of patients hospitalized with HF according to age. METHODS AND RESULTS: During 1996, a total of 1065 hospital in-patients had confirmed heart failure, with follow-up data through 2002. Patients were separated in two groups < or = 75 and > 75 years of age. Older patients were less frequently men (32 vs. 52%) and had a higher prevalence of previous stroke (14 vs. 10%). Echocardiography was performed less frequently in older patients (55% vs. 78%) and normal systolic function (55 vs. 40%), and aortic stenosis (12 vs. 7%) were more prevalent. They received less anticoagulants (11 vs. 43%) and beta-blockers (2 vs. 7%), while the opposite happened with aspirin (32 vs. 23%) and diuretics (88 vs. 80%). During follow-up, 507 patients died: 55.9% vs. 38.5%. Being > 75 years of age was the strongest predictor of mortality HR: 1.7, CI 95% 1.5-2.1, P < 0.0001. CONCLUSION: Patients with 76 or more years admitted with HF have a different clinical profile. Echocardiography, oral anticoagulation and beta-blockers were underused in these patients. Age was the strongest predictor of long-term mortality.     

Diastolic heart failure in the elderly: underlying mechanisms and clinical relevance

Diastolic heart failure (DHF) is now firmly established as a significant contributor to the heart failure syndrome. However, compared to the better studied systolic dysfunction heart failure relatively little is known about this form of the syndrome. Epidemiological data have demonstrated that it is particularly important in the elderly likely reflecting the combination of several changes occurring in the myocardium occurring with advancing years, including progressive fibrosis and stiffening of the myocardium, the impact of hypertension over the years and the increased likelihood of ischaemic heart disease. This review will focus on the relevant aetiological factors in DHF, possible pathophysiological mechanisms and outline new and evolving therapeutic strategies for this problem.     

Guidelines for the management of heart failure: differences in guideline perspectives

The development of clinical or practice guidelines is thought to be a successful strategy for improving quality of care. Accordingly, many professional organizations, societies, institutions of health care or policy, and even countries have published practice guidelines on a variety of topics, including heart failure.     

老年慢性心力衰竭伴发心肾综合征的临床特点及相关危险因素logistics回归分析

【】目的：探究老年慢性心力衰竭伴发心肾综合征(CRS)的临床特点及相关危险因素。方法:选取2014年3月~2016年5月在我院就诊的184例老年慢性心力衰竭患者作为研究对象,其中未发生CRS患者为非CRS组,伴发CRS患者为CRS组,采用logistics回归对老年患者慢性心力衰竭伴发CRS危险因素进行单因素和多因素分析。结果：45例患者为CRS组,发生率为24.46%,139例为非CRS组占75.95%。两组患者在年龄、心功能分级、糖尿病病史、急性心肌梗死、感染方面差异有统计学意义(P＜0.05);在性别、肺心病病史、房颤病史、脑血管病史方面差异无统计学意义(P＞0.05)。CRS组患者多伴有夜间阵发性呼吸困难、肺水肿、少尿、低血压,Hct、ALB、Hb、尿PH水平较低,中性粒细胞比例、BUN、WBC、Cr、CRP、尿蛋白水平较高,差异有统计学意义(P＜0.05)。引入多因素Logistic回归方程的变量为糖尿病史、年龄、入院期间Cr水平、Hb水平、CRP水平。结论：有糖尿病史、高龄,入院期间Cr水平、CRP水平上升,Hb水平降低为老年患者心力衰竭并发CRS的高危因素。     

Patient differences related to management in general practice and the hospital: a cross-sectional study of heart failure in the community.

AIM: To compare patients treated for heart failure in relation to the management in general practices versus hospital admission. METHODS AND RESULTS: Twelve randomly selected general practices (GP) were screened for patients receiving ACE-inhibitor, digoxin, or loop diuretic treatment. The first 500 volunteers of 959 potential subjects were invited to a cardiac examination after exclusion of 235 frail, physically or mentally disabled patients. A diagnosis of heart failure during hospital admission (Hospital-HF, n = 102) was more related (p < 0.05) to male sex (45% vs. 21%), advanced age (73 vs. 70 years), breathlessness (75% vs. 62%), LV systolic dysfunction (47% vs. 20%), objective cardiac abnormality (92% vs. 65%) and higher 4-year mortality (33% vs. 15%) than patients taking loop diuretics due to signs and symptoms of heart failure in GP (GP-HF). Patients without clinical heart failure (n = 301) had the same survival but less symptoms and cardiac abnormalities than GP-HF patients. CONCLUSION: A surplus morbidity and mortality was related to a hospital-based rather than a GP based diagnosis of HF. Patients managed in GP were different from patients entering previous clinical trials of heart failure. We estimate that the pool of patients hospitalised with systolic heart failure would be increased from 1.3 to 1.4 more if all patients from primary care were included.     

老年患者充血性心力衰竭的危险因素分析

目的:分析老年患者充血性心力衰竭(CHF)的危险因素。方法:788例年龄60岁的老年住院患者,其中162例心功能NYHA分级Ⅰ级且左心室射血分数LVEF50%为对照组,其余626例心功能NYHA分级Ⅱ~Ⅳ级且LVEF≤40%患者为CHF组。比较两组临床特征和实验室指标,并采用多因素Logistic逐步分析,探讨老年患者CHF的独立危险因素。结果:与对照组比较,CHF组冠心病、高血压病和快速心房颤动比例显著增高,收缩压、血清尿酸、肌酐、高敏C反应蛋白(hs-CRP)、N-末端B型利钠肽原(NT-proBNP)水平也增高,且增高程度随心功能恶化而加重;但CHF组血红蛋白水平降低。CHF组血管紧张素转化酶抑制剂、血管紧张素受体拮抗剂、地高辛、β受体阻滞剂的使用率高于对照组(P0.01)。多因素Logistic逐步回归分析显示,快速心房颤动、高尿酸血症、贫血、肾功能不全、hs-CRP和NT-proBNP增高是老年患者发生CHF的独立危险因素。结论:老年患者CHF受多个危险因素的影响。血清肌酐、hs-CRP和NT-proBNP水平可能部分反映老年CHF患者的病情严重性。     

Ventricular arrhythmias in congestive heart failure: clinical significance and management

The benefit of defibrillator therapy has been well established for patients with LV dysfunction (ejection fraction less than 35%), coronary artery disease, NSVT, and inducible and nonsuppressible ventricular tachycardia. Implantable cardioverter-defibrillator therapy is also indicated for all CHF patients in NYHA functional classes I, II, and III who present with aborted sudden cardiac death, or ventricular fibrillation, or hemodynamically unstable ventricular tachycardia--and also in patients with syncope with no documented ventricular tachycardia but with inducible ventricular tachycardia at electrophysiology study. The ongoing MADIT II trial was designed to evaluate the benefit of prophylactic ICD implantation in these patients (ejection fraction less than 30%, coronary artery disease, and NSVT) without prior risk stratification by PES. The CABG Patch trial concluded that prophylactic placement of an ICD during coronary artery bypass grafting in patients with low ejection fraction and abnormal SAECG is not justifiable. Except for the indications described above, ICD implantation has not been proved to be beneficial as primary or secondary therapy. Until more data are available, patients should be encouraged to enroll in the ongoing clinical trials.     

老年慢性心力衰竭伴抑郁症的临床特点及相关因素分析

目的分析老年慢性心力衰竭(CHF)伴抑郁症患者的临床特点及相关因素。方法选择50例确诊为老年CHF的患者为观察组,不伴有CHF的老年患者58为对照组,对两组患者的临床特点、家庭及社会支持以及Hoher监测结果等进行对比分析。结果观察组患者的严重睡眠障碍、焦虑激越、情绪低落、兴趣减退等症状的发生率与对照组比较差异有统计学意义(P均0.01)。对照组患者的家庭和睦及社会支持率明显高于观察组(P均0.01)。Holter监测显示CHF患者室性心律失常、房性心律失常发生率和心源性猝死明显高于对照组(P均0.05)。结论老年CHF伴抑郁症患者易产生严重睡眠障碍、焦虑激越、情绪低落等症状;CHF伴抑郁症患者心源性猝死率增高;良好的家庭及社会支持有利于预防和降低老年CHF抑郁症的发生。