Increased comorbidities in heart failure patients ≥ 85 years but declined from > 90 years: Data from the Swedish Heart Failure Registry

Objectives

Epidemiological studies of elderly heart failure (HF) patients (≥ 85 years) are limited with inconsistent findings. Our objective is to confirm and extend epidemiological study in elderly (≥ 85 years) patients using the Swedish Heart Failure Registry database.

Methods

This retrospective study included 8,347 HF patients aged ≤ 65 years and 15,889 HF patients aged ≥ 85 years. Elderly population was further divided into two subgroups: 11,412 patients were 85–90 years and 4,477 patients were > 90 years.

Results

The ≥ 85 year group was characterized by more women, higher systolic blood pressure (SBP), lower body-mass index (BMI), more than twice as many HF with normal left ventricular ejection fraction (HFNEF), higher incidence of cardiovascular and non-cardiovascular comorbidities and less use of proven therapeutics compared with the ≤ 65 year group. Compared with the 85–90 year subgroup, the > 90 year subgroup had a decline in cardiovascular and non-cardiovascular comorbidities except renal insufficiency and anaemia which continued to increase with ageing (p < 0.01). Tendency was the same regardless of gender but slightly different between systolic HF (SHF) and HFNEF. In the group with HFNEF, there were more women, higher SBP, lower N-terminal pro-B-type natriuretic peptide levels, less ischaemic heart disease, more hypertension and left bundle branch block regardless of age. Atrial fibrillation was more frequent in patients with HFNEF than with SHF in the elderly group (p < 0.01). Patients with HFNEF in the > 90 year subgroup had increasing incidence of ischaemic heart disease compared to 85–90 year group (p < 0.01).

Conclusions

HF patients ≥ 85 years had increased cardiovascular and non-cardiovascular comorbidities but with a decline from > 90 years.     

Adding glimepiride to insulin + metformin in type 2 diabetes of more than 10 years’ duration—A randomised,double-blind,placebo-controlled,cross-over study

Aims

To investigate the effect on glycaemic control of adding glimepiride to on-going treatment with metformin and insulin in patients with known diabetes more than 10 years.

Methods

Glimepiride 4 mg or placebo was added in randomised order for three months with a washout period of 6 weeks. All insulin regimens were allowed. Insulin doses were reduced if considered necessary. Continuous glucose monitoring was performed at the end of each period.

Results

Forty-three patients, median age 66 years (46–74), diabetes duration 16 (10–30), BMI 30 kg/m² (25–37) and mean HbA_1c 7.1% NGSP, (64 mmol/mol IFCC) were randomised. With placebo there was no change in HbA_1c while a decrease of 0.6%, (7 mmol/mol IFCC) (P < 0.001), was observed with glimepiride even though insulin doses had to be reduced in 23 patients (median change 29%, range 2–100%). Minor hypoglycaemia was reported but no severe hypoglycaemic event was observed. The ratio between C-peptide/glucose increased significantly (P < 0.001) with glimepiride, both fasting and postprandially and, in a stepwise multiple regression analysis of possible predictive factors for response, a more pronounced decrease in HbA_1c was associated with the magnitude of the increment in C-peptide/glucose. Older age was associated with a smaller response. Twenty-nine patients (67%) were defined as responders if this was defined as an HbA_1c decrease ≥0.5% (5 mmol/mol IFCC) or an insulin dose reduction ≥20%.

Conclusions

Even after long duration of diabetes, addition of glimepiride to insulin and metformin can be effective in lowering HbA_1c and/or reducing the need for exogenous insulin.     

Prognostic significance of peak oxygen consumption ≤ 10 ml/kg/min in heart failure: Context vs. criteria

Background

Both heart failure (HF) treatment and management may distort or enhance the predictive accuracy of low peak oxygen consumption (pVO₂ ≤ 10 ml/kg/min), blurring the identification of specific patients in whom heart transplantation (HT) could make a clinical difference. The aim of this study was to re-evaluate the prognostic significance of pVO₂ ≤ 10 ml/kg/min in systolic HF in light of changes in medical treatment and management.

Methods

Two-year outcomes were compared across the “millennium dawn” (MD) between two HF cohorts with pVO₂ ≤ 10 ml/kg/min and gas exchange ratio > 1.10: 116 patients were recorded between 1994 and 1999 (pre-MD: mean pVO₂ 8.6 ± 1.1 ml/kg/min) and 90 between 2001 and 2008 (post-MD: mean pVO₂ 8.8 ± 1.0 ml/kg/min). Cardiac-related death was considered an event and event censoring was interrupted at 24 months for surviving patients.

Results

Patients across the MD had the same age, NYHA class, left ventricular ejection fraction and pVO₂ (pre-MD: mean pVO₂ 8.6 ± 1.1; post-MD: mean pVO₂ 8.8 ± 1.0 ml/kg/min: NS). Seventy-one patients (34%) died: 51 (44%) in the pre-MD and 20 (22%) in the post-MD group (p < 0.01). The post-MD group showed a better mean 1-year (83% vs. 68%; χ² = 5.17, p = 0.0229) and 2-year survival (77% vs. 56%; χ² = 8.87, p = 0.0029) compared to pre-MD patients.

Conclusions

Two-year outcome of HF patients with pVO₂ ≤ 10 ml/kg/min has significantly improved in the post-MD era, suggesting the HT indication should not rely on a single CPET parameter, rather on a multifactorial clinical approach.     

Prognostic significance of mitral regurgitation in long-term all-cause mortality in patients aged ≥ 80 years with acute coronary syndrome

Background

Mitral regurgitation (MR) has been shown to be associated with a poor prognosis in the patients with acute myocardial infarction, whether or not percutaneous coronary intervention (PCI) is employed. However, the long-term prognostic significance of MR in octogenarian patients with acute coronary syndrome (ACS) remains unknown. We sought to determine the impact of MR on long-term all-cause mortality and to further reveal whether PCI could influence the prognosis in octogenarian MR patients with ACS.

Methods

In this study, we included a total of 353 consecutive hospitalized patients, aged ≥ 80 years, with ACS during the period of 5-year follow-up. Association between MR and long-term all-cause mortality was analyzed both in a overall cohort and in a matched cohort developed from a propensity score analysis.

Results

MR was independently associated with long-term all-cause mortality in the overall and matched cohorts (hazard ratio (HR) 1.58, 95% CI 1.01–2.47, P = 0.043; HR 1.90, 95% CI 1.15–3.13, P = 0.013). In the subgroup treated with PCI, MR also exhibited higher long-term all-cause mortality, PCI remained an independent determinant of improving long-term survival rate by reducing the mortality by 15.1% in ACS patients with MR aged ≥ 80 years.

Conclusions

Our study demonstrates that MR is independently associated with long-term all-cause mortality, and PCI is an independent determinant for improving the long-term survival rate in the octogenarian ACS patients with MR.     

Heart rate control with oral ivabradine in computed tomography coronary angiography: A randomized comparison of 7.5 mg vs 5 mg regimen

Background

Heart rate (HR) reduction is essential to achieve optimal image quality and diagnostic accuracy with computed tomography coronary angiography (CTCA). Administration of oral ivabradine seems to be more effective than beta-blockade in reducing HR in patients referred for CTCA.

Methods

Two-hundred-fifty-nine consecutive patients referred for CTCA were prospectively enrolled. Patients not receiving beta-blocker at baseline (group 1) and those with beta-blocker therapy (group 2) were enrolled in the study. Each group was randomized into 3 parallel arms with 1:1:1 allocation. Patients who did not receive beta-blocker at baseline: underwent CTCA without beta blocker (n = 49), and received ivabradine 5 mg (n = 48), or 7.5 mg ivabradine (n = 48). Patients with beta-blocker therapy: continued with the prior beta-blocker without any dose modification (n = 38), and received ivabradine 5 mg (n = 38), or ivabradine 7.5 mg (n = 38).

Results

HR and blood pressure were assessed at admission (T0), immediately before CTCA (T1) and during CTCA (T2). Administration of ivabradine 7.5 mg significantly reduced mean relative HR at T1 and T2 (p < 0.01), the rate of patients not achieving target HR at T1 (p < 0.001) and T2 (p < 0.01), and the percentage of patients needing additional IV beta-blockade prior to CTCA (p < 0.01). Results remained statistically significant even after correction for age, gender, ejection fraction, risk factors and HR at T0, in a multivariable analysis.

Conclusions

Ivabradine 7.5 mg is more effective than ivabradine 5 mg in increasing the rate of patients at target HR in patients referred for CTCA.     

Morbimortalité cardiovasculaires en 6 ans des hypertendus noirs du sud algérien

Introduction

Arterial hypertension is a major public health problem not only internationally, but also in our country, and it is the major risk factor for cardiovascular diseases. In south Algeria, the black population is nearly half the population of the oases of the Algerian Sahara.

The objectives of the study

The objectives of the study are to analyze the long-term fate of the black hypertensive subjects in Algerian oases in southern Algeria, in terms of morbidity and mortality, comparing the morphometric profile and cardiovascular complications with the white population of the same oases.

Materials and methods

One thousand four hundred and twenty-five subjects of both sexes were included (811 blacks and 614 white subjects), aged 40 and older, living in the Algerian Sahara and were reviewed after six years of decline. The control consisted of filling a questionnaire oriented on civil status, target organ damage, the number of hospitalizations and mortality. All calculations and statistical analyzes are processed by the SPSS 17.0 and Epi Info6 software.

Results

Mean age for the black population and the white population was 60.3 ± 11.1 and 58.6 ± 10.6 years, respectively. The incidence of hypertension was 50 % among blacks. The main complications observed were: stroke in 3.8 %, heart failure in 3.1 %, myocardial infarction in 1.7 %, hospitalizations related to cardiovascular complications of the black population was around 4.4 %, mortality 5.4 %.

Conclusion

These data on hypertension black subjects emphasize the importance of a policy of adequate local health issues raised, both in terms of the management of hypertension, as in investment in local medical research.     

Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors in patients with type 2 diabetes mellitus

Providing effective medical care for older patients with type 2 diabetes mellitus (T2D) that may contribute to their active aging has always been challenging. We examined the independent effect of age ≥ 60 years on disease control and its relationship with diabetes-related complications in patients with T2D in Malaysia. This was a cross-sectional study using secondary data from the electronic diabetes registry database Adult Diabetes Control and Management (ADCM). A total of 303 centers participated and contributed a total of 70,889 patients from May 2008 to the end of 2009. Demographic data, details on diabetes, hypertension, dyslipidemia and their treatment modalities, various risk factors and complications were updated annually. Independent associated risk factors were identified using multivariate regression analyses. Fifty-nine percent were female. Malay comprised 61.9%, Chinese 19% and Indian 18%. There were more Chinese, men, longer duration of diabetes and subjects that were leaner or had lower BMI in the older age group. Patients aged ≥ 60 years achieved glycemic and lipid targets but not the desired blood pressure. After adjusting for duration of diabetes, gender, ethnicity, body mass index, disease control and treatment, a significantly higher proportion of patients ≥ 60 years suffered from reported diabetes-related complications. Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors. Our findings caution against the currently recommended control of targets in older T2D patients with more longstanding diseases and complications.     

Thyroid metastases from clear cell renal carcinoma 18 years after nephrectomy

Single or multiple thyroid metastases from extra-thyroid primary tumors are reported to be rare. Malignancies that metastasize to the thyroid include cancers originating from lung, breast and kidney. We report our experience with a case of thyroid metastases, which were detected 18 years after curative kidney surgery for renal cell carcinoma. After 18 years, the patients noted the sudden appearance of a lump in the neck. Ultrasonography showed the presence of a multinodular goiter, all nodules being “cold” at scintiscan. Total thyroidectomy was performed; histology of all nodules revealed a metastatic thyroid cancer from renal cell carcinoma. The patient was still alive and in good health 16 months after thyroidectomy. History of patients with thyroid nodules should include inquiring about extra-thyroid malignancies, especially renal cell carcinoma, that may have been diagnosed even many years earlier. As a corollary, follow-up of such patients should include periodic thyroid exploration or at least a physical examination.