Elderly Chronic Heart Failure Patients Research Articles

442 Adherence, adaptation and acceptance of elderly chronic heart failure patients to receiving healthcare via telemonitoring

442 Adherence, adaptation and acceptance of elderly chronic heart failure patients to receiving healthcare via telemonitoring

Are Elderly Chronic Heart Failure Patients Satisfied and Compliant with Receiving Healthcare via Telemonitoring?

Are Elderly Chronic Heart Failure Patients Satisfied and Compliant with Receiving Healthcare via Telemonitoring?

Nebivolol: Its Role in the Treatment of Hypertension and Chronic Heart Failure

β-blockers are standard therapy in patients with cardiovascular disease, and have become a cornerstone in the treatment of both hypertension and chronic heart failure. However, two meta-analyses have recently raised doubts about the use of β-blockers in patients with essential hypertension. These concerns were mainly related to studies performed with atenolol. The mode of action of nebivolol is distinctly different from atenolol and other β-blockers. Besides being a highly selective β1-blocker, nebivolol also improves endothelial function and baroreflex sensitivity, and does not have any adverse effects on insulin sensitivity. In addition, its side effect profile is superior compared with other β-blockers and calcium channel blockers, and comparable to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. In patients with hypertension, randomized, controlled trials demonstrated that the effects of nebivolol on reduction of blood pressure are at least similar when compared with other β-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. In patients with chronic heart failure, smaller studies demonstrated beneficial effects with nebivolol on hemodynamics and left ventricular function. Moreover, a large-scale study recently demonstrated beneficial effects on mortality and morbidity in elderly chronic heart failure patients, which is the first mortality and morbidity study that specifically focused on elderly chronic heart failure patients.

Drug therapy of chronic heart failure in the elderly: the current state of clinical-trial evidence

beta-Blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists, and digoxin are the most common drug classes used to treat chronic heart failure. We examine current clinical trial evidence concerning heart-failure management in the elderly. beta-Blockers provide significant mortality benefit to elderly heart-failure patients and are remarkably well tolerated. Angiotensin-converting-enzyme inhibitors improve mortality and morbidity in systolic heart failure. However, the risk/benefit relationship of angiotensin-converting-enzyme therapy in the elderly has not been adequately determined. Angiotensin II receptor blockers improve morbidity in elderly and non-elderly chronic heart-failure patients; however, data are limited regarding mortality in these patients. Aldosterone receptor antagonists provide significant mortality benefit to elderly chronic heart-failure patients. Digoxin is beneficial as an additive therapy in the treatment of systolic heart failure regardless of advanced age. Agents that provide substantive clinical benefit overall also appear to do so in the elderly, based on subgroup analysis of major trials. There have been very few prospective, placebo-controlled trials specifically in elderly heart-failure patients. Elderly heart-failure patients generally tolerate standard chronic heart-failure therapies well. Standard chronic heart-failure therapies should not be withheld from elderly patients based on concerns regarding efficacy or fear of medication intolerance.

Tolerability of beta‐blockers in elderly patients with chronic heart failure: The COLA II study

Beta-blockers are recommended therapy for patients with chronic heart failure (CHF). However, there remains concern regarding tolerability of these agents in the elderly, which has contributed to the limited uptake of these agents in clinical practice. We conducted a multi-national, prospective evaluation of tolerability to carvedilol in 1030 CHF patients aged >70 years selected by their treating physician to receive this agent in everyday practice. NYHA Class II-IV CHF patients were assessed at baseline for key demographic parameters that may predict tolerability, then followed for 6 months after starting carvedilol. Tolerability was defined as being on >or=6.25 mg bd of carvedilol at 6 months having received a total of >or=3 months therapy. Tolerability overall was 80% with age 70-75 years 84.3%, 76-80 years 76.8% and >80 years 76.8%. Mean carvedilol dose achieved was 31.2 mg. In multivariate analysis, advanced age, low diastolic BP, LVEF, obstructive airways disease and presence of diabetes were predictors of tolerability. Carvedilol appears to be well tolerated in this elderly CHF patient cohort. Therefore, elderly CHF patients should not be denied treatment with carvedilol because of concerns regarding tolerability.

??-Adrenoceptor Antagonists in Elderly Patients with Chronic Heart Failure

Chronic heart failure (CHF) is a common and disabling condition with an incidence and prevalence that increase sharply with age. The median age of presentation of new heart failure cases is > 75 years. Effective treatments, including beta-adrenoceptor antagonists, have been proven in randomised, controlled trials. The average age in these placebo-controlled mortality and morbidity studies of beta-adrenoceptor antagonists in heart failure has, however, been < 63 years, and all patients with an ejection fraction > or = 40% were excluded. This lack of a representative sample of elderly patients with heart failure has raised concerns about extrapolating the available evidence for beta-adrenoceptor antagonists to a more elderly heart failure population. Beta-adrenoceptor antagonists may have a less beneficial effect or even an adverse effect in elderly heart failure patients. There is evidence that beta-adrenoceptor antagonists are less frequently prescribed in elderly CHF patients, and that this lack of treatment is associated with impaired outcomes. Establishing which beta-adrenoceptor antagonists, if any, are effective in elderly CHF is therefore of extreme importance. The elderly have a reduced cardiovascular reserve and may be less tolerant of the introduction of a vasoconstricting beta-adrenoceptor antagonist. In addition, the higher proportion of elderly CHF patients with relatively preserved systolic function (for which no treatment has been proven to reduce mortality and morbidity) means that we cannot say with certainty that beta-adrenoceptor antagonists have been proven to be effective in a general elderly CHF population. Third-generation beta-adrenoceptor antagonists with vasodilating actions in addition to their beta-adrenoceptor antagonist effects may offer several theoretical advantages over earlier beta-adrenoceptor antagonists for elderly CHF patients. Three of this class (carvedilol, bucindolol and nebivolol) have been evaluated with respect to their efficacy in reducing mortality and morbidity in CHF, and only two of these (carvedilol and nebivolol) had a proven outcome benefit in a properly powered randomised, controlled trial. Only the Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with Heart Failure (which used the vasodilating third-generation beta-adrenoceptor antagonist nebivolol) has prospectively investigated the treatment of CHF in elderly patients, including those with preserved systolic function, and demonstrated a significant reduction in the risk of death or cardiovascular hospitalisation. In conclusion, prescribers are advised that nebivolol should be preferred in elderly patients with CHF, because of its proven efficacy in a representative group of elderly CHF patients.

Does atrial fibrillation in very elderly patients with chronic systolic heart failure limit the use of carvedilol?

Background and aims It is well known that beta-blockers are useful in patients with chronic heart failure (CHF). These favourable effects have recently been observed even in elderly CHF patients. Objectives of the present study were to evaluate the feasibility, tolerability and safety of carvedilol therapy in a cohort of patients > 70 years of age with CHF and left ventricular ejection fraction < 40% with chronic atrial fibrillation. For this purpose, we designed an observational, 12-month prospective study. Results Among 240 patients who were referred to our centers and met inclusion criteria, 64 had chronic atrial fibrillation (27%). Thirty-nine out of these 64 subjects (61%) were treated with carvedilol, while 25 patients (39%) had contraindications to such treatment. In the cohort of 176 patients with stable sinus rhythm (control group), carvedilol could be administered in 121 patients (69%), while it was not given in 55 (31%, p = ns). Airways disease was the main reason for exclusion from carvedilol in this setting of patients. No difference in 1-year tolerability of study drug was observed among patients with chronic atrial fibrillation (29 of 33 patients = 87.9%) and stable sinus rhythm (95 of 102 = 93.1%). Adverse events leading to the discontinuation of carvedilol in these two populations were rare and never resulted in any disability, death or were life-threatening. Conclusion In over-70 patients with systolic CHF, chronic atrial fibrillation does not limit the possibility of testing beta-blocker therapy. Carvedilol was equally tolerated and safe in patients with atrial fibrillation and sinus rhythm.

Körperliche Aktivität bei älteren Patienten mit chronischer Herzinsuffizienz

Maximal exercise capacity undergoes a steady decline after the age of 30 by approximately 10 % per decade. As a consequence of this development older people > 65 years of age suffer from the exercise limitation caused by age-associated cardiac, vascular and skeletal muscle changes. These physiologic alterations make older people especially vulnerable for the cardiovascular and peripheral alterations associated with chronic heart failure (CHF). These changes are not phenomenologically different from age-associated changes. Physical activity plays an important role for regaining a considerable part of vasomotor function, skeletal muscle contractility, and cardiac reserve. Up to now there are no prospective trials comparing the effects of physical training between older and younger patients with CHF. However, smaller observational studies indicate that elderly patients benefit equally well from training interventions with regard to functional improvements in proportion to their lower baseline values. In an aging population training aims at maintaining skeletal muscle force and muscle mass as well as locomotor coordination. Ultimately, the goal is to reduce the substantial morbidity among elderly CHF patients which constitute 79 % of all hospital admissions for heart failure.

The impact of anti-anxiety and depression treatment on quality of the elderly chronic heart failure patients' life with emotional disorder

目的 了解抗焦虑抑郁治疗对老年心衰伴情绪障碍患者生活质量的影响.方法 106例心衰伴情绪障碍的患者随机分为治疗组和对照组,分别为57例、49例,治疗组在常规药物治疗基础上加抗焦虑、抑郁治疗,服用舒乐安定1mg,早晚各1次,氟西汀(百优解)20mg,早顿服1次,随访16周.结果治疗组与对照组比较,生活质量量表得分治疗组明显高于对照组,患者的再入院率分别为15.8%、18.3%,心脏事件发生率治疗组低于对照组(P<0.05).结论对心衰伴情绪障碍的老年患者,抗焦虑、抑郁治疗能明显改善患者的生活质量及预后。

Methodology of an ongoing, randomized, controlled trial to improve drug use for elderly patients with chronic heart failure

Background: Medications can improve the functioning and health-related quality of life of patients with chronic heart failure (CHF) and reduce morbidity, mortality, and costs of treatment. However, patients may not adhere to therapy. Patients with complex medication regimens and low health literacy are at risk for nonadherence. Objective: The primary goal of this project is to develop and assess a multilevel pharmacy-based program to improve patient medication adherence and health outcomes for elderly CHF patients with low health literacy. Methods: In this 4-year, controlled trial, patients aged ⩾ 50 years with a diagnosis of CHF who are being treated at Wishard Health Services (Indianapolis, Indiana) are randomly assigned to pharmacist intervention or usual care. Intervention patients receive 9 months of pharmacist support and 3 months of postintervention follow-up. The intervention involves a pharmacist providing verbal and written education, icon-based labeling of medication containers, and therapeutic monitoring. The pharmacist identifies patients' barriers to appropriate drug use, coaches them on overcoming these barriers, and coordinates medication use issues with their primary care providers. Daily updates of relevant monitoring data are delivered via an electronic medical record system and stored in a personal computer system designed to support pharmacist monitoring and facilitate documentation of interventions. To measure medication adherence objectively, electronic monitoring lids are used on all CHF medications for patients in both study groups. Other assessments include self-reported medication adherence, results of echocardiography (eg, ejection fraction), brain natriuretic peptide concentrations, and health-related quality of life. Health services utilization, refill adherence, and cost data derive from electronic medical records. After completion of this study, the data can be used to assess the effectiveness and cost-effectiveness of our intervention. Results: One hundred twenty-two patients have been assigned to receive the intervention and 192 to receive usual care. Conclusions: Our study aims to improve patients' knowledge and self-management of their medication and to improve medication monitoring in a multilevel pharmacy-based intervention. By doing so, we intend that the intervention will improve the health outcomes of elderly patients with CHF.

Clinical Utility of Digoxin in Elderly Patients in Sinus Rhythm with Chronic Heart Failure

The role of digoxin in therapy of elderly chronic heart failure (CHF) patients who are in sinus rhythm remains controversial. Digoxin is an oral inotrope which also has potentially beneficial autonomic effects in CHF. Physiological changes in the elderly, including haemodynamic, autonomic, pharmacokinetic and pharmacodynamic changes influence the dosing of digoxin. Digoxin toxicity, a particular problem in the elderly, makes attention to drug levels and drug interactions mandatory. The Digitalis Investigation Group (DIG) trial demonstrated no mortality benefit in CHF patients who remain in sinus rhythm, however evidence from this study and earlier withdrawal studies suggests symptomatic benefit with digoxin in these patients.