Elderly Heart Failure Population Research Articles

Palliative Care for the Elderly With Heart Diseases in Tertiary Health care: A Concept Analysis.

The increasing incidence of heart failure (HF) in the elderly leads to increased mortality, hospitalization, length of hospital stay, and health care costs. Older adults often face multiple drug treatments, comorbidities, frailty, and cognitive problems, which require early palliative care. However, these patients do not receive adequate palliative care. This concept analysis aimed to develop an in-depth understanding of palliative care for elderly patients with cardiac diseases in tertiary care. The analysis was guided by Walker and Avant's method, and databases were searched using keywords, such as palliative care, tertiary care, elderly, and heart. Covidence was used to review the results using the inclusion and exclusion criteria. The World Health Organisation's definition of palliative care is widely accepted. Palliative care for older adults with heart disease in tertiary care is preceded by chronic illness, polypharmacy, symptom burden, physical and cognitive decline, comorbidities, and psychosocial/spiritual issues. The main attributes of palliative care for this population include health care professionals and patient education, holistic patient/family-centered care, symptom management, shared decision-making, early integration, advanced care planning, and a multidisciplinary approach. Palliative care improves elderly cardiac patients' and their family satisfaction while reducing readmission, hospital stays, and unnecessary invasive procedures. Collaboration between hospitals, community organizations, transitional palliative care services, and research has the potential to improve early palliative care and the well-being of the elderly cardiac population. Advanced Practice Nurses (APNs) competencies play a crucial role in promoting palliative care in the elderly HF population.

Neighborhood matters for transitional care and heart failure hospital readmission in older adults

A retrospective correlational design with existing data was utilized to examine the relationship between early provider follow-up, nursing care coordination intensity, and 30-day hospital readmission in older adults with heart failure and determine if an interaction exists with neighborhood disadvantage. Forward logistic regression was conducted to determine which variables predicted early provider follow-up and readmission. Ordinary least squares regression, logistic regression, and bootstrap confidence intervals were used to test for mediation and moderation. A direct relationship between early provider follow-up and decreased readmission was identified, but no indirect relationship through care coordination intensity. Neighborhood disadvantage did not moderate the effect of provider follow-up on readmission. Early provider follow-up and care coordination intensity were related and moderated by neighborhood disadvantage, but not for those living in highly disadvantaged neighborhoods. Neighborhood disadvantage is a key factor that may negatively influence participation in transitional care interventions in the elderly heart failure population.

Prognostic Value of 99mTc-HMDP Scintigraphy in Elderly Patients With Chronic Heart Failure

This study evaluated the prevalence and prognostic significance of cardiac transthyretin amyloidosis (ATTR) diagnosed using 99mTc- hydroxymethylene-diphosphonate (99mTc-HMDP) scintigraphy in an elderly heart failure population. This retrospective study included 335 patients aged >70 years with heart failure and who underwent 99mTc-HMDP scintigraphy due to non-cardiac reasons in three imaging centres in Finland (Kymenlaakso Central Hospital, Jorvi Central Hospital, and Meilahti University Hospital). A Perugini grade >2 and heart-to-contralateral ratio (H/CL) of ≥1.30 were considered positive for cardiac ATTR. The overall and cardiovascular mortality were obtained from the national statistical service (Statistics Finland). There were 234 deaths, of which 70 were classified as being due to cardiovascular causes during a median follow-up of 1 (1-3) year. Transthyretin amyloidosis was diagnosed in 22 patients (6.6%) using visual analysis and 17 patients using the H/CL ratio (5.1%). Patients with ATTR were older (85±5 vs 80±5 yrs; p=0.002) and had higher N-terminal pro-brain natriuretic peptide (NT-ProBNP) levels (1,451 [813-3,799] vs 6,192 [2,030-8,833] ng/L; p=0.02). Age, bone metastases, and glomerular filtration rate were independent predictors of overall mortality in multivariable analysis. Age, glomerular filtration rate, ≥grade 2 visual cardiac uptake, and H/CL ratio were independent predictors of cardiovascular mortality. Cardiac uptake suggestive of ATTR was found in 5% of elderly patients with chronic heart failure. The presence of cardiac uptake on bone scintigraphy did not convey independent prognostic value on overall mortality but was independently associated with cardiovascular mortality.

Prognostic value of 99mTc-HMDP scintigraphy in elderly patients with chronic heart failure

Abstract Background Bone scintigraphy is an accurate modality for diagnosis of transthyretin amyloidosis (ATTR). Purpose We evaluated the prevalence and prognostic significance of cardiac ATTR in elderly heart failure population. Methods Our retrospective study included 335 patients aged over 70 years with diagnosed heart failure who underwent 99mTc-hydroxymethylenediphosphonate (99mTc-HMDP) scintigraphy due to non-cardiac indications. A Perugini grade >2 and heart-to-contralateral ratio (H/CL) of >1.30 was considered positive for ATTR. Results There were a total of 234 deaths of which 70 were classified as cardiovascular during a median follow-up of 3±2 years. ATTR was diagnosed in 17 patients using H/CL ratio (5.1%). Patients with ATTR were older (85±5 vs. 80±5 years, p=0.002) and had higher N-terminal pro-brain natriuretic peptide (Nt-ProBNP) levels (6692±5694 vs. 3285±5233 ng/l, p=0.02). Age, presence of bone metastasis and GFR were independent predictors of overall mortality. Age, GFR, ≥grade 2 visual cardiac uptake and H/CL ratio were independent predictors of cardiovascular mortality. Conclusions ATTR was found in 5% of elderly patients with heart failure. The presence of cardiac uptake on bone scintigraphy did not convey independent prognostic value on overall mortality but was associated with cardiovascular mortality. Funding Acknowledgement Type of funding sources: None.

Limited role for fibroblast growth factor 23 in assessing prognosis in heart failure patients: data from the TIME-CHF trial.

Fibroblast growth factor 23 (FGF23) is an intensively studied biomarker at the crossroads of cardiovascular disease, heart failure (HF) and chronic kidney disease. Independent associations between increasing FGF23 levels and cardiovascular events were found in many, but not all studies. By analysing data from the TIME-CHF cohort, we sought to investigate the prognostic value of FGF23 in an elderly, multimorbid HF patient cohort. We determined differences between intact (iFGF23) and C-terminal FGF23 (cFGF23) regarding their prognostic value and their levels over time in different HF subgroups according to left ventricular ejection fraction (LVEF). In this multicentre trial of 622 patients with symptomatic HF aged ≥60 years, we determined iFGF23 and cFGF23 at baseline, 3, 6 and 12-month follow-up. In unadjusted analyses, cFGF23 significantly predicted all HF-related outcomes at all time points. The predictive value of iFGF23 was less and not statistically significant at baseline. After multivariable adjustments, the association between both cFGF23 and iFGF23 and outcome lost statistical significance apart from cFGF23 at month 3. Overall, patients with preserved and mid-range LVEF had higher levels of iFGF23 and cFGF23 than those with reduced LVEF. Levels decreased significantly during the first 3months in mid-range and reduced LVEF patients, but did not significantly change over time in those with preserved LVEF. Fibroblast growth factor 23 is of limited value regarding risk prediction in this elderly HF population. Potentially heterogeneous roles of FGF23 in different LVEF groups deserve further investigation.

Body mass index and all-cause readmissions following acute heart failure hospitalization.

Obesity is associated with a lower mortality risk among patients with heart failure (HF). Whether this obesity paradox applies to all-cause hospitalizations is unknown. We aimed to investigate the association between body mass index (BMI) and 30-day all-cause readmissions following HF hospitalization. We retrospectively evaluated 2252 HF hospital admissions of Centers of Medicare Services beneficiaries from an academic medical center. We classified obesity using established BMI categories. All 30-day postdischarge readmission to all hospitals and mortality events were documented. We evaluated 30-day postdischarge unplanned, all-cause readmission and death in the total cohort, propensity-matched cohort, and by ejection fraction (EF). An Overweight-Obese BMI (BMI ≥ 25 kg/m2) was paradoxically associated with a lower mortality rate than a Normal BMI (18.5-24.9 kg/m2) (5.0% vs 8.5%, p = 0.0018). In contrast, an Overweight-Obese BMI was associated with a 29% (95% CI: 1.03-1.63) increased relative risk of all-cause readmission compared with a Normal BMI (23.2% vs 18.9%, p = 0.0288), which was consistent across obesity severity subgroups. Among 966 matched admissions, an Overweight-Obese BMI retained higher readmission risk compared with a Normal BMI (25.1% vs 17.2%, p = 0.003). After matching, readmissions remained higher for Overweight-Obese vs Normal BMI in admissions with reduced EF (25.7% vs 17.8%, p = 0.032) and preserved EF (23.0% vs 15.0%, p = 0.048). No difference in the percentage of readmissions for HF (40%) or noncardiovascular causes (45%) existed between Overweight-Obese and Normal BMI groups. Despite a lower mortality risk, increased BMI is associated with increased all-cause hospital readmission rates in an elderly HF population which persists after propensity matching.

Herat failure and chronic obstructive airway disease as combined comorbidities. Meta-analysis and Review

Background: The existence of COPD and heart failure in elderly population adds additional morbidity and mortality risk than if those with only one of the two comorbidities. The aim of the current metaanalysis was to explore the effect of COPD on heart failure patient in terms of all-cause mortality, cardiac mortality and recurrent heart failure hospitalization.

Correlation between B-Type Natriuretic Peptide and Functional/Cognitive Parameters in Discharged Congestive Heart Failure Patients.

The determination of B-type natriuretic peptides (BNP) may have a role in the diagnosis of heart failure (HF) or guiding HF therapy. This study investigated the role of BNP determination in a cohort of elderly patients admitted to hospital with acute decompensated HF and its correlation with main demographic, clinical, and instrumental data and evaluated possible association with major outcome such as mortality or readmission after a 6-month period of follow-up. Methods. From October 2011 to May 2014 consecutive patients admitted to our unit with symptoms of acute HF or worsening of chronic HF entered the study collecting functional, echocardiographic, and hydration parameters. Correlation between BNP and main parameters was analysed, as well as the mortality/6-month readmission rate. Results. In 951 patients (mean age 71 ys; 37% females) a positive correlation was obtained between BNP and age, creatinine levels, NYHA class at admission and discharge, and levels of hydration; an inverse, negative correlation between BNP and sodium levels, LVEF, distance performed at 6MWT at admission and at discharge, and scores at MMSE at admission and discharge emerged. BNP levels at admission and at discharge were furthermore clearly associated with mortality at 6 months (Chi-square 704.38, p = 0.03) and hospital readmission (Chi-square 741.57, p < 0.01). Conclusion. In an elderly HF population, BNP is related not only with clinical, laboratory, and instrumental data but also with multidimensional scales evaluating global status; higher BNP levels are linked with a worse prognosis in terms of mortality and 6-month readmission.

Interaction Between Pulmonary Hypertension and Diastolic Dysfunction in an Elderly Heart Failure Population

BackgroundPulmonary hypertension due to left heart disease is very common. Our aim was to investigate the relationship of the severity of left ventricular diastolic dysfunction with precapillary and postcapillary pulmonary hypertension (PH) in an elderly heart failure (HF) population. Methods and ResultsA post hoc analysis of the Trial of Intensified Medical Therapy in Elderly Patients With Congestive Heart Failure data was done. Baseline transthoracic echocardiography was used to categorize diastolic function, estimate pulmonary artery pressure and pulmonary capillary wedge pressure, and calculate the transpulmonary pressure gradient (TPG). Among 392 HF patients, PH was present in 31% of patients with grade 1, in 37% of patients with grade 2, and in 65% of patients with grade 3 diastolic dysfunction; 54% of all HF patients with PH had a TPG >12 mm Hg, suggesting not only a postcapillary but also an additional precapillary component of PH. Survival was not related to the severity of diastolic dysfunction, but was worse in patients with PH (hazard ratio 1.63, 95% confidence interval 1.07–2.51; P = .024). ConclusionsOur data indicate that HF patients with even mild diastolic dysfunction often have PH. Echocardiographic assessment suggest that the presence of PH might not simply be due to increased PCWP, but in part due to a precapillary component.

Plasma level of N-terminal pro brain natriuretic peptide (NT-proBNP) in elderly population in Poland — The PolSenior Study

BackgroundThe brain natriuretic peptides (BNP, NT-proBNP) are useful diagnostic markers of heart failure (HF), as exemplified by the ESC Heart Failure guidelines. The PolSenior project was an epidemiological study carried out to examine medical, psychological and socioeconomic aspects of aging in Poland. The aim of this study is an epidemiological description of HF based on elderly population from the PolSenior Study, stratified by NT-pro-BNP concentration values. Material and methodsThe research sample included 4979 respondents (2567 males and 2412 females) split into six equally sized age groups of elderly individuals. The study consisted of three visits performed by trained nurses and included a questionnaire survey, comprehensive geriatric assessment and blood and urine sampling with more than 50 biochemical parameters measured. Serum NT-pro-BNP was measured by electrochemiluminescence method (ECLIA). ResultsThe prevalence of chronic kidney disease (CKD) (77.8%) and atrial fibrillation (39.5%), number of hospitalizations (23.7%) and number of patients treated with HF drugs were highest in NT-proBNP >2000pg/ml group and least frequent in NT-proBNP <400pg/ml group. Obese patients had significantly more frequently NT-proBNP values <400pg/ml (73.0%) and less frequently NT-proBNP values >2000pg/ml (2.8%). Age over 70years and male gender were associated with the increased NT-pro-BNP (>400pg/ml) (OR 1.41; CI 1.20–1.65 for male gender). ConclusionsWe conclude that CKD and atrial fibrillation are associated with the occurrence of increased NT-pro-BNP, the surrogate for HF in elderly population. On the contrary, overweight or obesity is associated with lower prevalence of HF in elderly.

Re-evaluation of prognostic significance of NT-proBNP in a 5-year follow-up study assessing all-cause mortality in elderly patients (≥ 75 years) admitted to hospital due to suspect heart failure

BackgroundN-terminal pro-B-type natriuretic peptide (NT-proBNP) is a prognostic biomarker in heart failure (HF), especially in younger population. The prognostic value of NT-proBNP in an elderly HF population (≥75 years) remains less studied. The purpose of this study is to evaluate the prognostic value of NT-proBNP in patients aged≥75 years and admitted to hospital due to suspect HF with a median follow-up of 5 years. MethodsA prospective hospital cohort of 243 patients (82±4 years) who had NT-proBNP analyzed due to suspect HF during 2005–2007 was studied. ResultsAmong the study population, 75% had acute decompensated HF. Multivariable Cox proportional-hazard regression analysis and univariable Kaplan-Meier survival analysis demonstrated that NT-proBNP was not prognostic significant in HF cohort≥75 years old, and instead, pulmonary hypertension, history of valvular surgery and use of aldosterone receptor antagonist were significant prognostic indicators. However, subgroup analysis showed that in patients with NT-proBNP levels>8000 (ng/L), NT-proBNP is the only significant independent indicator for 5-year mortality whereas in patients with NT-proBNP≤8000(ng/L), enlargement of left atrium and pulmonary hypertension, instead of NT-proBNP, were significant prognostic indicators for mortality. ConclusionIn a HF population≥75 years old with acute decompensated HF, NT-proBNP was not significant prognostic indicator, except in a subgroup with NT-proBNP>8000 (ng/L). Therefore, the prognostic value of NT-proBNP in those HF patients≥75 years has to be interpreted with caution due to higher age and comorbidity.

Telemonitoring in CVD: Results of the WSD project

British Journal of Cardiac NursingVol. 7, No. 9 Evidence UpdateTelemonitoring in CVD: Results of the WSD projectJillian RileyJillian RileySearch for more papers by this authorJillian RileyPublished Online:27 Sep 2013https://doi.org/10.12968/bjca.2012.7.9.448AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Bower P, Cartwright M, Hirani SP et al. (2011) A comprehensive evaluation of the impact of telemonitoring in patients with long-term conditions and social care needs: protocol for the whole systems demonstrator cluster randomised trial. BMC Health Serv Res 11: 184 Crossref, Google ScholarChaudhry SI, Mattera JA, Curtis JP et al. (2010) Telemonitoring in patients with heart failure. N Engl J Med 363: 2301–2301 Crossref, Google ScholarCleland JGF, Louis AA, Rigby AS, Janssens U, Balk AHMM (2005) Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death. J Am Coll Cardiol 45: 1654–1654 Crossref, Google ScholarDar O, Riley J, Chapman C, Dubrey SW, Morris S, Rosen SD, Roughton M, Cowie MR (2009) A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home-HF study. Eur J Heart Fail 11: 319–319 Crossref, Google ScholarDarzi A (2008) High Quality Care for All: NHS Next Stage Review Final Report. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825 (accessed 24 August 2012). Google ScholarDepartment of Health (2005a) Building Telecare in England. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4115303 (accessed 24 August 2012) Google ScholarDepartment of Health (2005b) Supporting People with Long Term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4100252 (accessed 24 August 2012) Google ScholarDepartment of Health (2012) 3 million lives. http://www.3millionlives.co.uk/ (accessed 1st August 2012) Google ScholarInglis SC, Clark RA, McAlister FA et al. (2010) Structured telephone support or telemonitoring programmes for patients with chronic heart failure (Review) Cochrane Database Syst Rev 2010 (8): CD007228 Crossref, Google ScholarKoehler F, Winkler S, Schieber M et al. (2011) Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure. The Telemedical Interventional Monitoring in Heart Failure Study. Circulation 123: 1873–1873 Crossref, Google ScholarRiley JP, Cowie MRC (2011) Monitoring. In: McDonagh TAGardner RClark ALDargie H, eds, Oxford Textbook of Heart Failure. 1st edn. Oxford University Press, Oxford Crossref, Google ScholarSteventon A, Bardsley M, Billings J et al. (2012) Effect of telehealth on use of secondary care and mortality: findings of the Whole System Demonstrator cluster randomised trial. BMJ 344: e3874 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byGreater use of technology to enhance the patient experience7 October 2016 | British Journal of Cardiac Nursing, Vol. 11, No. 10 1 September 2012Volume 7Issue 9ISSN (online): 2052-2207 Metrics History Published online 27 September 2013 Published in print 1 September 2012 Information© MA Healthcare LimitedPDF download

Heart Failure in the Elderly: Diastolic Heart Failure, Medical Therapy, Women and End-Of-Life Care

Heart failure is a leading source of cardiovascular morbidity and mortality in the world. The disease is particlularly prevalent among older patients. The elderly population suffers a high disease burden associated with the distinctive pathophysiology and associated symptoms. There are several challenges healthcare providers face in the management of older patients with heart failure. The present article provides some thoughts on issues in heart failure management in older patients with an emphasis on diastolic heart failure, concerns of polypharmacotherapy, undetected and untreated heart failure among women, and end-of-life care concerns that are relatively unique to an elderly heart failure population. With the expected increase in the number of patients with heart failure and the fact that they might live longer but may suffer more, further efforts are required to aid understanding of the specific needs and challenges for healthier aging, even with a chronic and incurable disease.

Nebivolol in chronic heart failure: current evidence and future perspectives

Importance of the field: Chronic activation of the sympathetic nervous system leads to deterioration of cardiovascular function in heart failure patients. In systolic heart failure, β-blockers were proven to be effective in decreasing the number of deaths and improving morbidity. However, β-blockers are a heterogeneous drug group, consisting of agents with different selectivity for adrenergic receptors and/or additional effects in heart or peripheral circulation.Areas covered in the review: We describe the role of the sympathetic nervous system, β-blockers and specifically nebivolol in chronic heart failure.What the reader will gain: Nebivolol is a third-generation β-blocker, with high β1/β2 selectivity. Moreover, it has important vasodilating properties, by stimulating the production of nitric oxide. Smaller studies have already shown beneficial effects of nebivolol treatment on surrogate end points in heart failure patients. The recently published SENIORS (Phase III) study in an elderly heart failure population demonstrated a decreased number of clinical events in patients treated with nebivolol. Importantly, this effect was observed in patients with both impaired and preserved left ventricular systolic function.Take home message: Specific β-blockers may have distinct effects in various subgroups of heart failure patients. So far, nebivolol is the only β-blocker to have been shown effective in elderly heart failure patients, regardless of their left ventricular ejection fraction.

Prognostic stratification of chronic heart failure in elderly population: are cardiopulmonary tests and BNP really valuable?

Prognostic stratification of chronic heart failure in elderly population: are cardiopulmonary tests and BNP really valuable?

A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home‐HF study

Heart failure chiefly affects the elderly, with frequent emergency admissions. Telemonitoring can identify worsening heart failure but previous randomized trials have enrolled selected patient populations. The Home-HF study examined the impact of home telemonitoring on typical heart failure patients discharged from three acute hospitals in North West London, UK. Patients hospitalized with heart failure were randomized to telemonitoring or usual specialist care. Primary outcome measures were days alive and out of hospital. Secondary outcome measures were number and duration of heart failure hospitalizations, clinic visits, and quality of life. We recruited 182 patients. There was no difference in the primary outcome measure in the two groups, but there were significantly fewer unplanned hospitalizations for heart failure decompensation, and a reduction in clinic and emergency room visits in the telemonitoring group. There was no statistically significant difference in the mean direct health service costs. Home telemonitoring in a typical elderly population of heart failure patients produces a similar outcome to 'usual' specialist care, but reduces clinic and emergency room visits and unplanned heart failure rehospitalizations at little additional cost. This method of disease monitoring may allow specialist services to increase the number of patients under their care.

Neurohormones as Predictors of Outcome in an Elderly Heart Failure Population Naive of Neurohormonal Blockers Results from the CIBIS III Neurohormonal Substudy

Objectives: Although neurohormones have a well-established prognostic value in patients with chronic heart failure (CHF), little is known about this in CHF patients untreated with angiotensin-converting enzyme (ACE)-inhibitors, angiotensin-receptor blockers (ARBs) and beta-blockers. Methods: Baseline N-terminal pro atrial natriuretic peptide (NT-pro-ANP), N-terminal pro B-type natriuretic peptide (NT- pro-BNP), big endothelin (big-ET) and arginine-vasopressin (AVP) were tested for prognostic importance to predict the primary endpoint (death or hospitalisation) in 109 patients participating in the third Cardiac Insufficiency BIsoprolol Study(CIBIS III). Minimum follow-up time was 12 months (6 months monotherapy followed by 6 months combina- tiontherapy). Results: On average, patients had moderate elevation of all neurohormones tested. In univariate analysis, both below- median NT-pro-BNP (HR 0.37, 95% confidence interval (CI) 0.17-0.81, p=0.013) and below-median big-ET (HR 0.39, 95% CI 0.18-0.86, p=0.02) predicted decreased risk of all-cause death or hospitalisation, compared with above-median values. NT-pro-BNP lost its predictive power in multivariate analysis, while big-ET above median as well as body mass index (BMI) below median and presence of ischemic heart disease were predictive of increased risk of death or hospitali- sation. Using Cox stepwise regression analysis, only BMI (p=0.011) and big-ET (p=0.003) remained significant predictors of death or hospitalisation. Conclusion: In a cohort of elderly CHF patients naive of ACE-inhibitors, ARBs and beta-blockers, the best predictors of all-cause death or hospitalisation were a low BMI and elevated levels of big-endothelin.

??-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.

Prospective Study Of A New Prediction Equation For VO2 Peak In Elderly Diastolic Heart Failure

Recent studies have shown that diastolic dysfunction is the most common form of heart failure and is associated with severe exercise intolerance. However, due to the time and expense required, many clinics and rehabilitation centers are not able to assess metabolic gas exchange parameters including peak oxygen uptake (VO2 peak) and are forced to use a prediction equation based on the peak workload achieved by the patient. While improved from earlier editions, the ACSM (GETP 6TH edition) prediction equation still results in an error of approximately 10% when predicting VO2 peak in an elderly heart failure population. We previously examined the accuracy of the ACSM prediction equation on a cohort of elderly patients in the PARIS trial, and adapted the ACSM equation to better fit an elderly cohort. However, neither the ACSM nor the PARIS algorithm has been validated in an independent population of diastolic heart failure patients. PURPOSE To prospectively test and confirm the previously generated equation for predicting VO2 peak on a separate cohort of patients with diastolic heart failure. METHODS Symptom limited graded exercise tests were conducted on 67 consecutive elderly diastolic heart failure patients using a bicycle ergometer protocol that started at 12 watts and progressed to 25 watts after 3 minutes. The stages continued to increase by 25 Watts every three minutes until maximal effort was achieved. Breath-by-breath expired gas analysis was performed using a commercially available system with on-line computer calculations. Student t-tests and regression analysis were used to compare measured versus predicted VO2 peak values. The PARIS equation was VO2 peak =1.1 (ACSM)-1.4. RESULTS When applied to a separate cohort of 67 patients, the PARIS equation resulted in a significantly higher mean VO2 peak of 15.4 ml/kg/min when compared to the actual measured VO2 peak of 13.6 ml/kg/min (P <0.01). Regression analysis of the PARIS equation and the actual measured VO2 peak revealed a significant correlation (r=0.83) and SEE of 1.66. Likewise, the ACSM equation resulted in significantly greater mean VO2 peak of 15.3 ml/kg/min vs. actual measured VO2 peak of 13.6 ml/kg/ min (P <0.01). Regression analysis of the ACSM vs. measured values also revealed a significant correlation (r=0.81) and SEE 1.69. CONCLUSIONS These data demonstrate that VO2 peak can be predicted in elderly diastolic heart failure patients. However, both the ACSM and the PARIS equations systematically over-predicted VO2 peak in this important group of patients.

Heart failure in the elderly

Heart failure is the most common reason for hospitalization among older adults in the USA, and impacts five million people. Most people with heart failure are elderly, but in older people the management of the disease is complicated by comorbid conditions. Common problems in the elderly, such as dementia, frailty and depression, are more common in the elderly heart failure population. This review discusses an approach to identifying and managing these problems while managing heart failure. A suggested approach to older people with heart failure addresses the screening and integration of common geriatric problems into heart failure care.