Long-term Outcomes In Older Patients Research Articles

#2415 Estimated glomerular filtration rate thresholds associated with poor long-term outcomes in older patients with diabetes

Abstract Background and Aims Considering the natural decline of GFR with renal senescence, an age-adjusted estimated glomerular filtration rate (eGFR)-based chronic kidney disease (CKD) definition was recently proposed, which has been supported by that mortality risks start to increase at GFR <45 mL/min/1.73 m2 in older adults (≥65 years). However, the eGFR threshold for mortality and kidney outcomes in older patients with diabetes was less understood. We aimed to evaluate eGFR levels that raise the risk of mortality or end-stage kidney disease (ESKD) in older patients with diabetes. Method Older adult patients (≥65 years) with type 2 diabetes who visited our outpatient diabetes center during 2009 were retrospectively identified and followed up until 2017. Patients were categorized into four groups per their CKD-EPI equation-based eGFR: ≥60, 45–59, 30–44, and 15–29 mL/min/1.73 m2. Cox proportional hazard analysis for all-cause mortality and competing-risk analysis for ESKD (with a competing event of pre-ESKD death) were performed. Results Among 3,065 patients, 19%, 8%, and 2% of patients had eGFR 45–59, 30–44, and 15–29 mL/min/1.73 m2 at baseline, respectively. After adjusting various clinical covariates, including blood pressure, diabetes duration, urine albumin/creatinine ratio, HbA1c, serum cholesterol levels, and major comorbidities, patients with eGFR 30–44 and 15–29 mL/min/1.73 m2 had 1.51-fold (95% confidence interval [CI] 1.17–1.95, P < 0.001) and 2.66-fold (95% CI 1.87–3.79, P < 0.001) higher risks of mortality, respectively, whereas patients with eGFR 45–59 mL/min/1.73 m2 had a comparable risk (1.18, 95% CI 0.96–1.45, P = 0.127) to those with eGFR ≥60 mL/min/1.73 m2. Substitution hazard ratios for ESKD were 2.29 (95% CI 1.41–3.71, P = 0.001), 5.25 (95% CI 3.27–8.41, P < 0.001), and 16.74 (95% CI 9.73–28.80, P < 0.001) in patients with eGFR 45–59, 30–44, 15–29 mL/min/1.73 m2, respectively. In a subgroup of patients 75 or older (n = 800), patients with eGFR 45–59 mL/min/1.73 m2 exhibited comparable risks for both ESKD and mortality. Conclusion Reduced eGFR < 60 mL/min/1.73 m2 predicted an increased risk of ESKD in older patients with diabetes, suggesting that the current traditional eGFR threshold appears feasible. Thus, some high-risk individuals may be missed if age-adapted eGFR criteria with a lower eGFR threshold than 60 mL/min/1.73 m2 are universally applied for older adults ≥65 years.

Using the geriatric nutritional risk index to predict outcomes in older patients with remnant gastric cancer after gastrectomy: a retrospective multicenter study in Japan.

This study investigated the prognostic value of the geriatric nutritional risk index (GNRI) in patients undergoing curative gastrectomy for remnant gastric cancer (RGC). This multicenter retrospective study included 105 patients with RGC of ≥ 65 years of age who underwent curative gastrectomy at 10 institutions in Japan between January 2000 and December 2016. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) were analyzed. Receiver operating curve analyses indicated that the optimal cutoff value of the GNRI for OS was 95.4. Patients were categorized into high and low GNRI groups based on the optimal GNRI cutoff value. The GNRI was significantly correlated with body mass index (p < 0.001), amount of bleeding (p = 0.021), Clavien-Dindo grade 5 postoperative complications (p = 0.040), death caused by primary disease (p = 0.010), and death caused by other diseases (p = 0.002). The OS and DSS were significantly worse in the low GNRI group. A low GNRI and T3 or deeper tumor invasion were independent prognostic factors for OS and DSS. The GNRI is a promising predictor of both short- and long-term outcomes in older patients with RGC.

A simplified frailty index and nomogram to predict the postoperative complications and survival in older patients with upper urinary tract urothelial carcinoma.

This study was designed to investigate the clinical value of a simplified five-item frailty index (sFI) for predicting short- and long-term outcomes in older patients with upper urinary tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU). This retrospective study included 333 patients (aged ≥65 years) with UTUC. Patients were classified into five groups: 0, 1, 2, 3, and 3+, according to sFI score. The variable importance and minimum depth methods were used to screen for significant variables, and univariable and multivariable logistic regression models applied to investigated the relationships between significant variables and postoperative complications. Survival differences between groups were analyzed using Kaplan-Meier plots and log-rank tests. Cox proportional hazards regression was used to evaluate risk factors associated with overall survival (OS) and cancer-specific survival (CSS). Further, we developed a nomogram based on clinicopathological features and the sFI. The area under the curve (AUC), Harrel's concordance index (C-index), calibration curve, and decision curve analysis (DCA) were used to evaluate the nomogram. Of 333 cases identified, 31.2% experienced a Clavien-Dindo grade of 2 or greater complication. Random forest-logistic regression modeling showed that sFI significantly influenced the incidence of postoperative complications in older patients (AUC= 0.756). Compared with patients with low sFI score, those with high sFI scores had significantly lower OS and CSS (p < 0.001). Across all patients, the random survival forest-Cox regression model revealed that sFI score was an independent prognostic factor for OS and CSS, with AUC values of 0.815 and 0.823 for predicting 3-year OS and CSS, respectively. The nomogram developed was clinically valuable and had good ability to discriminate abilities for high-risk patients. Further, we developed a survival risk classification system that divided all patients into high-, moderate-, and low-risk groups based on total nomogram points for each patient. A simple five-item frailty index may be considered a prognostic factor for the prognosis and postoperative complications of UTUC following RNU. By using this predictive model, clinicians may increase their accuracy in predicting complications and prognosis and improve preoperative decision-making.

Effect of intraoperative dexmedetomidine on long-term survival in older patients after major noncardiac surgery: 3-year follow-up of a randomized trial

Study objectiveTo assess the impact of intraoperative dexmedetomidine on long-term outcomes of older patients following major noncardiac surgery mainly for cancer. DesignA long-term follow-up of patients enrolled in a randomized trial. SettingThe initial trial was performed in a tertiary care hospital in Beijing, China. ParticipantsPatients aged 60 years or older who were scheduled for major noncardiac surgery. InterventionParticipants were randomized to receive either dexmedetomidine (a loading dose of 0.6 μg/kg over 10 min, followed by a continuous infusion of 0.5 μg/kg/h until 1 h before end of surgery) or placebo during anesthesia. MeasurementsThe primary endpoint was overall survival. Secondary endpoints included recurrence-free survival and event-free survival. Cox proportional hazard models were used to adjust for predefined confounding factors. Propensity score matching was employed for sensitive analysis. ResultsAmong 620 patients who were randomized in the initial trial, 619 were included in the long-term analysis (mean age 69 years, 40% female, 77% oncological surgery). The median follow-up duration was 42 months (interquartile range 41 to 45). Overall survival did not differ between the two groups: there were 49/309 (15.9%) deaths with dexmedetomidine versus 63/310 (20.3%) with placebo (adjusted hazard ratio [HR] 0.78, 95% CI 0.53–1.13, P = 0.187). Recurrence-free survival was improved with dexmedetomidine (68/309 [22.0%] events with dexmedetomidine versus 98/310 [31.6%] with placebo; adjusted HR 0.67, 95% CI 0.49–0.92, P = 0.012). Event-free survival was also improved with dexmedetomidine (120/309 [38.8%] events with dexmedetomidine versus 145/310 [46.8%] with placebo; adjusted HR 0.78, 95% CI 0.61–1.00, P = 0.047). Results were similar after propensity-score matching and in the subgroup of cancer patients. ConclusionsIn older patients having major noncardiac surgery mainly for cancer, intraoperative dexmedetomidine did not improve overall survival but was associated with improved recurrence-free and event-free survivals.

Outcomes of elderly patients following thoracoscopic esophagectomy for esophageal cancer.

Thoracoscopic esophagectomy (TE) is widely used for esophageal cancer treatment. However, the short- and long-term outcomes of TE in older patients remain unknown. Thus, we investigated those outcomes as well as the effectivity of TE in this patient cohort. A total of 228 consecutive patients who underwent TE for esophageal cancer from 2002 to 2015 were included in the study and categorized into the elderly (≥ 75years) and non-elderly (< 75years) groups. The background was adjusted by propensity score matching. The short- and long-term outcomes were then compared between the two groups. There was no difference in the short-term outcomes between the two groups. The elderly group had significantly lower overall survival (OS) and relapse-free survival (RFS) than the non-elderly group. When pulmonary complications occurred, the OS and RFS were significantly decreased in the elderly group but not in the non-elderly group. Without pulmonary complications, the OS and RFS in the elderly group did not differ from those in the non-elderly group. The multivariate analysis showed that pulmonary complications were independent poor prognostic factors for OS and RFS in the elderly group but not in the non-elderly group. TE is safe and feasible for older patients. However, the OS and RFS of the elderly group were significantly worse than those of the non-elderly group, especially when pulmonary complications occurred. Therefore, perioperative management to prevent pulmonary complications is essential to improve the long-term outcomes of older patients receiving TE.

Older age is not a negative factor for video-assisted thoracoscopic lobectomy for pathological stage I non-small cell lung cancer: a single-center, retrospective, propensity score-matching study.

Video-assisted thoracoscopic surgery (VATS) has changed the surgical approach to non-small cell lung cancer (NSCLC) dramatically. The current study compares the outcomes of older and younger patients who underwent VATS lobectomy for NSCLC. In total, 424 eligible patients with pathological stage I NSCLC underwent VATS lobectomy between 2007 and 2017. Patients were classified into two groups (< 75 and ≥ 75years old), after which propensity score-matching was performed. After matching, 143 patients were identified. No significant difference in postoperative complication rates was observed; however, the ≥75-year-old group had a longer postoperative hospital stay (p = 0.001). The 5-year overall survival, relapse-free survival, and lung cancer-specific survival rates of the < 75- and ≥ 75-year-old groups were 87.1% vs. 85.6% (p = 0.537), 82.1% vs. 79.0% (p = 0.531), and 93.5% vs. 92.7% (p = 0.832), respectively. Despite the longer postoperative recovery following VATS lobectomy, the short- and long-term outcomes of older patients did not differ from those of younger patients. Thus, for early-stage NSCLC, older age alone was not a negative factor for lobectomy performed via minimally invasive surgery. Naturally, the systemic condition of this population must be evaluated carefully before surgery.

Assessing the mortality risk in older patients hospitalized with a diagnosis of sepsis: the role of frailty and acute organ dysfunction.

A prognostic stratification of mortality risk in older patients with sepsis admitted to medical wards is often challenging. To evaluate the ability of the Sequential Organ Failure Assessment (SOFA) score, serum biomarkers (lactate and C-Reactive Protein, CRP), and measures of comorbidity and frailty in predicting in-hospital and 6-month mortality in a cohort of older patients admitted to an Acute Geriatric Unit (AGU) with a diagnosis of sepsis. All patients aged 70years and over consecutively admitted to our AGU with sepsis in the study period were included. At admission, a Comprehensive Geriatric Assessment including two measures of frailty (Clinical Frailty Scale [CFS], Frailty Index [FI]) was obtained. To assess the predictivity of candidate prognostic markers, the Area Under the Receiver-Operating Characteristic (AUROC) curves were analyzed. A multivariate logistic regression analysis was also performed. We included 240 patients (median age = 85, IQR = 80-89, 40.8% women), of whom 33.8% died before discharge, and 60.4% at 6months. The SOFA score (AUROC = 0.678, 95% CI 0.610-0.747) and CRP serum levels (AUROC = 0.606, 95% CI 0.532-0.680) were good predictors of in-hospital mortality. The CFS (AUROC = 0.703, 95% CI 0.637-0.768) and the FI (AUROC = 0.677, 95% CI 0.607-0.746) better predicted 6-month mortality. Results of the regression analysis confirmed the findings of the AUROC study. The combined assessment of SOFA and measures of frailty improved the performance of the model both in the short and the long term. Both the severity of organ dysfunction and frailty scores should be addressed on AGU admission to establish the short- and long-term outcomes of older patients with sepsis.

Early differentiated CD28+ CD27+ T lymphocytes as a biomarker for short and long-term outcomes in older patients with pneumonia.

This study tested the hypothesis that a more senescent immune system would predict a worse outcome in older patients hospitalized for community-acquired pneumonia (CAP). CAP has long been responsible for high rates of mortality and readmissions among older people. Although immunosenescence is a key factor in the increased susceptibility to infections, there are no related biomarkers currently available in clinical practice. In this context, the aim of this prospective study was to identify immunosenescence-related biomarkers to predict outcomes in patients older than 65 years hospitalized for CAP. We evaluated 97 patients admitted to our hospital for CAP in 2019 and 2020. All patients were followed for 1 year. Our findings showed that elevated levels of early differentiated CD28+ CD27+ T cells at admission were associated with better short (2 months) and long-term (1 year) outcomes in terms of mortality and readmissions. Early differentiated CD28+ CD27+ CD4+ T cell counts were even better long-term predictors. In conclusion, early differentiated CD28+ CD27+ T cells could be useful biomarkers to identify high-risk older patients with CAP, helping clinicians with risk stratification and follow-up.

The impact of subclinical hypothyroidism on long-term outcomes in older patients undergoing percutaneous coronary intervention

BackgroundSubclinical hypothyroidism (SCH) is reportedly associated with an increased risk of adverse events in patients undergoing percutaneous coronary intervention (PCI). The prognostic significance of SCH in the elderly was poorly defined. The purpose of this study was to evaluate the association between SCH and long-term outcomes in older patients undergoing PCI.MethodsThree thousand one hundred sixty-eight patients aged 65 years or older who underwent PCI from January 2012 to October 2014 were included. Patients were divided into SCH group (n = 320) and euthyroidism (ET) group (n = 2848) based on thyroid function test. Cox proportional hazard regression analyses were used to estimate the relative risks (RRs) of all-cause death and cardiac death for patients with SCH during a 4-year follow-up period.ResultsThere were 227 deaths during the follow-up period including 124 deaths caused by cardiac events. There was no significant difference in mortality rate between the SCH group and the ET group (p > 0.05). After adjustment for covariates, compared with patients with ET, the RRs of death from all-cause and cardiac in patients with SCH were 1.261 (95%CI: 0.802–1.982, p = 0.315) and 1.231 (95%CI: 0.650–2.334, p = 0.524), respectively. When SCH was stratified by age, gender, and degree of thyroid-stimulating hormone elevation, no significant associations were also found in any stratum.ConclusionOur investigation revealed that SCH was negatively associated with the outcome of PCI in older patients.

Pituitary Disease in AIP Mutation-Positive Familial Isolated Pituitary Adenoma (FIPA): A Kindred-Based Overview.

Clinically-relevant pituitary adenomas occur in about 1:1000 of the general population, but only about 5% occur in a known genetic or familial setting. Familial isolated pituitary adenomas (FIPA) are one of the most important inherited settings for pituitary adenomas and the most frequent genetic cause is a germline mutation in the aryl hydrocarbon receptor-interacting protein (AIP) gene. AIP mutations lead to young-onset macroadenomas that are difficult to treat. Most are growth hormone secreting tumors, but all other secretory types can exist and the clinical profile of affected patients is variable. We present an overview of the current understanding of AIP mutation-related pituitary disease and illustrate various key clinical factors using examples from one of the largest AIP mutation-positive FIPA families identified to date, in which six mutation-affected members with pituitary disease have been diagnosed. We highlight various clinically significant features of FIPA and AIP mutations, including issues related to patients with acromegaly, prolactinoma, apoplexy and non-functioning pituitary adenomas. The challenges faced by these AIP mutation-positive patients due to their disease and the long-term outcomes in older patients are discussed. Similarly, the pitfalls encountered due to incomplete penetrance of pituitary adenomas in AIP-mutated kindreds are discussed.

Pre- and post-operative low prognostic nutritional index influences survival in older patients with gastric carcinoma

ObjectivesThe survival impact of the preoperative prognostic nutritional index (PNI) has been investigated in older patients with gastric carcinoma (GC), while that of the postoperative PNI has yet to be addressed. We evaluated the significance of PNI before and after surgery in older GC patients (≥75 years). Materials and MethodsIn total, 309 older GC patients undergoing radical gastrectomy between 2006 and 2016 were retrospectively reviewed. The PNI was evaluated before and at six months after gastrectomy. Patients were divided into low (<45) and high (≥45) PNI groups. The impact of low PNI on overall survival (OS), cancer-specific survival (CSS), and non-GC-related death were investigated. ResultsLow PNI was present in 134 patients (43.4%) preoperatively and 121 (39.2%) postoperatively. Low pre-PNI was independently associated with poor overall survival (P < .001). Similarly, OS was significantly stratified by post-PNI (P < .001). The significant survival difference according to post-PNI was present only in pStage I disease (P < .001). Low post-PNI independently increased the risk of non-GC-related death in a multivariable analysis (P = .002). In contrast, CSS was not stratified by post-PNI (P = .45). In the high pre-PNI group, total gastrectomy and super-older age (≥80 years) independently increased the risk of low post-PNI, which was significantly associated with poor survival outcomes. ConclusionsPre- and post-operative PNI are useful for predicting long-term outcomes in older patients with GC. Low postoperative PNI is a powerful determinant of mortality due to other diseases. Optimal perioperative management is required for those at high risk of malnutrition postoperatively.

FRAIL Scale also Predicts Long-Term Outcomes in Older Patients With Acute Coronary Syndromes

ObjectivesNo previous studies have assessed the role of the FRAIL scale in predicting long-term outcomes in older patients with acute coronary syndromes (ACS). Design, Setting and ParticipantsThe multicenter observational LONGEVO-SCA registry included unselected patients ≥80 years of age with ACS from 44 centers. A comprehensive geriatric assessment was performed during hospitalization. MeasuresFrailty was measured by the FRAIL scale. For the purpose of this study, main outcome measured was mortality or readmission at 24 months. ResultsA total of 498 patients were included. Mean age was 84.3 years. A total of 198 patients (33.1%) were prefrail and 135 (27.1%) frail. Patients who were prefrail and frail had a higher degree of comorbidities, and higher prevalence of disability, cognitive impairment, and nutritional risk. A total of 165 out of 498 patients (33.1%) died, and 331 patients (66.7%) died or were readmitted at 24 months. Both prefrailty and frailty were associated with a higher mortality compared with robust patients (P < .001). The incidence of mortality or readmission was also higher in patients who were prefrail or frail (P < .001). After adjusting for potential confounders, the association between frailty and mortality or readmission remained significant (hazard ratio 1.28 for prefrailty and hazard ratio 1.96 for frailty, P < .001). The FRAIL scale showed an optimal ability for predicting mortality or readmission (area under the receiver operating characteristics curve 0.86, 95% confidence interval 0.83‒0.89). The area under the receiver operating characteristics curve from the Global Registry of Acute Coronary Events risk score was 0.89. No significant differences were observed between both AUC values (P = .163). Conclusions and ImplicationsThe FRAIL scale independently predicted long-term outcomes in older patients with ACS. The predictive ability of this scale was comparable to the strongly recommended Global Registry of Acute Coronary Events risk score. Frailty assessment is mandatory for improving risk prediction in these complex patients.

Older Age Confers a Higher Risk of 30-Day Morbidity and Mortality Following Laparoscopic Bariatric Surgery: an Analysis of the Metabolic and Bariatric Surgery Quality Improvement Program.

There is a paucity of literature describing the association of age with the risk of adverse events following bariatric surgery. The purpose of this study is to investigate the association of age with 30-day morbidity and mortality following laparoscopic bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All adult patients undergoing laparoscopic Roux-en-Y gastric bypass (RNGYB) or sleeve gastrectomy (SG) were identified within the MBSAQIP database. Patients were divided into five equal age quintiles. Binary outcomes of interest, including cardiac, pulmonary, wound, septic, clotting, and renal events, in addition to the incidence of related 30-day unplanned reintervention, related 30-day mortality, and a composite morbidity and mortality outcome were compared across the age quintiles and procedures. A total of 266,544 patients met inclusion criteria. Older age was associated with an increased risk of all morbidity outcomes except venous thromboembolism events, 30-day mortality, and the composite morbidity and mortality outcome. Patients who underwent Roux-en-Y gastric bypass had worse outcomes per quintile for almost every outcome of interest when compared to patients who underwent sleeve gastrectomy. Older patients and patients who undergo Roux-en-Y gastric bypass are at an increased risk of perioperative morbidity and mortality following laparoscopic bariatric surgery. Additional studies are needed to determine the association of age with long-term weight loss and cardiometabolic comorbidity resolution following bariatric surgery in order to determine if the increased perioperative risk is offset by improved long-term outcomes in older patients undergoing bariatric surgery.

Long-term outcomes in older patients with hyperglycemia on admission for ischemic stroke

AimsEvaluate the association between admission blood glucose (ABG) and mortality in older patients with or without diabetes mellitus (DM) hospitalized for acute ischemic stroke (AIS). MethodsObservational data of patients ≥65years, admitted for AIS between January 2011 and December 2013. ABG levels were classified to categories: ≤70 (low), 70–110 (normal), 111–140 (mildly elevated), 141–180mg/dl (moderately elevated) and >180mg/dl (markedly elevated). Main outcome was all-cause mortality at the end-of-follow-up. ResultsCohort included 854 patients, 347 with (mean±SD age 80±8, 44% male), and 507 without DM (mean±SD age 78±8, 53% male). There was a significant interaction between DM, ABG and mortality at end-of-follow-up (p≤0.05). In patients without DM there was a dose-dependent association between ABG category and mortality: adjusted hazard ratios (95% CI) compared to normal ABG were 1.8 (1.2–2.8), 2.9 (1.6–5.2) and 4.5 (2.1–9.7), respectively, for mildly, moderately and markedly elevated ABG. In patients with DM there was no association between ABG and mortality. There was no interaction between DM, ABG and in-hospital mortality or length of stay (LOS). Irrespective of DM status, compared to normal ABG levels, increased ABG category was associated with increased in-hospital mortality: adjusted odds ratios were 3.9 (1.1–13.4), 7.0 (1.8–28.1), and 20.3 (4.6–89.6) with mildly, moderately and markedly elevated ABG, respectively. Mean LOS was 6±5, 7±8, 8±7, and 8±8days, respectively. ConclusionIn older patients without DM hospitalized for AIS, elevated ABG is associated with increased long-term mortality. Irrespective of DM status, elevated ABG was associated with increased in-hospital mortality and LOS.

246 - Influence of hyponatremia on short-/long-term outcomes in older patients with acute myocardial infarction

246 - Influence of hyponatremia on short-/long-term outcomes in older patients with acute myocardial infarction

P2 Outcomes in adults following anatomic repair of congenitally corrected transposition of the great arteries

<h3>Introduction</h3> Anatomic repair (double switch operation) for congenitally corrected transposition of the great arteries (ccTGA) is associated with good short to mid-term outcomes. An increasing number of these patients are surviving to adulthood. There is a paucity of data in adults regarding late sequelae. We sought to determine the long-term outcomes in older patients who have previously undergone a double switch operation for ccTGA. <h3>Methods</h3> A retrospective analysis of 16 patient records from 2001 to 2015 from a single institution was conducted. Median age was 23 years (range 18–56 years, 14 male). Six patients had undergone a Senning-arterial switch and 10 patients underwent a Rastelli-Senning procedure. Associated defects included VSD (n = 13), pulmonary stenosis (n = 2) and pulmonary atresia (n = 13). Three patients had undergone prior pulmonary artery banding and 7 patients systemic-pulmonary artery shunting. We determined freedom from re-operation/intervention, development of systemic left ventricular (LV) dysfunction, systemic mitral regurgitation, conduction disorders and arrhythmias. <h3>Results</h3> Median follow-up was 19 years (18–21 years). Eleven patients required further surgery with 4 patients having undergone two subsequent operations. Following anatomic repair, median time to 1^st operation was 11 years (7–13 years). Indications for re-operation included re-do RV-PA conduit in the Rastelli-Senning patients (n = 8) and aortic valve replacement in the Senning-arterial group (n = 3). 5 patients developed atrio-ventricular conduction block requiring a pacemaker. Three patients developed atrial arrhythmias, with 2 requiring ablation procedures. Six patients developed LV dysfunction. There were no deaths or need for cardiac transplantation in this series. <h3>Conclusion</h3> The majority of patients required a second operation, largely in the Rastelli-Senning group. In the Senning-arterial group, late aortic valve insufficiency occurred in 50% of the patients. Conduction disease and atrial arrhythmias contribute to late morbidity in these patients. Nevertheless, the majority of patients are free of heart failure. Despite good short-term outcomes and survival following anatomic repair, careful long-term evaluation for structural and electrophysiological abnormalities is required.

Online Health Information Tool Effectiveness for Older Patients: A Systematic Review of the Literature

Online health information tools (OHITs) have been found to be effective in improving health outcomes. However, the effectiveness of these tools for older patients has been far from clear. This systematic literature review therefore provides an overview of online health information tool effectiveness for older patients using a two-dimensional framework of OHIT functions (i.e., providing information, enhancing information exchange, and promoting self-management) and outcomes (i.e., immediate, intermediate, and long-term outcomes). Comprehensive searches of the PubMed, EMBASE, and PsycINFO databases are conducted to identify eligible studies. Articles describing outcomes of patient-directed OHITs in which a mean sample or subgroup of age ≥65 years was used are included in the literature review. A best evidence synthesis analysis provides evidence that OHITs improve self-efficacy, blood pressure, hemoglobin levels, and cholesterol levels. Limited evidence is found in support of OHIT effects on knowledge, perceived social support, health service utilization, glycemic control, self-care adherence, exercise performance, endurance, and quality of life. OHITs seem promising tools to facilitate immediate, intermediate, and long-term outcomes in older patients by providing information, enhancing information exchange, and promoting self-management. However, future studies should evaluate the effectiveness of OHITs for older patients to achieve stronger levels of evidence.

Association of Body Mass Index and Long-Term Outcomes in Older Patients With Non–ST-Segment–Elevation Myocardial Infarction

Prior studies have found that obese patients have paradoxically lower in-hospital mortality after non-ST-segment-elevation myocardial infarction than their normal-weight counterparts, yet whether these associations persist long term is unknown. We linked detailed clinical data for patients with non-ST-segment-elevation myocardial infarction aged ≥65 years in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Registry to Medicare claims data to obtain longitudinal outcomes. Using height and weight measured on admission, patients were categorized into 6 body mass index (BMI [kilograms per meter squared]) groups. Multivariable Cox proportional hazards models were used to estimate the association between BMI and (1) all-cause mortality, (2) all-cause readmission, (3) cardiovascular readmission, and (4) noncardiovascular readmission for 3 years after hospital discharge. Among older patients with non-ST-segment-elevation myocardial infarction (n=34,465), 36.3% were overweight and 27.7% were obese. Obese patients were younger and more likely to have hypertension, diabetes mellitus, and dyslipidemia than normal or underweight patients. Relative to normal-weight patients, long-term mortality was lower for patients classified as overweight (BMI, 25.0-29.9), obese class I (BMI, 30.0-34.9), and obese class II (BMI, 35.0-39.9), but not obese class III (BMI ≥40.0). In contrast, 3-year all-cause and cardiovascular readmission were similar across BMI categories. Relative to normal-weight patients, noncardiovascular readmissions were similar for obese class I but higher for obese class II and obese class III. All-cause long-term mortality was generally lower for overweight and obese older patients after non-ST-segment-elevation myocardial infarction relative to those with normal weight. Longitudinal readmissions were similar or higher with increasing BMI.

ASSA13-01-3 Correlation Between Coronary Artery Lesion Severity and Long-Term Clinical Outcomes in Chinese Older Population with Acute Coronary Syndrome

<h3>Background and Objective</h3> There is little long-term outcome data regarding acute coronary syndrome (ACS) in Chinese older populations (&gt;80 years old). Long-term outcomes of older patients with ACS maybe associated with increased coronary artery lesion severity. <h3>Methods and Results</h3> We classified 536 consecutive older patients with ACS based on the Gensini score into 4 groups: a control group (group 1), a group with Gensini score &lt; 20 (group 2), a group with Gensini score from 21 to 60 (group 3), and a group with Gensini score &gt; 61 (group 4). Survival and MACE rates were calculated using the Kaplan-Meier method. Multivariate Cox regression was used to identify mortality predictors. There were 66 (12.3%), 141 (26.3%), 167 (31.2%) and 162 (30.2%) patients in groups 1, 2, 3 and 4, respectively. The average follow-up was 27.1 ± 16.0 months. Heart rate, systolic blood pressure (SBP), eject fraction (EF), blood glucose level, e-GFR, morbidity from old myocardial infarction, smoking, ACS type, and GRACE score were the determinants of coronary artery lesion severity. Increasing coronary artery lesion severity was associated with increased long-term mortality and MACE rates. The overall long-term mortality rate was 9.1% and increased from 3.0% in group 1 to 16.7% in group 4. Age, gender, heart rate, SBP, chronic renal failure, e-GFR, GRACE score, Gensini score, and ACS type were the independent predictors of long-term mortality. <h3>Conclusions</h3> Long-term mortality of older patients with ACS was associated with increased coronary artery lesion severity. Gender and chronic renal failure were the major risk factors for long-term mortality.

Most Important Outcomes Research Papers on Valvular Heart Disease

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Reviews. This series will summarize the most important manuscripts, as selected by the Editor, which have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes as well as general cardiology audience. The studies included in this article represent the most significant research in the area of valvular heart disease. ( Circ Cardiovasc Quality and Outcomes . 2012;5:-e103.) In recent years, no field of clinical cardiology has experienced a great influx of transformational therapeutic options as has the area of valvular heart disease. Treatment of severe aortic stenosis (AS) has been revolutionized by transcatheter aortic valve replacement (TAVR), which has been shown to improve life expectancy and functional outcomes in patients with inoperable AS1,2 and to have short-term outcomes comparable to surgical aortic valve replacement (AVR) in patients at high perioperative risk.3,4 Analogously, mitral valve disease has been amenable to percutaneous valve replacement,5,6 as well as clipping procedures7 that can substantively reduce severe mitral regurgitation (MR) and improve functional outcomes. Even right-sided heart disease involving valves in pulmonary8,9 and tricuspid10 positions has been treated successfully with endovascular techniques. Yet, even with this growing focus on percutaneous valvular interventions, open surgical techniques remain the dominant treatment strategies and standard of care for most advanced lesions. Surgical valve repair and replacement account for 10% to 20% of all cardiac surgical procedures,11–13 approximately two thirds of which are for AS.11–13 For patients undergoing surgery, there remains considerable debate about risk stratification,14 intraoperative technique,15 and postoperative …