Risk Stratification In Elderly Patients Research Articles

Enhanced risk stratification in young and elderly patients treated with induction chemotherapy as well as in frail patients with AML.

6582 Background: Cytogenetic aberrations represent the main risk factor in AML. The recently published Muenster AML score ameliorated risk stratification in elderly patients treated with induction chemotherapy in a large trial using additional clinical factors. A second score for prediction of complete remission (CR), overall survival (OS) and early death was established for cases, where cytogenetic information is not available. Methods: We first retrospectively applied these two scores in 59 elderly patients with newly diagnosed AML treated with induction chemotherapy. Although the score was not designed to, we then tested these scores in a cohort of young (n=73) patients who received induction therapy and additionally in frail (n=118) patients with cytoreductive therapy or best-supportive care only. Results: For the proposed patient-cohort of elderly patients treated with induction chemotherapy, the AML Score including cytogenetic information was, as expected, highly predictive for achieving CR (100% vs. 42.9%, p<0.001) and for OS (44.6 vs. 2.6 months, p<0.001). Using the score without cytogenetic information, prediction of OS was also possible (16.2 vs. 5.9 months, p=0.02) whereas prediction of CR lost statistical significance. Interestingly, in the not intended cohort of young patients, both scores achieved a very good discrimination of risk groups, even without using cytogenetic information (OS: 88.6 vs. 24.4 months, p<0.01; achieving CR: 94.4% vs. 59.1%, p=0.02). In our cohort of frail patients not suitable for induction therapy, using the score with cytogenetics also clearly discriminated risk groups for short OS (20.7 vs. 3.8 months, p<0.001). Discrimination using the score without cytogenetic information was not statistically significant (15.0 vs. 5.2 months, n.s.). However, prediction of early death showed no statistically significance in all of our three patient cohorts. Conclusions: The Muenster AML Scores may enhance selective risk stratification in young and elderly patients treated with induction chemotherapy as well as in frail patients without intensive treatment also in cases, where cytogenetic information is not available.

The Geriatric Scoring System (GSS) in meningioma patients—validation

Meningiomas are the most common primary brain tumor, the incidence of which rises with age. The Geriatric Scoring System (GSS) was constructed in an attempt to answer which elderly subpopulation will benefit from a surgical intervention in terms of their overall physical and functional state of health. The GSS incorporates different prognostic indicators, both clinical and radiological, for risk stratification. The purpose of the study was to validate the previously defined GSS for the evaluation and risk stratification of elderly patients suffering from intracranial meningioma. One hundred and twenty patients aged over 65 years admitted to the RAMBAM Medical Center with meningiomas during the years 2005-2010 were characterized, forming an independent cohort. We report the presenting symptoms, chronic illness and radiological features, as well as perioperative and long-term follow-up results up to 5 years after the surgery. Nine outcome parameters were tested against the GSS score on admission. Survival, Barthel Index, Karnofsky Performance Scale (KPS), consciousness expressed by the Glasgow Coma Scale (GCS) [14] score 5 years after surgery, recurrence within and beyond 12 months of surgery, the length of hospitalization both overall and in a neurosurgical intensive care unit. A GSS score higher than 16 was associated with a significantly more favorable outcome. The present results suggest that common experience-based considerations may be optimized and implemented into a simple scoring system that in turn may allow for outcome prediction and evidence-based decision making.

A case for assessment of oscillatory breathing during cardiopulmonary exercise test in risk stratification of elderly patients with chronic heart failure

The prognostic value of exercise oscillatory breathing (EOB) during cardiopulmonary test (CPX) has been described in young chronic heart failure (HF) patients. We assessed the prognostic role of EOB vs other clinical and ventilatory parameters in elderly HF patients performing a maximal CPX. Methods and resultsWe prospectively followed-up 370 HF outpatients ≥65years after a symptom limited CPX. We tested the predictive value of clinical and ventilatory parameters for all-cause mortality and a composite of all-cause mortality and HF hospitalizations. Median age was 74years, 51% had ischemic heart disease, 25% NYHA class III; ejection fraction was 41% [34–50]. Peak oxygen consumption (PVO2) was 11.9 [9.9–14] mL/kg/min, the slope of the regression line relating ventilation to CO2 output, (VE/VCO2 slope) was 33.9 [29.8–39.2]. EOB was found in 58% of patients. At follow-up, 84 patients died and overall 158, using a time-to-first event approach, met the composite end-point. Independent predictors of all-cause mortality were CPX EOB and the ratio of VE/VCO2 slope to peak VO2, hemoglobin, creatinine and body mass index. The area under the ROC curve (AUC) of the Cox multivariable model was 0.80 (95% CI 0.73 to 0.87). Independent predictors of the composite end-point were EOB, VE/VCO2 slope, hemoglobin and HF admissions in the previous year (Model AUC 0.75) (95% CI 0.69 to 0.81). ConclusionsAmong elderly HF patients, EOB prevalence is higher than middle-aged cohorts. EOB and the ratio of VE/VCO2 slope to peak VO2 resulted the strongest ventilatory predictor of all-cause mortality, independent of ventricular function.

Additive prognostic value of cardiopulmonary exercise testing in elderly patients with heart failure

To date, the role of CPET (cardiopulmonary exercise testing) for risk stratification in elderly patients with HF (heart failure) with depressed or preserved ventricular function has not been evaluated. In the present study, we analysed whether CPET is useful in predicting outcome in this population. A total of 220 NYHA (New York Heart Association) class I-III patients with HF > or =70 years of age [median age, 75 years; 23% had NYHA class III; and 59% had preserved ventricular systolic function (left ventricular ejection fraction > or =40%)] performed maximal CPET (peak expiratory exchange ratio >1.00). Median peak oxygen uptake was 11.9 ml.kg(-1) of body weight.min(-1), median VE/VCO(2) slope (slope of the minute ventilation/carbon dioxide production ratio) was 33.2 and 45% had an EVR (enhanced ventilatory response) to exercise (VE/VCO(2) slope > or =34). During 19 months of follow-up, 94 patients (43%) met the combined end point of death and hospital admission for worsening HF, arrhythmias or acute coronary syndromes. By Cox multivariable analysis, a creatinine clearance of <50 ml/min {HR (hazard ratio), 1.657 [95% CI (confidence interval), 1.055-2.602]} and EVR [HR, 1.965 (95% CI, 1.195-3.231)] were the best predictors of outcome, while ventricular function had no influence on prognosis. In conclusion, in elderly patients with HF, a steeper VE/VCO(2) slope provides additional information for risk stratification across the spectrum of ventricular function and identifies a high-risk population, commonly not considered in exercise testing guidelines.

Quantitative Gated Single-Photon Emission Computed Tomography With 99mTc Sestamibi Predicts Major Cardiac Events in Elderly Patients With Known or Suspected Coronary Artery Disease The QGS-Prognostic Value in the Elderly (Q-PROVE) Study

Although electrocardiogram-gated single-photon emission computed tomography (SPECT) may be useful in risk stratification of elderly patients with coronary artery disease (CAD), few studies have prospectively evaluated its prognostic value in this patient population. A total of 175 patients aged 75 years or more with known or suspected CAD were prospectively evaluated by stress gated SPECT using a 20-segment model and an automatic functional analysis. Patients with acute coronary syndrome within the previous 3 months, and those who underwent coronary revascularization within 3 months after the SPECT study were excluded. Outcome assessment included prespecified cardiac events and noncardiac deaths. During a mean follow-up of 3.4 years, there were 18 cardiac events: 2 cardiac deaths, 1 nonfatal myocardial infarction, 3 coronary artery bypass grafting, 5 percutaneous coronary interventions, 1 unstable angina, 4 heart failures, and 2 malignant arrhythmias. Kaplan-Meier survival estimation indicated an event-free survival rate of 98.1% at 3 years in patients without myocardial ischemia, but 79.9% in those with ischemia as documented by gated SPECT (p=0.0001). Multivariate analysis using the Cox proportional hazard model demonstrated that stress-induced myocardial ischemia was the only independent predictor for subsequent cardiac events (p<0.01). Stress gated SPECT predicts cardiac events in patients aged 75 years or more with known or suspected CAD and may have a role in risk stratification of this patient population.

Evaluation of B-type natriuretic peptide to predict complicated pulmonary embolism in patients aged 65 years and older: brief report

Purposes We evaluated the use of plasma B-type natriuretic peptide (BNP) levels for risk stratification in elderly patients with acute pulmonary embolism (PE). Basic Procedures Bedside BNP assay was performed blindly at admission in consecutive patients older than 65 years with acute PE. A complicated PE was defined as any of the following: death, cardiopulmonary resuscitation, mechanical ventilation, use of vasopressors, thrombolysis, surgical embolectomy, or admission in intensive care unit. Main Findings Fifty-one patients (age, 79 ± 9 years) were included. Thirteen patients had adverse events: 11 were admitted in the intensive care unit and 3 died. The median BNP level (95% confidence interval [CI]) was higher in the group of patients with complicated PE, 274 pg/mL (95% CI, 142-581 pg/mL) vs 78 pg/mL (95% CI, 33-230 pg/mL) ( P < .05), respectively. The receiver operating characteristic curve showed that BNP significantly predicted a complicated PE with an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.58-0.83) ( P < .05). The best threshold value was 200 pg/mL with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 0.69 (0.43-0.87), 0.63 (0.47-0.77), 0.39 (0.22-0.59), 0.86 (0.69-0.94), and 0.65 (0.51-0.77), respectively. Conclusion Our study suggests that BNP is not a reliable marker of complicated PE in elderly patients.

B‐Type Natriuretic Peptide Predicts Postdischarge Prognosis in Elderly Patients Admitted Due to Cardiogenic Pulmonary Edema

To examine the prognostic role of predischarge B-type natriuretic peptide (BNP) levels in elderly patients admitted to the hospital due to cardiogenic pulmonary edema, 203 patients consecutively admitted to the Heart Failure Unit of the Cardiology Department were retrospectively evaluated. The primary clinical end point selected was a combination of: 1) deaths; plus 2) readmissions to the hospital for heart failure in the 6 months after discharge. Thirty-one deaths (15.3%) and 44 readmissions for heart failure (21.7%) were recorded. Cox multivariate regression analysis confirmed that BNP cutoff values (identified on receiver-operated curve analysis) are the most accurate predictor of events. Hazard ratios (HRs) increased from the lowest, for BNP < or = 200 pg/mL (HR=1), through BNP 201-499 pg/mL (HR=2.3200; p=0.0174), to the highest, for BNP > or = 500 pg/mL (HR=3.6233; p=0.0009). This study demonstrates that BNP is useful in predischarge risk stratification of elderly patients with cardiogenic pulmonary edema.

Mortality Risk Stratification in Chronic Kidney Disease

Current National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria for chronic kidney disease (CKD) are intended to apply to all age groups. However, it is unclear whether different levels of estimated GFR (eGFR) have the same prognostic significance in older and younger patients. The study cohort was composed of Department of Veterans Affairs (VA) patients who were aged 18 to 100 yr and had at least one outpatient serum creatinine measurement between October 1, 2001, and September 30, 2002 (n=2583,911). Patients with ESRD were excluded. GFR was estimated using the Modification of Diet in Renal Disease equation using each patient's first outpatient creatinine measurement during the study period. The association of eGFR with survival was measured by age group. Twenty percent of cohort patients had an eGFR<60 ml/min per 1.73 m2, ranging from 3% among 18- to 44-yr-olds to as high as 49% among 85- to 100-yr-olds. Fifty-two percent (n=266,421) of cohort patients with an eGFR<60 ml/min per 1.73 m2 had "very" moderate reductions in eGFR into the 50- to 59-ml/min per 1.73 m2 range. The association of eGFR with mortality was weaker in the elderly than in younger age groups: Whereas severe reductions in eGFR were associated with an increased risk for death in all age groups, "very" moderate reductions in eGFR (50 to 59 ml/min per 1.73 m2) were associated with an increased adjusted risk for death only among patients who were younger than 65 yr. Age-related attenuation of the association of eGFR with mortality was also present among women and black patients. In the clinical setting, mortality risk stratification in elderly patients should not be based on the same eGFR cut points as for younger age groups and would benefit from finer categorization of the 30- to 59-ml/min per 1.73 m2 eGFR group.

Mortality and perforated peptic ulcer: a case for risk stratification in elderly patients.

In a consecutive series of 284 patients with a perforated peptic ulcer (229 pyloroduodenal, 55 gastric) there was a 26 per cent hospital mortality rate, and patients aged greater than or equal to 70 years (n = 176) had a significantly higher mortality rate (34 per cent) than patients aged less than 70 years (14 per cent, P less than 0.001). Multiple clinical variables were significantly more common in the elderly group of patients (65 per cent), in those having non-steroidal anti-inflammatory drugs or steroid therapy (56 per cent), in patients where there is an absence of a previous dyspeptic history (69 per cent), and when risk factors such as delayed presentation (33 per cent) and the presence of shock on admission to hospital (27 per cent) are present. Definitive operations (vagotomy or gastrectomy) had an increased mortality rate in the elderly (P = 0.018). Risk scores based upon the presence of shock, delayed presentation or concurrent medical illness could have predicted 87 per cent of postoperative deaths in elderly subjects, and it is suggested that risk stratification and greater caution in the use of definitive operations for perforated ulcer may result in a reduction in the high mortality rate in elderly subjects.

Acute type B aortic dissection in elderly patients: clinical features, outcomes, and simple risk stratification rule

Background The clinical features and outcomes of elderly patients with acute type B aortic dissection (ABAD) are less well known. Accordingly, we sought to evaluate the clinical features and outcomes and derive a simple risk stratification rule for elderly with ABAD. Methods We categorized 383 patients with ABAD enrolled in the International Registry of Acute Aortic Dissection into two strata (aged less than 70 years and aged 70 years or more) and compared their clinical features and in-hospital outcomes. Further, we developed a clinical decision rule to risk-stratify elderly with ABAD. Results Forty-two percent (161 of 383) of patients with ABAD were aged 70 years or more. Hypertension, diabetes, history of prior aortic aneurysm, and arteriosclerosis were more common in the elderly patients, whereas Marfan syndrome and cocaine abuse were less common. The in-hospital complication of hypotension/shock was more common among elderly, and malperfusion of a visceral organ less frequent among elderly patients. In-hospital mortality was higher in the elderly cohort compared with the younger patients (16% versus 10%, p = 0.07). A classification tree identified that elderly patients with hypotension/shock had the highest risk of death (56%). In absence of this, any branch vessel involvement was associated with the next highest mortality rate (28.6%) followed by presence of periaortic hematoma (10.5%). In contrast, elderly patients without any of these three risk factors had an extremely low mortality rate (1.3%). Conclusions Our study highlights important differences between older and younger patients with ABAD in their clinical characteristics, management, and outcomes. We also propose a simple decision rule that allows stepwise risk-stratification in elderly patients with ABAD.

Post–myocardial infarction risk stratification in elderly patients

Background The purpose of this study was to examine the use of post–myocardial infarction (MI) risk stratification in the elderly. Although expert panels have recommended risk stratification after MI, limited data are available on whether patients actually undergo suggested testing. In particular, concern has been raised that the elderly, who are at high risk for recurrent ischemia and short-term death, are not referred as often as younger patients for post-MI testing. Methods We studied the records of 192,311 Medicare patients (age ≥65 years) admitted with MI between January 1992 and November 1992. By combining Medicare part A and part B data, we created a longitudinal record of patient care within 60 days of an MI admission. We describe the pattern of post-MI testing for ischemia and left ventricular function and outcomes as a function of patient age. Results Patients ≥75 years of age were significantly less likely than patients 65 to 74 years of age to have either cardiac catheterization (17% vs 43%) or any test for coronary artery disease severity (24% vs 53%). They were also less likely to have a test of left ventricular function (61% vs 76%). Even after adjustment for baseline characteristics, older patients remained less likely than younger patients to have an assessment of coronary artery disease severity (odds ratio, 0.44) or left ventricular function (odds ratio, 0.65). Conclusions Post-MI risk stratification declines with age and falls short of recommendations in our nation’s elderly. This lack of testing may result in lost opportunities for therapeutic interventions in this high-risk group. (Am Heart J 2001;142:37-42.)

Use of exercise thallium-201 imaging for risk stratification of elderly patients with coronary artery disease

Although coronary artery disease (CAD) may be asymptomatic, It is the most common cause of death in elderly patients in the U.S. This study examined the prognosis of 449 patients with a mean age of 65 years using exercise thallium-201 imaging. At a follow-up of 25 months, 45 patients underwent coronary artery revascularization, 8 died of cardiac causes and 10 had nonfatal acute myocardial infarctions (AMIs). Thus the total of patients with “hard” events was 18. The events included 12 of 276 patients with atypical or non-anginal symptoms versus 6 of 128 with typical angina (p = not significant); 7 of 51 patients (14%) with Q-wave AMI versus 11 of 353 (3%) without Q-wave AMI (p < 0.001); 1 of 183 patients (1%) with normal versus 17 of 221 (8%) with abnormal exercise thallium-201 images (p < 0.002); 10 of 76 patients (13%) with multi vessel thallium-201 abnormality vs 8 of 328 (2%) with no or 1-vessel thallium-201 abnormality (p < 0.001) and 10 of 96 patients (10%) with ≥3 abnormal segments by thallium-201 imaging (total segments = 9) versus 8 of 308 patients with no or <3 abnormal segments (p < 0.001). The number of segments with thallium-201 defects was 1 ± 2 in patients without and 3 ± 2 in patients with hard events (p < 0.002). Univariate and multivariate Cox survival analysis identified abnormal thallium images (chi-square = 14, p < 0.0001) and multivessel thallium-201 abnormality (chi-square = 5, p < 0.002) as independent predictors of events. The risk was <1% in patients with normal images, 5% in patients with 1-vessel thallium-201 abnormality and 13% in patients with multlvessel thallium-201 abnormality (Mantel-Cox, p < 0.0001) Thus, elderly patients with cardiac symptoms can be stratified into different risk groups based on the presence and extent of exercise-induced thallium-201 abnormality.