SP - Cardio (Cardiovascular)

Introduction: Older people may be less likely to receive cardiac resynchronisation therapy (CRT) for the management of chronic heart failure. We aimed to describe differences in clinical response, complications, and subsequent outcomes following CRT implantation in older patients when compared to those that were younger.

Methods: We conducted a retrospective cohort study of consecutive patients implanted with CRT between March 2008 and July 2017. We recorded complications, symptomatic and echocardiographic response, hospitalisations for heart failure, and all-cause mortality comparing patients aged <70, 70-79, and ≥80 years.

Results: During the study period, 574 patients (median age 76 years [IQR 68-81], 73.3% male) received CRT.  Patients aged ≥80 years had worse symptoms at baseline and were more likely to have co-morbidities. Although the provision of guideline-directed medical therapy for heart failure was less optimal in those ≥80 years old, left ventricular function was similar at baseline. Older patients were less likely to receive CRT-defibrillators (which were twice as likely to require generator replacement) compared to CRT-pacemakers. Complications were infrequent and not more common in older patients. Age was not a predictor of symptomatic or echocardiographic response to CRT (67.2%, 71.2%, and 62.6% responders in patients aged <70, 70-79, and ≥80 years, respectively; p=0.43) and time to first heart failure hospitalisation was similar across all groups (p=0.28). Finally, estimated 10-year survival was lower for older patients (49.9%, 23.9%, and 6.8% for patients aged <70, 70-79, and ≥80 years, respectively; p<0.001).

Conclusion: The benefits of CRT were consistent in selected older patients (≥80 years) despite a greater burden of co-morbidities and less optimal provision of guideline-directed medical therapy. These findings support the use of CRT in an aging population. 

Introduction

Frailty, independent of age, is associated with adverse outcomes following admission with Acute Coronary Syndrome (ACS) but is often not accounted in risk stratification scores. Those identified as frail may not be considered for invasive interventions despite evidence that they stand to benefit (1) and are at risk of worsening geriatric syndromes on discharge (2,3).

Purpose

We aimed to categorise clinical outcomes in older adults admitted with ACS, with or without frailty to suggest if there is a role for geriatrician input in reducing length of stay and preventing adverse events.

Methods

Anonymised data was obtained from an NHS trust’s MINAP registry of patients admitted with ACS between April 2022 to March 2023. Baseline demographics, Clinical Frailty Score (CFS), GRACE and HEART scores, total length of stay (LOS), days as inpatient pre- and post-procedure, adverse events during admission, readmission rates and all-cause mortality rate at 30 days and 1 year were calculated.

Results

288 patients over age 65 admitted with ACS were included in analysis.

Median age was 73 [IQR 67-80.75]. Patients over 75 years had higher rates of frailty (38.5% of 75-84 years and 50.0 % over 85 years had CFS ≥ 5 versus 14.9% 65-74 years (p<0.00001)).

253 (87%) patients underwent invasive angiogram during admission. Although, age was not a limiting factor, frail patients were less likely to have an angiogram: 24.9% CFS ≥ 5 versus 57.1% of CFS ≤ 3 (p=0.00199).

Mean LOS was 9.02 days with a median of 7[IQR 4-12] v mean LOS 6 days for all under 65 (p<0.0001). There was a trend for longer LOS post-angiogram particularly for patients with CFS 4-5 versus CFS 3 or less (11.3 days v 8.92 days p=0.053).

Conclusions

Older people admitted with ACS are more likely to have a prolonged admission. Input from geriatricians and the wider multidisciplinary team may help to identify and optimise care and decision making of patients admitted with ACS and mild to moderate frailty.

1. Damluji et al. J Am Heart Assoc. 2019;8:e013686

Introduction: Transcranial Doppler ultrasonography (TCD) and Near-Infrared spectroscopy (NIRS) are indirect measures of neurovascular coupling (NVC). NVC is the relationship between cerebral blood flow and neuronal activity to meet the metabolic demands of the brain. No studies have integrated TCD-NIRS to investigate the feasibility of measuring NVC in those with dementia, delirium, and depression.

Methods: 34 participants (median [IQR] age 73.0 [70.0,79.25], 52.9% female, healthy (HC, n=10), depression (n=11), dementia (n=8), delirium (n=5)), underwent continuous cerebral blood velocity measurements in the middle (dominant MCAv) and posterior (non-dominant PCAv) cerebral arteries using TCD at rest and in response to four tasks. Heart rate (3-lead ECG), end-tidal CO (nasal capnography), blood pressure (Finometer), and prefrontal oxygenated (HbO2) and deoxygenated (HbR) haemoglobin (NIRS) were also measured. NVC was determined as absolute change in MCAv (cm/s) or concentration change for an attention task (serial subtraction), passive motor (arm movement) and passive sensory task (cotton wool), or PCAv for a visuospatial task (dot counting). We determined differences in NVC by a mixed two-way repeated measures analysis of variance, with post-hoc testing via Tukey.

Results: Resting CBv (cm/s) was significantly different between groups in MCAv (HC: 53.9 (SD=8.09), depression: 41.9 (9.31), dementia: 42.5 (13.7), delirium: 32.6 (7.48), p=0.002) and PCAv (p=0.045), after correction for age and BP (p=0.011). TCD: initial NVC responses increased for all three groups (delirium excluded) for all tasks (20-30s), (p=0.021), but with no main effect of diagnosis. NIRS: There was a significant difference between tasks for the HbO2 and HbR responses (p=0.036, p=0.029). Diagnosis had a significant effect on the HbR response only (p=0.027).

Conclusion: An integrated TCD-NIRS protocol was feasible in these patient groups to measure NVC, but less-so in delirium. Further work is needed to investigate NVC using integrated TCD-NIRS in larger sample sizes.

Abstract

Background: Cholinesterase inhibitors (ChEIs) are the primary medication for dementia treatment. Bradycardia is a possible adverse effect associated with ChEIs. However, the relationship between ChEIs and bradycardia has not been definitively established, particularly in the Asian population. We conducted a study investigating the association between ChEIs and heart rate.

Methods: We retrieved data from electronic medical records (EMR) of patients aged over 60 who were diagnosed with mild cognitive impairment or dementia at Ramathibodi Hospital between January 2009 and December 2022. These patients had outpatient records at 3, 6, and 12 months after the diagnosis. After filtering out by eligibility criterias, patients were categorised into ChEIs and non-ChEIs use, and then were 1:1 matched by baseline characteristics. We compared heart rate changes between the groups using Student’s t-tests or Mann Whitney U test depending on their distribution and Bayesian linear regression. Bradycardia was analysed using Kaplan-Meier Estimates and Cox proportional hazards model.

Results: 790 eligible patients were included, with 395 patients in each group. The median of difference of changes from baseline heart rate between group were -0.5 BPM (p = 0.06), -1.5 BPM (p = 0.12), and -1.5 BPM (p = 0.002) at 3, 6, and 12 months, respectively. The bradycardia incidence was higher in the ChEIs group (38.5%) compared with the non-ChEIs group (30.6%) at 12 months, but this difference was not statistically significant (p = 0.2). Among all regarded variables, baseline heart rate, age and beta-blocker usage associated with bradycardia, with adjusted hazard ratios (aHR) = 0.888 (95% CI 0.873–0.904, p<0.001), 1.019 (95% CI 1.001 –1.037, p=0.035) and 1.334 (95% CI 1.045-1.703, p=0.021).

Conclusions: The use of ChEIs was found to be associated with a decrease in heart rate. However, the changes were minimal and may not have had clinical implications for the patient.

Introduction:

Infection caused by the SARS-CoV-2 has been found to have serious consequences for the cardiovascular system. Among these, the development of heart failure (HF) has been stipulated; however, its causality has not yet been established. Therefore, the purpose of this study is to evaluate the role of clinical and laboratory parameters in determining the risk of developing HF in patients infected with SARS-CoV-2.

Methodology:

151 electronic medical records were taken from hospitalized patients with confirmed SARS-CoV-2 infection and pneumonia, from 03/11/20 to 10/02/21. HF was diagnosed by signs and symptoms, elevated NTproBNP and echocardiogram. Nonparametric statistical tests were applied due to the lack of normality in the data distribution.

Results were considered statistically significant at p<.05. uncorrelated clinical and laboratory indicators were selected to predict hf validated with separate samples. confidence intervals (95% ci) calculated for all listed metrics. oversampling was used in the training set. resulting binary classification model showed validity evaluated metrics roc curves. results: study included 46 patients 105 without hf. median age 66.2 (50-92) years, a predominance of women 91 (60.3%). most both groups had concomitant diseases, however group more ≥4 diseases (63%). significant risk predictors ≥66 years (p < 0.001), procalcitonin level ≥0.09 ng />ml (p <.001), thrombocytopenia ≤220-10^9 />l (p = 0.01), neutrophil-to-lymphocyte ratio ≥4,11% (p =0,010), history of chronic kidney disease (p =0.018).

Conclusion:

A possible predictive model including age, procalcitonin, creatinine, bilirubin, C-reactive protein, lactate dehydrogenase, platelets, international normalized ratio, neutrophil-to-lymphocyte ratio, as well as QTc interval on electrocardiogram and history of chronic kidney disease has been found that could identify patients with COVID-19 at risk of developing heart failure, which will allow more effective and earlier care

Background: Hospital Electronic Health Records (EHRs) increasingly capture health and functional deficits. We report outcomes for acute cardiac patients in relation to an automated frailty measure derived from these EHR data.

Methods: We conducted a retrospective observational cohort study of consecutive cardiology admissions aged ≥70 years between April 2016 and August 2020, to three hospitals across Edinburgh, Scotland. The Continuous Dynamic Evaluation of Frailty (CODE-f) is an automated score between 0 (no markers present) and 1 (all present) representing 12 deficits generated from 31 admission EHR data points. This includes measures of cognition, functional dependence, mobility and falls risk. The primary outcome was mortality at 1 year. The secondary outcome was days alive and out of hospital (‘home time’) in the year after discharge for hospital survivors. In a nested cohort of 318 consecutive patients, the Clinical Frailty Scale (CFS) was determined from manual EHR review blinded to CODE-f scores.

Results: 2,406 patients were included (mean 79±6 years old, 60% male). A CODE-f score could be generated in 2,158 (90%) patients, with a median score of 0.13 (IQR 0–0.33). There were 352 (15%) deaths by 1 year. Patients in the highest CODE-f quartile (>0.35) had three times greater risk of death at one year than in the lowest quartile after adjustment for age and sex (27% versus 9%, adjusted odds ratio 3.44, 95% CI 2.47–4.82, p<.001). 16% of patients from the highest CODE-f quartile lost>90 days home time in the year after discharge, compared to 6% in the lowest two quartiles (p<.001). CODE-f scores correlated moderately well with CFS (spearman’s r="0.50," 95% ci 0.41–0.58, p<0.001).

Conclusion: An automated EHR measure can identify older adults at risk of death and poorer recovery after acute cardiac illness. This could inform treatment decisions future care planning.

Funding: Chief Scientist Office (pcl />18/05)

Introduction: Older people in care homes with atrial fibrillation (AF) have complex health needs and would benefit from taking part in research. This study assessed the feasibility of pharmacist implementation of the Atrial Fibrillation Better Care (ABC: Anticoagulation; Better symptoms; Cardiovascular comorbidity management) pathway, and collection of an AF-specific, resident-centred outcome.

Methods: Older residents (aged ≥65 years) with AF were recruited from care homes within Liverpool and Sefton and randomised to receive the pharmacist intervention, or continue their existing treatment. Resident quality of life was assessed using the Atrial Fibrillation Effect on Quality of Life Questionnaire (AFEQT).

Results: Twenty-two care homes were approached about the study, and seven signed up to take part between 28 September 2020 and 29 April 2021. Time taken to recruit care homes ranged from 0 to 122 days. There were 83 residents identified as potentially eligible to take part, but after screening only 28 residents (34%) were invited. Overall, 21 residents were recruited. Eleven residents received the pharmacist intervention and three had ABC recommendations made to their GPs. Two out of four recommendations were implemented. The pharmacist administered the AFEQT questionnaire to 17 residents with capacity and completion rates were 94% and 93% at baseline and six-months, respectively. Residents found the questionnaire difficult; most were unable to distinguish if symptoms were AF-related (n=3), or did not know they had AF (n=8), and questions related to physical activity were not applicable to any of the residents who were bed bound (n=5) or had severely limited mobility (n=12).

Conclusion: There were procedural (encountered before research starts), system (encountered during research) and resident-specific barriers that impacted this study. Barriers need addressing before wider implementation, and AF-specific quality of life measures need to be developed and validated for care home residents. A detailed commentary has been accepted for publication.