Validation of the French version of the Vulnerable Elders Survey-13 (VES-13).

BACKGROUND: Identifying and assessing degree and type of frailty among older persons is a major challenge when targeting high risk populations to identify preventive interventions. The Vulnerable Elders Survey-(VES-13) is a simple instrument to identify frailty defined as risk for death, functional decline or institutionalization. OBJECTIVE: Translate VES-13 into French and validate it. METHODS: The French version of VES-13 was developed by forward-backward translation of the VES-13 survey instrument. The authors assessed its feasibility, construct validity, and ability to predict the combined outcomes of admission to institution or death at 18 months, in 135 persons over 70 years of age living in the community. Subjects were recruited from three settings: Group 1 - a health prevention center (n = 45); Group 2 - an ambulatory care geriatric clinic (n = 40); and Group 3 - an intermediate care hospital unit (n = 50). The combined outcomes data were recorded by telephone interview with participants or a proxy. RESULTS: Feasibility of the French version, named Echelle de Vulnérabilité des Ainés-13 or EVA-13, was excellent. The scale classified 5 (11%) persons as vulnerable (score of 3 or more) in Group 1, 23 (58%) in Group 2 and 45 (90%) in Group 3 (p < 0.001) with scores of 0.91 +/- 1.16, 4.27 +/- 3.17 and 6.90 +/- 3.17, respectively (p < 0.001). At follow-up, among the 60 non-vulnerable subjects, 58 (96%) were alive and living at home, whereas 46 (65%) of the 70 vulnerable subjects were alive and living at home (p < 0.001). CONCLUSIONS: EVA-13 was determined to be valid and reliable.

Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation often recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence. This is an update of a review previously published in 2006, 2012 and 2015. OBJECTIVES: To determine the effects of long-term treatment with antiarrhythmic drugs on death, stroke, drug adverse effects and recurrence of atrial fibrillation in people who had recovered sinus rhythm after having atrial fibrillation. SEARCH METHODS: We updated the searches of CENTRAL, MEDLINE and Embase in January 2019, and ClinicalTrials.gov and WHO ICTRP in February 2019. We checked the reference lists of retrieved articles, recent reviews and meta-analyses. SELECTION CRITERIA: Two authors independently selected randomised controlled trials (RCTs) comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored, spontaneously or by any intervention. We excluded postoperative atrial fibrillation. DATA COLLECTION AND ANALYSIS: Two authors independently assessed quality and extracted data. We pooled studies, if appropriate, using Mantel-Haenszel risk ratios (RR), with 95% confidence intervals (CI). All results were calculated at one year of follow-up or the nearest time point. MAIN RESULTS: This update included one new study (100 participants) and excluded one previously included study because of double publication. Finally, we included 59 RCTs comprising 20,981 participants studying quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone and sotalol. Overall, mean follow-up was 10.2 months.All-cause mortalityHigh-certainty evidence from five RCTs indicated that treatment with sotalol was associated with a higher all-cause mortality rate compared with placebo or no treatment (RR 2.23, 95% CI 1.03 to 4.81; participants = 1882). The number need to treat for an additional harmful outcome (NNTH) for sotalol was 102 participants treated for one year to have one additional death. Low-certainty evidence from six RCTs suggested that risk of mortality may be higher in people taking quinidine (RR 2.01, 95% CI 0.84 to 4.77; participants = 1646). Moderate-certainty evidence showed increased RR for mortality but with very wide CIs for metoprolol (RR 2.02, 95% CI 0.37 to 11.05, 2 RCTs, participants = 562) and amiodarone (RR 1.66, 95% CI 0.55 to 4.99, 2 RCTs, participants = 444), compared with placebo.We found little or no difference in mortality with dofetilide (RR 0.98, 95% CI 0.76 to 1.27; moderate-certainty evidence) or dronedarone (RR 0.86, 95% CI 0.68 to 1.09; high-certainty evidence) compared to placebo/no treatment. There were few data on mortality for disopyramide, flecainide and propafenone, making impossible a reliable estimation for those drugs.Withdrawals due to adverse eventsAll analysed drugs increased withdrawals due to adverse effects compared to placebo or no treatment (quinidine: RR 1.56, 95% CI 0.87 to 2.78; disopyramide: RR 3.68, 95% CI 0.95 to 14.24; propafenone: RR 1.62, 95% CI 1.07 to 2.46; flecainide: RR 15.41, 95% CI 0.91 to 260.19; metoprolol: RR 3.47, 95% CI 1.48 to 8.15; amiodarone: RR 6.70, 95% CI 1.91 to 23.45; dofetilide: RR 1.77, 95% CI 0.75 to 4.18; dronedarone: RR 1.58, 95% CI 1.34 to 1.85; sotalol: RR 1.95, 95% CI 1.23 to 3.11). Certainty of the evidence for this outcome was low for disopyramide, amiodarone, dofetilide and flecainide; moderate to high for the remaining drugs.ProarrhythmiaVirtually all studied antiarrhythmics showed increased proarrhythmic effects (counting both tachyarrhythmias and bradyarrhythmias attributable to treatment) (quinidine: RR 2.05, 95% CI 0.95 to 4.41; disopyramide: no data; flecainide: RR 4.80, 95% CI 1.30 to 17.77; metoprolol: RR 18.14, 95% CI 2.42 to 135.66; amiodarone: RR 2.22, 95% CI 0.71 to 6.96; dofetilide: RR 5.50, 95% CI 1.33 to 22.76; dronedarone: RR 1.95, 95% CI 0.77 to 4.98; sotalol: RR 3.55, 95% CI 2.16 to 5.83); with the exception of propafenone (RR 1.32, 95% CI 0.39 to 4.47) for which the certainty of evidence was very low and we were uncertain about the effect. Certainty of the evidence for this outcome for the other drugs was moderate to high.StrokeEleven studies reported stroke outcomes with quinidine, disopyramide, flecainide, amiodarone, dronedarone and sotalol. High-certainty evidence from two RCTs suggested that dronedarone may be associated with reduced risk of stroke (RR 0.66, 95% CI 0.47 to 0.95; participants = 5872). This result is attributed to one study dominating the meta-analysis and has yet to be reproduced in other studies. There was no apparent effect on stroke rates with the other antiarrhythmics.Recurrence of atrial fibrillationModerate- to high-certainty evidence, with the exception of disopyramide which was low-certainty evidence, showed that all analysed drugs, including metoprolol, reduced recurrence of atrial fibrillation (quinidine: RR 0.83, 95% CI 0.78 to 0.88; disopyramide: RR 0.77, 95% CI 0.59 to 1.01; propafenone: RR 0.67, 95% CI 0.61 to 0.74; flecainide: RR 0.65, 95% CI 0.55 to 0.77; metoprolol: RR 0.83 95% CI 0.68 to 1.02; amiodarone: RR 0.52, 95% CI 0.46 to 0.58; dofetilide: RR 0.72, 95% CI 0.61 to 0.85; dronedarone: RR 0.85, 95% CI 0.80 to 0.91; sotalol: RR 0.83, 95% CI 0.80 to 0.87). Despite this reduction, atrial fibrillation still recurred in 43% to 67% of people treated with antiarrhythmics. AUTHORS' CONCLUSIONS: There is high-certainty evidence of increased mortality associated with sotalol treatment, and low-certainty evidence suggesting increased mortality with quinidine, when used for maintaining sinus rhythm in people with atrial fibrillation. We found few data on mortality in people taking disopyramide, flecainide and propafenone, so it was not possible to make a reliable estimation of the mortality risk for these drugs. However, we did find moderate-certainty evidence of marked increases in proarrhythmia and adverse effects with flecainide.Overall, there is evidence showing that antiarrhythmic drugs increase adverse events, increase proarrhythmic events and some antiarrhythmics may increase mortality. Conversely, although they reduce recurrences of atrial fibrillation, there is no evidence of any benefit on other clinical outcomes, compared with placebo or no treatment.

Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation frequently recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. This is an update of a review previously published in 2008 and 2012. OBJECTIVES: To determine in patients who have recovered sinus rhythm after having atrial fibrillation, the effects of long-term treatment with antiarrhythmic drugs on death, stroke, embolism, drug adverse effects and recurrence of atrial fibrillation. SEARCH METHODS: We updated the searches of CENTRAL in The Cochrane Library (2013, Issue 12 of 12), MEDLINE (to January 2014) and EMBASE (to January 2014). The reference lists of retrieved articles, recent reviews and meta-analyses were checked. SELECTION CRITERIA: Two independent authors selected randomised controlled trials comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored. Post-operative atrial fibrillation was excluded. DATA COLLECTION AND ANALYSIS: Two authors independently assessed quality and extracted data. Studies were pooled, if appropriate, using Peto odds ratio (OR). All results were calculated at one year of follow-up. MAIN RESULTS: In this update three new studies, with 534 patients, were included making a total of 59 included studies comprising 21,305 patients. All included studies were randomised controlled trials. Allocation concealment was adequate in 17 trials, it was unclear in the remaining 42 trials. Risk of bias was assessed in all domains only in the trials included in this update.Compared with controls, class IA drugs quinidine and disopyramide (OR 2.39, 95% confidence interval (95% CI) 1.03 to 5.59, number needed to treat to harm (NNTH) 109, 95% CI 34 to 4985) and sotalol (OR 2.23, 95% CI 1.1 to 4.50, NNTH 169, 95% CI 60 to 2068) were associated with increased all-cause mortality. Other antiarrhythmics did not seem to modify mortality, but our data could be underpowered to detect mild increases in mortality for several of the drugs studied.Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of atrial fibrillation (OR 0.19 to 0.70, number needed to treat to beneft (NNTB) 3 to 16). Beta-blockers (metoprolol) also significantly reduced atrial fibrillation recurrences (OR 0.62, 95% CI 0.44 to 0.88, NNTB 9).All analysed drugs increased withdrawals due to adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia. Only 11 trials reported data on stroke. None of them found any significant difference with the exception of a single trial than found less strokes in the group treated with dronedarone compared to placebo. This finding was not confirmed in others studies on dronedarone.We could not analyse heart failure and use of anticoagulation because few original studies reported on these measures. AUTHORS' CONCLUSIONS: Several class IA, IC and III drugs, as well as class II drugs (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolism, heart failure) remain to be established.

The value of B-type natriuretic peptide plasma concentrations in very old people with chronic peripheral oedema.

BACKGROUND: Chronic peripheral oedema is frequent in old patients, and very often results from multiple causes. AIM: To investigate whether determination of B-type natriuretic peptide plasma concentration helps with the diagnosis of chronic peripheral oedema aetiologies. METHODS: This was a cross-sectional observational study conducted in geriatric hospital wards (intermediate and long-term care) on consecutive in-hospital patients aged>75 years with chronic peripheral oedema and no dyspnoea. From medical history, physical examination, routine biological tests and chest radiography, two investigators determined the aetiologies of oedema, with special attention paid to recognizing chronic heart failure. This reference diagnosis was compared with the clinical diagnosis mentioned in the medical chart. Brain natriuretic peptide plasma concentrations were measured soon after the investigators' visit. RESULTS: Among the 141 patients (113 women and 28 men) aged 86±6 years, a single aetiology was identified in 53 (38%), and multiple aetiologies in 84 (60%). The main aetiologies were venous insufficiency (69%), chronic heart failure (43%), hypoproteinaemia (38%) and drug-induced oedema (26%). Chronic heart failure was frequently misdiagnosed by attending clinicians (missed in 18 cases and wrongly diagnosed in 14 cases). Brain natriuretic peptide concentration was significantly higher in patients with chronic heart failure than in those without: median (interquartile range) 490 (324-954) versus 137 (79-203) pg/mL, respectively (P<0.0001). The receiver operating characteristic curve showed that a concentration of 274pg/mL was appropriate for diagnosing chronic heart failure, with a specificity of 0.89 and a sensitivity of 0.82. Brain natriuretic peptide concentrations above this cut-off were significantly and independently associated with the diagnosis of chronic heart failure. CONCLUSIONS: Chronic heart failure is frequently misdiagnosed in old patients with chronic peripheral oedema, and B-type natriuretic peptide plasma concentration helped to improve the diagnosis of this condition and identify chronic heart failure.

[Gerontological evaluation benefits for very older people with cardiovascular disease]. / Apports de l'évaluation gérontologique pour les patients cardiovasculaires très âgés.

The multidimensional, multiprofessional gerontological evaluation helps identify geriatric syndromes and situations of fragility. This is a first step to establish a plan of care and assistance, to reduce the risk of falls, hospitalization, entry into institutions and to prevent a decline in independence. Older people with cardiovascular disease such as heart failure are at very high risk of repeated hospitalizations, with an average of 45% of patients re-hospitalized in the year following all-cause hospitalization. In the context of heart failure, frailty is an independent risk factor for mortality within 30 days of leaving hospital. Screening for frailty before transcatheter aortic valve implantation (TAVI) or interventional rhythmic procedure is a determining factor in decision-making for benefit in terms of survival and quality of life in elderly patients. Vascular diseases by their cerebral complications represent the first cause of mortality and the first cause of loss of functional independence in the subjects of more than 65 years. Vascular disease is a risk factor for cognitive impairment in the elderly.