Impairments identified by comprehensive geriatric assessment in potential candidates for left ventricular assist device and heart transplantation.

Background: The aim of this study was to assess the prevalence of frailty and other impairments in potential left ventricular assist device (LVAD) and heart transplantation (HTx) candidates by performing a preoperative comprehensive geriatric assessment (CGA) and reviewing the treatment recommendations resulting from the CGA. Methods and results: This cross-sectional study included 73 patients aged ≥40 years who received a CGA as part of the patient selection procedure for LVAD and HTx. In every patient, a conclusion comprising frailty and other impairments was formulated based on the medical, mental, functional, and social domains and recommendations were made. The mean age was 58 years (range 40-71) and 70 % were male. In 97 % of patients, at least one impairment was identified by the CGA. The most common impairments were polypharmacy, high morbidity burden, reduced renal function, osteopenia, depression, poor quality of life, reduced functionality, (risk of) malnutrition, reduced grip strength and high caregiver burden. A small proportion of the potential LVAD and HTx candidates were frail (7 % according to Fried's frailty criteria, 6 % according to the Edmonton Frail Scale) and 39 % were pre-frail. The domains for which most impairments were found and the domains for which most treatment recommendations were given matched well, with the functional domain as the frontrunner. Conclusion: This study showed that most of the potential candidates for LVAD or HTx have impairments on at least one domain of the CGA. Impairments and associated risks can contribute to the decision making process for candidacy for LVAD and HTx.

Association between perioperative statin treatment and short-term clinical outcomes following transcatheter aortic valve implantation: a retrospective cohort study.

BACKGROUND: Studies have found statin treatment to be associated with improved 1-year survival after transcatheter aortic valve implantation (TAVI), suggesting pleiotropic effects of statins on preventing perioperative complications. Statin treatment is not associated with postoperative cardiovascular complications or mortality; however, other postoperative complications have not been investigated. AIM: To explore whether preoperative statin treatment is associated with a lower short-term risk of mortality, readmission and major postoperative complications in older patients undergoing TAVI. METHODS: A retrospective cohort study including patients aged 65 years and older who had undergone a comprehensive geriatric assessment prior to TAVI between January 2014 and January 2021. The primary outcomes were 90-day mortality, 90-day readmissions and major postoperative complications according to the Clavien-Dindo classification. Multivariable logistic regression was performed with adjustment for potential confounders, namely age, gender, comorbidity, body mass index, smoking, diminished renal function, alcohol use and falls . RESULTS: This study included 584 patients, of whom 324 (55.5%) were treated with a statin. In the statin treated group, 15 (4.6%) patients died within 90 days of TAVI compared with 10 (3.8%) patients in the non statin group (adjusted OR 1.17; 95% CI 0.51 to 2.70). The number of 90-day readmissions was 39 (12.0%) and 34 (13.1%) (adjusted OR 0.91; 95% CI 0.54 to 1.52), respectively. In the statin treated group, 115 (35.5%) patients experienced a major complication compared with 98 (37.7%) in the non-statin group (adjusted OR 0.95; 95% CI 0.67 to 1.37). CONCLUSION: Preoperative statin treatment is not associated with improved short-term outcomes after TAVI. A randomised controlled trial with different statin doses may be warranted to investigate whether initiating statin treatment before TAVI improves both postoperative outcomes and long-term survival.

Predictors of clinical outcome following transcatheter aortic valve implantation: a prospective cohort study.

OBJECTIVE: In recent years, transcatheter aortic valve implantation (TAVI) has become the treatment of choice for patients with symptomatic aortic valve stenosis considered to be at increased or high surgical risk. The aim of this study was to identify predictors of postoperative adverse events in older adults undergoing TAVI. METHODS: A prospective observational cohort study of patients who were referred to a geriatric outpatient clinic for a geriatric assessment prior to TAVI was conducted. The outcomes were mortality and hospital readmission within 3 months of TAVI and the occurrence of major postoperative complications during hospitalisation according to the Clavien-Dindo classification. These three outcomes were also combined to a composite outcome. Univariate and multivariate logistic regression analyses were performed to identify predictors of the outcomes and composite outcome of adverse events. RESULTS: This cohort included 490 patients who underwent TAVI (mean age 80.7±6.2 years, 47.3% male). Within 3 months of TAVI, 19 (3.9%) patients died and 46 (9.4%) patients experienced a hospital readmission. A total of 177 (36.1%) patients experienced one or more major complications according to the Clavien-Dindo classification during hospitalisation and 193 patients (39.4%) experienced the composite outcome of adverse events. In multivariate analyses, cognitive impairment was identified as an independent predictor of major postoperative complications (OR 2.16; 95% CI 1.14 to 4.19) and the composite outcome of adverse events (OR 2.40; 95% CI 1.21 to 4.79). No association was found between the other variables and the separate outcomes and composite outcome. CONCLUSION: Cognitive impairment is associated with postoperative adverse events in older patients undergoing TAVI. Therefore, it is important to screen for cognitive impairment prior to TAVI and it is recommended to include this in current TAVI guidelines.

Statins After Ischemic Stroke in the Oldest: A Cohort Study Using the Clinical Practice Research Datalink Database.

[Figure: see text].

Statins After Myocardial Infarction in the Oldest: A Cohort Study in the Clinical Practice Research Datalink Database.

OBJECTIVE: To explore the effect of initiating statins for secondary prevention after a first myocardial infarction (MI) in patients aged 80 years and older. DESIGN: Retrospective cohort study. SETTING: Clinical Practice Research Datalink (1999-2016). PARTICIPANTS: Patients, aged 65 years and older, hospitalized after a first MI without a statin prescription in the year before hospitalization. The age group of 65 to 80 years was included to compare our results to current evidence. MEASUREMENTS: The primary outcome was a composite of recurrent MI, stroke, and cardiovascular mortality; and the secondary outcome was all-cause mortality. A time-varying Cox model was used to account for statin prescription over time. We compared at least 2 years of statin prescription time with untreated and less than 2 years of prescription time. Analyses were adjusted for potential confounders. The number needed to treat (NNT) was calculated based on the adjusted hazard ratios (HRs) and corrected for deaths during the first 2 years of follow-up. RESULTS: A total of 9020 patients were included. Among the 3900 patients aged 80 years and older, 2 years of statin prescriptions resulted in a lower risk of the composite outcome (adjusted HR = 0.81; 95% confidence interval [CI] = 0.66-0.99) and of all-cause mortality (adjusted HR = 0.84; 95% CI = 0.73-0.97). During 4.5 years of median follow-up, the NNT for prevention of the primary outcome was 59; and for mortality, the NNT was 36. Correcting for 36.2% deaths during the first 2 years increased the NNT on the primary outcome to 93 and to 61 on all-cause mortality. CONCLUSION: Our data support statin initiation after a first MI in patients aged 80 years and older if continued for at least 2 years. Especially in patients with a low risk of 2-year mortality, statins should be considered. J Am Geriatr Soc 68:329-336, 2020.

Haloperidol Use Among Elderly Patients Undergoing Surgery: A Retrospective 1-Year Study in a Hospital Population.

BACKGROUND: Haloperidol, frequently used for delirium, can lead to serious side effects, of which QTc prolongation is the most worrisome since it is associated with an increased risk of fatal cardiac arrhythmia. OBJECTIVES: The aim of this study was to measure the frequency of haloperidol use after procedures in patients aged ≥65 years in a hospital in the Netherlands. METHODS: This was a retrospective study among patients hospitalized in the Netherlands who were aged ≥65 years and who underwent a procedure between January 2008 and January 2009. The hospital's electronic drug database was used to identify the use of haloperidol during hospital admission. RESULTS: A total of 7782 procedures took place in 5946 elderly patients, and 1357 patients were readmitted for a second procedure in the same year. The overall frequency of haloperidol use was 5.4 %. Procedures were classified as elective (90 %) and as major (18 %). A total of 28 % (n = 570) of patients who underwent acute procedures and 24 % (n = 1086) of patients who underwent major procedures received haloperidol. Patients receiving haloperidol had a significantly longer hospital stay (14 vs. 1 day, p < 0.001) than patients without haloperidol. Haloperidol users were more likely to have more than one intervention than non-users (16.0 vs. 1.7 %, p < 0.001). In multivariable analysis, haloperidol use was associated with older age (odds ratio [OR] 1.09; 95 % confidence interval [CI] 1.07-1.11, p < 0.001), acute surgery (OR 2.09; 95 % CI 1.65-2.94, p < 0.001), and major procedures (OR 15.4; 95 % CI 11.5-21.5, p < 0.001). CONCLUSION: We show a frequency of haloperidol use of 5.4 %. Based on this high frequency, surveillance of adverse events in hospital should be performed systematically, particularly in the high-risk population that undergoes acute major surgery.