Assessing suitability for sacubitril-valsartan therapy in an Irish cohort: challenges and opportunities.

INTRODUCTION: Sacubitril-valsartan has been shown by the PARADIGM-HF trial to decrease hospital admissions and improve mortality in patients with heart failure with reduced ejection fraction. The PARADIGM trial had stringent exclusion criteria. It is not known how applicable these trial criteria are to real-life practice. In this study, we sought to determine the percentage of patients eligible for sacubitril-valsartan therapy in a level 3 hospital without a dedicated heart failure service. METHODS: All patients discharged from our service with a diagnosis of congestive cardiac using our hospital in-patient enquiry (HIPE) system underwent hierarchal analysis. In order to be deemed eligible for sacubitril-valsartan therapy, patients had to meet PARADIGM-HF inclusion criteria. RESULTS: Our 143 patients represented a more clinically unwell, elderly cohort than the PARADIGM trial study population. Only 24 patients (16.66%) had an ejection fraction of 40% or less. Our results indicate that only 4/143 patients in a real-world setting (2.79%) were eligible for sacubitril-valsartan therapy at the point of discharge as per the PARADIGM-HF study criteria. This is primarily due to the higher than expected percentage of patients in our cohort with an ejection fraction of over 40% (n = 120) and the low percentage of patients on therapeutic doses of ACEI/ARB (n = 15). CONCLUSIONS: Our study showed that a smaller than expected proportion of our patients in real-world practice are suitable for sacubitril-valsartan therapy at discharge. Most patients were in the HFPEF cohort which does not currently have evidence for treatment with sacubitril-valsartan. Low rates of prescribing of basic heart failure medicatons and the absence of dedicated heart failure services in a non-tertiary centre may explain the poor compliance observed. Improving guideline adherence and increasing awareness of evidence-based medication use at primary and secondary care levels would be of benefit to Irish heart failure patients.

Eosinophilic myocarditis: an often subtle and potentially under-recognised phenomenon.

A 34-year-old woman presented to our service with chest pain, a troponin rise and dynamic ECG changes. Of note, she had complained of fatigue, feeling constitutionally unwell and a generalised rash in the days prior to her presentation. Her echocardiogram showed normal wall motion and preserved ejection fraction. Her eosinophil count, normal at presentation, rose to a peak of 12.21×105/L. She was haemodynamically stable throughout with no evidence clinically of congestive cardiac failure. CT coronary angiogram showed no obstructive coronary artery disease. Cardiac MRI demonstrated areas of late gadolinium enhancement consistent with myocarditis. A diagnosis of eosinophilic myocarditis was made. No tissue biopsy was performed due to the patchy myocardial involvement and high potential for low-yield biopsy. Our patient was treated conservatively and has made an excellent recovery.

Education in geriatric medicine for community hospital staff.

Community hospitals provide many services for older people. They are mainly managed by nursing staff, with some specialist input. Little is known about education provided in these facilities. Most education in geriatric medicine is provided in hospitals, despite most elderly care being provided in the community. The authors surveyed senior nursing staff in Irish community hospitals to examine this area in more detail. Staff in all 18hospitals in the Health Service Executive (South) area were invited to participate. The response rate was 100%. Sixteen of the 18 respondents (89%) felt staff did not have enough education in geriatric medicine. Just over half of hospitals had regular staff education sessions in the area, with a minority of sessions led by a geriatrician, and none by GPs. Geriatrician visits were valued, but were requested only every 1-3 months. Staff identified challenging behaviour and dementia care as the areas that posed most difficulty.

Functional dyspepsia: motor abnormalities, sensory dysfunction, and therapeutic options.

Functional dyspepsia is a common condition, but as yet, the underlying etiology is unclear. In this article, upper gastrointestinal motor and sensory physiology are reviewed and the current evidence for motor and/or sensory functional abnormalities causing dyspeptic symptoms is presented. The complex interrelationship between abnormal motor activity and sensation is explored, as well as the potential roles for autonomic dysfunction and psychological state in modulating gastrointestinal sensation and motor function. Finally, based on clinical trial evidence, a treatment pathway for functional dyspepsia is suggested.

Pulmonary embolism: differences in presentation between older and younger patients.

BACKGROUND: the incidence of pulmonary embolism increases with age but the 'classical' presentation of acute pulmonary embolism may not occur in older persons. OBJECTIVES: to compare the clinical presentation of younger and older patients with acute pulmonary embolism. DESIGN: retrospective identification of 60 consecutive cases of spiral computed tomography confirmed acute pulmonary embolism over a 3-year period, with blinded review of radiological films and electrocardiographs, and analysis of clinical presentation. SETTING: a district general hospital serving a population of 200,000 people. SUBJECTS: 31 younger and 29 older patients with acute pulmonary embolism. RESULTS: older persons less often complained of pleuritic chest pain (P < 0.02), particularly as their primary presenting complaint (P < 0.002). Twenty-four percent of older but just 3% of younger persons presented with collapse (P < 0.02), despite similar proportions of central and peripheral emboli in the two groups. Older persons were more often cyanosed (P = 0.05) and hypoxic (P < 0.04) than younger persons but there were no significant differences with respect to heart rate, respiratory rate or mean arterial blood pressure. CONCLUSIONS: older people present atypically with acute pulmonary embolism, potentially leading to delays in diagnosis and initiation of treatment. Collapse is a particularly important symptom of acute pulmonary embolism in older persons, even in the absence of pain.

A new classification of higher level gait disorders in patients with cerebral multi-infarct states.

BACKGROUND: cerebral multi-infarct states may lead to gait disorders in the absence of cognitive impairment. Where these gait disorders occur in the absence of neurological signs they have been termed gait apraxia or more recently higher-level gait disorders. In this paper we hypothesise three main types based on presumptive sites of anatomical damage: (a) Ignition Apraxia, where damage is predominantly in the supplementary motor area and its connections, with good responses to external clues; (b) Equilibrium Apraxia, where damage is predominantly in the pre-motor area in its connections, with poor responses to external cues and (c) Mixed Gait Apraxia. SUBJECTS: the clinical features and measured gait parameters of 13 patients with cerebral multi-infarct states and higher-level gait disorder are described (7 with Ignition Apraxia and 6 with Equilibrium Apraxia) along with those of 6 healthy elderly control subjects. METHODS: baseline gait characteristics were assessed on a walkway, which measured the following: step lengths, width of base and velocity. RESULTS: measured baseline gait parameters support the above hypothesis. CONCLUSIONS: it is suggested, though not proven, that patients with Ignition Apraxia could have problems with internal cueing due to lesions in the supplementary motor area or its connections whereas those with Equilibrium Apraxia could have dysfunction predominantly in the pre-motor area and its connections.