Good performance in the management of acute heart failure in cardiogeriatric departments: the ICREX-94 experience.

CONTEXT: A growing number of elderly patients hospitalized for Acute Heart Failure (AHF) are being managed in cardiogeriatrics departments, but their characteristics and prognosis are poorly known. This study aimed to investigate the profile and outcome (rehospitalization at 90 days) of patients hospitalized for AHF in cardiogeriatrics departments in the Val-de-Marne area in the suburbs of Paris, and to compare them to AHF patients hospitalized in cardiology departments in the same area. METHODS: Observational study, ICREX-94, conducted in seven cardiology departments in France and three specific cardiogeriatrics departments in Val-de-Marne. RESULTS: A total of 308 patients were hospitalized for AHF between October 2017 and January 2019. During the 90 days following discharge, 29.6% patients were readmitted to the hospital. Compared with patients hospitalized in cardiology departments, patients in cardiogeriatrics departments were older (p < 0.001), less independent (living more often alone or in an institution) (p < 0.001), more often depressed (p < 0.001), had more often major neurocognitive disorder (p < 0.001), had a higher Human Development Index (HDI, p < 0.001), and were less often diagnosed with amyloidosis (p < 0.001). There was no difference in outcome whether patients were discharged from cardiology or cardiogeriatrics departments. The most frequent precipitating factors underlying AHF decompensation between the first and second hospitalization were arrhythmia and infection. CONCLUSION: AHF patients discharged from cardiogeriatrics departments, compared to cardiology departments, showed clinical differences but had the same prognosis regarding AHF rehospitalization at 90 days.

Phenotype and prognostic factors in geriatric and non-geriatric patients with transthyretin cardiomyopathy.

AIMS: Transthyretin cardiac amyloidosis (ATTR-CM) may be an underestimated cause of heart failure among geriatric patients and represent a unique phenotype and prognostic profile. METHODS AND RESULTS: This retrospective, observational, cohort study characterizes cardiac and extracardiac disorders at diagnosis and assesses prognosis among ATTR-CM patients based on age (geriatric vs. non-geriatric) and amyloidosis subtype (wild type, ATTRwt and hereditary, ATTRv). In total, 943 patients with ATTR-CM were included, of which 306 had ATTRv and 637 had ATTRwt. Among these, 331 (35.1%) were non-geriatric (<75 years), and 612 (64.9%) were geriatric (≥75 years). The population exhibited conduction abnormalities, atrial fibrillation and ischaemic heart disease that progressively deteriorated with age. Among ATTRwt patients, peripheral neuropathy, neurovegetative symptoms, and hearing loss were present across all age groups, but reports of carpal tunnel symptoms or surgery decreased with age. Conversely, among ATTRv patients, reports of extracardiac symptoms increased with age and Val122ILe mutation was highly prevalent among geriatric patients. The 3-year survival was higher among non-geriatric ATTR-CM patients (76%) than geriatric patients (55%) and predictors of 3-year mortality differed. Notably, predictors identified among geriatric patients were alkaline phosphatase (ALP) (HR = 1.004, 95% CI: [0.001-1.100)], troponin T hs (HR = 1.005, 95% CI: [1.001-1.120)] and tricuspid insufficiency (HR = 1.194, 95% CI: [1.02-1.230)]. Whereas, among non-geriatric patients, NT-proBNP (HR = 1.002, 95% CI: [1.02-1.04], global longitudinal strain (HR = 0.95, 95% CI: [0.922-0.989], and glomerular filtration rate (HR = 0.984, 95% CI: [0.968-1.00) were identified. We propose a 3-stage prognostic staging system combining troponin T hs (≥44 ng/L) and ALP levels (≥119 UI/L). In the geriatric population, this model discriminated survival more precisely than the National Amyloidosis Centre staging, particularly for classifying between stage 1 (82%), stage 2 (50%) and stage 3 (32%) for ATTRv and ATTRwt. CONCLUSIONS: These diagnostic and prognostic indicators, along with ATTR subtype, highlight the distinct characteristics of this important, geriatric ATTR-CM patient group. Recognizing these mortality markers can be valuable for geriatricians to improve the prognostic quality management of geriatric patients with ATTR-CM.

Patients with cardiac amyloidosis are at a greater risk of mortality and hospital readmission after acute heart failure.

AIMS: Cardiac amyloidosis (CA) is an under-diagnosed cause of heart failure (HF) and has a worse prognosis than other forms of HF. The frequency of death or rehospitalization following discharge for acute heart failure (AHF) in CA (relative to other causes) has not been documented. The study aims to compare hospital readmission and death rates 90 days after discharge for AHF in patients with vs. without CA and to identify risk factors associated with these events in each group. METHODS AND RESULTS: Patients with HF and CA (HF + CA+) were recruited from the ICREX cohort, after screening of their medical records. The cases were matched 1:5 by sex and age with control HF patients without CA (HF + CA-). There were 27 HF + CA + and 135 HF + CA- patients from the ICREX cohort included in the study. Relative to the HF + CA- group, HF + CA+ patients had a higher heart rate (P = 0.002) and N-terminal prohormone of brain natriuretic peptide levels (P < 0.001) and lower blood pressure (P < 0.001), weight, and body mass index values (P < 0.001) on discharge. Ninety days after discharge, the HF + CA+ group displayed a higher death rate, a higher all-cause hospital readmission rate, and a higher hospital readmission rate for AHF. Death and hospital readmissions occurred sooner after discharge in the HF + CA+ group than in the HF + CA- group. CONCLUSIONS: The presence of CA in patients with HF was associated with a three-fold greater risk of death and a two-fold greater risk of all-cause hospital readmission 90 days after discharge. These findings emphasize the importance of close, active management of patients with CA and AHF.

Chronology of COVID-19 Symptoms in Very Old Patients: Study of a Hospital Outbreak.

BACKGROUND: We wanted to better understand the frequency and temporal distribution of symptoms of COVID-19 in very old patients, which are currently not well defined. METHODS: In an observational, descriptive study, we followed all patients being at three geriatric convalescence and rehabilitation units when a COVID-19 outbreak emerged in those units in March 2020. For those who developed the disease, we recorded any new symptom occurring at diagnosis, in the previous 14 and the following 21 days. A group of SARS-Cov-2-negative patients served as controls. RESULTS: Sixty-nine of the 176 inpatients (mean age: 86 years) were infected by SARS-Cov-2 during the outbreak. At the moment of diagnosis, a majority of patients had fever (71.0%), malaise-asthenia (24.6%), or respiratory symptoms (66.7%). However, 48 patients (69.6% of all SARS-Cov-2 positive patients) also presented, usually several days before, other symptoms: (a) gastrointestinal symptoms (39.1% of all patients, median onset eight days before diagnosis, IQR -9 to +3 days); (b) neurological symptoms (30.4% of all patients, median onset five days before diagnosis, IQR -11 to -3 days), notably delirium (24.6%); and (c) other symptoms, like falls and unexplained decompensation of chronic conditions (29.0% of all patients, median onset four days before diagnosis, IQR -10 to 0). None of those symptoms were observed in similar proportion in 25 control SARS-CoV-2-negative patients, hospitalized during the same period. CONCLUSIONS: Diarrhea, nausea-vomiting, delirium, falls, and unexplained decompensation of chronic conditions were the first symptoms of COVID-19 in a majority of older patients in this cohort, preceding typical symptoms by several days. Recognizing those early symptoms could hasten the diagnosis of COVID-19 in this population.

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.

Coronavirus Disease 2019 Outcomes in French Nursing Homes That Implemented Staff Confinement With Residents.

IMPORTANCE: Coronavirus disease 2019 (COVID-19) is a major threat to nursing homes. During the COVID-19 pandemic wave that hit France in March and April 2020, staff members of some French nursing homes decided to confine themselves with their residents on a voluntary basis to reduce the risk of entry of the severe acute respiratory syndrome coronavirus 2 into the facility. OBJECTIVE: To investigate COVID-19-related outcomes in French nursing homes that implemented voluntary staff confinement with residents. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted in French nursing homes from March 1 to May 11, 2020. Participants included residents and staff members of the nursing homes where staff participated in voluntary self-confinement as well as those of the facilities for elderly people where staff did not practice self-confinement. Rates of COVID-19 cases and mortality in the cohort of nursing homes with self confinement were compared with those derived from a population-based survey of nursing homes conducted by French health authorities. EXPOSURES: Nursing homes with staff who self-confined were identified from the media and included if the confinement period of staff with residents was longer than 7 days. MAIN OUTCOMES AND MEASURES: Mortality related to COVID-19 among residents and COVID-19 cases among residents and staff members. COVID-19 was diagnosed by primary care or hospital physicians on the basis of fever and respiratory signs (eg, cough, dyspnea) or a clinical illness compatible with COVID-19; COVID-19 diagnoses were considered confirmed if real-time reverse transcriptase-polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 on nasopharyngeal swab was positive and considered possible if the test had not been performed or results were negative. Cases of COVID-19 were recorded by a telephone interview with the directors of nursing homes with staff who self-confined and by a nationwide declaration survey to health authorities for all facilities. RESULTS: This study included 17 nursing homes in which 794 staff members confined themselves to the facility with their 1250 residents. The national survey included 9513 facilities with 385 290 staff members and 695 060 residents. Only 1 nursing home with staff who self-confined (5.8%) had cases of COVID-19 among residents, compared with 4599 facilities in the national survey (48.3%) (P < .001). Five residents (0.4%) in the nursing homes with staff who self-confined had confirmed COVID-19, compared with 30 569 residents (4.4%) with confirmed COVID-19 in the national survey (P < .001); no residents of facilities with self-confinement had possible COVID-19, compared with 31 799 residents (4.6%) with possible COVID-19 in the national survey (P < .001). Five residents (0.4%) in the nursing homes with staff who self-confined died of COVID-19, compared with 12 516 (1.8%) in the national survey (odds ratio, 0.22; 95% CI, 0.09-0.53; P < .001). Twelve staff members (1.6%) from the facilties with self-confinement had confirmed or possible COVID-19, compared with 29 463 staff members (7.6%) in the national survey (P < .001). CONCLUSIONS AND RELEVANCE: In this cohort study of French nursing homes during the COVID-19 pandemic, mortality rates related to COVID-19 were lower among nursing homes that implemented staff confinement with residents compared with those in a national survey. These findings suggest that self-confinement of staff members with residents may help protect nursing home residents from mortality related to COVID-19 and residents and staff from COVID-19 infection.

[Hypotensions in the elderly: Clinical and therapeutic features]. / Hypotensions du sujet âgé : aspects cliniques et thérapeutiques.

Hypotension and especially very low diastolic blood pressure could be an at-risk situation in very old and frail patients and in those with coronary heart disease. Chronic hypotension in people with heart failure is an indicator of poor prognosis and hinders the management of therapy. Orthostatic hypotension is a decrease in blood pressure>20mmHg for systolic and/or>10mmHg for diastolic within 3minutes after transition from supine to upright. Orthostatic hypotension may be symptomatic or not. The search for orthostatic hypotension is part of the clinical examination of elderly patients with hypertension, falling, diabetes and or polymedication. First intention treatment aims to correct modifiable modifying factors and to limit the circulatory consequences of orthostatism by elastic venous compression.