Review on the management of cardiovascular risk factors in the elderly.

Cardiovascular risk factors (CVRF) are very prevalent in the elderly population and in addition to predisposing to cardiovascular disease they are related to functional decline, which limits the quality of life in this population. The objective of this work is to offer a review of the current evidence in the management of CVRF in the elderly population. The search strategy was executed in PubMed, Clinicalstrials.org and Embase, to search for clinical trials, observational cohort or cross-sectional studies, reviews, and clinical practice guidelines focused or including elderly population. The results provided were refined after reading the title and abstract, as well as elimination of duplicates, and were finally identified and assessed following the GRADE methodology. A total of 136 studies were obtained for all predefined risk factors, such as sedentary lifestyle, smoking, obesity and metabolic syndrome, hypertension, diabetes mellitus, dyslipidemia and alcohol. We described the results of the studies identified and assessed according to their methodological quality in different recommendation sections: diagnostic and prevention, intervention, or treatment in the elderly population. As the main limitation to the results of this review, there is the lack of quality studies whose target population is elderly patients. This issue limits the recommendations that can be made in this population. Due to this reason, comprehensive geriatric assessment seems the best tool currently available to implement the most appropriate treatment plans based on the baseline situation and comorbidity of each elderly patient.

Infective Endocarditis in the Elderly: Challenges and Strategies.

The specific management of infective endocarditis (IE) in elderly patients is not specifically addressed in recent guidelines despite its increasing incidence and high mortality in this population. The term "elderly" corresponds to different ages in the literature, but it is defined by considerable comorbidity and heterogeneity. Cancer incidence, specifically colorectal cancer, is increased in older patients with IE and impacts its outcome. Diagnosis of IE in elderly patients is challenging due to the atypical presentation of the disease and the lower performance of imaging studies. Enterococcal etiology is more frequent than in younger patients. Antibiotic treatment should prioritize diminishing adverse effects and drug interactions while maintaining the best efficacy, as surgical treatment is less commonly performed in this population due to the high surgical risk. The global assessment of elderly patients with IE, with particular attention to frailty and geriatric profiles, should be performed by multidisciplinary teams to improve disease management in this population.

Prevalence, Characteristics, and Outcomes of COVID-19-Associated Acute Myocarditis.

BACKGROUND: Acute myocarditis (AM) is thought to be a rare cardiovascular complication of COVID-19, although minimal data are available beyond case reports. We aim to report the prevalence, baseline characteristics, in-hospital management, and outcomes for patients with COVID-19-associated AM on the basis of a retrospective cohort from 23 hospitals in the United States and Europe. METHODS: A total of 112 patients with suspected AM from 56 963 hospitalized patients with COVID-19 were evaluated between February 1, 2020, and April 30, 2021. Inclusion criteria were hospitalization for COVID-19 and a diagnosis of AM on the basis of endomyocardial biopsy or increased troponin level plus typical signs of AM on cardiac magnetic resonance imaging. We identified 97 patients with possible AM, and among them, 54 patients with definite/probable AM supported by endomyocardial biopsy in 17 (31.5%) patients or magnetic resonance imaging in 50 (92.6%). We analyzed patient characteristics, treatments, and outcomes among all COVID-19-associated AM. RESULTS: AM prevalence among hospitalized patients with COVID-19 was 2.4 per 1000 hospitalizations considering definite/probable and 4.1 per 1000 considering also possible AM. The median age of definite/probable cases was 38 years, and 38.9% were female. On admission, chest pain and dyspnea were the most frequent symptoms (55.5% and 53.7%, respectively). Thirty-one cases (57.4%) occurred in the absence of COVID-19-associated pneumonia. Twenty-one (38.9%) had a fulminant presentation requiring inotropic support or temporary mechanical circulatory support. The composite of in-hospital mortality or temporary mechanical circulatory support occurred in 20.4%. At 120 days, estimated mortality was 6.6%, 15.1% in patients with associated pneumonia versus 0% in patients without pneumonia (P=0.044). During hospitalization, left ventricular ejection fraction, assessed by echocardiography, improved from a median of 40% on admission to 55% at discharge (n=47; P<0.0001) similarly in patients with or without pneumonia. Corticosteroids were frequently administered (55.5%). CONCLUSIONS: AM occurrence is estimated between 2.4 and 4.1 out of 1000 patients hospitalized for COVID-19. The majority of AM occurs in the absence of pneumonia and is often complicated by hemodynamic instability. AM is a rare complication in patients hospitalized for COVID-19, with an outcome that differs on the basis of the presence of concomitant pneumonia.

Comparison of a polypharmacy-based scale with Charlson comorbidity index to predict 6-month mortality in chronic complex patients after an ED visit.

AIMS: The aim of this study was to test whether a newly designed polypharmacy-based scale would perform better than Charlson's Comorbidity Index (CCI) to predict outcomes in chronic complex adult patients after a reference Emergency Department (ED) visit. METHODS: We built a polypharmacy-based scale with prespecified drug families. The primary outcome was 6-month mortality after the reference ED visit. Predefined secondary outcomes were need for hospital admission, 30-day readmission, and 30-day and 90-day mortality. We evaluated the ability of the CCI and the polypharmacy-based scale to independently predict 6-month mortality using logistic regression, receiver operating characteristic (ROC) curves, and cumulative survival curves using Kaplan-Meier estimates and the log-rank test for three-category distributions of the polypharmacy-based scale and the CCI. Finally, we sought to replicate our results in two different external validation cohorts. RESULTS: We included 201 patients (53.7% women, mean age = 81.4 years), 162 of whom were admitted to the hospital at the reference ED visit. In separate multivariable analyses accounting for gender, age and main diagnosis at discharge, both the polypharmacy-based scale (P < .001) and the CCI (P = .005) independently predicted 6-month mortality. The polypharmacy-based scale performed better in the ROC analyses (area under the curve [AUC] = 0.838, 95% confidence interval [CI] = 0.780-0.896) than the CCI (AUC = 0.628, 95% CI = 0.548-0.707). In the 6-month cumulative survival analysis, the polypharmacy-based scale showed statistical significance (P < .001), whereas the CCI did not (P = .484). We replicated our results in the validation cohorts. CONCLUSIONS: Our polypharmacy-based scale performed significantly better than the CCI to predict 6-month mortality in chronic complex patients after a reference ED visit.

Insight into functional tricuspid valve regurgitation pathogenesis, pathological stages, and surgical management.

The tricuspid valve has generally been ignored, and considered as a "second class structure" in cardiac valve surgery. Tricuspid valve regurgitation is considered "functional" in over 70% of cases, generally produced by pulmonary hypertension secondary to left heart diseases in the context of an anatomically normal tricuspid valve apparatus. Many questions and doubts persist regarding to the pathogenesis of so-called functional tricuspid valve regurgitation. This article reviews the interfering factors in the function of the tricuspid valve to better identify the entity of the term "functional" and clarify its different pathological stages including the surgical procedures recommended in each stage.

Stratification and management of cardiovascular risk in cancer patients. A consensus document of the SEC, FEC, SEOM, SEOR, SEHH, SEMG, AEEMT, AEEC, and AECC.

Both cancer treatment and survival have significantly improved, but these advances have highlighted the deleterious effects of vascular complications associated with anticancer therapy. This consensus document aims to provide a coordinated, multidisciplinary and practical approach to the stratification, monitoring and treatment of cardiovascular risk in cancer patients. The document is promoted by the Working Group on Cardio Oncology of the Spanish Society of Cardiology (SEC) and was drafted in collaboration with experts from distinct areas of expertise of the SEC and the Spanish Society of Hematology and Hemotherapy (SEHH), the Spanish Society of Medical Oncology (SEOM), the Spanish Society of Radiation Oncology (SEOR), the Spanish Society of General and Family Physicians (SEMG), the Spanish Association of Specialists in Occupational Medicine (AEEMT), the Spanish Association of Cardiovascular Nursing (AEEC), the Spanish Heart Foundation (FEC), and the Spanish Cancer Association (AECC).

Spontaneous coronary artery dissection in old patients: clinical features, angiographic findings, management and outcome.

AIMS: Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown. METHODS AND RESULTS: The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.028). They also had more often severe coronary tortuosity (36% vs. 11%, P = 0.036) and showed more frequently coronary ectasia (24% vs. 9%, P < 0.01). Older patients were more often managed conservatively (89% vs. 75%, P = 0.025), with no significant differences in major adverse cardiac events during index admission (7% vs. 8%, P = 0.858). There were no differences between groups in terms of in-hospital stay, new acute myocardial infarction, unplanned coronary angiography or heart failure. CONCLUSION: Older patients with SCAD show different clinical and angiographic characteristics compared with younger patients. Initial treatment strategy was different between groups, though in-hospital outcomes do not significantly differ (NCT03607981).

Consensus document and recommendations on palliative care in heart failure of the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology.

Heart failure is a complex entity, with high morbidity and mortality. The clinical course and outcome are uncertain and difficult to predict. This document, instigated by the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology, addresses various aspects related to palliative care, where most cardiovascular disease will eventually converge. The document also establishes a consensus and a series of recommendations with the aim of recognizing and understanding the need to implement and progressively apply palliative care throughout the course of the disease, not only in the advanced stages, thus improving the care provided and quality of life. The purpose is to improve and adapt treatment to the needs and wishes of each patient, who must have adequate information and participate in decision-making.

Safety of sacubitril/valsartan initiated during hospitalization: data from a non-selected cohort.

AIMS: Sacubitril/valsartan is safe when initiated during hospitalization in a clinical trial setting. Its safety in real-life population is not stablished. We compared the initiation of sacubitril/valsartan during hospitalization in a non-selected population, in the PIONEER-HF trial, and in non-selected outpatients. METHODS AND RESULTS: Multicentre registry included 527 patients: 100 were started on sacubitril/valsartan during hospitalization (19.0%) and 427 as outpatients (81.0%). Compared with those in the pivotal trial, inpatients in our cohort were older (71 ± 12 vs. 61 ± 14 years; P < 0.001); had more frequently Functional Class II (41 [41.0%] vs. 100 [22.7%]; P < 0.001), higher levels of N-terminal pro-B type natriuretic peptide (4044 [1630-8680] vs. 2013 [1002-4132] pg/mL; P < 0.001), better glomerular filtration rate (63.5 [51.0-80.0] vs. 58.4 [47.5-71.5] mL/min; P = 0.01), and higher systolic blood pressure (121 [110-136] vs. 118 [110-133] mmHg; P = 0.03); and received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers more frequently (92 [92.0%] vs. 208 [52.7%]; P < 0.001). Compared with non-selected outpatients, inpatients were older (71 ± 12 vs. 68 ± 12 years, P = 0.02), had more frequent Functional Class III-IV (58 [58.0%] vs. 129 [30.3%], P < 0.001), had higher levels of N-terminal pro-B type natriuretic peptide (4044 [1630-8680] vs. 2182 [1134-4172]; P < 0.001), and were receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers target dose less frequently (55 [55.0%] vs. 335 [78.5%]; P < 0.001). They also started sacubitril/valsartan with a low dose (50 mg/12 h) more frequently (80 [80.0%] vs. 209 [48.8%], P < 0.001). The initiation of sacubitril/valsartan in outpatients was an independent predictor of high-dose use (OR 3.1; 95% confidence interval 1.7-5.6, P < 0.001). The follow-up time in both cohorts, including all patients enrolled, was similar (7.0 ± 0.1 vs. 7.2 ± 2.6 months, P = 0.72). All-cause admissions during follow-up were more frequent in inpatients (30 [30.0%] vs. 68 outpatients [15.9%], P = 0.001), with no relevant differences in all-cause mortality. There was no significant difference in sacubitril/valsartan withdrawal rate (17 inpatients [17.0%] vs. 49 outpatients [11.5%], P = 0.13). The incidence of adverse effects was also similar: hypotension (16 inpatients [16.0%] vs. 71 outpatients [16.7%], P = 0.88), worsening renal function (7 inpatients [7.0%] vs. 29 outpatients [6.8%], P = 0.94), and hyperkalaemia (1 inpatient [1.0%] vs. 21 outpatients [4.9%], P = 0.09). We did not register any case of angioedema. CONCLUSIONS: It is safe to initiate sacubitril/valsartan during hospitalization in daily clinical practice. Inpatients have a higher risk profile and receive low starting doses more frequently than outpatients.

Atrial Fibrillation in Active Cancer Patients: Expert Position Paper and Recommendations.

Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology.

Atrial fibrillation in the elderly.

Atrial fibrillation (AF) is the most common arrhythmia in elderly population, with age being one of the most important factors involved in its pathogenesis. Conduction disturbances may be present on the surface electrocardiogram before AF onset in some patients. Once this arrhythmia is diagnosed, antithrombotic therapy is mandatory in most cases, as this is the only treatment that has demonstrated to improve survival. Age increases both the risk of thromboembolic and bleeding complications, while benefits from anticoagulant therapy outweigh that from bleeding in most scenarios, also in very elderly patients. However, elderly patients with AF are often undertreated. Non-vitamin K antagonist oral anticoagulants have emerged as an alternative to vitamin K antagonists, with significant less adverse events and better profile in terms of efficacy and safety. Other conditions related to age should be carefully evaluated in these patients (including frailty, comorbidity and polypharmacy) to ensure an individualized clinical and therapeutic approach.

Sacubitril/Valsartan in Daily Clinical Practice: Data From a Prospective Registry.

Sacubitril/valsartan (SV) is a new therapy in heart failure with reduced ejection fraction. Our aim was to determine the efficacy and safety of this drug daily clinical practice. We performed a multicenter registry in 10 hospitals. All patients who started SV from October 2016 to March 2017 on an outpatient basis were included. A total of 427 patients started treatment with SV. Mean follow-up was 7.0 ± 0.1 months. Forty-nine patients (11.5%) discontinued SV, and 12 (2.8%) died. SV discontinuation was associated with higher cardiovascular (hazard ratio 13.22, 95% confidence interval, 6.71-15.73, P < 0.001) and all-cause mortality (hazard ratio 13.51, 95% confidence interval 3.22-56.13, P < 0.001). Symptomatic hypotension occurred in 71 patients (16.6%). Baseline N-terminal pro-B-type natriuretic peptide levels, functional class, and left ventricular ejection fraction improved at the end of follow-up in patients who continued with SV (all P values ≤0.001). This improvement was not significant in patients with SV discontinuation. SV has a good tolerability in patients from daily clinical practice. SV withdrawal in patients with heart failure and reduced ejection fraction was independently associated with increased all-cause mortality. Patients who continued with SV presented an improvement in functional class left ventricular ejection fraction and N-terminal pro-B-type natriuretic peptide levels.

Clinical Profile of a Nonselected Population Treated With Sacubitril/Valsartan Is Different From PARADIGM-HF Trial.

Our aim is to describe the characteristics of the patients receiving sacubitril/valsartan (SV) in daily clinical practice. This is a prospective registry in 10 hospitals including all patients who started SV in everyday clinical practice. From October 2016 to March 2017, 427 patients started treatment with SV. The mean age was 68.1 ± 12.4 years, and 30.5% were women (22.0% in PARADIGM-HF, P < 0.001). Comparing our cohort with patients included in PARADIGM-HF, baseline treatment was different, with a lower ratio of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (2.7 vs. 3.5, P < 0.001), and a higher proportion of patients with implantable cardioverter defibrillator (53.8% vs. 15%, P < 0.001), and cardiac resynchronization therapy (25.8% vs. 5%, P < 0.001). Treatment with mineralocorticoid receptor antagonists was more frequent (76.7% vs. 60.0%, P < 0.001), and the use of beta-blockers was similar (94.6% vs. 93.0%, P = 0.43). We observed more patients in functional class III-IV (30.4 vs. 24.8, P = 0.015), higher levels of Nt pro-BNP [3421 (904-4161) vs. 1631 (885-3154) pg/mL] and worse renal function (creatinine level 1.3 ± 0.7 vs. 1.1 ± 0.3 mg/dL, P < 0.001). In real life, patients receiving SV have a higher risk profile than in the pivotal trial, poorer functional class, higher levels of natriuretic peptides, and worse renal function.

Impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure. / Impacto de las variables geriátricas en la mortalidad a 30 días de los ancianos atendidos por insuficiencia cardiaca aguda?

OBJETIVE: To study the impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure (AHF). METHODS: Retrospective analysis of cases in the OAK Registry (Older Acute Heart Failure Key Data), a prospectively compiled database of consecutive patients aged 65 years or older treated for AHF in 3 Spanish emergency departments over a 4-month period (November-December 2011 and January-February 2014). The patients underwent a geriatric assessment adapted for emergency department use on weekdays between 8 AM and 10 PM. Demographic, clinical, laboratory, and geriatric assessment variables were recorded. The geriatric variables were concurrent diseases; polypharmacy; frailty; functional, social, and cognitive status at baseline; results of screening for confusional state, cognitive impairment, and depression; and nutritional status. The primary outcome was all-cause mortality at 30 days. RESULTS: We included 565 patients with a mean (SD) age of 83 (7.1) years; 346 (61.6%) were women. Sixty-five (11.5%) died within 30 days. Independent factors associated with 30-day mortality were acute confusional state (adjusted odds ratio [aOR], 2.2; 95% CI, 1.0­4.8; P=.04), acute illness (aOR, 1.8; 95% CI, 0.9­3.4; P=.05), loss of appetite in the past 3 months (aOR, 1.8; 95% CI, 1.0­3.4; P=.04), frailty (aOR, 2.0, 95% CI, 1.0­4.1; P=.05), and severe disability (aOR, 4.4; 95% CI, 1.9­11.4; P=.01). CONCLUSIONS: Certain geriatric variables should be considered when assessing short-term risk in older patients with AHF.

OBJETIVOS: Estudiar el impacto de las variables geriátricas en la mortalidad a 30 días entre los ancianos con insuficiencia cardiaca aguda (ICA). MÉTODO: Análisis retrospectivo del registro Older Acute heart failure Key data (OAK) que incluye prospectivamente a pacientes consecutivos 65 años con ICA en 3 servicios de urgencias españoles durante 4 meses (noviembre-diciembre 2011 y enero-febrero 2014). Se realizó una valoración geriátrica adaptada a urgencias durante los días laborales de 8 am a 10 pm. Se recogieron variables demográficas, clínicas, analíticas y geriátricas (comorbilidad, polifarmacia, fragilidad, situación basal funcional, cognitiva y social, despistaje de síndrome confusional, deterioro cognitivo y depresión, y situación nutricional). La variable de resultado fue la mortalidad por cualquier causa a los 30 días. RESULTADOS: Se incluyeron 565 pacientes con edad media 83 años (DE 7,1), 346 mujeres (61,6%). Sesenta y cinco sujetos (11,5%) fallecieron a los 30 días. La presencia de síndrome confusional agudo (OR ajustada = 2,2; IC95% 1,0-4,8; p = 0,04), de enfermedad aguda (OR ajustada = 1,8; IC95% 0,9-3,4; p = 0,05) o pérdida de apetito (OR ajustada = 1,8; IC95% 1-3,4; p = 0,04) en los últimos 3 meses, y de fragilidad (OR ajustada = 2,0; IC95% 1,0-4,1; p = 0,05) o dependencia funcional grave (OR ajustada = 4,4; IC95% 1,9-11,4; p = 0,01) fueron factores independientes asociados con mortalidad a los 30 días. CONCLUSIONES: Existen ciertas variables geriátricas que debieran contemplarse en la estratificación de riesgo a corto plazo de los pacientes ancianos con ICA.