Cardiac surgery in nonagenarians.

AIM: To evaluate outcomes following cardiac surgery in nonagenarians. METHODS: A retrospective analysis of patients > or = 90 years of age undergoing cardiac surgery at Barnes-Jewish Hospital from 1996-2006 was performed. The Social Security Death Index was used to determine late survival. RESULTS: Twenty-two subjects were identified. The mean age was 91 years (range 90-94) and 64% were women. The most common comorbidities included hypertension in 91% and heart failure (HF) in 65%. Mean New York Heart Association class was 3.5, mean left ventricular ejection fraction was 50% (range 27-80%), and mean creatinine clearance was 34 +/- 11 cc/min. No patients had prior cardiac surgery. Nine patients underwent coronary bypass grafting only, 11 had valve replacement only, and 2 had both. Concurrent operations included 1 ventricular septal defect repair, 2 carotid endarterectomies, and 1 ascending aortic patch angioplasty. Two cases were urgent, 2 were emergent, and the remainder were elective. There was one intraoperative death (5%), during urgent mitral valve replacement. The most common postoperative complications included atrial fibrillation and need for vasopressors for >48 hrs. Mean length of intensive care and total hospital stay were 3.4 +/- 4.5 and 12.2 +/- 8.5 days, respectively. Independent predictors of increased hospital stay were higher serum creatinine (P=0.028) and the presence of HF (P=0.050). Survival to 30, 90 and 365 days were, respectively: 86%, 77%, and 64%. At study conclusion, 7 patients (32%) were alive at a mean follow-up of 4.1 years. CONCLUSION: Despite higher morbidity and mortality, in carefully selected nonagenarians referred for cardiac surgery, short-term complication rates and long-term outcomes appear to be acceptable.

Effects of age, sex, race, diagnosis-related group, and hospital setting on lipid management in patients with coronary artery disease.

Among 1,211 patients hospitalized with documented CAD at either a university hospital or a large suburban community hospital, 36% failed to receive appropriate evaluation and treatment for dyslipidemia. Younger patients, those admitted to a university hospital, and those undergoing percutaneous coronary intervention were substantially more likely to receive appropriate lipid management than other subgroups.

Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation.

BACKGROUND AND PURPOSE: Antithrombotic therapy can prevent strokes and transient ischemic attacks (TIAs) in carefully selected patients who have chronic nonvalvular atrial fibrillation (NVAF). Our objectives were 3-fold: to document the use of warfarin and aspirin therapy in Missouri Medicare beneficiaries with chronic NVAF; to identify factors associated with warfarin and aspirin underuse; and to determine the association between prescription of warfarin and aspirin at hospital discharge and adverse outcomes in this elderly, frail population. METHODS: We linked chart reviews from all Missouri hospitals to Medicare claims data from 1993 to 1996. From chart reviews, we documented Medicare beneficiaries' demographic factors, comorbid conditions, and antithrombotic therapy prescribed at the time of hospital discharge. From Medicare claims, we determined the date of outcomes-death from any cause or hospitalization for an ischemic event (a stroke, a TIA, or a myocardial infarction). RESULTS: Only 328 (55%) of the 597 Medicare beneficiaries were prescribed antithrombotic therapy at hospital discharge: 34% received warfarin and 21% received aspirin. Advanced age, female gender, and rural residency predicted underuse of antithrombotic therapy. After controlling for these factors, as well as stroke risk factors and contraindications to anticoagulation, the prescription of warfarin was associated with a 24% relative risk reduction (RRR) in adverse outcomes (P=0.003). Prescription of aspirin was associated with a nonsignificant 5% RRR in these events (P=0.56). CONCLUSIONS: The underuse of antithrombotic therapy in Medicare beneficiaries who have NVAF is associated with measurable adverse outcomes. The benefit of warfarin therapy may extend to frail, elderly patients, a group that was excluded from randomized controlled trials. The role of antiplatelet therapy in this population deserves further study because many of these patients have relative contraindications to warfarin.

The cost-effectiveness of losartan versus captopril in patients with symptomatic heart failure.

The Losartan Heart Failure ELITE Study recently found that in patients with symptomatic heart failure and a left ventricular ejection fraction of /=65 years with symptomatic heart failure. Data on health care resource utilization were collected as part of the trial. We conducted a cost-effectiveness analysis to estimate the lifetime benefits of treatment and the associated costs. We observed no differences between treatments in the number of hospitalizations, hospital days, and emergency room visits per patient over the trial period. We estimated the total cost of losartan to be USD 54 (95% CI: USD -1,717, USD 1,755) less per patient than captopril over this time frame. We also estimated that over the projected remaining lifetime of the study population, losartan compared to captopril would increase survival by 0.20 years (undiscounted) at an average cost of USD 769 (discounted) more per patient. This cost increase translated into a cost-effectiveness ratio of USD 4,047 per year of life gained for losartan relative to captopril. In patients with symptomatic heart failure, losartan compared to captopril increased survival with better tolerability at a cost well within the range accepted as cost-effective.

Cost-effectiveness analysis in clinical practice: the case of heart failure.

Heart failure is the leading cause of hospitalization in adults older than 65 years, and it is currently the most costly cardiovascular disorder in the United States, with estimated annual expenditures in excess of $20 billion. Recent studies have shown that selected pharmacological agents, behavioral interventions, and surgical therapies are associated with improved clinical outcomes in patients with heart failure, but the cost implications of these diverse treatment modalities are not widely appreciated. In this review, a brief outline of cost-effectiveness analysis is provided, and current data on the cost-effectiveness of specific approaches to managing heart failure are discussed. Available evidence indicates that angiotensin converting enzyme inhibitors, other vasodilators, digoxin, carvedilol, multidisciplinary heart failure management teams, and heart transplantation are all cost-effective approaches to treating heart failure; moreover, some of these interventions may result in net cost savings.

Heart failure disease management: a critical review.

BACKGROUND: Despite major advances in the pharmacotherapy of heart failure, hospitalization rates remain high, owing in large part to a multitude of psychosocial, behavioral, and financial factors that serve as barriers to effective compliance with prescribed treatment. To deal with these issues, many centers have adopted a multidisciplinary approach to heart failure disease management. METHODS AND RESULTS: A systematic review of the literature was conducted using the Medline database supplemented by reference lists from published articles. From 1983 to 1998, 16 studies describing multidisciplinary heart failure disease management programs were published in the English language literature. Of these, 10 were nonrandomized, observational studies and 6 were randomized clinical trials. All studies reported significant benefits in terms of reducing hospital utilization, and several studies reported improved quality of life, functional capacity, patient satisfaction, and compliance with diet and medications. In all studies in which a cost analysis was performed, heart failure disease management programs were found to be cost-effective. The limitations of the current data include concerns about the generalizability of published findings to the large and heterogenous population of patients with heart failure in the community, the feasibility of translating specific disease management programs into diverse practice environments, uncertainty about how to design and implement a maximally cost-effective heart failure disease management strategy, and how to best tailor the treatment program to the needs of each individual patient. The impact of heart failure disease management programs on survival is also unknown. CONCLUSION: Based on currently available data, heart failure disease management programs appear to be a cost-effective approach to reducing morbidity and enhancing quality of life in selected patients with heart failure. However, additional study is needed involving larger and more diverse populations to define the optimal approach to heart failure disease management.

Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults.

OBJECTIVES: To review the epidemiology, pathophysiology, and etiology of congestive heart failure (CHF) in older adults. METHODS: Published reports relevant to the epidemiology, pathophysiology, and etiology of CHF were systematically reviewed. Studies involving older adults and more recent studies were emphasized. RESULTS: More than 75% of patients with CHF in the United States are older than 65 years of age, and CHF is the leading cause of hospitalization in older adults. CHF is also a major cause of chronic disability, and annual expenditures for CHF currently exceed $10 billion. In addition, both the incidence and prevalence of CHF are increasing, largely as a result of the aging of the population. Older adults are predisposed to developing CHF as a result of age-related changes in the cardiovascular system and the high prevalence of hypertension, coronary artery disease, and valvular heart disease in this age group. Although the fundamental pathophysiology of CHF is similar in younger and older patients, older individuals are more prone to develop CHF in the setting of preserved left ventricular systolic function. This syndrome, referred to as diastolic heart failure, accounts for up to 50% of all cases of CHF in adults more than 65 years of age. Coronary heart disease and hypertension are the most common etiologies of CHF in older adults, and they often coexist. Valvular heart disease, especially aortic stenosis and mitral regurgitation, are also common in older adults, whereas nonischemic dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy occur less frequently. CONCLUSIONS: Congestive heart failure is a major public health problem in the United States today as a result of its high and increasing prevalence in the older population as well as its substantial impact on healthcare costs and quality of life. There is an urgent need to develop more effective strategies for the prevention and treatment of CHF in older individuals.

A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.

BACKGROUND: Congestive heart failure is the most common indication for admission to the hospital among older adults. Behavioral factors, such as poor compliance with treatment, frequently contribute to exacerbations of heart failure, a fact suggesting that many admissions could be prevented. METHODS: We conducted a prospective, randomized trial of the effect of a nurse-directed, multidisciplinary intervention on rates of readmission within 90 days of hospital discharge, quality of life, and costs of care for high-risk patients 70 years of age or older who were hospitalized with congestive heart failure. The intervention consisted of comprehensive education of the patient and family, a prescribed diet, social-service consultation and planning for an early discharge, a review of medications, and intensive follow-up. RESULTS: Survival for 90 days without readmission, the primary outcome measure, was achieved in 91 of the 142 patients in the treatment group, as compared with 75 of the 140 patients in the control group, who received conventional care (P = 0.09). There were 94 readmissions in the control group and 53 in the treatment group (risk ratio, 0.56; P = 0.02). The number of readmissions for heart failure was reduced by 56.2 percent in the treatment group (54 vs. 24, P = 0.04), whereas the number of readmissions for other causes was reduced by 28.5 percent (40 vs. 29, P not significant). In the control group, 23 patients (16.4 percent) had more than one readmission, as compared with 9 patients (6.3 percent) in the treatment group (risk ratio, 0.39; P = 0.01). In a subgroup of 126 patients, quality-of-life scores at 90 days improved more from base line for patients in the treatment group (P = 0.001). Because of the reduction in hospital admissions, the overall cost of care was $460 less per patient in the treatment group. CONCLUSIONS: A nurse-directed, multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure.

Early readmission of elderly patients with congestive heart failure.

Repetitive hospitalizations are a major health problem in elderly patients with chronic disease, accounting for up to one fourth of all inpatient Medicare expenditures. Congestive heart failure, one of the most common indications for hospitalization in the elderly, is also associated with a high incidence of early rehospitalization, but variables identifying patients at increased risk and an analysis of potentially remediable factors contributing to readmission have not previously been reported. We prospectively evaluated 161 patients 70 years or older that had been hospitalized with documented congestive heart failure. Hospital mortality was 13% (n = 21). Among patients discharged alive, 66 (47%) were readmitted within 90 days. Recurrent heart failure was the most common cause for readmission, occurring in 38 patients (57%). Other cardiac disorders accounted for five readmissions (8%), and noncardiac illness led to readmission in 21 cases (32%). Factors predictive of an increased probability of readmission included a prior history of heart failure, four or more admissions within the preceding 8 years, and heart failure precipitated by an acute myocardial infarction or uncontrolled hypertension (all P less than .05). Using subjective criteria, 25 first readmissions (38%) were judged possibly preventable, and 10 (15%) were judged probably preventable. Factors contributing to preventable readmissions included noncompliance with medications (15%) or diet (18%), inadequate discharge planning (15%) or follow-up (20%), failed social support system (21%), and failure to seek medical attention promptly when symptoms recurred (20%). Thus, early rehospitalization in elderly patients with congestive heart failure may be preventable in up to 50% of cases, identification of high risk patients is possible shortly after admission, and further study of nonpharmacologic interventions designed to reduce readmission frequency is justified.

Effect of DRGs on three-month readmission rate of geriatric patients with congestive heart failure.

We reviewed the three-month hospital readmission rates of 410 patients ages 70 years or older discharged alive with a first time diagnosis of congestive heart failure during the period January 1983-June 1986. The mean age was 79.8 years, 59.5 per cent were women. Mean length of initial hospital stay decreased from 10.8 days in 1983 to 7.8 days in 1986. One hundred-nineteen patients (29 per cent) were rehospitalized at least once within three months of initial discharge. The readmission rates by year were: 1983, 40.0 per cent; 1984, 27.5 per cent; 1985, 21.4 per cent; 1986, 23.2 per cent. During this same interval, the percentage of patients referred for home health care services increased from 3.3 per cent in 1983 to 13.0 per cent in 1984, 5.8 per cent in 1985, and 12.5 per cent in 1986. Thus, decreased length of hospital stay was associated with a parallel decline in early readmission rate and increased utilization of home health care services. Although this study has important methodologic limitations, the data suggest that shorter hospital stays under the DRG system are not necessarily associated with an increased rate of early rehospitalization.

TPA: is it worth the price?

What, then, are the relative merits of TPA and streptokinase? Existing evidence supports the concept that reperfusion rates are somewhat higher with TPA, particularly after 4 hours when streptokinase is relatively ineffective but the degree of myocardial salvage is likely to be small. Streptokinase has the major advantage of a proven track record, both in terms of improved survival and a low incidence of complications. TPA has the theoretical advantages of less activation of the systemic thrombolytic system and a shorter half-life, but the clinical relevance of these factors has not been shown and may be difficult to prove. Also, whereas a reasonable treatment protocol has been established by consensus for streptokinase, the optimal dosage and infusion time for TPA have not been defined and may be subject to individual variation. Finally, the cost of TPA is substantially higher than for streptokinase. In light of these considerations, the FDA advisory panel's recommendation to withhold approval of TPA becomes easier to understand. Clearly, additional evidence verifying the safety and efficacy of TPA is needed. If and when TPA is released, the clinician will be faced with a choice of thrombolytic agents. Assuming equal safety and efficacy, streptokinase may remain the drug of choice for most patients because of its lower cost. Finally, it is likely that the next few years will see additional refinements in TPA that may further enhance efficacy while decreasing the incidence of complications, and that a competitive market for TPA will reduce the cost. Reports of these developments are anxiously awaited.