[Management of patients with type 2 diabetes during cardiac prevention and rehabilitation. An expert opinion from the Italian Alliance for Cardiovascular Rehabilitation and Prevention (ITACARE-P)]. / La gestione del paziente con diabete di tipo 2 in Cardiologia Preventiva e Riabilitativa. Expert opinion della Italian Alliance for Cardiovascular Rehabilitation and Prevention (ITACARE-P).

Patients with diabetes, regardless of their cardiovascular disease and their index event, are more and more often referred to Cardiac Rehabilitation Units. These patients usually show high or very high cardiovascular risk, marked disability and poor quality of life. Furthermore, those with older age, frailty, and female sex have even more rehabilitative needs, thus requiring fine individualized approaches. Consequently, in order to identify their therapeutic goals, the glycemic target should be pursued together with the effective reduction of the global cardiovascular risk. Modern exercise protocols are based on the synergic effect of both aerobic and strength training of moderate and high effort intensities, in order to achieve improvements of cardiorespiratory fitness and glycemic values as well. Exercise training and nutritional intervention are strictly related during the rehabilitation program, thus promoting better lifestyle in the long term too. New antidiabetic drugs (such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists) should be included into a specific "patient journey" along with other core components of the rehabilitation program. Therefore, the active role of all allied professionals (namely nurses, physiotherapists, dietitians and psychologists) is essential to the success of the cardiometabolic team. Diabetes should be routinely included in the outcome evaluation of cardiac rehabilitation programs and in every follow-up plan through a successful crosstalk among cardiologists, diabetologists and patients.

Prediction of worsening postoperative renal function in older candidates to elective cardiac surgery: Choosing the best eGFR formula may not be enough.

BACKGROUND: Though renal impairment is highly prevalent in older patients and influence post-operative outcomes in cardiac surgery; its prognostic relevance is debated and not fully assessed by surgical risk scores. OBJECTIVE: We investigated the predictive role of estimated glomerular filtration rate formulas for in-hospital worsening renal function (WRF) after cardiac surgery. METHODS: We prospectively enrolled in single-center cohort study, patients aged ≥ 75 years candidate to elective cardiac surgery. Four creatinine-based equations were used to calculate estimated glomerular filtration rate (eGFR) formulas: Cockroft-Gault, Modification of Diet in Renal Disease, Chronic Kidney Disease Epidemiology, and Berlin Initiative Study 1 formulas. Each patient underwent geriatric and clinical evaluation before surgery with calculation of the Society of Thoracic Surgeons scores. In-hospital WRF was defined as a composite of an increase in SCr ≥0.5 mg/dl or the occurrence of grade III KDIGO acute kidney injury. The association between each eGFR equation, alone and in models including clinical variables, and WRF was analyzed using logistic regressions and ROC analysis. RESULTS: WRF occurred in 69 patients (19.8%), and the predictors of WRF were previous acute myocardial infarction, hypertension, 4-mt gait speed performance, and preoperative eGFR, irrespective of the equation used. With all equations, inclusion of these additional variables in the logistic regression models improved the prediction of WRF (AUCs 0.798-0.810). CONCLUSIONS: An accurate assessment of renal function and of physical performance should be incorporated into cardiac surgery risk scores to improve prediction of in-hospital WRF and, hence, risk stratification in older adults undergoing elective cardiac surgery.

Predictors of physical frailty improvement in older patients enrolled in a multidisciplinary cardiac rehabilitation program.

Cardiac rehabilitation (CR) improves clinical and functional recovery in older patients after acute cardiac syndromes, whose outcome is influenced by cardiac disease severity, but also by comorbidity and frailty. The aim of the study was to analyze the predictors of physical frailty improvement during the CR program. Data were collected in all patients aged > 75 years consecutively admitted from 1 January to December 2017 to our CR, consisting of 5-day-per-week of 30-min session of biking or calisthenics on alternate days for 4 weeks. Physical frailty was measured with short physical performance battery (SPPB) at the entry and the end of CR. Outcome was represented by an increase of at least 1 point in the SPPB score from baseline to the end of the CR program. In our study population of 100 patients, mean age 81 years, we demonstrated that a strong predictor of improvement in SPPB score was the poorer performance in the test at baseline; for Δ-1 point of score, we registered an OR 2.50 (95% CI = 1.64-3.85; p = 0.001) of probability to improve the physical performance at the end of CR. Interestingly those patients with worse performance at SPPB balance and chair standing task showed greater probability of ameliorating their physical frailty profile at the end of CR. Our data strongly suggest that CR program after acute cardiac syndrome produces a significant physical frailty improvement in those patients with worse frailty phenotype with an impairment in chair standing or balance at entry.

Predictive Factors for Hemorrhagic Transformation in Acute Ischemic Stroke in the REAL-World Clinical Practice.

BACKGROUND: Few data exists on predictive factors of hemorrhagic transformation (HT) in real-world acute ischemic stroke patients. The aims of this study were: (i) to identify predictive variables of HT (ii) to develop a score for predicting HT. METHODS: We retrospectively analyzed the clinical, radiographic, and laboratory data of patients with acute ischemic stroke consecutively admitted to our Stroke Unit along two years. Patients with HT were compared with those without HT. A multivariate logistic regression analysis was performed to identify independent predictors of HT on CT scan at 24 hours to develop a practical score. RESULTS: The study population consisted of 564 patients with mean age 77.5±11.8 years. Fifty-two patients (9.2%) showed HT on brain CT at 24 hours (4.9% symptomatic). NIHSS score ≥8 at Stroke Unit admission (3 points), cardioembolic etiology (2 points), acute revascularization by systemic thrombolysis and/or mechanical thrombectomy (1 point), history of previous TIA/stroke (1 point), and major vessel occlusion (1 point) were found independent risk factors of HT and were included in the score (Hemorrhagic Transformation Empoli score (HTE)). The predictive power of HTE score was good with an AUC of 0.785 (95% CI: 0.749-0.818). Compared with 5 HT predictive scores proposed in the literature (THRIVE, SPAN-100, MSS, GRASPS, SITS-SIC), the HTE score significantly better predicted HT. CONCLUSIONS: NIHSS score ≥8 at Stroke Unit admission, cardioembolism, urgent revascularization, previous TIA/stroke, and major vessel occlusion were independent predictors of HT. The HTE score has a good predictive power for HT. Prospective studies are warranted.

Predictors of 1-year outcome in very old patients managed in a Heart Failure Unit after an acute decompensation.

PURPOSE: Consensus exits about the clinical benefits of an early referral to multidisciplinary Heart Failure Unit-HFU for old frail patients with HF. Nevertheless, few data are present regarding the prognosis and the predictors of outcome in oldest-old patients managed in this clinical setting. The aim of present study is to identify predictors of 1-year all-cause mortality in very old patients enrolled in our multidisciplinary HFU after an episode of acute decompensated HF. METHODS: This study is a retro-prospective, single-center cohort analysis of patients managed in our multidisciplinary HFU. Inclusion criterion was diagnosis of HF according to ESC guidelines and age ≥ 85 years, while no exclusion criteria were pre-defined. Baseline clinical and comprehensive geriatric evaluations were recorded during the first visit and follow-up visits were repeated according to our standardized timetable protocol. Primary end-point was 1-year all-cause mortality. RESULTS: We enrolled 75 patients aged 89.2 ± 2.8 years; 39 (52.0%) were females. During 1-year follow-up, seventeen patients (22.7%) died. Residual congestion with higher level (> 4) of EVEREST score (HR 1.24: 95% CI 1.04-1.47) and living alone (HR 3.34: 95% CI 1.16-9.64) resulted the two independent predictors of 1-year all-cause mortality at the multivariate Cox regression model. Finally, patients living alone and with an EVEREST score > 4 experienced a worse prognosis as clearly described by a steeper descendent Kaplan-Meier curve. CONCLUSION: In a very old population of patients after an acute decompensated HF, residual congestion and social isolation as living alone identify those with high risk of 1-year death.

Cardiac Rehabilitation in Advanced aGE after PCI for acute coronary syndromes: predictors of exercise capacity improvement in the CR-AGE ACS study.

BACKGROUND: The positive effect of cardiac rehabilitation (CR) on outcomes after acute coronary syndromes (ACS) is established. Nevertheless, enrollment rates into CR programs remain low, although ACS carry a high risk of functional decline particularly in the elderly. AIM: We aimed to determine if a multidisciplinary CR improves exercise capacity in an older population discharged after ACS systematically treated with PCI. METHODS: CR-AGE ACS is a prospective, single-center, cohort study. All patients aged 75+ years consecutively referred to Cardiac Rehabilitation outpatient Unit at Careggi University Hospital, were screened for eligibility. Moderate/severe cognitive impairment, disability in 2+ basic activities of daily living, musculoskeletal diseases, contraindication to Cardiopulmonary Exercise Test, and diseases with an expected survival < 6 months, were exclusion criteria. Participants attended a CR program, based on 5-day-per-week aerobic training sessions for 4 weeks. RESULTS: We enrolled 253 post-ACS patients with a mean age 80.6 ± 4.4 years. After CR, 136 (56.2%) 77 (31.3%) patients obtained, respectively, at least a moderate (∆+5%) or an optimal (∆+15%) increase in VO2peak. Baseline VO2peak (- 1 ml/kg/min: OR 1.18; 95% CI 1.09-1.28), the number of training sessions (+1 session: OR 1.07; 95% CI 1.01-1.15), and mild-to-moderate baseline disability (yes vs. no: OR 0.22; 95% CI 0.01-0.57) were the predictors of VO2peak changes. CONCLUSIONS: A CR program started early after discharge from ACS produces a significant increase in exercise capacity in very old patients with mild-to-moderate post-acute physical impairment. Baseline VO2peak, the number of training sessions, and the level of baseline disability are the independent predictors of improvement.

Lower extremity performance predicts length of hospital stay in older candidates to elective cardiac surgery.

INTRODUCTION: Prolonged hospital stay must be considered as risk factor for poor outcomes after cardiac surgery; different variables have been advocated as predictors of in-hospital stay. Nevertheless, most patients requiring prolonged hospital stay are frail older subjects; thus, we hypothesized a significant influence of pre-operative physical performance, as a frailty measure, on in-hospital stay after elective cardiac surgery. METHODS: In a prospective, single-center, cohort study we enrolled patients aged 75+ years referred to our Division of Cardiac Surgery at Careggi University Hospital, for their first elective cardiac surgery. All participants were preoperatively evaluated by a team composed by a cardiac surgeon, a cardiologist, an anaesthesist, and a geriatrician to assess global cardiac surgery risk; lower extremity performance was measured with the Short Physical Performance Battery-SPPB. RESULTS: A total of 518 patients were included in the study. Mean age was 79.5 ±â€¯3.3 years; 256 (49.4%) were women. Isolated coronary by pass graft was performed in 37 patients (7.1%), isolated valve surgery in 115 (22.0%), and combined cardiac surgery procedures in 366 (70,9%). In a multivariable model, SPPB score was strongly associated with hospital length of stay both as continuous, categorized and dichotomous variable (p < 0.001; p = 0.002; p = 0.002 respectively) in all study population, and in subgroup of patients candidate to cardiac surgery considered by the Society of Thoracic Surgeons calculator score (p = 0.023; p = 0.056; p = 0.013 respectively). CONCLUSIONS: Our findings support the use of pre-operative SPPB evaluation before elective cardiac surgery based on the independent ability to predict length of hospital stay.

Telehealth Management and Risk Stratification of Older Patients With Chronic Heart Failure During COVID-19 Pandemic: Prognostic Evaluation of the TeleHFCovid19-Score.

OBJECTIVES: To evaluate 6-month risk stratification capacity of the newly developed TeleHFCovid19-Score for remote management of older patients with heart failure (HF) during the coronavirus disease 2019 pandemic. DESIGN: Monocentric observational prospective study. SETTING AND PARTICIPANTS: Older HF outpatients remotely managed during the first pandemic wave. METHODS: The TeleHFCovid19-Score (0-29) was obtained by an ad hoc developed multiparametric standardized questionnaire administered during telephone visits to older HF patients (and/or caregivers) followed at our HF clinic. Questions were weighed on the basis of clinical judgment and review of current HF literature. According to the score, patients were divided in progressively increasing risk groups: green (0-3), yellow (4-8), and red (≥9). RESULTS: A total of 146 patients composed our study population: at baseline, 112, 21, and 13 were classified as green, yellow, and red, respectively. Mean age was 81±9 years, and women were 40%. Compared to patients of red and yellow groups, those in the green group had a lower use of high-dose loop diuretics (P < .001) or thiazide-like diuretics (P = .027) and had reported less frequently dyspnea at rest or for basic activities, new or worsening extremity edema, or weight increase (all P < .001). At 6 months, compared with red (62.2%) and yellow patients (33.3%), green patients (8.9%) presented a significantly lower rate of the composite outcome of cardiovascular death and/or HF hospitalization (P < .001). Moreover, receiver operating characteristic curve analysis showed a high sensibility and specificity of our score at 6 months (area under the curve = 0.789, 95% CI 0.682-0.896, P < .001) with a score <4.5 (very close to green group cutoff) that identified lower-risk subjects. CONCLUSIONS AND IMPLICATIONS: The TeleHFCovid19-Score was able to correctly identify patients with midterm favorable outcome. Therefore, our questionnaire might be used to identify low-risk chronic HF patients who could be temporarily managed remotely, allowing to devote more efforts to the care of higher-risk patients who need closer and on-site clinical evaluations.

New Drugs for Heart Failure: What is the Evidence in Older Patients?

Heart failure (HF) is a major public health concern, with a high prevalence in the older population. The majority of randomized clinical trials evaluating new emerging pharmacologic agents for HF (eg, angiotensin receptor-neprilysin inhibitors, sodium-glucose cotransporter 2 inhibitors, intravenous iron for deficiency treatment, transthyretin stabilizers, soluble guanylate cyclase stimulators, cardiac myosin activators, and new potassium binders) have found positive results on various clinical outcomes, particularly in patients with reduced ejection fraction. These treatments might have an important role in the management of older patients as well. Nevertheless, trials demonstrating benefit of these drugs have involved patients significantly younger (on average, approximately 10 years) and fewer comorbidities than those commonly encountered in clinical practice. We describe the recent evidence regarding the newest HF drugs and their applicability to older individuals in terms of efficacy and safety, and we discuss their effects on outcomes particularly valuable to older patients, such as preservation of cognitive function, functional status, independence, and quality of life. Although available subgroup analyses seem to confirm efficacy and safety across the age spectrum for some of these drugs, their effects on older patients centered outcomes often have been neglected. Future HF trials should be designed to include older patients more representative of the real clinical practice, to overcome generalizability biases.

Acute heart failure in the elderly: setting related differences in clinical features and management.

BACKGROUND: Administrative data show that acute heart failure (HF) patients are older than those enrolled in clinical registries and frequently admitted to non-cardiological settings of care. The purpose of this study was to describe clinical characteristics of old patients hospitalised for acute HF in Cardiology, Internal Medicine or Geriatrics wards. METHODS: Data came from ATHENA (AcuTe Heart failurE in advaNced Age) registry which included elderly patients (≥ 65 years) admitted to the above mentioned settings of care from December 1, 2014 to December 1, 2015. RESULTS: We enrolled 396 patients, 15.4% assigned to Cardiology, 69.7% to Internal Medicine, and 14.9% to a Geriatrics ward. Mean age was 83.5 ± 7.6 years (51.8% of patients ≥ 85 years) and was higher in patients admitted to Geriatrics (P < 0.001); more than half were females. Medical treatments did not differ significantly among settings of care (in a context of a low prescription rate of renin-angiotensin-aldosterone system inhibitors) whereas significant differences were observed in comorbidity patterns and management guidelines recommendation adherence for decongestion evaluation with comparison of weight and N-terminal pro-B-type natriuretic peptide levels on admission and at discharge (both P = 0.035 and P < 0.001), echocardiographic evaluation ( P < 0.001) and follow-up visits planning ( P < 0.001), all higher in Cardiology. Mean in-hospital length of stay was 9 ± 5.9 days, significantly higher in Geriatrics (13.7 ± 6.5 days) and Cardiology (9.9 ± 6.7 days) compared to Internal Medicine (8 ± 5.2 days), P < 0.001. In-hospital mortality was 9.3%, resulting higher in Geriatrics (18.6%) and Cardiology (16.4%) than Internal Medicine (5.8%), P = 0.001. CONCLUSIONS: In elderly patients hospitalised for acute HF, clinical characteristics and management differ significantly according to the setting of admission.

Pre-operative physical performance as a predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery.

OBJECTIVE: Risk stratification of cardiac surgery patients is usually based on the Society of Thoracic Surgeons (STS) score, that has limited predictive value in older persons. We aimed assessing whether the Short Physical Performance Battery (SPPB) improves, beyond the STS score, assessment of hospital prognosis in older patients undergoing elective cardiac surgery. METHODS: All patients aged 75+ years referred for elective cardiac surgery to Careggi University Hospital (Florence, Italy) from April 2013 to March 2017 were evaluated pre-operatively. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM): low (<4%), intermediate (4 to 8%), and high risk (>8%). Primary study outcomes were hospital mortality and STS-defined major morbidity. Length of hospital stay was an additional outcome. RESULTS: Out of 235 participants (females: 46.5%; mean age: 79.6 years), 144 (61.3%) were at low, 67 (28.5%) at intermediate and 24 (10.2%) at high risk, based on the STS-PROM. SPPB (mean±SEM) was 8.8 ± 0.2, 7.0 ± 0.5, and 6.0 ± 0.8 in participants at low, intermediate, and high risk, respectively (p<0.001). The primary outcome occurred in 62 participants (26.4%). In low-risk participants, the SPPB score predicted the primary endpoint (adjusted OR 0.77, 95% CI 0.66-0.89 per each point increase; p<0.001) controlling for STS-Major Morbidity or Operative Mortality (STS-MM) score. This result was not observed in the intermediate-high risk group. CONCLUSIONS: SPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, classified as low risk with the STS risk score. The SPPB, applied preoperatively, might improve risk stratification in older patients undergoing elective cardiac surgery.

Protocol for Telehealth Evaluation and Follow-up of Patients With Chronic Heart Failure During the COVID-19 Pandemic.

Because of the Coronavirus Disease 2019 (COVID-19) pandemic, we were forced to cancel scheduled visits for nearly 150 patients followed in our heart failure (HF) outpatient clinic. Therefore, we structured a telephone follow-up, developing a standardized 23-item questionnaire from which we obtained the Covid-19-HF score. The questionnaire was built to reproduce our usual clinical evaluation investigating a patient's social and functional condition, mood, adherence to pharmacological and nonpharmacological recommendations, clinical and hemodynamic status, pharmacological treatment, and need to contact emergency services. The score was used as a clinical tool to define patients' clinical stability and timing of the following telephone contact on the basis of the assignment to progressively increasing risk score groups: green (0-3), yellow (4-8), and red (≥9). Here we present our experience applying the score in the first 30 patients who completed the 4-week follow-up, describing baseline clinical characteristics and events that occurred in the period of observation.

Cardiac rehabilitation protocols in the elderly.

Cardiac rehabilitation (CR) is a comprehensive multidisciplinary program individually tailored to the needs of patients with cardiovascular disease. Cardiovascular disease is prevalent in older adults and is the leading cause of death and major disability in adults ≥75 years of age. The mean age of patients eligible for CR is increasing, with greater complexity and specific geriatric features, such as multimorbidity, frailty, and disability. In this population, CR interventions should be aimed to prevent disability and preserve the residual functional capacity. Every patient should be assessed with a multidimensional evaluation that includes clinical, functional, emotional, cognitive and social domains. Exercise-based CR programs have shown to be effective in improving function and quality of life, by reducing disability and age-related deconditioning and contributing favorably to improved health outcomes in an aged population. Very old and frail patients seem to get an even greater potential benefit, and an early start after an acute event can prevent the post-hospital syndrome. Despite these proven benefits, CR is often underused in this population and a great effort should be done to encourage them to attend these programs. There are just a few studies about CR programs in very old and frail patients, therefore a future goal should be to fill this gap.

Role of Frailty on Risk Stratification in Cardiac Surgery and Procedures.

The number of older people candidates for interventional cardiology, such as PCI but especially for transcatheter aortic valve implantation (TAVI) , would increase in the future. Generically, the surgical risk, the amount of complications in the perioperative period, mortality and severe disability remain significantly higher in the elderly than in younger. For this reason it's important to determine the indication for surgical intervention, using tools able to predict not only the classics outcome (length of stay, mortality), but also those more specifically geriatrics, correlate to frailty: delirium, cognitive deterioration, risk of institutionalization and decline in functional status. The majority of the most used surgical risks scores are often specialist-oriented and many variables are not considered. The need of a multidimensional diagnostic process, focused on detect frailty, in order to program a coordinated and integrated plan for treatment and long term follow up, led to the development of a specific geriatric tool: the Comprehensive Geriatric Assessment (CGA). The CGA has the aim to improve the prognostic ability of the current risk scores to capture short long term mortality and disability, and helping to resolve a crucial issue providing solid clinical indications to help physician in the definition of on interventional approach as futile. This tool will likely optimize the selection of TAVI older candidates could have the maximal benefit from the procedure.

Long-term functional outcomes after cardiac rehabilitation in older patients. Data from the Cardiac Rehabilitation in Advanced aGE: EXercise TRaining and Active follow-up (CR-AGE EXTRA) randomised study.

AIM: Cardiac rehabilitation promotes functional recovery after cardiac events. Our study aimed at evaluating whether, compared to usual care, a home-based exercise programme with monthly reinforcement sessions adds long-term functional benefits to those obtained with cardiac rehabilitation in the elderly. METHODS: After a 4-week outpatient cardiac rehabilitation, 160 of 197 patients aged 75 years and older screened for eligibility with different indications for cardiac rehabilitation, were randomly assigned to a control (C) or an active treatment (T) group. During a 12-month follow-up, C patients received usual care, while T patients were prescribed a standardised set of home-based exercises with centre-based monthly reinforcements for the first 6 months. The main (peak oxygen consumption) and three secondary outcome measures (distance walked in 6 minutes, inferior limbs peak 90° Torque strength, health-related quality of life) were assessed at baseline, at random assignment and at 6 and 12-month follow-ups with the cardiopulmonary exercise test, 6-minute walking test, isokinetic dynamometer and the Short Form-36 questionnaire, respectively. RESULTS: Both C and T groups obtained a significant and similar improvement from baseline to the end of the 4-week cardiac rehabilitation programme in the three functional outcome measures. However, at univariable and age and gender-adjusted analysis of variance for repeated measures, changes from random assignment to 6 or 12-month follow-up in any outcome measure were similar in the C and T groups. CONCLUSION: Results from this randomised study suggest that a home-based exercise programme with monthly reinforcements does not add any long-term functional benefit beyond those offered by a conventional, 4-week outpatient cardiac rehabilitation programme. TRIAL REGISTRATION: ClinicalTrial.gov Identifier: NCT00641134.

Development of the Decannulation Prediction Tool in Patients With Dysphagia After Acquired Brain Injury.

OBJECTIVES: Patients with acquired brain injuries (ABIs) often need tracheostomy because of dysphagia. However, many of them may recover over time and be eventually decannulated during post-acute rehabilitation. We developed the Decannulation Prediction Tool (DecaPreT) to identify, early in the post-acute course, patients with ABIs who can be safely decannulated. DESIGN: Nonconcurrent cohort study. SETTING AND PARTICIPANTS: Patients with ABI, as well as with dysphagia and tracheostomy, were retrospectively selected from the database of a neurorehabilitation unit in Correggio, Reggio Emilia, Italy. MEASURES: Potential bivariate predictors of decannulation were screened from variables collected on admission during clinical examination, conducted by an expert speech therapist. Multivariable prediction was then obtained in 2 separate random subsamples to develop and validate the logistic regression model of the DecaPreT. RESULTS: Of 463 patients with ABI (mean age 52.2 years) selected, 73.0% could be safely decannulated before discharge. After bivariate screening, multivariable predictors of decannulation were identified in the development subsample and confirmed in the validation subsample, each with its odds ratio and 95% confidence interval as follows: age tertile (1.77, 1.08-2.89; P = .024), no saliva aspiration (3.89, 1.73-8.64; P = .001), pathogenesis of ABI (trauma vs other causes vs stroke vs anoxia: 2.23, 1.41-3.54; P = .001), no vegetative status (8.47; 2.91-24.63; P < .001), and coughing score (voluntary and reflex vs voluntary vs reflex vs neither voluntary nor reflex cough: 2.62, 1.70-4.05; P < .001). In the validation subsample, the predicting equation obtained an area under the receiver operating characteristics curve of 0.836. IMPLICATIONS: The DecaPreT predicts safe decannulation in patients with dysphagia and tracheostomy, using simple clinical variables detected early in the post-acute phase of ABI. The tool can help clinicians choose timing and intensity of rehabilitation interventions and plan discharge.

DAPT plus anticoagulant therapy: The difficult coexistence post-ACS in older patients with atrial fibrillation.

Atrial fibrillation (AF) and coronary artery disease requiring percutaneous coronary intervention (PCI) and stenting often coexist in older patients. This poses the difficult problem of concurrent anticoagulant and double antiplatelet therapy (triple therapy). Current treatment guidelines do recommend triple therapy, especially in the course of acute coronary syndrome (ACS), with limitations due to an excessive risk of bleeding associated with this therapeutic regimen. This review summarizes randomized clinical trials and observational studies that compared triple therapy with a variety of different therapeutic options. Although the available evidence is not completely satisfactory and other studies are urgently needed, alternative regimens to triple therapy in AF patients undergoing PCI and stenting are promising, at least in terms of safety.

Cardiac surgery in the elderly: What goals of care?

At present, the majority of cardiac surgery interventions have been performed in the elderly with successful short-term mortality and morbidity, however significant difficulties must to be underlined about our capacity to predict long-term outcomes such as disability, worsening quality of life and loss of functional capacity.The reason probably resides on inability to capture preoperative frailty phenotype with current cardiac surgery risk scores and consequently we are unable to outline the postoperative trajectory of an important patients' centered outcome such as disability free survival. In this perspective, more than one geriatric statements have stressed the systematic underuse of patient reported outcomes in cardiovascular trials even after taking account of their relevance to older feel and wishes. Thus, in the next future is mandatory for geriatric cardiology community closes this gap of evidences through planning of trials in which patients' centered outcomes are considered as primary goals of therapies as well as cardiovascular ones.