Oral Anticoagulant Use and Appropriateness in Elderly Patients with Atrial Fibrillation in Complex Clinical Conditions: ACONVENIENCE Study.

Non-valvular atrial fibrillation (NVAF) is the most common arrhythmia in older patients. Although direct-acting oral anticoagulants (DOAC) are the antithrombotic treatment of choice, irrespective of age, certain factors may limit their use. The aim of the ACONVENIENCE study was to consult the opinion of a multidisciplinary panel of experts on the appropriateness of using OACs in elderly patients (>75 years) with NVAF associated with certain complex clinical conditions. A consensus project was performed on the basis of a systematic review of the literature, and application of a two-round Delphi survey. The agreement of 79 panellists on 30 Delphi-type statements was evaluated, and their opinion on the appropriateness of different oral anticoagulants in 16 complex clinical scenarios was assessed. A total of 27 consensus statements were agreed upon, including all statements addressing anticoagulation in older patients and in patients at high risk of bleeding complications, and most of those addressing frailty, dementia, risk of falling, and complex cardiac situations. It was almost unanimously agreed upon that advanced age should not influence the anticoagulation decision. Apixaban was the highest-rated therapeutic option in 14/16 situations, followed by edoxaban. There is a high degree of agreement on anticoagulation in older patients with NVAF. Age should not be the single limiting factor when prescribing OACs, and the decision should be made based on net clinical benefit and a comprehensive geriatric assessment. Apixaban, followed by edoxaban, was considered the most appropriate treatment in the various complex clinical situations examined.

Volumetric BMD by 3D-DXA and Trabecular Bone Score in Adults With Down Syndrome.

Adults with Down syndrome (DS) have lower bone mineral density (BMD) than the general population. The objective of our study was to describe bone mineral status in DS population through volumetric BMD (vBMD) and trabecular bone score (TBS). Retrospective study of 297 subjects recruited from the Adult DS Outpatient Clinic of a tertiary care hospital in Spain, who underwent a bone densitometry for clinical purposes between January 2010 and June 2015. vBMD determination and TBS analysis on conventional DXA (Hologic QDR 4500) densitometer were performed in this cohort. The mean (±SD) age of our population was 34.3 (±10.9) years; 51% were women. Trabecular vBMD at total hip and femoral neck was lower in males than in females (191.7 ± 48.4 mg/cm3 vs 206.9 ± 46.7 mg/cm3, p = 0.007, and 250.5 ± 70.1 mg/cm3 vs 275.7 ± 66.2 mg/cm3, p = 0.002, respectively). Trabecular and cortical vBMD decreased with age, but age decline in trabecular vBMD was more pronounced in males. Likewise, lumbar TBS declined with age being normal in 63%, low in 29% and very low in 8% of subjects with DS, without differences between sexes. TBS showed a positive correlation (r = 0.37; p < 0.001, Kappa index= 0.275) with conventional DXA lumbar Z-score. vBMD at the hip showed lower values in DS subjects than in the general population, especially in males. Moreover, TBS was also lower at lumbar spine. Therefore, both assessments could be used as complementary tools to areal BMD (Z-score) to assess bone status in DS subjects.

The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation.

Unless contraindicated, anticoagulant therapy should be prescribed to elderly patients with atrial fibrillation. Direct-acting oral anticoagulants (DOACs) are superior to vitamin K antagonists for preventing stroke. This, together with their higher net clinical benefit, makes DOACs the treatment of choice in this population. However, due to the concerns about bleeding and the need for dose adjustment based on clinical variables, underdosing of DOACs is common and the risk of stroke high. Drugs with more easily adjusted doses are likely associated with a lower risk of dosing errors and, therefore, a greater protective effect. Correct dosing can ensure a maximal net benefit of DOACs in elderly patients with atrial fibrillation.

Correction to: Influence of frailty on anticoagulant prescription and clinical outcomes after 1­year follow­up in hospitalised older patients with atrial fibrillation.

In the original publication, all the collaborator names were incorrectly tagged and published online. The correct given and family names for the collaborators names should list as follows.

Influence of frailty on anticoagulant prescription and clinical outcomes after 1-year follow-up in hospitalised older patients with atrial fibrillation.

Frailty is an important prognostic factor in older adults with cardiovascular diseases. We aim to describe the characteristics of elderly hospitalised frail patients with non-valvular atrial fibrillation (NVAF) and to assess the influence of frailty, along with other functional and health status variables on anticoagulation prescription, 1-year all-cause mortality, and the incidence of ischemic and bleeding complications. An observational, prospective multicentre study was carried out on patients with NVAF over the age of 75, who were admitted to the Internal Medicine departments in Spain. A total of 615 patients were evaluated (mean age 85.23 ± 5.16 years, 54.3% females, 48.3% frail). Frail patients had higher CHA2DS2-VASc and HAS-BLED scores, more comorbidities and worse functional status and cognitive impairment compared to non-frail. During hospitalisation, 58 (9.4%) patients died (12.5% frail, 6.6% non-frail, p = 0.01). Among the participants discharged, 69.8% received anticoagulants, 13% anti-platelets only and 16.9% no anti-thrombotics, with no difference by frailty status. Frailty is not a predictor of anticoagulant prescription at discharge (OR 0.93, 95% CI 0.55-1.57), while functional dependency remains significantly associated (OR for severe dependency 0.44, 95% CI 0.23-0.82). After the 1-year follow-up, frail patients have a higher risk of death (HR 1.99, 95% CI 1.43-2.76). Among patients taking anticoagulants, the incidence of stroke and major bleeding is similar between frailty groups. In our study, frailty is related to worse global health status. It has no impact on antithrombotic prescription, nor is a predictor of AF complications, even though frail subjects have a higher mortality during hospitalisation and after 1-year follow-up.

Acute kidney injury is linked to higher mortality in elderly hospitalized patients with non-valvular atrial fibrillation.

AIM: Renal insufficiency is associated with medical complications in patients with non-valvular atrial fibrillation (NVAF). However, data for elderly patients are scarce. Thus, the main objectives of the present study were to analyze the characteristics of elderly patients with NVAF and acute or chronic renal disease, describe their management in real-life conditions, and detect factors associated with complications. METHODS: The NONAVASC registry includes patients > 75 years with NVAF, hospitalized by any cause in 64 Spanish Internal Medicine departments. Patients were categorized into acute kidney injury (AKI), chronic kidney disease (CKD) or preserved renal function (PRF). All variables associated with in-hospital mortality with P < 0.10 in univariate analysis were included to develop a multivariate logistic-regression model. RESULTS: The study included 804 patients (53.9% women), 352 (43.8%) of whom met diagnostic criteria for CKD. AKI was detected in 119 (14.8%) patients. AKI was associated with greater length of stay, higher mortality and an increased rate of patient transfer to nursing homes. After logistic-regression analysis, we found an association between mortality and AKI (OR 2.4, 95% CI 1.03-5.53; P = 0.045). The increase in creatinine values (OR 1.8, 95% CI 1.19-2.73; P = 0.005) and the decrease in albumin values (OR 2.0, 95% CI 1.05-3.73; P = 0.033) were also linked to mortality. CONCLUSIONS: Our study shows the relationship between AKI and creatinine value increase and a higher mortality in elderly patients with NVAF. In light of our findings, the detection of renal function impairment in these patients should alert physicians and consider them as high-risk patients.

Use of oral anticoagulants in complex clinical situations with atrial fibrillation. / Uso de anticoagulantes orales en situaciones clínicas complejas con fibrilación auricular.

The present article provides an update on anticoagulant treatment in patients with atrial fibrillation in distinct clinical scenarios requiring particular considerations, such as ischaemic heart disease, electrical cardioversion, pulmonary vein ablation, the presence of valvular disease with or without prosthetic valves, and renal insufficiency, as well as old age and frailty. In patients with non-valvular atrial fibrillation, the presence of renal insufficiency increases both thrombotic and haemorrhagic risk. In mild and moderate stages, direct-acting anticoagulants confer a greater benefit than warfarin, although they usually require dose adjustment. In renal failure/dialysis, there is no solid evidence that warfarin is beneficial and the use of direct-acting anticoagulants is not recommended. Because of its pathophysiology, oral anticoagulation could have a beneficial effect in patients with heart disease. However, vitamin K antagonists have not shown a satisfactory risk-benefit ratio. In contrast, direct-acting anticoagulants, at reduced doses, could have a beneficial effect in this scenario in association with antiplatelet agents. The use of direct-acting anticoagulants prior to electrical cardioversion in patients with non-valvular atrial fibrillation seems to be associated with a risk of cardioembolic events that is at least comparable to that of vitamin K antagonists. Their use avoids delay in the application of electrical cardioversion in patients without adequate INR levels. In the context of their use before and after atrial fibrillation ablation, dabiga-tran and rivaroxaban have demonstrated at least non-inferiority with vitamin K antagonists in terms of safety. In patients with any type or grade of valvular disease and atrial fibrillation, the indication of antithrombo-tic treatment must be evaluated in the same way as in patients with atrial fibrillation and no valvular di-sease. Whenever anticoagulation is required, direct-acting anticoagulants are the treatment of choice in nearly all situations, except in patients with mechanical valves or who have significant rheumatic mitral disease, who should be treated with vitamin K antagonists. The choice of appropriate antithrombotic stra-tegy in frail elderly patients is complex and involves multiple factors beyond assessment of embolic and haemorrhagic risk. Comprehensive geriatric assessment is essential for an individualised final decision. Moreover, any such decision should be consensus-based and periodically reviewed. Direct-acting anticoa-gulants could be the most beneficial alternative in most elderly patients with non-valvular atrial fibrillation.

El reto del tratamiento antitrombótico en ancianos con fibrilación auricular. ¿Justifica la edad la estrategia antitrombótica en ancianos con fibrilación auricular? / The challenge of antitrombotic treatment prescription in older adults with atrial fibrillation. Does age justify the anti-thrombotic strategy in elderly patients with atrial fibrillation?

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Factors associated with discontinuing or not starting oral anticoagulant therapy in older hospitalized patients with non-valvular atrial fibrillation.

AIM: To determine the factors associated with discontinuing or not starting oral anticoagulation (OA) therapy in older patients with non-valvular atrial fibrillation (NVAF). METHODS: A prospective, multicenter cohort study was carried out of patients aged >75 years with NVAF hospitalized in internal medicine departments in Spain. For each patient, we recorded creatinine, hemoglobin and platelets levels, as well as CHA2DS2-VASc and HAS-BLED scores and the Charlson Comorbidity Index. We measured the ability to carry out basic activities of daily life with the Barthel Index, and the cognitive state with the Short Portable Mental Status questionnaire. RESULTS: We included 723 patients with NVAF, with a mean age of 84.8 years (SD 5.2 years); 390 (53.9%) of the patients were women. Before admission, 375 (51.9%) patients were treated with OA. Previously diagnosed NVAF (OR 4.099, 95% CI 1.824-9.211, P = 0.001), the number of errors in the Short Portable Mental Status questionnaire (OR 1.180, 95% CI 1.020-1.365, P = 0.026), peripheral arterial disease (OR 0.285, 95% CI 0.114-0.711, P = 0.007) and hemoglobin levels (OR 0.812, 95% CI 0.682-0.966, P = 0.019) were independently associated with not starting OA therapy at discharge. Of the 375 patients treated with OA at admission, 87 (23.2%) had their OA discontinued at discharge. The HAS-BLED score (OR 1.516, 95% CI 1.211-1.897, P < 0.001) and previous acute myocardial infarction (OR 0.327, 95% CI 0.121-0.883, P = 0.027) were associated with the discontinuation of OA. CONCLUSIONS: There are factors associated with discontinuing or not starting OA in older patients with NVAF, which often have no clinical justification. Geriatr Gerontol Int 2018; 18: 1219-1224.

Uso de anticoagulantes orales en situaciones clínicas complejas con fibrilación auricular / Use of oral anticoagulants in complex clinical situations with atrial fibrillation

En el presente capítulo se actualiza el tratamiento anticoagulante en pacientes con fibrilación auricular y diferentes situaciones clínicas que requieren consideraciones particulares, como son la cardiopatía isquémica, la cardioversión eléctrica, la ablación de venas pulmonares, la presencia de valvulopatías con o sin prótesis, la insuficiencia renal o la ancianidad y fragilidad. En pacientes con fibrilación auricular no valvular, la presencia de insuficiencia renal incrementa tanto el riesgo trombótico como el hemorrágico. En los estadios leves y moderados, los anticoagulantes de acción directa mostraron un mayor beneficio que warfa-rina, aunque suelen requerir ajuste de dosis. En el estadio de fallo renal/diálisis, no hay evidencia sólida de que la warfarina resulte beneficiosa y la utilización de los anticoagulantes de acción directa no está recomendada. Por su fisiopatología, se ha considerado que la anticoagulación oral podría ejercer un efecto beneficioso en los pacientes con cardiopatía isquémica. Sin embargo, los anticoagulantes antivitamina K no han demostrado una relación riesgo-beneficio satisfactoria. Por el contrario, los anticoagulantes de acción directa, en dosis reducidas, podrían ejercer un efecto beneficioso en este escenario en asociación con los antiagregantes. El uso de los anticoagulantes de acción directa previo a la cardioversión eléctrica en pacientes con fibrila-ción auricular no valvular parece tener asociado un riesgo de eventos cardioembólicos, al menos comparable a los anticoagulantes antivitamina K, evitando la demora en aplicar esta técnica en pacientes sin niveles adecuados de INR precardioversión eléctrica. En el contexto de su uso periablación de fibrilación auricular, el dabigatrán y el rivaroxabán demostraron al menos no inferioridad respecto a los anticoagulantes antivitamina K en cuanto a seguridad. La coexistencia de cualquier tipo y grado de valvulopatías con la fibrilación auricular obliga a evaluar la in-dicación de tratamiento antitrombótico de la misma manera que si no existiera valvulopatía. Cuando sea necesaria la anticoagulación, los anticoagulantes de acción directa son de elección en casi todas las situaciones, excepto en los pacientes portadores de una prótesis mecánica o que padezcan enfermedad mitral reumática significativa, que deben tratarse con anticoagulantes antivitamina K. La elección de la estrategia antitrombótica adecuada en el anciano frágil es una cuestión compleja en que interfieren múltiples factores, más allá de la evaluación del riesgo embólico y hemorrágico. La realización de una evaluación geriátri-ca integral es fundamental para que la decisión final sea individualizada. Además, esta se debe consensuar y revaluar periódicamente. Los anticoagulantes de acción directa podrían ser la alternativa más favorable en la mayoría de los pacientes ancianos con fibrilación auricular no valvular

The present article provides an update on anticoagulant treatment in patients with atrial fibrillation in distinct clinical scenarios requiring particular considerations, such as ischaemic heart disease, electrical cardioversion, pulmonary vein ablation, the presence of valvular disease with or without prosthetic valves, and renal insufficiency, as well as old age and frailty. In patients with non-valvular atrial fibrillation, the presence of renal insufficiency increases both thrombotic and haemorrhagic risk. In mild and moderate stages, direct-acting anticoagulants confer a greater benefit than warfarin, although they usually require dose adjustment. In renal failure/dialysis, there is no solid evidence that warfarin is beneficial and the use of direct-acting anticoagulants is not recommended. Because of its pathophysiology, oral anticoagulation could have a beneficial effect in patients with heart disease. However, vitamin K antagonists have not shown a satisfactory risk-benefit ratio. In contrast, direct-acting anticoagulants, at reduced doses, could have a beneficial effect in this scenario in association with antiplatelet agents. The use of direct-acting anticoagulants prior to electrical cardioversion in patients with non-valvular atrial fibrillation seems to be associated with a risk of cardioembolic events that is at least comparable to that of vitamin K antagonists. Their use avoids delay in the application of electrical cardioversion in patients without adequate INR levels. In the context of their use before and after atrial fibrillation ablation, dabiga-tran and rivaroxaban have demonstrated at least non-inferiority with vitamin K antagonists in terms of safety. In patients with any type or grade of valvular disease and atrial fibrillation, the indication of antithrombo-tic treatment must be evaluated in the same way as in patients with atrial fibrillation and no valvular di-sease. Whenever anticoagulation is required, direct-acting anticoagulants are the treatment of choice in nearly all situations, except in patients with mechanical valves or who have significant rheumatic mitral disease, who should be treated with vitamin K antagonists. The choice of appropriate antithrombotic stra-tegy in frail elderly patients is complex and involves multiple factors beyond assessment of embolic and haemorrhagic risk. Comprehensive geriatric assessment is essential for an individualised final decision. Moreover, any such decision should be consensus-based and periodically reviewed. Direct-acting anticoa-gulants could be the most beneficial alternative in most elderly patients with non-valvular atrial fibrillation

Bone Mineral Density Distribution Curves in Spanish Adults With Down Syndrome.

According to reports from small-sized case series, adults with Down syndrome (DS) appear to have lower bone mineral density (BMD) than the general population. The objective of our study was to further characterize the bone mass acquisition curve in an adult DS population. This is a retrospective study of 297 adults with DS from the Adult Down Syndrome Outpatient Clinic of a tertiary care hospital in Madrid, Spain, who underwent a bone densitometry (Hologic QDR-4500W), for clinical purposes between January 2010 and June 2015. The mean age of our sample population was 34 yr (±10.9); 51% were women. Bone mass peak was reached earlier and was lower than the general population (around 20-25 yr), with almost parallel curves. The mean BMD was 0.715 ± 0.12 g/cm2 in femoral neck (FN) and 0.872 ± 0.11 g/cm2 in lumbar spine (LS). According to FN scores, 52% of the subjects were classified as osteopenic and 18% as osteoporotic. According to LS scores, frequencies were 54% and 25%, respectively. BMD was considered inadequate for the age (Z-score < -2 standard deviation) in 18% of the subjects at FN and 40% at LS. BMD at LS was significantly lower in males than in females (52% vs 38%, p < 0.001). Male DS subjects had a 2.58-fold (95% confidence interval: 1.57-4.25) higher risk of developing reduced BMD at LS than females. Persons with DS reach the bone mass peak earlier and this bone mass is lower than the general population. Among subjects with DS, male gender is a risk factor for developing low BMD, especially at LS.

Características y tratamiento antitrombótico de los pacientes ancianos con fibrilación auricular no valvular hospitalizados en Medicina Interna. Registro NONAVASC / Antithrombotic treatment and characteristics of elderly patients with non-valvular atrial fibrillation hospitalized at Internal Medicine departments. NONAVASC registry

Introducción y objetivos. La prevalencia de fibrilación auricular no valvular (FANV) aumenta con la edad y se asocia a alta morbimortalidad. El objetivo principal fue conocer las características de los pacientes ancianos con FANV hospitalizados y los factores clínico-funcionales que determinan la estrategia antitrombótica utilizada. Pacientes y métodos. Estudio observacional, prospectivo, multicéntrico realizado en pacientes mayores de 75 años con FANV, hospitalizados por cualquier causa en Medicina Interna. Resultados. Se evaluaron 804 pacientes con una edad media de 85 años (rango: 75-101); el 53,9% fueron mujeres. La prevalencia de factores de riesgo y enfermedades vasculares fue elevada: hipertensión (87,6%), insuficiencia cardíaca (65,4%), cardiopatía isquémica (24,4%), enfermedad cerebrovascular (22,4%) e insuficiencia renal (45%). Entre los pacientes con diagnóstico previo al ingreso de FANV el 86,2% recibía tratamiento antitrombótico: anticoagulantes (59,7%), antiagregantes (AAG) (17,8%) y doble terapia (8,7%). Los factores asociados con la utilización del mismo fueron el antecedente de síndrome coronario agudo y la FANV de más de un año de evolución. Se asociaron con el uso de antiagregación la edad avanzada, la FANV de menos de un año de evolución, las puntuaciones superiores de HAS-BLED y el deterioro cognitivo grave. La fibrilación auricular permanente favorecía la prescripción de anticoagulantes. Conclusiones. Los pacientes mayores de 75 años con FANV hospitalizados en Medicina Interna tienen numerosas comorbilidades. El porcentaje de anticoagulación es escaso y un 18% recibe solo antiagregación, influyendo en su selección la edad, el tiempo de evolución de la fibrilación auricular y la gravedad del deterioro cognitivo (AU)

Background and objetives. The prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies. Patients and methods. Observational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments. Results. We evaluated 804 patients with a mean age of 85 years (range 75-101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favoured the use of anticoagulants. Conclusions. Hospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice (AU)

Antithrombotic treatment and characteristics of elderly patients with non-valvular atrial fibrillation hospitalized at Internal Medicine departments. NONAVASC registry. / Características y tratamiento antitrombótico de los pacientes ancianos con fibrilación auricular no valvular hospitalizados en Medicina Interna. Registro NONAVASC.

BACKGROUND AND OBJETIVES: The prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies. PATIENTS AND METHODS: Observational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments. RESULTS: We evaluated 804 patients with a mean age of 85 years (range 75-101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favoured the use of anticoagulants. CONCLUSIONS: Hospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice.

Factors associated with late diagnosis of HIV infection and missed opportunities for earlier testing.

Late diagnosis (LD) of human immunodeficiency virus (HIV) infection continues to be a significant problem that increases disease burden both for patients and for the public health system. Guidelines have been updated in order to facilitate earlier HIV diagnosis, introducing "indicator condition-guided HIV testing". In this study, we analysed the frequency of LD and associated risk factors. We retrospectively identified those cases that could be considered missed opportunities for an earlier diagnosis. All patients newly diagnosed with HIV infection who attended Hospital La Princesa, Madrid (Spain) between 2007 and 2014 were analysed. We collected epidemiological, clinical and immunological data. We also reviewed electronic medical records from the year before the HIV diagnosis to search for medical consultations due to clinical indicators. HIV infection was diagnosed in 354 patients. The median CD4 count at presentation was 352 cells/mm(3). Overall, 158 patients (50%) met the definition of LD, and 97 (30.7%) the diagnosis of advanced disease. LD was associated with older age and was more frequent amongst immigrants. Heterosexual relations and injection drug use were more likely to be the reasons for LD than relations between men who have sex with men. During the year preceding the diagnosis, 46.6% of the patients had sought medical advice owing to the presence of clinical indicators that should have led to HIV testing. Of those, 24 cases (14.5%) were classified as missed opportunities for earlier HIV diagnosis because testing was not performed. According to these results, all health workers should pursue early HIV diagnosis through the proper implementation of HIV testing guidelines. Such an approach would prove directly beneficial to the patient and indirectly beneficial to the general population through the reduction in the risk of transmission.

Cardiovascular profile in critically ill elderly medical patients: prevalence, mortality and length of stay.

PURPOSE: Data are demonstrating the increase in utilization of critical care by the elderly. Around 11% of ICU patients are ≥80years-old. METHODS: An observational retrospective study was conducted between 2003 and 2011, including elderly patients (≥80years old) admitted from medical services to the intensive care unit (ICU) in a tertiary university hospital. The final sample size was N=202. RESULTS: Mortality rates were: ICU 34.1%, in-hospital 44% and 1-year cumulative mortality 55.4% (20.4% for hospital survivors). Multivariate analysis showed that APACHE II score: OR 1.10, 95% CI (1.03-1.18), SAPS II score: OR 1.03, 95% CI (1.01-1.06), a score <3 on the Cruz Roja Hospital mental scale: 0.51 OR, 95% CI (0.01-0.57) and ICU admission for cardiovascular disease: OR 5.05, 95% CI (1.98-12.84) were independently associated with mortality ICU. Factors independently associated with 1-year mortality were: dyslipidemia OR 7.25 (1.47-35.60), chronic kidney failure OR 13.23, 95% CI (2.28-76.6), stroke OR 10.44, 95% CI (2.26-48.25) and antihypertensive treatment OR 0.08, 95% CI (0.01-0.48). In multiple linear regression, ICU length of stay was associated with mechanical ventilation B coefficient 6.41, 95% CI (1.18-11.64) and in-hospital length of stay was related to age: B coefficient -2.17, 95% CI (-4.02 to -0.33). CONCLUSIONS: Prevalence of cardiovascular risk factors and cardiovascular disease was high, and basal cardiovascular treatment was underused. Primary diagnosis for cardiovascular disease at ICU admission should be assessed as predictor of ICU mortality. Intensifying cardiovascular basal treatment could decrease 1-year mortality. Cardiovascular profile did not show an effect on in-hospital mortality and length of stay.