ABSTRACT
BACKGROUND: Many patients with heart failure (HF) are repeatedly hospitalized. Heart failure self-care may reduce readmission rates. Hospitalizations may also affect self-care. OBJECTIVE: The purpose of this secondary analysis was to test the hypotheses that better HF self-care is associated with a lower rate of all-cause readmissions and that readmissions motivate patients to improve their self-care. METHODS: This was a prospective cohort study of patients with HF (N = 400) who were enrolled during a stay at an urban teaching hospital between 2014 and 2016. The Self-Care of Heart Failure Index v6.2 was administered during the hospital stay, along with other questionnaires, and repeated at 6-month intervals after discharge. All-cause readmissions and deaths were ascertained for 24 months. RESULTS: A total of 333 (83.3%) were readmitted at least once, and 117 (29.3%) of the patients died during the follow-up period. A total of 1581 readmissions were ascertained. Higher Self-Care of Heart Failure Index Maintenance scores predicted more rather than fewer readmissions (adjusted hazard ratio, 1.09; 95% confidence interval, 1.01-1.17; P < .01). Conversely, more readmissions predicted higher Maintenance scores (b = 0.29; 95% confidence interval, 0.02-0.56; P < .05). CONCLUSIONS: These findings do not support the hypothesis that HF self-care maintenance or management helps to reduce the rate of all-cause readmissions, but they do suggest that the experience of multiple readmissions may help to motivate improvements in HF self-care.
Subject(s)
Heart Failure , Patient Readmission , Self Care , Humans , Heart Failure/therapy , Patient Readmission/statistics & numerical data , Male , Female , Aged , Prospective Studies , Middle Aged , Longitudinal Studies , Aged, 80 and overABSTRACT
Major depressive disorder is a well-established risk factor for cardiac events in patients with coronary heart disease, but clinical trials have produced little evidence that treating depression reliably improves cardiac event-free survival in these patients. In this review, we offer evidence that certain symptoms that commonly remain after otherwise successful treatment of depression-insomnia, fatigue, and anhedonia-independently predict cardiac events. This may help to explain the failure of previous depression treatment trials to improve cardiac event-free survival even when other symptoms of depression improve. We thus propose that adverse cardiovascular effects that have long been attributed to syndromal depression may be instead caused by persistent fatigue, insomnia, and anhedonia, regardless of whether other symptoms of depression are present. We also identify interventions for these symptoms and call for more research to evaluate their effectiveness in depressed patients with coronary heart disease.
Subject(s)
Coronary Disease , Humans , Coronary Disease/psychology , Coronary Disease/mortality , Coronary Disease/complications , Depressive Disorder, Major/psychology , Depressive Disorder, Major/therapy , Antidepressive Agents/therapeutic use , Depression/therapyABSTRACT
Calcific aortic stenosis can be considered a model for geriatric cardiovascular conditions due to a confluence of factors. The remarkable technological development of transcatheter aortic valve replacement was studied initially on older adult populations with prohibitive or high-risk for surgical valve replacement. Through these trials, the cardiovascular community has recognized that stratification of these chronologically older adults can be improved incrementally by invoking the concept of frailty and other geriatric risks. Given the complexity of the aging process, stratification by chronological age should only be the initial step but is no longer sufficient to optimally quantify cardiovascular and noncardiovascular risk. In this review, we employ a geriatric cardiology lens to focus on the diagnosis and the comprehensive management of aortic stenosis in older adults to enhance shared decision-making with patients and their families and optimize patient-centered outcomes. Finally, we highlight knowledge gaps that are critical for future areas of study.
ABSTRACT
The 1986 Bethesda Conference on Cardiovascular Disease (CVD) in the Elderly, co-chaired by Drs. Nanette Wenger, Frank Marcus, and Robert O'Rourke, delineated the anticipated social, political, ethical, economic and technological impact of an aging population on the incidence, prevalence, and management of CVD in the US and worldwide. In the ensuing 4 decades, older patients have come to comprise an increasingly large proportion of the CVD population, and there has been an explosion of research in all aspects of CVD affecting older adults. Correspondingly, Geriatric Cardiology is now an established field within cardiovascular medicine. In this communication, we provide a focused update on intersections between CVD and geriatrics from basic science to clinical practice, a review of major advances in diagnosis and treatment of older adults with CVD, and a preview of future research directions in the still evolving field of geriatric cardiology.
ABSTRACT
BACKGROUND: Traditional cardiac rehabilitation (CR) improves cardiovascular outcomes and reduces mortality, but less is known about the relative benefit of intensive CR (ICR) which incorporates greater lifestyle education through 72 sessions (versus 36 in CR). Our objective was to determine whether ICR is associated with a mortality and cardiovascular benefit compared with CR. METHODS: Retrospective cohort study of Medicare Fee-For-Service beneficiaries in a 100% sample, claims data set. Qualifying events were captured from May 1, 2016 to December 31, 2019 and ICR/CR utilization captured from May 1, 2016 to December 31, 2020. Among patients attending at least 1 day of either CR or ICR, Cox proportional hazards models using a 1 to 5 propensity score match were used to compare utilization and the association of ICR versus CR participation with (1) all-cause mortality and (2) cardiovascular-related hospitalizations or nonfatal cardiac events. Dose-response was assessed by the number of days attended. RESULTS: From 2016 to 2019, 1 277 358 unique patients met at least one qualifying indication for ICR/CR from 2016 to 2019. Of these, 262 579 (20.6%) and 4452 (0.4%) attended at least one session of CR or ICR, respectively (mean [SD] age, 73.2 [7.8] years; 32.3% female). In the matched sample, including 26 659 total patients (median, 2.4-year follow-up), ICR was associated with 12% lower all-cause mortality (multivariable adjusted hazard ratio, 0.88 [95% CI, 0.78-0.99]; P=0.036) compared with CR but no significant difference for cardiovascular-related hospitalization or nonfatal cardiac events. The mortality benefit was seen for both ICR and CR per day strata, with each modality demonstrating a clear dose-response benefit. CONCLUSIONS: ICR is associated with lower mortality than traditional CR among Medicare beneficiaries but no difference in cardiovascular-related hospitalization or nonfatal cardiac events. Moreover, ICR and CR demonstrate a dose-response relationship for mortality. Additional studies are needed to confirm these observations and to better understand the mechanisms by which ICR may lead to a reduction in mortality.
Subject(s)
Cardiac Rehabilitation , Cardiovascular Diseases , Humans , Female , Aged , United States/epidemiology , Male , Retrospective Studies , Medicare , Proportional Hazards Models , Cardiovascular Diseases/diagnosis , Cardiovascular Diseases/therapyABSTRACT
We review a comprehensive risk assessment approach for percutaneous coronary interventions in older adults and highlight the relevance of geriatric syndromes within that broader perspective to optimize patient-centered outcomes in interventional cardiology practice. Reflecting the influence of geriatric principles in older adults undergoing percutaneous coronary interventions, we propose a "geriatric" heart team to incorporate the expertise of geriatric specialists in addition to the traditional heart team members, facilitate uptake of the geriatric risk assessment into the preprocedural risk assessment, and address ways to mitigate these geriatric risks. We also address goals of care in older adults, highlighting common priorities that can impact shared decision making among older patients, as well as frequently encountered pharmacotherapeutic considerations in the older adult population. Finally, we clarify gaps in current knowledge and describe crucial areas for future investigation.
ABSTRACT
BACKGROUND: Depression is a recognized barrier to heart failure self-care, but there has been little research on interventions to improve heart failure self-care in depressed patients. OBJECTIVES: To investigate the outcomes of an individually tailored self-care intervention for patients with heart failure and major depression, and to determine whether the adequacy of self-care at baseline, the severity of depression or anxiety, or other factors affect the outcomes of this intervention. DESIGN: Secondary analysis of data from a pre-registered randomized controlled trial (NCT02997865). METHODS: Outpatients with heart failure and comorbid major depression (nâ¯=â¯139) were randomly assigned to cognitive behavior therapy or usual care for depression. In addition, an experienced cardiac nurse provided the tailored self-care intervention to all patients in both arms of the trial starting eight weeks after randomization. Weekly self-care intervention sessions were held between Weeks 8 and 16; the frequency was tapered to biweekly or monthly between Weeks 17 and 32. The Self-Care of Heart Failure Index (v6.2) was used to assess self-care outcomes, with scores ≥70 on each of its three scales (Maintenance, Management, and Confidence) being consistent with adequate self-care. The Week 16 Maintenance scale score was the primary outcome for this analysis. RESULTS: At baseline, 107 (77%) of the patients scored in the inadequate self-care range on the Maintenance scale. Between Weeks 8 and 16, Maintenance scores improved more in patients with initially inadequate than initially adequate self-care (11.9 vs. 3.2 points, pâ¯=â¯.003). Sixty-six (48%) of the patients with initially inadequate Maintenance scores achieved scores in the adequate range by Week 32 (pâ¯<â¯.0001). Covariate-adjusted predictors of better Maintenance outcomes included adequate Maintenance at baseline (pâ¯<â¯.0001), higher anxiety at baseline (pâ¯<â¯.05), and higher dosages of the self-care intervention (pâ¯<â¯.0001). Neither treatment with cognitive behavior therapy nor less severe major depression predicted better self-care outcomes. CONCLUSIONS: Depressed patients with inadequate heart failure self-care are able to achieve clinically significant improvements in self-care with the help of an individually tailored self-care intervention. Further refinement and testing are needed to increase the intervention's potential for clinical implementation.
Subject(s)
Depressive Disorder, Major , Heart Failure , Humans , Depressive Disorder, Major/therapy , Depression/psychology , Self Care , Heart Failure/complications , Heart Failure/therapy , Heart Failure/psychology , Comorbidity , Quality of LifeABSTRACT
Background: Prior randomized clinical trials have reported benefit of fluvoxamine ≥200â mg/d vs placebo for patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods: This randomized, double-blind, placebo-controlled, fully remote multisite clinical trial evaluated whether fluvoxamine prevents clinical deterioration in higher-risk outpatients with acute coronavirus disease 2019 (COVID-19). Between December 2020 and May 2021, nonhospitalized US and Canadian participants with confirmed symptomatic infection received fluvoxamine (50â mg on day 1, 100â mg twice daily thereafter) or placebo for 15 days. The primary modified intent-to-treat (mITT) population included participants who started the intervention within 7 days of symptom onset with a baseline oxygen saturation ≥92%. The primary outcome was clinical deterioration within 15 days of randomization, defined as having both (1) shortness of breath (severity ≥4 on a 0-10 scale or requiring hospitalization) and (2) oxygen saturation <92% on room air or need for supplemental oxygen. Results: A total of 547 participants were randomized and met mITT criteria (n = 272 fluvoxamine, n = 275 placebo). The Data Safety Monitoring Board recommended stopping early for futility related to lower-than-predicted event rates and declining accrual concurrent with vaccine availability in the United States and Canada. Clinical deterioration occurred in 13 (4.8%) participants in the fluvoxamine group and 15 (5.5%) participants in the placebo group (absolute difference at day 15, 0.68%; 95% CI, -3.0% to 4.4%; log-rank P = .91). Conclusions: This trial did not find fluvoxamine efficacious in preventing clinical deterioration in unvaccinated outpatients with symptomatic COVID-19. It was stopped early and underpowered due to low primary outcome rates. Clinical Trials Registration: ClinicalTrials.gov Identifier: NCT04668950.
ABSTRACT
As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patients who are likely to derive net benefit vs those who have disproportionate risks for harm. Conventional risk assessment tools from national cardiovascular societies typically rely on 3 pillars: 1) cardiovascular risk; 2) physiologic and hemodynamic risk; and 3) anatomic and procedural risks. We propose adding a fourth pillar: geriatric syndromes, as geriatric domains can supersede all other aspects of risk.
ABSTRACT
This Viewpoint discusses pitfalls in measurement and interpretation of post hoc frailty scores and proposes standardized frailty assessment in randomized clinical trials.
Subject(s)
Cardiovascular Diseases , Frailty , Humans , Aged , Risk Assessment , Geriatric AssessmentABSTRACT
OBJECTIVE: Both depression and inadequate self-care are common in patients with heart failure. This secondary analysis examines the one-year outcomes of a randomized controlled trial of a sequential approach to treating these problems. METHODS: Patients with heart failure and major depression were randomly assigned to usual care (n = 70) or to cognitive behavior therapy (n = 69). All patients received a heart failure self-care intervention starting 8 weeks after randomization. Patient-reported outcomes were assessed at Weeks 8, 16, 32, and 52. Data on hospital admissions and deaths were also obtained. RESULTS: One year after randomization, Beck Depression Inventory (BDI-II) scores were - 4.9 (95% C.I., -8.9 to -0.9; p < .05) points lower in the cognitive therapy than the usual care arm, and Kansas City Cardiomyopathy scores were 8.3 (95% C.I., 1.9 to 14.7; p < .05) points higher. There were no differences on the Self-Care of Heart Failure Index or in hospitalizations or deaths. CONCLUSIONS: The superiority of cognitive behavior therapy relative to usual care for major depression in patients with heart failure persisted for at least one year. Cognitive behavior therapy did not increase patients' ability to benefit from a heart failure self-care intervention, but it did improve HF-related quality of life during the follow-up period. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02997865.
Subject(s)
Cognitive Behavioral Therapy , Heart Failure , Humans , Quality of Life , Self Care , Depression/therapy , Heart Failure/therapy , Heart Failure/psychologyABSTRACT
AIMS: Randomized clinical trials of hypertension treatment intensity evaluate the effects on incident major adverse cardiovascular events (MACEs) and serious adverse events (SAEs). Occurrences after a non-fatal index event have not been rigorously evaluated. The aim of this study was to evaluate the association of intensive (<120 mmHg) to standard (<140 mmHg) blood pressure (BP) treatment with mortality mediated through a non-fatal MACE or non-fatal SAE in 9361 participants in the Systolic Blood Pressure Intervention Trial. METHODS AND RESULTS: Logistic regression and causal mediation modelling to obtain direct and mediated effects of intensive BP treatment. Primary outcome was all-cause mortality (ACM). Secondary outcomes were cardiovascular (CVM) and non-CV mortality (non-CVM). The direct effect of intensive treatment was a lowering of ACM [odds ratio (OR) 0.75, 95% confidence interval (CI): 0.60-0.94]. The MACE-mediated effect substantially attenuated (OR 0.96, 95% CI: 0.92-0.99) ACM, while the SAE-mediated effect was associated with increased (OR 1.03, 95% CI: 1.01-1.05) ACM. Similar patterns were noted for intensive BP treatment on CVM and non-CVM. We also noted that SAE incidence was 3.9-fold higher than MACE incidence (13.7 vs. 3.5%), and there were a total of 365 (3.9%) ACM cases, with non-CVM being 2.6-fold higher than CVM [2.81% (263/9361) vs. 1.09% (102/9361)]. The SAE to MACE and non-CVM to CVM preponderance was found across all age groups, with the ≥80-year age group having the highest differences. CONCLUSION: The current analytic techniques demonstrated that intensive BP treatment was associated with an attenuated mortality benefit when it was MACE-mediated and possibly harmful when it was SAE-mediated. Current cardiovascular trial reporting of treatment effects does not allow expansion of the lens to focus on important occurrences after the index event.
The benefit of intensive (<120 mmHg) blood pressure (BP) treatment, reduction in all-cause mortality (ACM), was attenuated when mediated through non-fatal major adverse cardiovascular events. This was driven by cardiovascular mortality (CVM). The harm of intensive BP treatment, increase in ACM, was amplified when mediated through serious adverse events. This was driven by non-CVM. Current reporting of treatment effects in cardiovascular trials does not allow for expansion of the lens to focus on important occurrences after the index event.
Subject(s)
Cardiovascular Diseases , Hypertension , Humans , Aged , Blood Pressure , Mediation Analysis , Hypertension/diagnosis , Hypertension/drug therapy , Hypertension/epidemiology , Cause of Death , Antihypertensive Agents/adverse effects , Cardiovascular Diseases/diagnosis , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/chemically inducedABSTRACT
Sarcopenia is the loss of muscle strength, mass, and function, which is often exacerbated by chronic comorbidities including cardiovascular diseases, chronic kidney disease, and cancer. Sarcopenia is associated with faster progression of cardiovascular diseases and higher risk of mortality, falls, and reduced quality of life, particularly among older adults. Although the pathophysiologic mechanisms are complex, the broad underlying cause of sarcopenia includes an imbalance between anabolic and catabolic muscle homeostasis with or without neuronal degeneration. The intrinsic molecular mechanisms of aging, chronic illness, malnutrition, and immobility are associated with the development of sarcopenia. Screening and testing for sarcopenia may be particularly important among those with chronic disease states. Early recognition of sarcopenia is important because it can provide an opportunity for interventions to reverse or delay the progression of muscle disorder, which may ultimately impact cardiovascular outcomes. Relying on body mass index is not useful for screening because many patients will have sarcopenic obesity, a particularly important phenotype among older cardiac patients. In this review, we aimed to: (1) provide a definition of sarcopenia within the context of muscle wasting disorders; (2) summarize the associations between sarcopenia and different cardiovascular diseases; (3) highlight an approach for a diagnostic evaluation; (4) discuss management strategies for sarcopenia; and (5) outline key gaps in knowledge with implications for the future of the field.
Subject(s)
Cardiovascular Diseases , Sarcopenia , Humans , Sarcopenia/diagnosis , Sarcopenia/epidemiology , Sarcopenia/therapy , Cardiovascular Diseases/diagnosis , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/therapy , Quality of Life , Body Composition , Muscle Strength/physiology , Muscle, Skeletal/metabolismSubject(s)
Cardiac Surgical Procedures , Cardiology , Humans , United States , Treatment Outcome , Heart , Coronary Vessels , Cardiology/education , Clinical Competence , Societies, MedicalABSTRACT
Intensive cardiac rehabilitation (ICR) programs are approved by the Centers for Medicare & Medicaid Services on the basis of their expected benefits for cardiovascular disease (CVD) risk factors and health outcomes. However, the impact of outpatient ICR on diet quality, quality of life (QOL), and CVD risk factors has not been prospectively assessed. The aim of this cohort study was to test the hypothesis that patients enrolled in a Pritikin outpatient ICR program would show improved diet quality, QOL, and CVD health indexes, and that the improvements would be greater than those of patients in traditional cardiac rehabilitation (CR). Patients enrolled in ICR (n = 230) or CR (n = 62) were assessed at baseline and at visit 24. Diet quality was assessed using the Rate Your Plate questionnaire, and QOL was assessed through the Dartmouth COOP Functional Health Assessment questionnaire. Secondary end points included anthropometrics, CVD biomarkers, hemodynamics, and fitness. Patients in ICR programs displayed significant improvements at visit 24 versus baseline in Rate Your Plate and Dartmouth COOP Functional Health Assessment scores, weight, body mass index (BMI), waist circumference, fat mass, total and low-density lipoprotein cholesterol, 6-minute walk distance, and grip strength. Patients in ICR had greater improvements in diet quality (p = 0.001), weight (p = 0.001), and BMI (p <0.001) than did those in CR. In summary, this prospective study of Pritikin outpatient ICR revealed significant improvements in diet quality, QOL, adiposity, and other CVD risk factors. The improvements in diet quality, body weight, and BMI were greater than those observed with traditional CR.