Considerations Regarding Management of Heart Failure in Older Adults.

Understanding noncardiovascular comorbidities and geriatric syndromes in elderly patients with heart failure (HF) is important as the average age of the population increases. Healthcare professionals need to consider these complex dynamics when managing older adults with HF, especially those older than 80. A number of small studies have described associations between HF and major geriatric domains. With information on patients' cognitive, functional decline, and ability to adhere to therapy, physicians can plan for individualized treatment goals and recommendations for these patients.

Multiple radiologist review of adrenal CT still frequently misses lateralized surgical primary aldosteronism.

Patients with primary aldosteronism (PA) have increased morbidity and mortality compared to those with essential hypertension. Accurate detection of lateralized PA is important so that affected patients can receive potentially curative adrenalectomy. However, around 40% of patients with lateralized PA have "normal" adrenal glands on computed tomography (CT). Additional independent review of imaging has been shown to improve diagnostic accuracy in many areas of imaging. Therefore, the authors sought to establish if multi-reader re-assessment of previously reported normal CT scans would result in increased detection of surgically remediable disease. The authors found that re-assessment of CT imaging by one, two, or three additional radiologists (or a combination thereof) slightly increased the detection of lateralized disease, but these differences were not statistically significant (p > .05). Readers had low inter-observer agreement (kappa = 0.17). If detection of a discrete nodule on CT was made a prerequisite for adrenal vein sampling (AVS), a second read by another reviewer would still result in an excess of missed cases (84.2%, 36.8%, and 65.8%, respectively, for each of the three independent reviewers). Therefore, a "normal" CT does not preclude the possibility of lateralized PA. Adrenal vein sampling should still be strongly considered wherever available and whenever surgery is considered for treatment of PA, irrespective of CT findings.

Diagnostic and prognostic value of Technetium-99m pyrophosphate uptake quantitation for transthyretin cardiac amyloidosis.

BACKGROUND: 99mTc-pyrophosphate imaging has emerged as an important non-invasive method to diagnose transthyretin cardiac amyloidosis (ATTR-CM). Quantitation of 99mTc-pyrophosphate activity, on SPECT images, could be a marker of ATTR-CM disease burden. We assessed the diagnostic accuracy and clinical significance of 99mTc-pyrophosphate quantitation. METHODS AND RESULTS: Patients who underwent 99mTc-pyrophosphate imaging for suspected ATTR-CM were included. Using SPECT images, radiotracer activity in the myocardium was calculated using cardiac pyrophosphate activity (CPA) and volume of involvement (VOI), with thresholds for abnormal activity derived from LVBP activity. Diagnostic accuracy was assessed using area under the receiver operating characteristic curve (AUC). In total, 124 patients were identified, mean age 73.9 ± 11.4, with ATTR-CM diagnosed in 43 (34.7%) patients. CPA had the highest diagnostic accuracy (AUC .996, 95% CI .987-1.00), and was significantly higher compared to the Perugini score (AUC .952, P = .016). In patients with ATTR-CM, CPA was associated with reduced left ventricular ejection fraction (adjusted odds ratio 1.28, P = .035) and heart failure hospitalizations (adjusted hazard ratio 1.29, P = .006). CONCLUSION: Quantitative assessment of myocardial radiotracer activity with CPA or VOI have high diagnostic accuracy for ATTR-CM. Both measures are potential non-invasive markers to follow progression of disease or response to therapy.

Role of Geriatric Syndromes in the Management of Atrial Fibrillation in Older Adults: A Narrative Review.

OBJECTIVES: Atrial fibrillation (AF) is common in older adults and associated with increased risk of cardiovascular events including thromboembolism. However, less is known about its association with noncardiovascular events, especially geriatric syndromes and conditions such as dementia, depression, impaired physical function, polypharmacy, falls, and poor quality of life. This review aims to help healthcare professionals integrate the special needs of older adults into their management of AF. DESIGN: Nonsystematic review. A literature search on published articles on AF and geriatric syndromes and conditions was performed using the electronic databases MEDLINE, EMBASE and SCOPUS, and DARE until December 2017. Non-English articles were excluded. SETTINGS AND PARTICIPANTS: Older adults with and without AF from different settings. MEASURES: Various cognitive, mood, and functional measurements were used in these studies. In studies regarding polypharmacy, the Beers or PRISCUS criteria were used to identify inappropriate medications. In quality of life measurements studies, instruments like Medical Outcomes Study Short Form 36 and Atrial Fibrillation Quality of Life questionnaire were used. RESULTS: This literature review finds that AF has a substantial association with geriatric syndromes and conditions and that AF is a risk factor for the development of geriatric syndromes and conditions. Evidence is limited regarding the potential benefit of long-term treatment of AF in lowering the risk of developing geriatric syndromes and conditions. CONCLUSIONS/IMPLICATIONS: Considering the impact of AF on cardiovascular outcomes and geriatric syndromes and conditions in older adults, healthcare professionals need to consider these complex dynamics while managing AF in older adults. An individual approach to AF management is needed in older adults with multiple comorbidity and polypharmacy that may help lower the risk of disease-disease, disease-drug, and drug-drug interactions. Special consideration needs to be given to patients' cognitive and functional impairment and ability to adhere to therapy.

Classic challenges and emerging approaches to medication therapy in older adults.

Prescribing medications safely and effectively in older adults is a complex process. This review discusses challenges with medication prescribing in older adults and outlines a holistic approach to medication management in older adults. Well-known challenges including the alterations in pharmacokinetics and pharmacodynamics that often occur with aging are discussed. Other classic concerns including polypharmacy, potentially inappropriate medication use, prescribing cascades, suboptimal prescribing, paradoxical harm and unintended consequences of medications, and drug interactions are reviewed. Newer approaches, including deprescribing, pharmacogenomics, and the future potential for senolytic therapy are also discussed. All healthcare providers should consider these challenges when prescribing medications in older adults. Choosing a drug that fits both a patient's pathophysiology and biology, avoiding drugs with significant side effects, titrating doses, and deprescribing are all critical in optimizing medication therapy.

Cardiac rehabilitation and its effects on cognition in patients with coronary artery disease and heart failure.

INTRODUCTION: Cardiac rehabilitation program is an evidence-based intervention and established model of exercise delivery following myocardial infarction and heart failure. Although it forms an important part of recovery and helps to prevent future events and complications, there has been little focus on its potential cognitive benefits. Areas covered: Coronary artery disease and heart failure are common heart problems associated with significant morbidity and mortality, and cognitive decline is commonly seen in affected individuals. Cognitive impairment may influence patient self-management by reducing medication adherence, rendering patients unable to make lifestyle modifications and causing missed healthcare visits. Cognitive assessment in cardiac rehabilitation as an outcome measure has the potential to improve clinical, functional and behavioral domains as well as help to reduce gaps in the quality of care in these patients. Expert commentary: Limited evidence at present has shown that cardiac rehabilitation and exercise has potential in preventing cognitive decline. Cardiac prehabilitation, a rehabilitation-like program delivered before cardiac surgery, may also play a role in preventing postoperative cognitive dysfunction, but needs future research studies to support it.

Comparison of two commonly used clinical cognitive screening tests to diagnose mild cognitive impairment in heart failure with the golden standard European Consortium Criteria.

INTRODUCTION: This study on mild cognitive impairment (MCI) in heart failure (HF) compares the utility of Montreal Cognitive Assessment (MoCA) to the Mini-Mental Status Exam (MMSE) for diagnosing MCI in a HF population when compared to the golden standard European Consortium Criteria (ECC). METHODS: Participants were recruited from the Alberta HEART study at the Mazankowski Alberta Heart Institute in Edmonton and St. Mary's hospital in Camrose. This study enrolled 53 community adults aged>50years: 33 HF and 20 controls. Participants were assessed using both the MMSE and MoCA for MCI. MCI was diagnosed using the golden standard, European Consortium Criteria. Sensitivity and specificity analysis, positive and negative predictive values, likelihood ratios and kappa statistic were calculated. RESULTS: The mean age was 72.8years (SD 8.4), 60.4% were females and 34% had underlying ischemic heart disease. Overall, two thirds of patients (22/33, 66%) with HF had MCI. In comparison to European Consortium Criteria, the sensitivity and specificity of MoCA were 82% and 91% in identifying individuals with MCI, and MMSE were 9% and 91%, respectively. The positive and negative predictive values for MoCA were 95% and 71%, and for MMSE were 67% and 33%, respectively. Kappa statistics showed good agreement between MoCA and consortium criteria (kappa=0.68) and a low agreement between MMSE and consortium criteria (kappa=0.07). CONCLUSION: Cognitive dysfunction is common in patients with HF. Overall, the MoCA seems to be a better screening tool than MMSE for MCI in HF patients.

Cognitive decline in heart failure.

Cognitive impairment (CI) is common in older adults with heart failure (HF). The prevalence of CI is higher among patients with HF than in those without. The spectrum of CI in HF is similar to that observed in the general population and may range from delirium to isolated memory or non-memory-related deficits to dementia. Both HF with reduced ejection fraction and HF with preserved ejection fraction have been associated with defects in different domains of cognition. Numerous risk factors have been shown to contribute to CI in HF. Additionally, various pathophysiological mechanisms related to HF can contribute to cognitive decline. These conditions are not routinely screened for in clinical practice settings with HF populations, and guidelines on optimal assessment strategies are lacking. Validated tools and criteria should be used to differentiate acute cognitive decline (delirium) from chronic cognitive decline such as mild cognitive impairment and dementia. CI in HF has been associated with higher rates of disability and impairment in self-care activities that may in turn increase healthcare cost, hospital readmission and mortality. Early detection of CI may improve clinical outcomes in older adults with HF. Appropriate HF management strategies may also help to reduce CI in patients with HF, and future research is needed to develop and test newer and more effective interventions to improve outcomes in patients with HF and CI.