Cardiac rehabilitation and acute aortic dissection: understanding and addressing the evidence GAP a systematic review.

Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO2 max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896.

Lower All-Cause Mortality Risk in Females and Males with Peripheral Artery Disease following Pain-Free Home-Based Exercise: A 7-Year Observational Study.

We evaluated the sex-specific difference in response upon participation in an exercise program with respect to the risk of adverse clinical outcomes among patients with peripheral artery disease (PAD) and claudication. The records of 400 PAD patients were assessed between 2012 and 2015. Two hundred of them were addressed to a walking program prescribed at the hospital and executed at home at symptom-free walking speed (Ex), while the remaining 200 acted as a control group (Co). The number and date of deaths, all-cause hospitalizations, and amputations for a 7-year period were collected from the regional registry. At baseline, no differences were observed (MEXn = 138; FEXn = 62; MCOn = 149; FCOn = 51). The 7-year survival rate was significantly higher in FEX (90%) than in MEX (82% hazard ratio, HR: 0.542 95% CI 0.331-0.885), FCO (45%, HR: 0.164 95% CI 0.088-0.305), and MCO (44%; HR: 0.157 95% CI 0.096-0.256). A significantly lower rate of hospitalization (p < 0.001) and amputations (p = 0.016) was observed for the Ex group compared to the Co group, without differences by sex. In conclusion, in PAD patients, active participation in a home-based pain-free exercise program was associated with a lower rate of death and better long-term clinical outcomes, particularly among women.

Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals?

BACKGROUND: Masked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic. METHODS: Comorbidity was assessed by Charlson comorbidity index (CCI) and CHA2DS2VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA2DS2VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg. RESULTS: We studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA2DS2VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047-3.500]. Logistic regression analysis showed that only CHA2DS2VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161-1.985; P = 0.002), but CCI was not. CONCLUSIONS: ABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.

Do Sex-Related Differences of Comorbidity Burden and/or In-Hospital Mortality Exist in Cancer Patients? A Retrospective Study in an Internal Medicine Setting.

Cancer represents important comorbidity, and data on outcomes are usually derived from selected oncologic units. Our aim was to evaluate possible sex-related differences and factors associated with in-hospital mortality (IHM) in a consecutive cohort of elderly patients with cancer admitted to internal medicine. We included all patients admitted to our department with a diagnosis of cancer during 2018. Based on the International Classification of Diseases, 9th Revision, Clinical Modification, demography, comorbidity burden, and diagnostic procedures were evaluated, with IHM as our outcome. We evaluated 955 subjects with cancer (23.9% of total hospital admissions), 42.9% were males, and the mean age was 76.4 ± 11.4 years. Metastatic cancer was diagnosed in 18.2%. The deceased group had a higher modified Elixhauser Index (17.6 ± 7.7 vs. 14 ± 7.3, p < 0.001), prevalence of cachexia (17.9% vs. 7.2%, p < 0.001), and presence of metastasis (27.8% vs. 16.3%, p = 0.001) than survivors. Females had a higher age (77.4 ± 11.4 vs. 75.5 ± 11.4, p = 0.013), and lower comorbidity (10.2 ± 5.9 vs. 12.0 ± 5.6, p < 0.001) than males. IHM was not significantly different among sex groups, but it was independently associated with cachexia and metastasis only in women. Comorbidities are highly prevalent in patients with cancer admitted to the internal medicine setting and are associated with an increased risk of all-cause mortality, especially in female elderly patients with advanced disease.

Validation and Comparison of a Modified Elixhauser Index for Predicting In-Hospital Mortality in Italian Internal Medicine Wards.

PURPOSE: Burden of comorbidities appears to be related to clinical outcomes in hospitalized patients. Clinical stratification of admitted patients could be obtained calculating a comorbidity score, which represents the simplest way to identify the severity of patients' clinical conditions and a practical approach to assess prevalent comorbidities. Our aim was to validate a modified Elixhauser score for predicting in-hospital mortality (IHM) in internal medicine admissions and to compare it with a different one derived from clinical data previously used in a similar setting, having a good prognostic accuracy. PATIENTS AND METHODS: A single-center retrospective study enrolled all patients admitted to internal medicine department between January and June 2016. A modified Elixhauser score was calculated from chart review and administrative data; moreover, a second prognostic index was calculated from chart review only. Comorbidity scores were compared using c-statistic. RESULTS: We analyzed 1614 individuals without selecting the reason for admission, 224 (13.9%) died during hospital stay. Deceased subjects were older (83.3±9.1 vs 78.4±13.5 years; p<0.001) and had higher burden of comorbidities. The modified Elixhauser score calculated by administrative data and by chart review and the comparator one was 18.13±9.36 vs 24.43±11.27 vs 7.63±3.3, respectively, and the c-statistic was 0.758 (95% CI 0.727-0.790), 0.811 (95% CI 0.782-0.840) and 0.740 (95% CI 0.709-0.771), respectively. CONCLUSION: The new modified Elixhauser score showed a similar performance to a previous clinical prognostic index when it was calculated using administrative data; however, its performance improved if calculation was based on chart review.

Acute Kidney Injury and In-Hospital Mortality: A Retrospective Analysis of a Nationwide Administrative Database of Elderly Subjects in Italy.

BACKGROUND: The aim of this study was to investigate the association between acute kidney injury (AKI) and in-hospital mortality (IHM) in a large nationwide cohort of elderly subjects in Italy. METHODS: We analyzed the hospitalization data of all patients aged ≥65 years, who were discharged with a diagnosis of AKI, which was identified by the presence of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and extracted from the Italian Health Ministry database (January 2000 to December 2015). Data regarding age, gender, dialysis treatment, and comorbidity, including the development of sepsis, were also collected. RESULTS: We evaluated 760,664 hospitalizations, the mean age was 80.5 ± 7.8 years, males represented 52.2% of the population, and 9% underwent dialysis treatment. IHM was 27.7% (210,661 admissions): Deceased patients were more likely to be older, undergoing dialysis treatment, and to be sicker than the survivors. The population was classified on the basis of tertiles of comorbidity score (the first group 7.48 ± 1.99, the second 13.67 ± 2,04, and third 22.12 ± 4.13). IHM was higher in the third tertile, whilst dialysis-dependent AKI was highest in the first. Dialysis-dependent AKI was associated with an odds ratios (OR) of 2.721; 95% confidence interval (CI) 2.676-2.766; p < 0.001, development of sepsis was associated with an OR of 1.990; 95% CI 1.948-2.033; p < 0.001, the second tertile of comorbidity was associated with an OR of 1.750; 95% CI 1.726-1.774; p < 0.001, and the third tertile of comorbidity was associated with an OR of 2.522; 95% CI 2.486-2.559; p < 0.001. CONCLUSIONS: In elderly subjects with AKI discharge codes, IHM is a frequent complication affecting more than a quarter of the investigated population. The increasing burden of comorbidity, dialysis-dependent AKI, and sepsis are the major risk factors.