[Anticoagulation in geriatric patients with atrial fibrillation : With what and for whom no more?] / Antikoagulation bei Vorhofflimmern im Alter : Womit und bei wem nicht mehr?

Based on established risk scores, such as the CHA2DS2-VASc score, the indications for oral anticoagulation are given for patients over 65 years old with atrial fibrillation and even more so for patients over 75 years old. Before beginning anticoagulation a geriatric assessment for evaluation of the cognitive ability, the activities of daily living and the risk of falling should be made because of the known complications of anticoagulation. Geriatric patients with non-valvular atrial fibrillation (AF) are increasingly being treated with non-vitamin K antagonist oral anticoagulants (NOAC) to prevent ischemic stroke. The European Society for Cardiology (ESC) guidelines for the management of AF recommended NOACs as the preferred treatment and vitamin K antagonists (VKA) only as an alternative option. Meanwhile, apixaban, rivaroxaban, and edoxaban as factor Xa inhibitors and dabigatran as a thrombin inhibitor, are more commonly used in clinical practice in patients with AF. Although, these drugs have pharmacodynamics and pharmacokinetic similarities and are often grouped together, it is important to recognize that the pharmacology and dose regimens differ between compounds. Especially in elderly patients the new drugs have interesting advantages compared to VKA, i. e., less drug-drug interactions with concomitant medication and a more favorable risk-benefit ratio mostly driven by the reduction of bleeding. Treatment of anticoagulation in elderly patients requires weighing the serious risk of stroke with an equally high risk of major bleeding and pharmacoeconomic considerations. The easier practicality of NOACs in routine practice must be emphasized as no international normalized ratio (INR) monitoring is necessary and the interruption of treatment for planned interventions is uncomplicated. A regular monitoring of the indications for NOACs is indispensable (as for all other medications). Especially elderly patients have the greatest benefit from NOAC along with a low renal elimination rate and they should certainly not be withheld from elderly patients who have a clear need for oral anticoagulation.

Optimal Stroke Prevention in the Geriatric Patient with Atrial Fibrillation: Position Paper of an Interdisciplinary Expert Panel.

The present position paper summarises the outcomes of an expert panel discussion held by hospital-based and office-based physicians with ample experience in the treatment of geriatric patients. The optimal approach to stroke prevention in geriatric patients with atrial fibrillation (AF) has not been adequately clarified. Despite their high risk of stroke and clear indication for anticoagulation according to established risk scores, in practice geriatric AF patients often are withheld treatment because of comorbidities and comedications, concerns about low treatment adherence or fear of bleeding events, in particular due to falls. The panel agreed that geriatric patients should receive oral anticoagulation as a rule, unless a comprehensive neurological and geriatric assessment (including clinical examination, gait tests and validated instruments such as Modified Rankin Scale, Mini-mental state examination or Timed Test of Money Counting) provides sound reasons for refraining from treatment. All patients with a history of falls should be thoroughly evaluated for further evaluation of the causes. Patients with CHADS2 score ≥ 2 should receive anticoagulation even if at high risk for falls. The novel oral anticoagulants (NOAC) facilitate management in the geriatric population with AF (no INR monitoring needed, easier bridging during interventions) and have, based on available data, an improved benefit-risk ratio compared to vitamin K antagonists. Drugs with predominantly non-renal elimination are safer in geriatric patients and should be preferred.

[Diabetes care and incidence of severe hypoglycemia in nursing home facilities and nursing services: The Heidelberg Diabetes Study]. / Behandlungsqualität des Diabetes mellitus und Inzidenz schwerer Hypoglykämien in stationären und ambulanten Versorgungseinrichtungen: Heidelberger Diabetesstudie.

AIM: The goal of this study was to perform a structured analysis of the treatment quality and acute complications of geriatric patients with diabetes mellitus (DM) cared for by nursing services and nursing home facilities. Secondly, structural problems and potentials for improvement in the care of multimorbid older people with DM treated by nursing homes and nursing services were analysed from the viewpoint of geriatric nurses, managers of nursing homes and general practitioners. METHODS: In all, 77 older persons with DM from 13 nursing homes and 3 nursing services were included in the analysis (76.6% female, HbA1c 6.9 ± 1.4%, age 81.6 ± 9.9 years). Structural problems and potentials for improvement were collected from 95 geriatric nurses, 9 managers of nursing homes and 6 general practitioners using semistandardized questionnaires. RESULTS: Metabolic control was too strict in care-dependent older people with DM (mean HbA1c value: 6.9 ± 1.4 %; recommended by guidelines: 7-8%). The measurement of HbA1c was performed in 16 of 77 people (20.8%) within the last year despite a high visitation frequency of the general practitioners (12.7 ± 7.7 within the last 6 months). The incidence of severe hypoglycemia was 7.8%/patient/year. Regarding the management in case of diabetes-related acute complications 33 geriatric nurses (34.7%) stated not having any written standard (nursing home 39%, geriatric services 16.7%). CONCLUSION: Complex insulin therapies are still used in older people with DM with the consequence of a high incidence of severe hypoglycemia. Concrete management standards in the case of diabetes-related acute complications for geriatric nurses are lacking for more than one third of the nursing services.

[Optimal stroke prevention in the geriatric patient with atrial fibrillation: position paper of an interdisciplinary expert panel]. / Optimale Schlaganfallprävention bei geriatrischen Patienten mit Vorhofflimmern. Konsensbericht eines interdiszipIinären Expertengremiums.

BACKGROUND: The optimal approach to stroke prevention in geriatric patients with atrial fibrillation (AF) has not been adequately clarified. Despite their high risk of stroke and clear indication for anticoagulation according to established risk scores, in practice geriatric AF patients often are withheld treatment because of comorbidities and comedications, concerns about low treatment adherence or fear of bleeding events, in particular due to falls. METHOD: The present position paper summarises the outcomes of an expert panel discussion held by hospital-based and office-based physicians with ample experience in the treatment of geriatric patients. RESULTS AND CONCLUSIONS: The panel agreed that geriatric patients should receive oral anticoagulation as a rule, unless a comprehensive neurological and geriatric assessment (including clinical examination, gait tests and validated instruments such as Modified Rankin Scale, Mini-mental state examination or Timed Test of Money Counting) provides sound reasons for refraining from treatment AII patients with a history of falls should be thoroughly evaluated for further evaluation of the causes. Patients with CHADS2 score ≥ 2 should receive anticoagulation even if at high risk for falls. The novel oral anticoagulants (NOAC) facilitate management in the geriatric population with AF (no INR monitoring needed, easier bridging during interventions) and have an improved benefit-risk ratio compared to vitamin K antagonists. Drugs with predominantly non-renal elimination are safer in geriatric

[Requirements for perioperative intensive care of geriatric patients]. / Besonderheiten der perioperativen Intensivmedizin beim geriatrischen Patienten.

BACKGROUND: Demographic change has also caused changes in perioperative intensive care because the proportion of geriatric patients who must undergo surgical procedures is increasing. With the current preoperative assessment instruments, it is still not possible to identify high-risk patients of this collective or to make a reliable prognosis concerning postoperative course. MATERIALS AND METHODS: In addition to pain control, important aspects to minimize complications in postoperative intensive care include adequate oxygenation, adequate fluid management, an adequate supply of energy and nutrients, good control of blood sugar levels, and early mobilization of patients. RESULTS: The perioperative intensive care treatment of geriatric patients requires the readiness to engage in interdisciplinary collaboration because only with this close dialog can the treatment results be sustained.

Polypharmacy in the elderly from the clinical toxicologist perspective.

INTRODUCTION: Polypharmacy is closely associated with multimorbidity in the elderly and can lead to problems and drug interactions. AIM: This study assessed polypharmacy in the elderly, tracking inquiries to the Poison Information Centre Nuremberg (PICN) and patients needing toxicological intensive care therapy. METHODS: From 2006-2009, all PICN inquiries involving individuals > 70 years were tracked, as were cases at the Toxicological Intensive Care Unit (T-ICU) regarding adverse drug reactions (ADRs) and drug poisoning. RESULTS: Of 11,683 PICN calls about pharmaceuticals, 175 (1.5%) were from people > 70 years; 156 (4.8%) of 3,272 T-ICU patients were > 70 years. Calls about psychopharmaceuticals (46.9%) and analgesics (25.7%) were most frequent. Among the T-ICU patients, psychopharmaceuticals like sedatives and hypnotics were frequently involved (20.5%), as were tricyclic antidepressants (17.9%) and analgesics (29.5%). Ethanol was co-ingested by 18.3%. CONCLUSION: Population-specific poison prevention strategies are needed to reduce toxic exposures. Such strategies could include pharmacist intervention, improved prescriber communication and education regarding the geriatric population, and computerized drug databases.

[Diabetes and dementia]. / Diabetes und Demenz.

Diabetes mellitus is a known risk factor for cognitive dysfunction and dementia. Chronic hyperglycemia, genetic predisposition, arterial hypertension, hyperlipoproteinemia, micro- and macrovascular diseases, and depression play a major role in the development of cognitive dysfunction. Both pathophysiology of diabetes and dementia and the specifics of diabetes therapy in patients with dementia are presented in this review.

[Diabetes and cardiovascular diseases in old age]. / Diabetes und kardiovaskuläre Erkrankungen im Alter.

The treatment of cardiovascular diseases in diabetic geriatric patients needs an individual risk-benefit analysis. The overtreatment of hyperglycemia in the sense of metabolic control that is too tight (HbA(1)c level <6%) may lead to increased mortality. As a rule, the target HbA(1)c level in geriatric patients with diabetes mellitus should be between 7 and 8%.

[Diagnostics of acute myocardial infarction in elderly patients]. / Diagnostik des akuten Myokardinfarkts bei älteren Patienten.

The early diagnosis of an acute myocardial infarction (MI) is improved by the introduction of novel high-sensitivity troponin assays. These assays can measure low level myocardial injury not detectable by standard troponin assays. Especially in older patients who appear to have a higher basal troponin level, the results must always be judged in the context of the medical history, physical examination, electrocardiogram (ECG) and any further findings. Even small increases in high-sensitivity troponin indicate increased risk for death or MI during follow-up. In the case of MI an invasive strategy results in better survival rates compared with conservative therapy but at the expense of an increased risk of bleeding in elderly patients. This article provides an overview on the diagnosis of MI in elderly patients.

Detection of coronary microembolisation by Doppler ultrasound during percutaneous coronary interventions.

OBJECTIVE: To validate an intracoronary Doppler ultrasound device for high intensity transient signals (HITS) detection and to assess the incidence of HITS during percutaneous coronary intervention (PCI). METHODS AND RESULTS: In an in vitro model, particle count and number of HITS detected by an intracoronary 0.014 inch Doppler wire were closely correlated (r = 0.97, p < 0.001). In the clinical study, 32 patients (mean (SD) age 61 (11) years; 23 men, nine women) with coronary artery disease were treated with balloon dilatation and stent implantation for a single vessel stenosis. In these patients HITS were detected during PCI in 84% (27 of 32). Reproducibility (r = 0.99, p < 0.001) and interobserver agreement (r = 0.84, p < 0.001) of HITS counts were significant. The number of HITS after stent implantation was significantly higher than after balloon dilatation (11 (7) v 2 (4), p < 0.001). Postprocedural coronary flow velocity reserve (CFVR) was < 2.0 in 55% (16 of 29) of all patients after balloon dilatation and < 2.0 in 23% (six of 26) after stent implantation. The number of HITS after stent implantation did not differ significantly between patients with CFVR < 2.0 and patients with CFVR > or = 2.0 (12 (8) v 10 (7), not significant). CONCLUSIONS: Embolic particles can be detected as HITS by an intracoronary Doppler ultrasound device. Coronary microembolism is often observed during PCI, especially after stent implantation. However, the incidence of HITS alone does not explain a reduced CFVR after PCI.

Recovery of impaired microvascular function in collateral dependent myocardium after recanalisation of a chronic total coronary occlusion.

OBJECTIVE: To assess the potential for recovery of impaired microvascular function in collateral dependent myocardium after recanalisation of a chronic total coronary occlusion and the determinants of this recovery. PATIENTS AND DESIGN: 120 patients underwent a successful recanalisation of a chronic total coronary occlusion (duration > 2 weeks) and a follow up angiography after a mean (SD) of 5.0 (1.2) months. The coronary flow velocity reserve (CFVR) and the fractional flow reserve were measured after recanalisation and at follow up. Global and regional left ventricular (LV) function were analysed by quantitative angiography. RESULTS: Microvascular dysfunction, defined by a CFVR < 2.0 and a fractional flow reserve > or = 0.75, was observed in 55 (46%) patients after recanalisation. Microvascular function improved during follow up in 24 (20%). The CFVR increased during follow up from 2.01 (0.58) to 2.50 (0.79) (p < 0.001), due to a decrease in basal average peak velocity from 30.7 (14.9) cm/s to 25.5 (13.3) cm/s (p = 0.001). Improved microvascular function was associated with an improved regional LV function, shown by a correlation between increased wall motion severity index and increased CFVR (r = 0.38, p = 0.003). The major determinant of microvascular dysfunction at baseline was the presence of diabetes mellitus (odds ratio 4.3, 95% confidence interval 1.8 to 10.2), which remained so at follow up (odds ratio 4.1, 95% confidence interval 1.3 to 13.4). Improvement of LV function was not impaired by the presence of microvascular dysfunction after recanalisation. CONCLUSIONS: The frequently observed microvascular dysfunction after recanalisation of a chronic total coronary occlusion is a transient phenomenon in most patients and is influenced by the presence of diabetes mellitus. It does not impede the recovery of LV function. Improved regional LV function is associated with improved microvascular function.

[Coronary flow velocity reserve and collateral resistance after recanalization of chronic total coronary occlusions and periprocedural CK and cTNI elevation]. / Koronare Flussreserve und Kollateralwiderstand nach erfolgreicher Rekanalisation chronischer Koronarverschlüsse und periprozedurale CK- und Troponin-I-Erhöhung.

After recanalization and stenting of chronic total coronary occlusions (TCO), a reduced coronary flow velocity reserve (CFVR) and rise in collateral resistance (R(Coll)) is frequently observed. Coronary microembolization may account for these observations. In 86 patients (age 64+/-10 years; 77 men, 9 women) with TCO (duration >4 weeks), PTCA was performed with successful stent implantation in all lesions. Before PTCA, viable myocardium was detected by stress echocardiography or nuclear imaging techniques. By simultaneously measuring coronary Doppler flow velocity and pressure before and after PTCA, CFVR and R(Coll) were calculated. Over a period of 24 hours after intervention, creatine kinase (CK; upper limit of normal [ULN] for women 1.17 micromol/L/s, for men 1.33 micromol/L/s) and cardiac troponin I (cTNI; threshold 0.1 ng/mL) were studied. CFVR was <2 in 48% of all patients. A rise in R(Coll) was observed in 83% of all patients. The incidence of CK and/or cTNI elevation was only observed in 10% of all patients. These patients with CK and/or cTNI elevation did not show a significant difference of CFVR and rise in R(Coll) as compared with patients without CK and cTNI elevation. CFVR or rise in R(Coll) did not correlate with CK elevation. Coronary microembolization is not a likely cause of reduced CFVR and increased R(Coll) after PTCA of TCO. Other factors such as microvascular dysfunction and autoregulatory changes in collateral function may account for these observations.

Altered action of angiotensin II in patients with type 2 diabetes mellitus of recent onset.

OBJECTIVE: Angiotensin II (Ang II) increases insulin sensitivity in healthy volunteers. This effect is thought to be mediated, at least in part, by an increase in skeletal muscle blood flow. In the past it had been documented that some biological actions of Ang II are altered in diabetes. We addressed the issue of whether this is also true for its action on insulin sensitivity. DESIGN AND METHODS: Twelve healthy volunteers (aged 43+/-9 years) and 15 patients with type 2 diabetes mellitus (NIDDM) of recent onset (aged 45+/-9 years) were allocated in random order in a double-blind placebo-controlled design to be administered a sham infusion or an infusion of 2 ng Ang II/kg per min. Insulin-stimulated glucose uptake (the M value) was measured with the euglycaemic clamp technique, leg muscle blood flow (MBF) with plethysmography, blood pressure with a Dinamap device, and glomerular filtration rate and effective renal plasma flow with the steady-state inulin (Cin) and p-aminohippurate (CPAH) clearance methods, respectively. RESULTS: In volunteers the mean M-value after Ang II infusion (10.1+/-1.5 mg/kg per min) was significantly higher (P < 0.01) than that after sham infusion (8.2+/-0.9 mg/kg per min). In contrast, in diabetic patients it was not significantly different with Ang II (6.1+/-1.3 mg/kg per min) and sham infusion (5.5+/-1.2 mg/kg per min). The difference in the mean absolute increase in the M value (deltaM) between groups was significant (P< 0.02). The Ang II-induced increase in MBF under euglycaemic conditions was attenuated in diabetic patients (from 15.0+/-3.5 to 15.5+/-3.9 ml/100 ml per min, NS) compared with volunteers (from 16.8+/-3.3 to 19.1+/-3.7 ml/100 ml per min, P< 0.01). Again, the difference between the mean absolute increases in MBF (deltaMBF) in the groups was significant (P < 0.01). A significant correlation was found between deltaMBF and deltaM (r= 0.62, P<0.01). The absolute acute increase in mean arterial blood pressure with Ang II was similar in diabetic patients and volunteers. Mean Cin, CPAH and fractional sodium excretion values were significantly lower and renal vascular resistances and filtration fractions higher during the Ang II than they were during the placebo clamp period. This was observed in patients as well as in healthy subjects, but the effects of Ang II on renal haemodynamics and sodium handling were more pronounced in diabetic patients. CONCLUSIONS: In patients with NIDDM of recent onset the stimulatory effect of Ang II on insulin sensitivity and on skeletal muscle blood flow is attenuated. In contrast, the effects of Ang II on renal perfusion and sodium handling are more pronounced in patients with NIDDM than they are in healthy subjects.