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1.
Am J Med ; 2020 Oct 24.
Artigo em Inglês | MEDLINE | ID: mdl-33228950

RESUMO

BACKGROUND: Older adult patients with frailty are rarely involved in rehabilitation programs after myocardial infarction. Our aim was to investigate the benefits of exercise intervention in these patients. METHODS: A total of 150 survivors after acute myocardial infarction, ≥70 years and with pre-frailty or frailty (Fried scale ≥1 points), were randomized to control (n = 77) or intervention (n = 73) groups. The intervention consisted of a 3-month exercise program, under physiotherapist supervision, followed by an independent home-based program. The main outcome was frailty (Fried scale) at 3 months and 1 year. Secondary endpoints were clinical events (mortality or any readmission) at 1 year. RESULTS: Mean age was 80 years (range = 70-96). In the intervention group, 44 (60%) out of 73 patients participated in the program and 23 (32%) completed it. Overall, there was a decrease in the Fried score in the intervention group at 3 months, with no effect at 1 year. However, in the intention-to-treat analysis, such change did not achieve statistical significance (P = 0.110). Only treatment comparisons made among the subgroups that participated in (P = 0.033) and completed (P = 0.018) the program achieved statistical significance. There were no differences in clinical events. Worse Fried score trajectory along follow-up increased mortality risk (hazard ratio [HR] = 2.38, 95% confidence interval [CI] 1.24-4.55, P = 0.009) CONCLUSIONS: Recruitment and retention for a physical program in older adult patients with frailty after myocardial infarction was challenging. Frailty status improved in the subgroup that participated in the program, although this benefit was attenuated after shifting to a home-based program. A better frailty trajectory might influence midterm prognosis. (ClinicalTrials.govNCT02715453).

3.
Eur J Intern Med ; 81: 78-82, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32553586

RESUMO

INTRODUCTION: There is scarce information about the clinical profile and prognosis of acute heart failure (AHF) at the extreme ranges of age. We aimed to evaluate the 1-year death (all-cause mortality and HF-death) and HF-rehospitalizations of patients ≥85 years admitted for AHF. METHODS: We prospectively evaluated a cohort of 3054 patients admitted with AHF from 2007 to 2018 in a third-level center. Age was categorized per 10-year categories (<65 years; 65-74 years, 75-84 years, and ≥85 years). The risk of mortality and HF-rehospitalizations across age categories was evaluated with Cox regression analysis and Cox regression adapted for competing events as appropriate. RESULTS: The mean age was 73.6 ± 11.2 years, 48.9% were female, and 52.8% had preserved left ventricular ejection fraction (HFpEF). A total of 414 (13.6%) patients were ≥85 years. Among this group of age, female sex and HFpEF phenotype were more frequent. At 1-year follow-up 667 all-cause deaths (22,1%), 311 HF-deaths (10.1%) and 693 HF-hospitalizations (22,7%) were recorded. After multivariable adjustment, and compared to patients <65 years, a stepwise increased risk of all-cause mortality and HF-death was found for each decade increase in age, especially for patients ≥85 years (HR=3.47; 95% CI: 2.49 - 4.84, p<0.001, HR=3.31; 95% CI: 1.95 - 5.63; p<0.001, respectively). This subgroup of patients also showed an increased risk of HF-rehospitalization (HR=1.58; 95% CI: 1.16 - 2.16, p=0.004). CONCLUSIONS: Super elderly patients admitted with AHF showed a dramatically increased risk of 1-year death. This subset of patients also shown an increased risk of 1-year HF-readmission.

4.
Clin Cardiol ; 43(5): 423-429, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32073676

RESUMO

BACKGROUND: The pathophysiology of heart failure with preserved ejection fraction (HFpEF) is complex and multifactorial. Chronotropic incompetence (ChI) has emerged as a crucial pathophysiological mechanism. Beta-blockers, drugs with negative chronotropic effects, are commonly used in HFpEF, although current evidence does not support its routine use in these patients. HYPOTHESIS: We postulate beta-blockers may have deleterious effects in HFpEF and ChI. This work aims to evaluate the short-term effect of beta-blockers withdrawal on functional capacity assessed by the maximal oxygen uptake (peakVO2) in patients with HFpEF and ChI. METHODS: This is a prospective, crossover, randomized (1:1) and multicenter study. After randomization, the clinical and cardiac rhythm will be continuously registered for 30 days. PeakVO2 is assessed by cardiopulmonary exercise testing (CPET) at 15 and 30 days in both groups. Secondary endpoints include quality of life, cognitive, and safety assessment. Patients with stable HFpEF, functional class New York Heart Association (NYHA) II-III, chronic treatment with beta-blockers, and ChI will be enrolled. A sample size estimation [alfa: 0.05, power: 90%, a 20% loss rate, and delta change of mean peakVO2: +1.2 mL/kg/min (SD ± 2.0)] of 52 patients is necessary to test our hypothesis. RESULTS: Patients started enrolling in October 2018. As January 14th, 2020, 28 patients have been enrolled. It is projected to enroll the last patient at the end of July 2020. CONCLUSIONS: Optimizing therapy that improves functional capacity remains an unmeet priority in HFpEF. Deprescribing beta-blockers in patients with HFpEF and ChI seems a plausible intervention to improve functional capacity. This trial is an attempt towards precision medicine in this complex syndrome. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03871803.

5.
Am J Cardiol ; 125(7): 1033-1038, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-31959430

RESUMO

Low lymphocyte count, as a marker of inflammation and immunosuppression, may be useful for identifying frail patients. In this work, we aimed to evaluate the association between low-relative lymphocyte count (Lymph%) and frailty status in patients >65 years old with acute coronary syndromes (ACS), and whether Lymph% is associated with morbimortality beyond standard prognosticators and frailty. In this prospective observational study, we included 488 hospital survivors of an episode of an ACS >65 years old. Total and differential white blood cells and frailty status were assessed at discharge. Frailty was evaluated using the Fried score at discharge and defined as Fried≥3. The independent association between Lymph% and Fried≥3 was evaluated by multivariate logistic regression analysis. The associations between Lymph% with long-term all-cause mortality and recurrent admission were evaluated with Cox regression and shared frailty regression, respectively. The mean age of the sample was 78 ± 7 years and 41% were females. The median (interquartile range) of the Lymph% was 21% (15 to 27) and 41% showed Fried≥3. In multivariate analysis, Lymph% was inversely related to the odds of frailty with an exponential increase risk from values below 15% (p = 0.001). Likewise, Lymph% was inverse and independently associated with a higher risk of long-term mortality (p = 0.011), recurrent all-cause (p = 0.020), and cardiovascular readmissions (p = 0.024). In conclusion, in patients >65 years with a recent ACS, low Lymph% evaluated at discharge is associated with a higher risk of frailty. Low Lymph% was also associated with a higher risk of long-term mortality and recurrent admissions beyond standard prognosticators and Fried score.


Assuntos
Síndrome Coronariana Aguda/sangue , Fragilidade/sangue , Avaliação Geriátrica/métodos , Síndrome Coronariana Aguda/mortalidade , Idoso , Biomarcadores/sangue , Feminino , Fragilidade/mortalidade , Humanos , Contagem de Linfócitos , Masculino , Prognóstico , Estudos Prospectivos , Fatores de Risco , Espanha/epidemiologia , Taxa de Sobrevida/tendências
6.
Int J Cardiol ; 302: 30-33, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-31924393

RESUMO

BACKGROUND: The potential sex-differential effect of frailty in patients with acute coronary syndromes (ACS) has not been well-evaluated. We sought to examine the sex-differential association between frailty status on long-term mortality in elderly patients with an ACS. METHODS AND RESULTS: This is a prospective observational single-center study that included 488 elderly patients (>65 years) hospitalized for ACS who survived the index hospitalization. Multivariate Cox regression was used to determine the association among the exposures (interaction of sex with Fried score and sex with Fried ≥ 3) and all-cause mortality. The mean age of the sample was 78 ±â€¯7 years; 41% were female and the median Fried score was higher in women [3 (2-3) vs. 2 (1-2) points, p < 0.001]. At a median follow-up of 3.12 years (IQR:1.38-5.13), 182 deaths (37.3%) were registered. The association of Fried ≥ 3 with mortality varied across sex (p-value for interaction = 0.022). In males, Fried ≥ 3 was independently associated with all-cause death (HR = 1.89; CI 95%:1.25-2.85, p = 0.003). However, it showed a neutral effect on women (HR = 0.92; CI 95%:0.57-1.49, p = 0.726). CONCLUSIONS: In this work, we found that the frailty status assessed by Fried score was independently associated with mortality in elderly males but not in females with ACS.

7.
Int J Cardiol ; 290: 15-20, 2019 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-31130280

RESUMO

BACKGROUND: Growth differentiation factor 15 (GDF-15) is a marker of cell senescence. Age is a well-known determinant of GDF-15 levels, yet no study has analyzed the relationship between geriatric conditions and GDF-15. We hypothesize that geriatric conditions reflecting biological age might be stronger determinants of GDF-15 than chronological age in elderly patients with acute coronary syndrome. METHODS: A total of 208 patients (mean age = 78.3 ±â€¯7.0 years) were included. Prior to discharge, a thorough geriatric assessment was performed and GDF-15 measured. Predictors of GDF-15 (transformed by its natural logarithm) were determined with linear regression. Furthermore, Cox regression was used for the analysis of all-cause mortality. The median follow-up was 728 days. RESULTS: Median GDF-15 concentration was 2432 pg/ml. In multivariate analysis, frailty (Fried score, p = 0.001), and comorbidity (Charlson index, p = 0.003) were independent determinants of lnGDF-15 while age was not significant (p = 0.17). Other covariates included in the model were male gender (p = 0.017), diabetes (p = 0.169), Killip class ≥2 (p = 0.046) and glomerular filtration rate (p = 0.001). The Fried score and Charlson index provided significant incremental value in the R2 model (0.362 vs 0.447; p = 0.0001). A total of 66 (32%) patients died. LnGDF-15 was a significant mortality predictor (HR = 1.82, 95% CI 1.12-2.94, p = 0.015) along with the Fried score (p = 0.013) and the Charlson index (p = 0.030). CONCLUSIONS: Geriatric conditions are strong determinants of GDF-15 levels on top of age in acute coronary syndromes. Furthermore, GDF-15 was associated with mortality independently of geriatric status. Geriatric assessment and GDF-15 are complementary tools.


Assuntos
Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico , Avaliação Geriátrica/métodos , Fator 15 de Diferenciação de Crescimento/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Alta do Paciente/tendências
8.
Biomark Med ; 12(9): 987-999, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30043644

RESUMO

AIM: We evaluated the relationship between iron deficiency (ID) and long-term mortality risk in elderly patients with acute coronary syndrome (ACS). METHODS: In this prospective observational study, we included 252 patients older than 65 years with ACS. Transferrin saturation (TSAT) and ferritin were collected before discharge. RESULTS: Mean age, hemoglobin and GRACE score were 78 ± 7 years, 12.4 ± 1.8 g/dl and 138.8 ± 25.3, respectively, 112(44.4%) patients were women, and 151(59.9%) presented ID. During the follow-up, 121 (48%) patients died. Mortality rates among TSAT quartiles were: 2.38, 1.60, 0.90 and 0.95 × 10 person-years for Q1TSAT to Q4TSAT, respectively (p < 0.001) and did not differ across ferritin quartiles (p = 0.601), whereas ID definition was borderline associated (p = 0.060). Adjusted TSAT levels remained inverse, nonlinearly associated with long-term mortality risk (p < 0.001), with an exponential increased-risk from values about 20% and below. CONCLUSION: Lower TSAT levels were independently associated with increased mortality risk in these patients.


Assuntos
Síndrome Coronariana Aguda , Ferritinas/sangue , Ferro/deficiência , Transferrina/metabolismo , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/mortalidade , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Humanos , Estudos Prospectivos , Taxa de Sobrevida
9.
Mayo Clin Proc ; 92(6): 934-939, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28389067

RESUMO

The aim of the present study was to investigate the prognostic value of geriatric conditions beyond age after acute coronary syndrome. This was a prospective cohort design including 342 patients (from October 1, 2010, to February 1, 2012) hospitalized for acute coronary syndrome, older than 65 years, in whom 5 geriatric conditions were evaluated at discharge: frailty (Fried and Green scales), comorbidity (Charlson and simple comorbidity indexes), cognitive impairment (Pfeiffer test), physical disability (Barthel index), and instrumental disability (Lawton-Brody scale). The primary end point was all-cause mortality. The median follow-up for the entire population was 4.7 years (range, 3-2178 days). A total of 156 patients (46%) died. Among the geriatric conditions, frailty (Green score, per point; hazard ratio, 1.11; 95% CI, 1.02-1.20; P=.01) and comorbidity (Charlson index, per point; hazard ratio, 1.18; 95% CI, 1.0-1.40; P=.05) were the independent predictors. The introduction of age in a basic model using well-established prognostic clinical variables resulted in an increase in discrimination accuracy (C-statistic=.716-.744; P=.05), though the addition of frailty and comorbidity provided a nonsignificant further increase (C-statistic=.759; P=.36). Likewise, the addition of age to the clinical model led to a significant risk reclassification (continuous net reclassification improvement, 0.46; 95% CI, 0.21-0.67; and integrated discrimination improvement, 0.04; 95% CI, 0.01-0.09). However, the addition of frailty and comorbidity provided a further significant risk reclassification in comparison to the clinical model with age (continuous net reclassification improvement, 0.40; 95% CI, 0.16-0.65; and integrated discrimination improvement, 0.04; 95% CI, 0.01-0.10). In conclusion, frailty and comorbidity are mortality predictors that significantly reclassify risk beyond age after acute coronary syndrome.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Idoso Fragilizado/estatística & dados numéricos , Avaliação Geriátrica/métodos , Atividades Cotidianas , Síndrome Coronariana Aguda/mortalidade , Fatores Etários , Idoso , Disfunção Cognitiva , Comorbidade/tendências , Pessoas com Deficiência , Humanos , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Prognóstico , Estudos Prospectivos , Fatores de Risco
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