Comprehensive geriatric assessment and hospital mortality among older adults with decompensated heart failure.

BACKGROUND: The aim of this study is to assess whether a simple comprehensive geriatric assessment (CGA) score predicts hospital mortality among very elderly patients admitted with heart failure (HF). METHODS: This is a prospective follow-up of 581 individuals aged ≥75 years admitted for decompensated HF to an acute geriatric unit from October 2006 to September 2009. A CGA score (range, 0-10) was constructed using baseline individual data on 5 domains: dependence in activities of daily living (Katz index), mobility (qualitative mobility scale), cognition (Mini-Mental State Examination), comorbidity (Charlson index), and number of prescribed medications. RESULTS: Mean age of patients was 85.8 ± 5.8 years, 67% were women, and 75% had preserved ventricular function (ejection fraction >45%). Fifty percent of patients required assistance in ≥1 activities of daily living, 66% had mobility problems, 45% had cognitive impairment, the mean Charlson index was 3.97 ± 3.01, and 36% had >7 medications prescribed. As a result, the mean CGA score was 4.8 ± 2.2. Hospital mortality was 8.2%. In multivariate analysis, variables associated with hospital mortality included New York Heart Association functional class III (odds ratio [OR] 4.1, 95% CI 1.5-10.8), class IV (OR 19.6, 95% CI 6.3-61), pulmonary edema on chest radiography (OR 3.0, 95% CI 1.3-6.6), renal failure (OR 2.8, 95% 1.2-6.2), and the CGA score (OR 1.2, 95% CI 1.02-1.4 for each point of increment). The area under the receiver operating characteristic curve was 0.856 (95% CI 0.790-0.921), and the model classified 93.4% of cases correctly. CONCLUSIONS: In our cohort of very old patients with HF, a simple CGA score predicts hospital mortality.

Housing conditions and mortality in older patients hospitalized for heart failure.

BACKGROUND: Although decent housing is recognized as a prerequisite for good health, very few studies in developed countries have examined the influence of housing characteristics on disease prognosis. This work examined whether housing conditions predict mortality in older adults with heart failure (HF). METHODS: This is a cohort study comprising 433 patients hospitalized for HF-related emergencies in 4 Spanish hospitals between January 1, 2000, and June 30, 2001. At baseline, patients reported whether their homes lacked an elevator (in an apartment building), hot water, heating, an indoor bathroom, a bathtub or shower, individual bedroom, automatic washing machine, and telephone and whether they frequently felt cold. Analyses included all-cause deaths identified prospectively until January 1, 2005. RESULTS: Among study participants, 165 (38.1%) lived in a home without one of the services considered; and 111 (25.6%) lacked ≥2 services. During follow-up, 260 deaths (60%) occurred. After adjustment for the main confounders, mortality was higher in those who lived in homes without an elevator (hazard ratio [HR] 1.39, 95% CI 1.07-1.80) and in those who frequently felt cold (HR 1.39, 95% CI 1.01-1.92). In comparison with living in a home with all the services considered, mortality was higher for persons living in a home lacking 1 service (HR 1.42, 95% CI 1.10-1.93) or ≥2 services (HR 1.94, 95% CI 1.37-2.74). Patients living in homes lacking any of the services more often had poor functional status, higher comorbidity, lower educational level, and less income. CONCLUSION: Poor housing conditions are associated with higher mortality in HF. Patients living in these homes are especially vulnerable because they have poorer clinical situation and lower socioeconomic position.

Mechanisms of the association between depressive symptoms and long-term mortality in heart failure.

BACKGROUND: The long-term prognostic influence of depression on patients hospitalized for heart failure (HF) is unknown. No previous study has examined systematically the mechanisms of the relationship between depression and mortality in HF. METHODS: Prospective study of 433 patients hospitalized for HF-related emergencies in 4 Spanish hospitals. Baseline depressive symptoms were assessed with the 10-item Geriatric Depression Scale (GDS). The association between depressive symptoms and mortality was summarized with hazard ratios (HRs) obtained from Cox regression, with sequential adjustment for possible mechanisms of the association. RESULTS: Of the 433 study participants, 103 (23.8%) had major depression (GDS-10 > or =5) at baseline. During a mean follow-up of 5.7 years, 305 deaths (70%) occurred. Compared with those who were not depressed, subjects with major depression showed higher mortality (age and sex-adjusted HR 1.52, 95% CI 1.15-2.01). Subsequent adjustment for comorbidity reduced the HR to 1.45 (95% CI 1.10-1.93). Additional adjustment for severity of cardiac lesion and for lifestyles, foremost physical inactivity, led to a HR of 1.27 (95% CI 0.95-1.70). After further adjustment for pharmacologic treatment of HF and particularly for disability in instrumental activities of daily living, the HR dropped almost to the null value (HR 1.10, 95% CI 0.82-1.49). CONCLUSIONS: Depressive symptoms in patients hospitalized for HF are associated with higher long-term mortality; this association is largely explained by the frequent comorbidity, physical inactivity, and disability of these patients.

[Characteristics and one-year outcomes in elderly patients hospitalised with heart failure and preserved, mid-range and reduced ejection fraction]. / Características y resultados tras un año en pacientes ancianos ingresados con insuficiencia cardiaca y fracción de eyección reducida, intermedia o conservada.

INTRODUCTION: The latest European Society of Cardiology Heart Failure (HF) guidelines define three types of HF according to the ejection fraction (EF): HF with reduced EF (HFrEF) when EF<40%, HF with mid-range EF (HFmrEF), when EF 40-49%, and HF with preserved EF (HFpEF) when EF≥50%. The objective of this study was to analyse the characteristics and results of elderly patients hospitalised with HF according to the new classification using EF. METHODS: A prospective study was carried out with 531 HF patients aged ≥75 years classified according to EF, and admitted in the geriatric wards of 6 hospitals in Spain. An analysis was performed on the demographic and clinical characteristics, as well as well as the morbidity and mortality at one year of follow-up. RESULTS: As regards EF, 17.1% had HFrEF, 10% had HFmrEF, and 72.9% had HFpEF. Patients with HFmrEF were more similar to those with HFrEF in terms of a younger age, predominance of men, and previous admission due to HF. This was also the case with the use of drugs for neurohormonal blockade. Patients with HFrEF (compared to those with HFmrEF and HFpEF), had higher mortality (35.2%, 24.5%, and 25.6%, respectively), more readmissions for HF (17.6%, 15.1%, and 14.5%, respectively), and more events (61.5%, 45.3%, and 52.5%, respectively), although there were no significant differences. There were also no differences observed in the survival analysis between the EF groups and the time-dependent outcome variables. CONCLUSIONS: In elderly patients hospitalised with HF, those classified as HFmrEF did not show any clear differences with respect to those with HFrEF or HFpEF. There were no differences in terms of morbidity and mortality.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]. / Geriatría transversal. Un reto asistencial para el siglo xxi.

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Impact of anticoagulation in patients with dementia and atrial fibrillation. Results of the CardioCHUVI-FA registry.

INTRODUCTION AND OBJECTIVES: Population aging is associated with an increased prevalence of atrial fibrillation (AF) and dementia. This study aimed to analyze the impact of oral anticoagulation in elderly patients with AF and moderate-severe dementia. METHODS: We conducted a single-center retrospective study analyzing patients aged ≥ 85 years with a diagnosis of AF between 2013 and 2018. The impact of anticoagulation on mortality, embolisms, and bleeding events was assessed by multivariate Cox analysis. In patients with dementia, this analysis was complemented by propensity score matching, depending on whether the patients were prescribed anticoagulant treatment or not. RESULTS: Of the 3549 patients aged ≥ 85 years with AF, 221 had moderate-severe dementia (6.1%), of whom 88 (60.2%) were anticoagulated. During a follow-up of 2.8 ±1.7 years, anticoagulation was associated with lower embolic risk and higher bleeding risk both in patients with dementia (hazard ratio [HR]embolisms, 0.36; 95%CI, 0.15-0.84; HRbleeding, 2.44; 95%CI, 1.04-5.71) and in those without dementia (HRembolisms, 0.58; 95%CI, 0.45-0.74; HRbleeding, 1.55, 95%CI, 1.21-1.98). However, anticoagulation was associated with lower mortality only in patients without dementia (HR, 0.63; 95%CI, 0.53-0.75) and not in those with dementia (adjusted HR, 1.04; 95%CI, 0.63-1.72; P=.541; HR after propensity score matching 0.91, 95%CI, 0.45-1.83; P=.785). CONCLUSIONS: In patients aged ≥ 85 years with moderate-severe dementia and AF, oral anticoagulation was significantly associated with a lower embolic risk and a higher bleeding risk, with no differences in total mortality.

Vitamin K Antagonists and Direct Oral Anticoagulants in Nonagenarian Patients With Atrial Fibrillation.

OBJECTIVES: Nonagenarian patients are underrepresented in clinical trials that have evaluated oral anticoagulation in patients with atrial fibrillation (AF). The aim of this study was to assess the pronostic impact of oral anticoagulation in patients with AF age ≥90 years. DESIGN: Retrospective multicenter study of nonagenarian patients with AF. SETTING AND PARTICIPANTS: A total of 1750 nonagenarian inpatients and outpatients with nonvalvular AF between January 2013 and December 2018 in 3 Spanish health areas were studied. METHODS: Patients were divided into 3 groups based on antithrombotic therapy: nonoral anticoagulants (30.5%), vitamin-K antagonists (VKAs; 28.6%), and direct oral anticoagulants (DOACs; 40.9%). During a mean follow-up of 23.6 ± 6.6 months, efficacy outcomes (death and embolic events) were evaluated using a Cox regression analysis and safety outcomes (bleeding requiring hospitalization) by competing-risk regression. Results were complemented with a propensity score matching analysis. RESULTS: During follow-up, 988 patients died (56.5%), 180 had embolic events (10.3%), and 186 had major bleeding (10.6%). After multivariable adjustment, DOACs were associated with a lower risk of death and embolic events than nonanticoagulation [hazard ratio (HR) 0.75, 95% confidence interval (CI)] 0.61‒0.92), but VKAs were not (HR 0.87, 95% CI 0.72‒1.05). These results were confirmed after propensity score matching analysis. For bleeding, both DOACs and VKAs proved to be associated with a higher risk (HR for DOAC 1.43; 95% CI 0.97‒2.13; HR for VKA 1.94; 95% CI 1.31‒2.88), although findings for DOACs were not statistically significant (P = .074). For intracranial hemorrhage (ICH), only VKAs-not DOACs-presented a higher risk of ICH (HR 4.43; 95% CI 1.48‒13.31). CONCLUSIONS AND IMPLICATIONS: In nonagenarian patients with AF, DOACs led to a reduction in mortality and embolic events in comparison with nonanticoagulation. This reduction was not observed with VKAs. Although both DOACs and VKAs increased the risk of bleeding, only VKAs were associated with higher ICH rates.

Frailty, disability and comorbidity: different domains lead to different effects after surgical aortic valve replacement in elderly patients.

OBJECTIVES: Frailty syndrome predicts adverse outcomes after surgical aortic valve replacement. However, disability or comorbidity is frequently associated with preoperative frailty evaluation. The effects of these domains on early and late outcomes were analysed. METHODS: A prospective study including patients aged ≥75 years with symptomatic severe aortic stenosis who received aortic valve replacement with or without coronary artery bypass grafting was conducted. We used the Cardiovascular Health Study Frailty Phenotype to assess frailty, the Lawton-Brody index to define disability and the Charlson comorbidity index (CCI) to evaluate comorbidity. RESULTS: Frailty was identified in 57 (31%), dependence in 18 (9.9%) and advanced comorbidity (CCI ≥ 4) in 67 (36.6%) of the 183 enrolled patients. Operative mortality (1.6%), transfusion rate and duration of stay increased in patients with CCI ≥4 (P < 0.005). There was a non-significant trend for these adverse outcomes among the frail patients. Follow-up was achieved in all patients (median/interquartile range 869/699-1099 days). Kaplan-Meier univariable analysis showed a reduced survival rate for frail and dependent patients and for those with multiple comorbidities (P < 0.05). According to multivariable analysis, frailty and comorbidity were independent risk factors for 1-year mortality, while disability and comorbidity, but not frailty, were risk factors for 3-year mortality (P < 0.05). CONCLUSIONS: Surgical aortic valve replacement in patients aged ≥75 years is a safe procedure with low mortality rates. Operative outcomes are mainly affected by comorbidities. The main influence of survival occurs throughout the first year, and an improved functional status prevents any progression towards disabilities, which could potentially benefit long-term outcomes. CLINICAL TRIAL REGISTRATION NUMBER: NCT02745314.

Prognosis of Patients With Severe Aortic Stenosis After the Decision to Perform an Intervention.

INTRODUCTION AND OBJECTIVES: Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. METHODS: Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR. RESULTS: Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 ± 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 ± 1.6 for TAVI and 3.5 ± 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95%CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95%CI, 1.5-4.5), reduced mobility (HR, 4.6; 95%CI, 1.7-12.6), and nonintervention (HR, 2.3; 95%CI, 1.02-5.03). CONCLUSIONS: Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention.

Safety of Direct Oral Anticoagulants and Vitamin K Antagonists in Oldest Old Patients: A Prospective Study.

OBJECTIVE: The safety of direct oral anticoagulants (DOACs) in oldest old patients with nonvalvular atrial fibrillation (NVAF) in daily clinical practice has not been systematically assessed. This study examined the safety of DOACs and dicumarol (a vitamin K antagonist) in NVAF geriatric patients. DESIGN: Prospective study from January 2010 through June 2015, with follow-up through January 2016. SETTING: Geriatric medicine department at a tertiary hospital. PARTICIPANTS: A total of 554 outpatients, 75 years or older, diagnosed of NVAF and starting oral anticoagulation. MEASUREMENTS: The main outcome was bleeding, which was classified into major (including those life-threatening) and nonmajor episodes. Statistical analyses were performed with Cox regression. RESULTS: A total of 351 patients received DOACs and 193 dicumarol. Patients on DOACs were older, with more frequent comorbidities, mobility limitation and disability in activities of daily living, as well as higher mortality, than those treated with dicumarol. The incidence of any bleeding was 19.2/100 person-years among patients on DOACs and 13.7/100 person-years on dicumarol; corresponding figures for major bleeding were 5.2 for those on DOACs, and 3.3 for those on dicumarol. In crude analyses, hazard ratios (95% confidence intervals) for any bleeding, and for mayor bleeding in patients on DOACs vs dicumarol were 1.60 (1.04-2.44) and 2.22 (0.88-5.59), respectively. Excess risk of bleeding associated with DOACs vs dicumarol disappeared after adjustment for clinical characteristics, so that corresponding figures were 1.19 (0.68-2.08) and 1.01 (0.35-2.93). Results did not vary across subgroups of high-risk patients. CONCLUSION: In very old patients with NVAF, the higher risk of bleeding associated with DOACs vs dicumarol could be mostly explained by the worse clinical profile of patients receiving DOACs. Risk of bleeding was rather high, and warrants close clinical monitoring.

Health Literacy and Health Outcomes in Very Old Patients With Heart Failure.

INTRODUCTION AND OBJECTIVES: Health literacy (HL) has been associated with lower mortality in heart failure (HF). However, the results of previous studies may not be generalizable because the research was conducted in relatively young and highly-educated patients in United States settings. This study assessed the association of HL with disease knowledge, self-care, and all-cause mortality among very old patients, with a very low educational level. METHODS: This prospective study was performed in 556 patients (mean age, 85 years), with high comorbidity, admitted for HF to the geriatric acute-care unit of 6 hospitals in Spain. About 74% of patients had less than primary education and 71% had preserved systolic function. Health literacy was assessed with the Short Assessment of Health Literacy for Spanish-speaking Adults questionnaire, knowledge of HF with the DeWalt questionnaire, and HF self-care with the European Heart Failure Self-Care Behaviour Scale. RESULTS: Disease knowledge progressively increased with HL; compared with being in the lowest (worse) tertile of HL, the multivariable beta coefficient (95%CI) of the HF knowledge score was 0.60 (0.01-1.19) in the second tertile and 0.87 (0.24-1.50) in the highest tertile, P-trend = .008. However, no association was found between HL and HF self-care. During the 12 months of follow-up, there were 189 deaths. Compared with being in the lowest tertile of HL, the multivariable HR (95%CI) of mortality was 0.84 (0.56-1.27) in the second tertile and 0.99 (0.65-1.51) in the highest tertile, P-trend = .969. CONCLUSIONS: No association was found between HL and 12-month mortality. This could be partly due to the lack of a link between HL and self-care.

Acurate diagnosis of delirium in elderly patients.

PURPOSE OF REVIEW: Delirium remains one of the most common complicating diagnoses in ailing elderly patients and a leading cause of morbidity, decreased quality of life, prolonged hospital stay, institutionalization and mortality. Despite its clinical importance and health-related costs, it often remains unrecognized or misdiagnosed. We evaluate currently available tools for the screening and diagnosis of delirium, their relevance and suitability for use in various clinical settings, as well as interobserver consistency amongst doctors and other nonclinician interviewers. RECENT FINDINGS: Extensive clinical trial evidence has been published recently concerning advances on the three fundamental elements of delirium assessment in elderly people: identification, severity assessment and reporting of existing predisposing and precipitating factors. SUMMARY: Despite advances on the pathophysiology and recognition of delirium, its detection relies on individual clinical expertise, a high index of suspicion and repeated cognitive testing of high-risk patients. Delirium diagnosis remains a clearly underresearched area; particularly, more work is required to adapt cognitive screening tools for use by nonclinicians, to develop cost-effective biochemical and molecular diagnostic techniques and to assess the effects of divulging updated consensus guidelines.

The frailty syndrome is associated with adverse health outcomes in very old patients with stable heart failure: A prospective study in six Spanish hospitals.

BACKGROUND: Most studies on the association between the frailty syndrome and adverse health outcomes in patients with heart failure (HF) have used non-standard definitions of frailty. This study examined the association of frailty, diagnosed by well-accepted criteria, with mortality, readmission and functional decline in very old ambulatory patients with HF. METHODS: Prospective study with 497 patients in six Spanish hospitals and followed up during one year. Mean (SD) age was 85.2 (7.3) years, and 79.3% had LVEF >45%. Frailty was diagnosed as having ≥3 of the 5 Fried criteria. Readmission was defined as a new episode of hospitalisation lasting >24h, and functional decline as an incident limitation in any activity of daily living at the 1-year visit. Statistical analyses were performed with Cox and logistic regression, as appropriate, and adjusted for the main prognostic factors at baseline. RESULTS: At baseline, 57.5% of patients were frail. The adjusted hazard ratio (95% confidence interval) for mortality among frail versus non-frail patients was 1.93 (1.20-3.27). Mortality was higher among patients with low physical activity [1.64 (1.10-2.45)] or exhaustion [1.83 (1.21-2.77)]. Frailty was linked to increased risk of readmission [1.66 (1.17-2.36)] and functional decline [odds ratio 1.67 (1.01-2.79)]. Slow gait speed was related to functional decline [odds ratio 3.59 (1.75-7.34)]. A higher number of frailty criteria was associated with a higher risk of the three study outcomes (P trend<0.01 in each outcome). CONCLUSIONS: Frailty was associated with increased risk of 1-year mortality, hospital readmission and functional decline among older ambulatory patients with HF.

[Prevalence of depression and associated medical and psychosocial factors in elderly hospitalized patients with heart failure in Spain]. / Prevalencia de depresión, y factores biomédicos y psicosociales asociados, en ancianos hospitalizados con insuficiencia cardiaca en España.

INTRODUCTION AND OBJECTIVES: This study provides an estimate of the prevalence of depression, and identifies associated medical and psychosocial factors, in elderly hospitalized patients with heart failure (HF) in Spain. METHODS: The study included 433 patients aged 65 years or more who underwent emergency admission at four Spanish hospitals between January 2000 and June 2001 and who had a primary or secondary diagnosis of HF. Depression was defined as the presence of three or more symptoms on the 10-item Geriatric Depression Scale. RESULTS: In total, 210 (48.5%) study participants presented with depression: 71 men (37.6%) and 139 women (57.0%). Depression was more common in patients with the following characteristics: NYHA functional class III-IV (adjusted odds ratio or aOR=2.00, 95% confidence interval or 95% CI, 1.23-3.24), poor score on the physical domain of the quality-of-life assessment (aOR=3.14; 95% CI, 1.98-4.99), being dependent for one or two basic activities of daily living (BADLs) (aOR=2.52; 95% CI, 1.41-4.51), being dependent for > or =3 BADLs (aOR=2.47; 95% CI, 1.20-5.07), being limited in at least one instrumental activity of daily living (aOR=2.20: 95% CI, 1.28-3.79), previous hospitalization for HF (aOR=1.71; 95% CI, 1.93-5.45), spending more than 2 hours/day alone at home (aOR=3.24; 95% CI, 1.93-5.45), and being dissatisfied with their primary care physician (aOR=1.90; 95% CI, 1.14-3.17). CONCLUSIONS: Depression is very common in elderly hospitalized patients with HF and is associated with several medical and psychosocial factors. The high prevalence of depression, the poorer prognosis for HF in patients with depressive symptoms, and the existence of simple diagnostic tools and effective treatment argue in favor of systematic screening for depression in these patients.

The frailty syndrome and mortality among very old patients with symptomatic severe aortic stenosis under different treatments.

BACKGROUND: The role of frailty as a prognostic factor in non-selected patients with symptomatic severe aortic stenosis (SAS) is still uncertain. This study aims to examine the association between the frailty syndrome and mortality among very old patients with symptomatic SAS, and to assess whether the association varies with the type of SAS treatment. METHODS AND RESULTS: Prospective study of 606 patients aged ≥75years with symptomatic SAS, recruited from February 2010 to January 2015, who were followed up through June 2015. At baseline, frailty was defined as having at least three of the following five criteria: muscle weakness, slow gait speed, low physical activity, exhaustion, and unintentional weight loss. Statistical analyses were performed with multivariate Cox regression. At baseline, 49.3% patients were frail. During a mean follow-up of 98weeks, 35.3% of patients died. The hazard ratio (95% confidence interval) of mortality among frail versus non-frail patients was 1.83 (1.33-2.51). The corresponding results were 1.58 (1.09-2.28) among patients under medical treatment, 3.06 (1.25-7.50) in those with transcatheter aortic valve replacement, and 1.97 (0.83-4.67) in those with surgical aortic valve replacement, p for interaction=0.21. When the frailty criteria were considered separately, mortality was also higher among patients with slow gait speed [1.52 (1.05-2.19)] or low physical activity [1.35 (1.00-1.85)]. CONCLUSIONS: Frailty is associated with increased mortality among patients with symptomatic SAS, and this association does not vary with the type of SAS treatment. Future studies evaluating the benefits of different treatments in SAS patients should account for baseline frailty.

Comparison of 1-Year Outcome in Patients With Severe Aorta Stenosis Treated Conservatively or by Aortic Valve Replacement or by Percutaneous Transcatheter Aortic Valve Implantation (Data from a Multicenter Spanish Registry).

The factors that influence decision making in severe aortic stenosis (AS) are unknown. Our aim was to assess, in patients with severe AS, the determinants of management and prognosis in a multicenter registry that enrolled all consecutive adults with severe AS during a 1-month period. One-year follow-up was obtained in all patients and included vital status and aortic valve intervention (aortic valve replacement [AVR] and transcatheter aortic valve implantation [TAVI]). A total of 726 patients were included, mean age was 77.3 ± 10.6 years, and 377 were women (51.8%). The most common management was conservative therapy in 468 (64.5%) followed by AVR in 199 (27.4%) and TAVI in 59 (8.1%). The strongest association with aortic valve intervention was patient management in a tertiary hospital with cardiac surgery (odds ratio 2.7, 95% confidence interval 1.8 to 4.1, p <0.001). The 2 main reasons to choose conservative management were the absence of significant symptoms (136% to 29.1%) and the presence of co-morbidity (128% to 27.4%). During 1-year follow-up, 132 patients died (18.2%). The main causes of death were heart failure (60% to 45.5%) and noncardiac diseases (46% to 34.9%). One-year survival for patients treated conservatively, with TAVI, and with AVR was 76.3%, 94.9%, and 92.5%, respectively, p <0.001. One-year survival of patients treated conservatively in the absence of significant symptoms was 97.1%. In conclusion, most patients with severe AS are treated conservatively. The outcome in asymptomatic patients managed conservatively was acceptable. Management in tertiary hospitals is associated with valve intervention. One-year survival was similar with both interventional strategies.

Comorbidity and intervention in octogenarians with severe symptomatic aortic stenosis.

BACKGROUND: The benefit from intervention in elderly patients with symptomatic severe aortic stenosis (AS) and high comorbidity is unknown. Our aims were to establish the correlation between the Charlson comorbidity index and the prognosis of octogenarians with symptomatic sever AS and to identify patients who might not benefit from intervention. METHODS: We used the data from PEGASO (Pronóstico de la Estenosis Grave Aórtica Sintomática del Octogenario--Prognosis of symptomatic severe aortic stenosis in octogenarians), a prospective registry that included consecutively 928 patients aged ≥ 80 years with severe symptomatic AS. RESULTS: The mean Charlson comorbidity index was 3.0 ± 1.7, a total of 151 patients (16.3%) presented high comorbidity (index ≥ 5). Median survival was lower for patients with high comorbidity than for those without (16.7 ± 1.2 vs. 26.5 ± 0.6 months, p < 0.001). In patients without high comorbidity planned interventional management was clearly associated with prognosis (log rank p < 0.001), which was not the case in patients with high comorbidity (log rank p > 0.10). In multivariate analysis, the only variables that were independently associated with prognosis were planned medical management and Charlson index. Patients with high comorbidity presented non-cardiac death more frequently than those who had not (28.6% vs. 19.5%, p = 0.008). CONCLUSIONS: One sixth of octogenarians with symptomatic severe AS have very high comorbidity (Charlson index ≥ 5). These patients have a poor prognosis in the short term and do not seem to benefit from interventional treatment.

Comprehensive geriatric assessment and 2-year mortality in elderly patients hospitalized for heart failure.

BACKGROUND: In older adults hospitalized for heart failure, a poor score on a comprehensive geriatric assessment (CGA) is associated with worse prognosis during hospitalization and at 1 month after discharge. However, the association between the CGA score and long-term mortality is uncertain. METHODS AND RESULTS: This is a prospective study of 487 patients aged ≥75 years admitted for decompensated heart failure. At discharge, a CGA score (range, 0-10) was calculated based on limitation in activities of daily living, mobility limitation, comorbidity, cognitive decline, and previous medication use. The analysis of the association between the CGA score and 2-year subsequent mortality was performed with Cox regression and adjusted for the main confounders. A 1-point increase in the CGA score was associated with a 19% higher mortality (hazard ratio, 1.19; 95% confidence interval, 1.11-1.27). Results were similar regardless of age, sex, left ventricular ejection fraction, and the coexistence of atrial fibrillation, ischemic heart disease, or hypertensive cardiopathy. All components of the CGA score showed a consistent association with higher death risk: the hazard ratio (95% confidence interval) of mortality was 1.78 (1.25-2.54) with ≥3 versus 0 limitations in activities of daily living, 1.36 (1.0-1.86) with moderate or severe versus no or mild limitation in mobility, 1.98 (1.29-3.03) with a ≥5 versus ≤1 score on the Charlson index, 2.48 (1.84-3.34) with previous cognitive decline, and 1.77 (0.99-3.18) in those using ≥8 versus ≤3 medications. CONCLUSIONS: The score on a simple CGA is associated with long-term mortality in older patients hospitalized for heart failure.