Sex-related difference in long-term mortality in elderly heart failure patients with preserved left ventricular systolic function.
Explore the source record for details and available documents.
Aged↗
Biomedical subjects
Ali Ahmed
Publications and source records attributed to Ali Ahmed.
Heart failure mortality among older Medicare beneficiaries: association with left ventricular function evaluation and angiotensin-converting enzyme inhibitor use.
BACKGROUND: Left ventricular function evaluation and angiotensin-converting enzyme (ACE) inhibitor use are the two basic indicators of heart failure quality of care. In this retrospective follow-up study, we analyzed the association between these two quality indicators and mortality in elderly hospitalized heart failure patients. METHODS: The patients in our study were older Alabama Medicare beneficiaries discharged with a diagnosis of heart failure in 1994. Cox regression analyses, adjusted for various patient and care characteristics, were performed to estimate the overall mortality rate. RESULTS: The mean age of the 1,090 patients in our study was 79+/-7.5 years. Both left ventricular function evaluation (hazard ratio, 0.83; 95% confidence interval, 0.705-0.976) and ACE inhibitor use (hazard ratio, 0.77; 95% confidence interval, 0.655-0.905) were associated with a lower 3-year mortality rate. Adjustment for various patient and care characteristics did not alter these associations. CONCLUSION: Left ventricular function evaluation and ACE inhibitor use were each associated with increased survival time in older Medicare beneficiaries with heart failure.
Age Factors↗
Interaction between aspirin and angiotensin-converting enzyme inhibitors: should they be used together in older adults with heart failure?
PURPOSE: To determine whether the prostacyclin-inhibiting properties of aspirin counteracts the bradykinin-induced prostacyclin-stimulating effects of angiotensin-converting enzyme (ACE) inhibitors, thereby attenuating the beneficial effects of ACE inhibitors in heart failure patients. BACKGROUND: Most heart failure patients are older adults. Heart failure is the number one hospital discharge diagnosis of older Americans. The renin-angiotensin system plays a major role in the pathophysiology of heart failure, and ACE inhibitors play a pivotal role in the management of heart failure. Large-scale double-blind randomized trials have demonstrated the survival benefits of using ACE inhibitors in patients with heart failure associated with left ventricular systolic dysfunction. In addition to inhibiting the conversion of angiotensin I to angiotensin II, ACE inhibitors also decrease the breakdown of bradykinin. Bradykinin, a potent vasodilator, acts by stimulating formation of vasodilatory prostaglandins such as prostacyclin, whereas aspirin or acetyl salicylic acid inhibits the enzyme cyclooxygenase, which in turn decreases the production of the prostaglandins. Coronary artery disease and hypertension are the two major underlying causes of heart failure. Most heart failure patients are also on aspirin. There is evidence that aspirin at a daily dose of 80 to 100 mg prevents the synthesis of thromboxane A2 by platelets while relatively sparing the synthesis of prostacyclin in the vascular endothelium. Aspirin at a daily dose of 325 mg has significant inhibitory effects on the vasodilatory prostacyclin synthesis. Studies have demonstrated that, in heart failure patients, low-dose aspirin has no adverse effect on hemodynamic, neurohumoral, or renal functions. Whether the prostacyclin-inhibiting effects of aspirin attenuate some of the beneficial effects of ACE inhibitors mediated by prostacyclin stimulation in heart failure patients is currently unknown. METHODS: Data from large clinical trials investigating the interaction between aspirin and ACE inhibitors were analyzed to determine the effect of aspirin on the vasodilatory actions of ACE inhibitors in heart failure patients, and the results were analyzed on the basis of theoretical and laboratory findings. The studies included are the Studies of Left Ventricular Dysfunction (SOLVD) (N=6,797), the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II) (N=6,090), the Captopril and Thrombolysis Study (CATS) (N=296), and another study involving 317 subjects. The data from these clinical trials investigating the interaction between aspirin and ACE inhibitors included 13,470 subjects. Most of the subjects received aspirin. In the SOLVD study, subjects received aspirin or dipyridamole. Subjects were followed up for an average of about 6 years. RESULTS: In the SOLVD study, subjects were followed up for 41.1 months in the treatment trial and 37.4 months in the prevention trial. Patients who received aspirin or dipyridamole at baseline did not receive the survival benefits of enalapril, whereas patients who received enalapril did not receive the survival benefits of aspirin. In a rather small study of 317 subjects with left ventricular systolic dysfunction (ejection fraction <35%) who were followed up for a relatively longer period of time (5.7 years), the favorable long-term prognosis of patients receiving aspirin was independent of receipt of an ACE inhibitor. A retrospective subgroup analysis of data from the CONSENSUS II study demonstrated that the 6-month mortality rate of patients with acute myocardial infarction (MI) who received enalapril and aspirin was higher than the combined mortality rates of patients receiving enalapril or aspirin alone. This strong interaction between aspirin and the ACE inhibitor enalapril suggests that the survival benefit of enalapril was significantly lower in patients also taking aspirin than in those taking enalapril alone. This interaction was not associated with other nonfatal major events. In the CATS study, use of low-dose aspirin (80 or 100 mg) did not attenuate beneficial effects of captopril (immediate and 1-year follow up) after acute MI. CONCLUSION: There is a theoretical possibility that the negative interaction between ACE inhibitors and aspirin may reduce the beneficial effects of ACE inhibitors in patients with heart failure, but the information obtained from the existing databases is limited by the retrospective nature of the analyses and does not establish the association definitively. Double-blind randomized controlled trials should be conducted to determine whether such a negative interaction indeed exists.
Angiotensin-Converting Enzyme Inhibitors↗
Use of angiotensin-converting enzyme inhibitors in patients with heart failure and renal insufficiency: how concerned should we be by the rise in serum creatinine?
PURPOSE: To determine the association between the early rise in serum creatinine levels associated with the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and the long-term renoprotective properties of these drugs in patients with chronic renal insufficiency. BACKGROUND: Large-scale clinical trials have demonstrated survival benefits of ACE inhibitors in patients with heart failure. In patients with renal insufficiency, whether associated with diabetes mellitus or not, use of ACE inhibitors is associated with slowing in the progression of renal disease. In fact, patients who have the most advanced renal insufficiency at baseline are the ones who show the maximum slowing of the disease progression, but these patients are also more likely to show an early rise in serum creatinine levels after ACE inhibitor therapy. There is evidence that patients with renal insufficiency often do not receive ACE inhibitors. There is also evidence that patients with heart failure are not receiving this life-saving drug or are receiving it at dosages lower than that used in the clinical trials. One of the main reasons for this underutilization of ACE inhibitors in patients with heart failure is the underlying renal insufficiency or the rise in serum creatinine level after initiation of therapy with an ACE inhibitor. METHODS: The authors reviewed 12 randomized clinical trials of ACE inhibitor or ARB therapy in patients with preexisting chronic renal insufficiency, with or without diabetes mellitus or heart failure. Studies were included for review if they met the following criteria: subjects were randomized to receive ACE inhibitor; subjects were followed up for a minimum of 2 years; and most of the subjects had baseline chronic renal insufficiency (>or=25% loss of renal function), irrespective of cause. Of the 12 studies that met these criteria, six were multicenter double-blind placebo-controlled studies. The other six were smaller randomized studies. The studies had a mean +/- standard deviation follow-up of 3.2 +/- 0.3 years. One thousand one hundred two patients were randomized to receive ACE inhibitors or ARBs. Of these, 705 (64%) had data on renal function at baseline (within 6 months of the start) and at the end of the study. The authors examined the changes in serum creatinine levels or glomerular filtration rates (GFR) in patients who were randomized to receive ACE inhibitors. The authors also assessed the blood pressures achieved in the trials. RESULTS: Patients with preexisting chronic renal insufficiency who achieved their blood pressure control goals were likely to demonstrate an early rise in serum creatinine levels, approximately 25% above the baseline (approximately 1.7 mg/dL) after initiation of ACE inhibitor or ARB therapy. This rise in serum creatinine was more acute (by approximately 15% from the baseline) during the first 2 weeks of therapy and was more gradual (additional approximately 10%) during the third and fourth weeks of therapy (Figure 1). The serum creatinine level was likely to stabilize after about 4 weeks, provided patients had a normal salt and fluid intake. In addition, patients who did not show a rise in serum creatinine level during the first 2 to 4 weeks of therapy, were less likely to experience one after that period, unless they were dehydrated from use of diuretics or gastroenteritis or had used a nonsteroidal antiinflammatory drug (NSAID). In spite of this early rise in serum creatinine in patients with chronic renal insufficiency (a serum creatinine level of >or=124 micromol/L or >or=1.4 mg/dL) who were randomized to receive an ACE inhibitor, these patients receiving the drug showed a 55% to 75% lower risk of worsening renal function than those with normal renal function receiving the drug. The rate of risk reduction was inversely related to the severity of renal impairment at baseline, but data were limited on the benefit of ACE inhibitors in patients with more advanced renal insufficiency (GFR <30 mL/min). The authors noted that those aged 65 and older were likely to have much lower GFRs for given levels of serum creatinine than younger patients and were therefore likely to have advanced renal insufficiency at serum creatinine levels as low as 2 mg/dL (vs 4 mg/dL for younger patients). Patients with normal renal function were likely to show a much smaller rise in serum creatinine level (approximately 10% above the baseline of 0.9 mg/dL), mostly occurring during the first week after initiation of therapy, with subsequent stabilization, whereas patients with normal renal function suffering from heart failure, volume depletion, or bilateral renal artery stenosis experienced a significant rise (approximately 225% above baseline) in serum creatinine level, much higher in magnitude and rate than that experienced by those with renal insufficiency (Figure 1). Serum creatinine levels in these patients sharply increased (by approximately 75% above baseline) in the 2 weeks after the initiation of therapy with an ACE inhibitor, followed by an even sharper increase (another approximately 150%) during the subsequent 2 weeks. Patients with chronic renal insufficiency (serum creatinine>1.5 mg/dL) who received therapy with ACE inhibitors had about a five times higher risk of developing hyperkalemia than those with normal renal function, whereas presence of heart failure increased the risk of hyperkalemia by about three times over those without heart failure. Concomitant use of diuretics was associated with an approximately 60% reduction in risk of hyperkalemia. CONCLUSION: The authors conclude that, in patients with renal insufficiency (serum creatinine>1.4 mg/dL) treated with ACE inhibitors, there is a strong association between early (within the first 2 months) and moderate (not exceeding 30% over baseline) rise in serum creatinine and slowing of the renal disease progression in the long run. The authors recommend that ACE inhibitor therapy should not be discontinued unless serum creatinine level rise above 30% over baseline during the first 2 months after initiation of therapy or hyperkalemia (serum potassium level >or=5.6 mmol/L) develops.
Angiotensin-Converting Enzyme Inhibitors↗
Neutropenia associated with mirtazapine use: is a drop in the neutrophil count in a symptomatic older adults a cause for concern?
Explore the source record for details and available documents.
Aged↗
Quality and outcomes of heart failure care in older adults: role of multidisciplinary disease-management programs.
PURPOSE: To determine whether the management of heart failure by specialized multidisciplinary heart failure disease-management programs was associated with improved outcomes. BACKGROUND: The advent of angiotensin-converting enzyme inhibitors, beta-blockers, and spironolactone has revolutionized the management of heart failure. Randomized double-blind studies have demonstrated survival benefits of these drugs in heart failure patients. Nevertheless, in spite of these advances, heart failure continues to be a syndrome of poor outcomes.1-4 There is also evidence that a significant portion of heart failure patients does not receive this evidence-based therapy that reduces morbidity and mortality.5-7 Various disease-management programs have been proposed and tested to improve the quality of heart failure care. Most of these programs are specialized multidisciplinary heart failure clinics lead by cardiologists or heart failure specialists and conducted by nurses or nurse practitioners. Similar to the Department of Veterans Affairs (VA) multidisciplinary geriatric assessment clinics, these clinics also use many other services, including pharmacists, dietitians, physical therapists, and social workers. Some of these programs also have an affiliated home health service. Several observation studies, using mostly pre- and postcomparison designs, have demonstrated the effectiveness of these programs in the process of care, resource use, healthcare costs, and clinical outcomes in patients with heart failure.8 Risk of hospitalization was reduced by 50% to 85% in six of the studies.8 Subsequently, several randomized trials were conducted to determine the effectiveness of these programs. The purpose of this systematic review was to determine the effectiveness of these programs on mortality and hospitalization rates of heart failure patients. METHODS: Published articles on human randomized trials involving specialized heart failure disease-management programs in all languages were searched using Medline from 1966 to 1999 and other online databases using the following terms and Medical Subject Headings: case management (exp); comprehensive health care (exp); disease management (exp); health services research (exp); home care services (exp); clinical protocols (exp); patient care planning (exp); quality of health care (exp); nurse led clinics; special clinics; and heart failure, congestive (exp). In addition, a manual search of the bibliographies of searched articles was performed to identify articles otherwise missed in the above search. Personal communications were made with three authors to obtain further data on their studies. Using a data abstraction tool, two of the investigators separately abstracted data from the selected articles. Data from the selected studies were combined using the DerSimonian and Laird random effects model and the Mantel-Haenszel-Peto fixed effects model. Meta-Analyst 0.998 software (J. Lau, New England Medical Center, Boston, MA) was used to determine risk ratios (RRs) with 95% confidence intervals (CIs) of mortality and hospitalization for patients receiving care through these specialized programs compared with those receiving usual care. The Cochran Q test was used to test heterogeneity among the studies, and sensitivity analyses were performed to examine the effect of various covariates, such as duration of intervention, and other characteristics of the disease-management programs. RESULTS: The original search resulted in 416 published articles, of which 35 met preliminary selection criteria. Of these, 11 were randomized trials and were selected for the meta-analysis. Studies that were not randomized trials, did not involve heart failure patients or disease-management programs, or had missing outcomes were excluded. Of the 11 studies selected, nine involved specialized follow-up using multidisciplinary teams and the remaining two involved follow-up by primary care physicians and telephone. These studies involved 1,937 heart failure patients with a mean age of 74. The follow-up period ranged from no follorom no follow-up (one study) to 1 year (one study). Patients receiving care from specialized heart failure disease-management programs had a 13% lower risk of hospitalization than those receiving usual care (summary RR = 0.87; 95% CI = 0.79 -0.96), but the Cochran Q test demonstrated significant heterogeneity among the studies (P =.003). Subgroup analysis of the nine studies using specialized follow-up by a multidisciplinary team showed similar results (summary RR = 0.77, 95% CI = 0.68-0.86; test of heterogeneity, P>.50). Seven of the nine studies did not show any significant association between intervention and reduced hospitalization, but the two studies that used follow up by primary care physicians and telephone failed to show any significant reduction in hospitalization (summary RR = 0.94, 95% CI = 0.75-1.19). In fact, one of the studies demonstrated a higher risk of hospitalization for patients receiving intervention (RR = 1.26, 95% CI = 1.04-1.52). Of the 11 studies, only six reported mortality as an outcome. None of these studies found any association between intervention and mortality (summary RR = 1.15, 95% CI = 0.96-1.37; test of heterogeneity, P>.15). Five of the studies used quality of life or functional status as outcomes, and, of them, only one demonstrated significant positive association. The results of the sensitivity analyses were negative for any significant association with duration of intervention or follow-up or year of study. Eight studies performed cost analyses and seven demonstrated cost-effectiveness of the intervention. CONCLUSIONS: The authors concluded that specialized disease-management programs were cost-effective, and heart failure patients cared for by these programs were more likely to undergo fewer hospitalizations, but the study did not provide any conclusive association between these programs and quality of care or mortality. The authors recommend that disease-management programs involve patient education and specialized follow-up by a multidisciplinary team including home health care.
Comment↗
Survival benefits of angiotensin-converting enzyme inhibitors in older heart failure patients with perceived contraindications.
OBJECTIVES: To determine the association between angiotensin-converting enzyme (ACE) inhibitor therapy and survival of older heart failure patients with conditions perceived by physicians as contraindications to ACE inhibitors. SETTING: Hospital. DESIGN: Retrospective follow-up study. PARTICIPANTS: Hospitalized older heart failure patients with systolic blood pressure of 90 mmHg or less, serum creatinine of 2.5 mg/dL or more, serum potassium of 5.5 mmol/L or more, or severe aortic stenosis. MEASUREMENTS: One-year postdischarge mortality (with and without adjustment for various patient and care characteristics). Logistic regression analyses were used to estimate the effect of the perceived contraindications on subsequent use of ACE inhibitors. Using Cox proportional hazards models, crude and adjusted hazard ratios (HRs) of 1-year mortality with 95% confidence intervals (CIs) were estimated for patients discharged on ACE inhibitors and compared with those without. HRs were estimated for all patients and were repeated after stratifying patients based on the presence of perceived contraindications to ACE inhibitor use. RESULTS: Of the 295 subjects, 52 (18%) had conditions perceived as contraindications, 186 (63%) received ACE inhibitors, and 107 (40%) died within 1 year of discharge. Presence of a perceived contraindication was independently associated with underutilization of ACE inhibitors on discharge (adjusted OR = 0.35, 95% CI = 0.17-0.71). ACE inhibitor prescription at discharge was associated with lower 1-year mortality overall (HR = 0.58, 95% CI = 0.40-0.85) and for the groups of patients with (HR = 0.34, 95% CI = 0.14-0.81) and without (HR = 0.66, 95% CI = 0.42-1.02) perceived contraindications. CONCLUSIONS: ACE inhibitor use was associated with a significant survival benefit in this cohort of hospitalized older heart failure patients with perceived contraindications.
Aged↗
Quality of care of nursing home residents hospitalized with heart failure.
OBJECTIVES: To determine whether the quality of heart failure (HF) care of hospitalized nursing home (NH) residents is different from that of patients admitted from other locations. DESIGN: Retrospective chart review. SETTING: Nursing home residents discharged from hospitals. PARTICIPANTS: Medicare beneficiaries aged 65 and older. MEASUREMENTS: Subjects were discharged with a primary discharge diagnosis of HF in Alabama in 1994. They were categorized as having been admitted from a NH or other locations. Bivariate logistic regression analysis was used to estimate crude odds ratios (ORs) and 95% confidence intervals (CIs) for left ventricular function (LVF) evaluation and angiotensin-converting enzyme (ACE) inhibitor use for NH residents relative to nonresidents. Multivariate generalized linear models were developed to determine independence of associations. RESULTS: Subjects (N = 1,067 years) had a mean age +/- standard deviation of 79 +/- 7.4, 60% were female, and 18% were African Americans. Fewer NH residents (n = 95) received LVF evaluation (39% vs 60%, P <.001) and ACE inhibitors (50% vs 72%, P =.111). NH residents had lower odds for LVF evaluation (OR = 0.42, 95% CI = 0.27-0.64). The odds for ACE inhibitor use, although of similar magnitude, did not reach statistical significance (OR = 0.40, 95% CI = 0.12-1.28). After adjustment of patient and care characteristics, admission from a NH was significantly associated with lower LVF evaluation (adjusted OR = 0.64, 95% CI = 0.49-0.82) but not with ACE inhibitor use (adjusted OR = 0.59, 95% CI = 0.16-2.14). CONCLUSIONS: Quality of HF care received by hospitalized NH residents was lower than that received by others. Further studies are needed to determine reasons for the lack of appropriate evaluation and treatment of NH patients with HF who are admitted to hospitals.
Age Factors↗
Correlates and outcomes of preserved left ventricular systolic function among older adults hospitalized with heart failure.
BACKGROUND: Heart failure (HF) in older adults is often associated with preserved left ventricular systolic function (LVSF). The objective of this retrospective follow-up study was to determine the correlates and outcomes of preserved LVSF among older adults hospitalized with HF. METHODS: We studied older Medicare beneficiaries hospitalized with HF (n = 1091) who had documented LVSF evaluation (n = 438). LVSF was defined as preserved if left ventricular ejection fraction was > or =40%. The Fisher exact test and the Student t test were used to compare baseline characteristics between patients with preserved versus those with impaired LVSF. Multivariate logistic regression analysis was used to determine the correlates of preserved LVSF. Cox proportional hazards analyses were used to determine the associations between LVSF and both 4-year mortality rates and 6-month readmission rates and the associations between angiotensin-converting enzyme (ACE) inhibitor use and 4-year mortality rates, separately, in patients with preserved and impaired LVSF. RESULTS: Of the 438 patients, 200 (46%) had preserved LVSF. Women were more likely to have preserved LVSF (odds ratio [OR] = 2.44, 95% CI 1.57-3.81) than men. Preserved LVSF was associated with lower 4-year mortality rates (adjusted hazards ratio [HR] = 0.67, 95% CI 0.52-0.86) but not with 6-month readmission rates (adjusted HR = 0.66, 95% CI 0.41-1.09). The use of ACE inhibitors was associated with lower 4-year mortality rates in patients with impaired LVSF (adjusted HR = 0.61, 95% CI 0.43-0.86) but not in those with preserved LVSF (HR = 0.96, 95% CI 0.65-1.42). CONCLUSIONS: Among older adults hospitalized with HF, preserved LVSF was common among women and was associated with significantly higher morbidity and mortality rates, which were unaffected by treatment with ACE inhibitors.
Aged↗
Inappropriate use of digoxin in older hospitalized heart failure patients.
BACKGROUND: Older adults are more likely to suffer from the adverse effects of digoxin. Studies have described the inappropriate use of digoxin in various populations. The objective of this study was to determine the correlates of inappropriate digoxin use in older heart failure patients. METHODS: We studied older hospitalized heart failure patients with documented left ventricular (LV) function evaluation and electrocardiography. Digoxin use was considered inappropriate if patients had preserved LV systolic function (ejection fraction greater > or =40%) or if they had no atrial fibrillation (AF). We compared baseline patient characteristics by indication for digoxin and tested statistical significance using Pearson's chi-square analysis and Student's t tests. Using logistic regression, we determined the correlates of inappropriate use and initiation of digoxin. RESULTS: Subjects (N = 603) had a mean age of 79 (+/-7) years; 59% were women, and 18% were African American. A total of 376 patients (62%) were discharged on digoxin, and 223 (37%) had no indication for its use. Half of the patients without an indication for digoxin received the drug. Of 132 patients without an indication and not already on digoxin, 38 (29%) were initiated on it. After adjustment for various patient and care characteristics, prior digoxin use (adjusted odds ratio [OR] 11.47, 95% confidence interval [CI] 5.72-23.02) and pulse > or =100/min (adjusted OR 2.33, 95% CI 1.10-4.94) were associated with inappropriate digoxin use. Pulse > or =100/min was also associated with inappropriate initiation of the drug (adjusted OR 2.95, 95% CI 1.28-6.78). CONCLUSIONS: Inappropriate use of digoxin was common and was associated with prior use. Tachycardia was associated with inappropriate use and initiation. Electrocardiography and echocardiography should be performed in all older heart failure patients. Digoxin therapy should not be initiated or continued in patients without any evidence of LV systolic dysfunction or chronic AF.
Aged↗
Age-related underutilization of left ventricular function evaluation in older heart failure patients.
BACKGROUND: Underutilization of left ventricular function (LVF) evaluation in older patients with heart failure has been well documented, but age-related variation in the use of LVF evaluation has not been. METHODS: We studied age-related variation of LVF evaluation in older Medicare-beneficiaries discharged with a diagnosis of heart failure in 1994 in Alabama. RESULTS: A total of 1,090 patients had a mean +/- SD age of 79 +/- 7.5 years; 60% were female and 18% were African American. Of these, 636 (58%) had LVF evaluation. Compared with patients aged 65 to 74 years, those 75 to 84 years of age and those aged 85 and older were less likely to receive LVF evaluation. Age of 85 years and older was also independently associated with lower odds of LTF evaluation. CONCLUSION: The overall rate of LVF evaluation was low, and performance of evaluation decreased with patient age. Left ventricular function evaluation should be performed in all patients with heart failure. Considerable opportunities exist for improving care among hospitalized Medicare beneficiaries diagnosed with heart failure.
Age Factors↗
Age-related underutilization of angiotensin-converting enzyme inhibitors in older hospitalized heart failure patients.
BACKGROUND: The extent to which age plays a role in the underutilization of angiotensin-converting enzyme (ACE) inhibitors in heart failure patients has not been well studied. METHODS: We studied age-related variation in the use of ACE inhibitors in older Medicare beneficiaries discharged alive in Alabama with a diagnosis of heart failure with left ventricular systolic dysfunction. RESULTS: A total of 285 patients had a mean age +/- SD of 78 +/- 6.9 years; 59% were female and 21% were African American. Of the 285 patients, 181 (63%) were prescribed ACE inhibitors at discharge. Therapy with ACE inhibitors was initiated in 47% of the patients. Compared with patients 65 to 74 years, those 85 years and older had lower odds of receiving ACE inhibitors at discharge. Among patients not admitted on an ACE inhibitor, those 85 years and older also had lower odds of ACE inhibitor therapy being initiated. CONCLUSION: The overall rate of ACE inhibitor use was low, and age of 85 years and older was independently associated with lower use and initiation of ACE inhibitors. Opportunities remain to increase the use of ACE inhibitors in older patients with heart failure.
Age Factors↗
Diagnosis of heart failure in older adults: predictive value of dyspnea at rest.
The objective of this study was to describe the predictive value of dyspnea at rest in the diagnosis of heart failure in older adults. We have conducted a retrospective chart review of older adults hospitalized with heart failure in 11 hospitals in Alabama, US. We defined dyspnea at rest as dyspnea not accompanied by activities, sleep, or lying down. We confirmed diagnosis of heart failure using modified Framingham criteria (based on available variables). We estimated values for sensitivity, specificity, predictive value positive and likelihood ratio positive of dyspnea at rest along with their 95% confidence intervals (95% CI). Patients had a mean (+/-S.D.) age 79 (+/-7.5) years, were 60% female and 18% African-American. The prevalence (pre-test probability) of heart failure was 77%. Dyspnea at rest was reported by 975 (89%) patients. Dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea were, respectively, reported by 279 (26%), 356 (33%) and 230 (21%) patients. The sensitivity, specificity and positive predictive value (post-test probability) of dyspnea at rest were, respectively, 92% (95% CI = 90 - 94%), 19% (95% CI = 14 - 24%) and 79% (95% CI = 77 - 82%). Patients with dyspnea at rest were 13% (likelihood = 1.13; 95% CI = 1.06 - 1.20) more likely to have heart failure than those without. Presence of any three of the symptoms of dyspnea at rest, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue and lower extremity edema increased the positive predictive value to 90% (95% CI = 87 - 93%). Dyspnea at rest was the commonest symptom among elderly hospitalized HF patients and had high sensitivity, but low specificity and positive predictive value, which increased in the presence of other symptoms.
Aged↗
Predictors of nursing home admission for older adults hospitalized with heart failure.
The objective of this retrospective chart review study was to determine the prevalence and predictors of nursing home admission of older hospitalized heart failure patients. Subjects were Medicare beneficiaries discharged with a principal diagnosis of heart failure in 1994 in the state of Alabama, United States. The outcome variable was admission to a nursing home after hospital discharge. Using multivariable logistic regression analyses we determined patient and care variables independently associated with admission to a nursing home. Patients (n = 985) had a mean (+/- S.D.) age of 79 (+/- 7.5) years, 61% were female and 18% African-American. Eighty-three (8%) patients were admitted to a nursing home. Over 80% of those admitted to a nursing home had prior nursing home residence. After adjustment for various demographic, clinical and care variables, age (adjusted odds ratio [OR] = 1.14; 95% confidence interval [95%CI] = 1.06-1.23), pre-admission residence in a nursing home (adjusted OR = 1422; 95%CI = 341-5923), and length of hospital stay (adjusted OR = 1.11; 95%CI = 1.02-1.20) were independently associated with admission to a nursing home. Among patients with no prior nursing home residency (n = 908), 15 (2%) patients were newly admitted to a nursing home upon discharge. In addition to age and length of stay, diabetes (adjusted OR = 6.46; 95%CI = 1.58-26.41) was independently associated with new admission to a nursing home. In conclusion, nursing home admission rate for this cohort of older hospitalized heart failure patients was low. Age, length of hospital stay, and diabetes were associated with new nursing home admissions. Further studies are needed to identify modifiable risk factors for nursing home admissions and to develop appropriate interventions.
Age Distribution↗
Treatment of chronic heart failure in long-term care facilities: implications of recent heart failure guidelines recommendations.
Use of angiotensin-converting enzyme inhibitor in heart failure with left ventricular systolic dysfunction has revolutionized management of heart failure and resulted in several national heart failure guidelines. However, studies have documented underutilization of these life saving drugs. Subsequently, results of other randomized clinical trials revealed the beneficial effects of angiotensin receptor blockers, beta-blockers, and spironolactone in heart failure with systolic dysfunction, which prompted several other guidelines. However, all these guidelines were primarily restricted to systolic dysfunction. Heart failure is as much a geriatric syndrome as it is a cardiac. Most heart failure patients are older adults. About half of the heart failure in older adults is not associated with left ventricular systolic dysfunction. Two recent heart failure guidelines, from the European Society of Cardiology and the American College of Cardiology/American Heart Association, published respectively in September and December 2001 included recommendations for patients with preserved left ventricular systolic function and other special populations, including older adults and those at end of life. The purpose of this article is to review the relevance of these two guidelines to heart failure patients living in long-term care facilities. As our population is aging, more heart failure patients are expected to live in long-term care facilities. Appropriate evaluation and management of these patients are essential to improve quality of heart failure care in the coming decades.
Aged↗
Predictors of mortality and hospitalization in women with heart failure in the Digitalis Investigation Group trial.
We performed a retrospective follow-up study of 1926 women with heart failure who participated in the Digitalis Investigation Group trial. Adjusted hazard ratios and 95% confidence intervals for covariates that were significant independent predictors of all-cause mortality were age in years (1.02; 1.01-1.03; P<0.001), NYHA class IH-IV (1.56; 1.31-1.87), diabetes (1.63; 1.36-1.95), glomerular filtration rate in mL/min/1.73 m(2) (0.99; 0.98-4).996; P=0.001), pulmonary congestion by chest x-ray (1.57; 1.22-2.02), left ventricular ejection fraction (LVEF) (0.99; 0.98-0.993; P<0.001), and use of digoxin (1.20; 1.02-1.42). Covariates that were significant independent predictors of hospitalization due to worsening heart failure were: nonwhite race (1.28; 1.03-1.58), NYHA class III-IV (1.55; 1.30-1.84), diabetes (1.75; 1.47-2.09), glomerular filtration rate as mL/min/1.73 m(2) (0.99; 0.986-0.996; P<0.001), pulmonary congestion by chest x-ray (1.42; 1.12-1.81), and use of ACE inhibitors (0.67; 0.49-0.91). Longer duration of heart failure, higher NYHA classes, diabetes, chronic kidney disease, pulmonary congestion, and lower LVEF were significant independent predictors of all-cause mortality, all-cause hospitalization, and hospitalization for heart failure in women with heart failure.
Aged↗
Racial variations in cardiology care among hospitalized older heart failure patients.
In this retrospective follow-up study, the authors examined the association between race and the receipt of cardiology care in 1062 Medicare beneficiaries 65 years of age and older who were hospitalized with heart failure. The primary outcome measure was receipt of care from a cardiologist (via admission or consultation). Using logistic regression analyses, crude and adjusted odds ratios (OR) and 95% confidence intervals (95%CI) of receipt of cardiology care were estimated for nonwhite versus white patients. Two hundred (19%) patients were nonwhites and 483 (46%) patients received care from cardiologists. Proportion of patients receiving cardiology care was lower among nonwhite patients (35% versus 48% among whites; P = 0.001), and nonwhite race was associated with a lower odds of receiving cardiology care (crude OR = 0.57; 95%CI = 0.42-0.79). After adjustment for various patient characteristics and process-of-care variables, the magnitude and precision of the association between nonwhite race and a lower odds of receiving care from a cardiologist remained unchanged (adjusted OR = 0.43; 95% CI = 0.30-0.62). These findings suggest that nonwhite elderly hospitalized heart failure patients are less likely to be cared for by cardiologists.
Aged↗
Clinical characteristics of nursing home residents hospitalized with heart failure.
OBJECTIVE: The purpose of this retrospective study was to describe the clinical characteristics of heart failure among nursing home residents hospitalized with heart failure and determine the validity of dyspnea at rest in the diagnosis of heart failure. METHODS: Subjects were nursing home residents hospitalized with a diagnosis of heart failure. Data on demographic and various admission characteristics were collected by chart abstraction. Proportions of patients presenting with various symptoms and signs of heart failure have been described. The diagnosis of heart failure was confirmed using modified Framingham criteria. The sensitivity, specificity, and positive predictive value of the symptom of dyspnea at rest in the diagnosis of heart failure in nursing home residents hospitalized with heart failure were then estimated. RESULTS: Patients (N = 98) were elderly, predominantly female and about one-fifth African-American. Dyspnea at rest was the presenting symptom of 85 (87%) patients. Sixty-eight (69%) patients met modified Framingham criteria for the diagnosis of heart failure. Dyspnea at rest had a sensitivity of 91%, specificity of 23%, and predictive value positive of 73% for diagnosis of heart failure. CONCLUSION: Dyspnea at rest was the most common symptom among this cohort of nursing home residents hospitalized with heart failure and has a potential to play a useful role in the diagnosis of heart failure in these patients.
Journal Article↗