Cardiovascular

Introduction: Older people may be less likely to receive cardiac resynchronisation therapy (CRT) for the management of chronic heart failure. We aimed to describe differences in clinical response, complications, and subsequent outcomes following CRT implantation in older patients when compared to those that were younger.

Methods: We conducted a retrospective cohort study of consecutive patients implanted with CRT between March 2008 and July 2017. We recorded complications, symptomatic and echocardiographic response, hospitalisations for heart failure, and all-cause mortality comparing patients aged <70, 70-79, and ≥80 years.

Results: During the study period, 574 patients (median age 76 years [IQR 68-81], 73.3% male) received CRT.  Patients aged ≥80 years had worse symptoms at baseline and were more likely to have co-morbidities. Although the provision of guideline-directed medical therapy for heart failure was less optimal in those ≥80 years old, left ventricular function was similar at baseline. Older patients were less likely to receive CRT-defibrillators (which were twice as likely to require generator replacement) compared to CRT-pacemakers. Complications were infrequent and not more common in older patients. Age was not a predictor of symptomatic or echocardiographic response to CRT (67.2%, 71.2%, and 62.6% responders in patients aged <70, 70-79, and ≥80 years, respectively; p=0.43) and time to first heart failure hospitalisation was similar across all groups (p=0.28). Finally, estimated 10-year survival was lower for older patients (49.9%, 23.9%, and 6.8% for patients aged <70, 70-79, and ≥80 years, respectively; p<0.001).

Conclusion: The benefits of CRT were consistent in selected older patients (≥80 years) despite a greater burden of co-morbidities and less optimal provision of guideline-directed medical therapy. These findings support the use of CRT in an aging population. 

Introduction

Treating hypertension in older patients (>65y) remains controversial given limited evidence around optimising blood pressure in frailty. Although studies suggest improved cardiovascular benefit, NICE guidelines emphasise the need for careful clinical decisions to balance benefits and risks. This local audit assessed the appropriateness of antihypertensive regimens prescribed for older patients against NICE guidelines and STOPP/START criteria. Secondary aims assessed admissions related to antihypertensive medication, polypharmacy reviews during inpatient stays, and management of postural hypotension.

Methods

Retrospective chart analysis of 29 patients including adults > 65y admitted under Ageing and Complex Medicine consultants with diagnosis synonymous to hypertension, postural hypotension, or falls.

Results

A third of the cohort were on inappropriate antihypertensive medications on admission; 56% of these being contraindicated STOPP criteria drugs. 78% majority had medications reviewed, resulting in an improvement from 69% to 89% of patients being on appropriate antihypertensives from admission to discharge.  The admission diagnosis’ of at least 55% of patient cohort were related to antihypertensive medication. There was better compliance of checking lying and standing blood pressure (LSBP) within 48h admission but lower value of 36% was observed within 48 hours prior to discharge. Of those measured, a significant 74% and 50% of patients demonstrated positive postural drops on admission and discharge.  18% of all patients re-attended hospital within six months with similar diagnosis’.

Conclusion

Many older adults in the local area are admitted to hospital whilst on inappropriate antihypertensive regimens. Those admitted due to falls often experience symptoms caused by their medication effects. There is substandard dynamic assessment of lying-standing blood pressure during antihypertension management which likely contributes towards high rate of hospital readmission. Quality improvement measures such as targeted teaching sessions have since been undertaken to improve competence and confidence in clinicians managing hypertension. Further interventions to improve LSBP monitoring, primary care education and patient information provision are ongoing.

Introduction

There is an association between frailty and arterial stiffness. However, arterial stiffness does not uniformly correlate with the spectrum of frailty states. Both oxidative stress and inflammaging contribute to vascular aging. There are no human studies exploring links between arterial stiffness, oxidative stress, inflammaging and frailty. Our objective is to investigate arterial stiffness and inflammaging as predictors of frailty states.

Methods

An observational longitudinal cohort study will be used to examine the association between arterial stiffness, oxidative stress, and inflammation in 50 older adults (≥70 years) with clinical frailty scores (CFS) ≤6 over six months. All study measurements will be taken at baseline. Frailty assessment will include hand-grip strength, timed-up and go test, mini-mental state examination, geriatric depression scale and sarcopenia using body composition measurements with Tanita®. Arterial stiffness measurements will include carotid-femoral pulse wave velocity (cfPWV) and carotid-radial pulse wave velocity (crPWV) using Complior (Alam Medical, France). CAVI device will measure Cardio-ankle vascular index and ankle brachial index (ABI). Oxidative stress blood markers nitrotyrosine (NT) and 8-hydroxy-2’-deoxyguanosin (8-oxo-dG) and inflammation markers high-sensitive C-reactive protein (hs-CRP) and interlukin-6(IL-6) will be measured at baseline and 6-months along with lipid profile and glycated haemoglobin.

Data Analysis

Descriptive statistics for continuous data using means and standard deviations for normality distributed variables or medians and inter-quartile ranges for skewed variables will be used. Participants will be categorized into CFS 1-3, and CFS 4-6. Categorical data will use frequencies and comparison between groups. Change in frailty between the groups over 6 months will be compared using paired t-test. Simple linear regression will be done between frailty measures, arterial stiffness, inflammation, and oxidative stress biomarkers. Significance will be at p<.05.

Conclusion

This study data will inform a larger, multi-centre exploring further the interplay between frailty, biomarkers, and arterial stiffness parameters. is funded by BGS.

Introduction: Evidence of the optimal blood pressure target for older people with disability in long-term care is limited. We aim to estimate the associations of blood pressure with all-cause and cause-specific mortality in older people with different profiles of disability.

Methods: This prospective cohort study was based on the government-led long-term care program in Chengdu, China, including 41,004 consecutive disabled adults aged ≥ 60 years. The association between blood pressure and mortality was analyzed with doubly robust estimation, which combined exposure model by inverse probability weighting and outcome model fitted with Cox regression. The non-linearity was examined by restricted cubic spline. The primary endpoint was all-cause mortality, and the secondary endpoints were cardiovascular and non-cardiovascular mortality.

Results: The associations between systolic blood pressure (SBP) and all-cause mortality were close to a U-shaped curve in mild-moderate disability group (Barthel index ≥ 40), and a reversed J-shaped in severe disability group (Barthel index < 40). In mild-moderate disability group, SBP < 135 mmHg was associated with elevated all-cause mortality risks (HR 1.21, 95% CI, 1.10-1.33), compared to SBP between 135-150 mmHg. In severe disability group, SBP <150 mmHg increased all-cause mortality risks (HR 1.21, 95% CI, 1.16-1.27), compared to SBP between 150-170 mmHg. The associations were robust in subgroup analyses in terms of age, cardiovascular comorbidity and antihypertensive treatment. Diastolic blood pressure (DBP) < 67 mmHg (HR 1.29, 95% CI, 1.18-1.42) in mild-moderate disability group and < 79 mmHg (HR 1.15, 95% CI, 1.11-1.20) in severe disability group both demonstrated an increased all-cause mortality risk.

Conclusion: The optimal blood pressure range was higher in older long-term care people with severe disability than those with mild-moderate disability. This study provides new evidence for optimal individualized management of blood pressure in disabled older people in long-term care settings.

Introduction

Frailty, independent of age, is associated with adverse outcomes following admission with Acute Coronary Syndrome (ACS) but is often not accounted in risk stratification scores. Those identified as frail may not be considered for invasive interventions despite evidence that they stand to benefit (1) and are at risk of worsening geriatric syndromes on discharge (2,3).

Purpose

We aimed to categorise clinical outcomes in older adults admitted with ACS, with or without frailty to suggest if there is a role for geriatrician input in reducing length of stay and preventing adverse events.

Methods

Anonymised data was obtained from an NHS trust’s MINAP registry of patients admitted with ACS between April 2022 to March 2023. Baseline demographics, Clinical Frailty Score (CFS), GRACE and HEART scores, total length of stay (LOS), days as inpatient pre- and post-procedure, adverse events during admission, readmission rates and all-cause mortality rate at 30 days and 1 year were calculated.

Results

288 patients over age 65 admitted with ACS were included in analysis.

Median age was 73 [IQR 67-80.75]. Patients over 75 years had higher rates of frailty (38.5% of 75-84 years and 50.0 % over 85 years had CFS ≥ 5 versus 14.9% 65-74 years (p<0.00001)).

253 (87%) patients underwent invasive angiogram during admission. Although, age was not a limiting factor, frail patients were less likely to have an angiogram: 24.9% CFS ≥ 5 versus 57.1% of CFS ≤ 3 (p=0.00199).

Mean LOS was 9.02 days with a median of 7[IQR 4-12] v mean LOS 6 days for all under 65 (p<0.0001). There was a trend for longer LOS post-angiogram particularly for patients with CFS 4-5 versus CFS 3 or less (11.3 days v 8.92 days p=0.053).

Conclusions

Older people admitted with ACS are more likely to have a prolonged admission. Input from geriatricians and the wider multidisciplinary team may help to identify and optimise care and decision making of patients admitted with ACS and mild to moderate frailty.

1. Damluji et al. J Am Heart Assoc. 2019;8:e013686

Introduction/Background: Teamwork is very important in hospitals where the medical on-call team manage the stroke and thrombolysis alert calls. In addition to technical skills, human factors play a very significant role in meeting a target door-to-needle time.

Aim: To improve door-to-needle time by improving human factors (leadership, understanding and delegation of roles and confidence in participation) and technical factors (quick NIHSS and efficient documentation of vital information on radiology request forms for urgent CT head).

Method: We conducted 6 simulation-based training sessions and de-briefing sessions (role-playing and education around technical and non-technical skills) starting from November 2022. We measured the participants’ responses before and after the sessions, with the help of Kirkpatrick’s four level training evaluation model. We measured and compared the thrombolysis breakdown data (total of 38 consecutive patients from May 2022 to February 2023) throughout the process. We used statistical process control (SPC) charts to calculate and visually represent median values to demonstrate the changes.

Results: Thrombolysis breakdown data revealed substantial improvement post intervention (November 2022) compared to data from May-October 2022. SPC charts demonstrated significant reduction and step change in median door-to-needle time (83.7 to 52.2 minutes) and CT imaging to reporting time (36.2 min to 19.5 min).

Conclusion: A series of simulation-based training sessions and debriefing sessions for stroke thrombolysis was able to demonstrate statistically significant improvement in door-to-needle time. We will continue the simulation sessions and will assess sustainability of the interventions.

References: 1. Ajmi SC, Advani R, Fjetland L, et al Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre. BMJ Quality & Safety 2019;28:939-948. 2. Chalwin, R.P. and Flabouris, A. (2013), Non-technical skills training for MET. Intern Med J, 43: 962-969. https://doi.org/10.1111/imj.12172

Introduction: 

There is limited data on the prevalence of hypertriglyceridemia (HTG), a recognized risk factor for cardiovascular disease, in the northeastern region of Colombia. Therefore, we aimed to characterize the local prevalence of HTG and cardiovascular disease-related variables in the subsidized regime population of a city in northeastern Colombia during the period 2020-2022.

Materials and Methods: 

We conducted a retrospective review of medical records from all health centers in Bucaramanga, Santander, Colombia. The study included patients aged 60-95 years who were part of the subsidized regime and had records of cardiovascular risk variables, including the lipid profile. Mean ± standard deviation (SD) was used to describe quantitative variables. Microsoft Excel was employed for database creation, and statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS, v.22.1; Chicago, IL).

Results: 

We included 105,461 patients, of whom 72,556 (69%) were female. The mean age was 66 years. The most common comorbidities were hypertension (82%), followed by non-insulin-requiring diabetes mellitus (28%), chronic kidney disease (24%), hypercholesterolemia (24%), insulin-requiring diabetes mellitus (8%), and COPD (8%). A total of 58,456 (55%) patients had hypertriglyceridemia, with mean triglyceride levels of 194.9 mg/dL. Mean cholesterol levels were 168.4 mg/dL, mean HDL levels were 42.7 mg/dL and mean LDL levels were 111.9 mg/dL.

Conclusions: 

More than half of the population enrolled in the subsidized healthcare regime in Bucaramanga, Santander, Colombia, was found to have hypertriglyceridemia during the period 2020-2022, along with other variables related to cardiovascular disease. This finding aligns with reports from other regions of the country.

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.

Background:

Heart Failure (HF) is a major cause of poor health, hospitalisation, and death, particularly amongst older people. Routinely prescribed HF medication can improve these outcomes, but many patients do not take their medications. Aims: To develop a tailored multi-component intervention to enhance medication adherence in older HF patients in preparation for a future pilot RCT. Objectives: To determine what intervention components and strategies are necessary and acceptable to create a support package to help and encourage HF patients to take their medication regularly. To develop an intervention manual to support the delivery of the proposed intervention.

Research methodology:

The study is an intervention development study using qualitative methods and an intervention development tool. To ensure that the experiences, beliefs, and preferences of HF patients are included the intervention is being co-developed with stakeholders including patients, informal carers, cardiologists, geriatricians, health psychologists, HF nurses and pharmacists using an iterative process where decisions about content, format, style and delivery are made together. Findings from previous work are being mapped to the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework(TDF). Key factors known to improve adherence will be combined with motivational strategies and factors personal to each individual to develop a novel intervention. An expert panel including two HF patients will meet to co-design discuss, review, and agree the mapping decisions. Once the behaviours to be targeted for change are identified the TDF will be used to specify these behaviours in terms of who needs to do what differently, when, where how and with whom? During the process HF patients will also be recruited to participate in several focus groups to evaluate the outcomes of the mapping exercise and identify any concerns or potential barriers to delivery as the intervention is refined. Finally the intervention will be manualised ready for piloting.