Applicability of the PRECISE-DAPT score in elderly patients with myocardial infarction

Background Elderly patients with acute coronary syndromes(ACS)are at higher risk both for ischemic and bleeding complications.Current guidelines recommend the PRECISE-DAPT score for bleeding risk stratification in this setting,but no study assessed its applicability in elderly patients.This study aimed to assess the performance of the PRECISE-DAPT score in a series of non-selected elderly patients with ACS from routine clinical practice.Methods The IFFANIAM registry included prospectively patients aged>75 years with ST segment elevation myocardial infarction(STEMI).Main outcome measured was the incidence of relevant bleeding after discharge(bleeding leading to hospital readmission,need for transfusion,intervention,stop of antithrombotic drugs or death).Bleeding risk was classified:(A)according to PRECISE-DAPT values above or not the recommended cut-off point(>25);and(B)according to the quartiles of PRECISE-DAPT values observed in the IFFANIAM series(QI:<30;Q2:30-35;Q3:36-44;Q4:>45).Results A total of 208 patients were included.Mean age was 81.9±4.5 years.Most patients(92.6%)had a PRECISE-DAPT value>25.A total of 25 patients(12.0%)had bleeding events and 49 patients(23.6%)died.No significant differences regarding the incidence of bleeding were observed according to the recommended cutt of point>25.However,a progressive increase in the incidence of bleeding was observed across PRECISE-DAPT quartiles observed in this series(P=0.038).Conclusions The vast majority of elderly patients have PRECISE-DAPT values above the recommended cut-off point for bleeding risk.Using different cut-off points could be a more rational approach for predicting bleeding risk in these complex patients.

Frailty and acute coronary syndrome: does gender matter?

There are important sex-related differences in elderly patients with acute coronary syndrome(ACS).Women are older,more frequently frail,and present more comorbidities than men.Atypical symptoms at presentation are also more common in female patients,they are leaded to a delayed diagnosis and treatment.Coronary angiography and subsequent revascularization are frequently underused in elderly women and they tend to receive less guidelines-recommended therapies.The prognosis in elderly frail women with ACS is poor,and it is with high mortality and readmissions rates.Bleeding is recurrent ischemic events in which it is more frequent in women than in men.Recovery time might be long,and a multidisciplinary approach is desirable to improve prognosis and quality of life.Further studies are needed in order to clarify the benefit of the different therapies in the group of frail women,and this is particularly true for revascularization,as scientific evidence in this group is very scarce.

Diagnosis of interatrial block

In the 70＇s, we classified for the first time the blocks at the atrial level into interatrial blocks （IAB）, partial and advanced, and other types of atrial blocks including the concept of atrial aberrancy, and atrial dissociation.

Prediction of sudden death in elderly patients with heart failure

Most heart failure （HF） related mortality is due to sudden cardiac death （SCD） and worsening HF, particularly in the case of reduced ejection fraction. Predicting and preventing SCD is an important goal but most works include no or few patients with advanced age, and the prevention of SCD in elderly patients with HF is still controversial. A recent reduction in the annual rate of SCD has been recently described but it is not clear if this is also true in advanced age patients. Age is associated with SCD, although physicians frequently have the perception that elderly patients with HF die mainly of pump failure, underestimating the importance of SCD. Other clinical variables that have been associated to SCD are symptoms, New York Heart Association functional class, ischemic cause, and comorbidities （chronic obstructive pulmonary disease, renal dysfunction and diabetes）. Some test results that should also be considered are left ventricular ejection fraction and diameters, natriuretic peptides, non-sustained ventricular tachycardias and autonomic abnormalities. The combination of all these markers is probably the best option to predict SCD. Different risk scores have been described and, although there are no specific ones for elderly populations, most include age as a risk predictor and some were developed in populations with mean age 〉 65 years. Finally, it is important to stress that these scores should be able to predict any type of SCD as, although most are due to tachyarrhythmias, bradyarrhythmias also play a role, particularly in the case of the elderly.

Clinical and prognostic implications of delirium in elderly patients with non–ST-segment elevation acute coronary syndromes

Background Elderly patients with non-ST-segment elevation acute coronary syndromes(NSTE-ACS)may present delirium but its clinical relevance is unknown.This study aimed at detennining the clinical associated factors,and prognostic implications of delirium in old-aged patients admitted for NSTE-ACS.Methods LONGEVO-SCA is a prospective multicenter registry including unselected patients with NSTE-ACS aged>80 years.Clinical variables and a complete geriatric evaluation were assessed during hospitalization.The association between delirium and 6-month mortality was assessed by a Cox regression model weighted for a propensity score including the potential confounding variables.We also analysed its association with 6-month bleeding and cognitive or functional decline.Results Among 527 patients included,thirty-seven(7%)patients presented delirium during the hospitalization.Delirium was more frequent in patients with dementia or depression and in those from nursing homes(27.0%vs.3.1%,24.3%vs.11.6%,and 11.1%V5.2.2%,respectively;all P<0.05).Delirium was significantly associated with in-hospital infections(27.0%vs.5.3%,P<0.001)and usage of diuretics(70.3%vs.49.8%,P=0.02).Patients with delirium had longer hospitalizations[median 8.5(5.5-14)vs.6.0(4.0-10)days,P=0.02]and higher incidence of 6-month bleeding and mortality(32.3%vs.10.0%and 24.3%vs.10.8%,respectively;both P<0.05)but similar cognitive or functional decline.Delirium was independently associated with 6-month mortality(HR=1.47,95%CI:1.02-2.13,P=0.04)and 6-month bleeding events(OR=2.87;95%CI:1.98-4」6,P<0.01).Conclusions In-hospital delirium in elderly patients with NSTE-ACS is associated with some preventable risk factors and it is an independent predictor of 6-month mortality.

Atrial fibrillation in the elderly

Atrial fibrillation （AF） is the most frequent arrhythmia. Due to population aging, AF is a growing epidemic and its importance will continue to increase in the next decades. Although the prevalence of AF is high in advanced age, the number of subjects with predisposing factors for AF is even higher. Most of these factors increase the risk of atrial fibro- sis, an important component of atrial arrhythmia mecha- nisms. In fact, the new techniques to detect atrial fibrosis are showing the strong association between atrial fibrosis and AF risk. Regarding predisposing factors for AF, interatrial block （LAB） seems to be a key factor.

Prevalence and incidence of interatrial block in global population and in different clinical situations

The high prevalence of interatrial block （IAB） is widely neglected due to its frequent underdiaguosis. Its prevalence depends mainly on age and also on the presence of associ- ated heart disease. In patients without structural heart dis- ease, it is mainly an elderly condition. This is particularly true for advanced IAB, rarely found in global population before 65 years but with prevalence of 8% in the 70＇s and 25% in centenarians,tll When studying prevalence data of this condition, three factors should be taken into account in order to interpret differences that are frequently related with the methodology used （Table 1, Figure 1）.

End-of-life care in a cardiology department： have we improved？

Background End-of-life care is not usually a priority in cardiology departments. We sought to evaluate the changes in end-of-life care after the introduction of a do-not-resuscitate （DNR） order protocol. Methods ＆ Results Retrospective analysis of all deaths in a cardiology department in two periods, before and after the introduction of the protocol. Comparison of demographic characteristics, use of DNR orders, and end-of-life care issues between both periods, according to the presence in the second period of the new DNR sheet （Group A）, a conven- tional DNR order （Group B） or the absence of any DNR order （Group C）. The number of deaths was similar in both periods （n = 198 vs. n = 197）. The rate of patients dying with a DNR order increased significantly （57.1% vs. 68.5%; P = 0.02）. Only 4% of patients in both periods were aware of the decision taken about cardiopulmonary resuscitation. Patients in Group A received the DNR order one day earlier, and 24.5% received it within the first 24 h of admission （vs. 2.6% in the first period; P 〈 0.001）. All patients in Group A with an implantable cardioverter defibrillator （ICD） had shock therapies deactivated （vs. 25.0% in the first period; P = 0.02）. Conclusions The introduction of a DNR order protocol may improve end-of-life care in cardiac patients by increasing the use and shortening the time of registration of DNR orders. It may also contribute to increase ICD deactivation in patients with these orders in place. However, the introduction of the sheet in late stages of the disease failed to improve patient participation.

Anticoagulation in elderly patients at high risk of atrial fibrillation without documented arrhythmias

Recent studies have suggested that patients with high CHA2DS2VASc-score [Congestive Heart failure, hyperten- sion, Age ≥ 75 years （doubled）, Diabetes, Stroke （doubled）, Vascular disease, Age 65-74 years, Sex category （female sex）] thromboembolic complications occurred irrespective of the presence of atrial fibrillation （AF） and anticoagulant therapy may be initiated irrespective of documented AF.

Hospital without dyspnea： rationale and design of a multidisciplinary intervention

Dyspnea is a common and disabling symptom of respiratory and heart diseases, which is growing in incidence. During hospital admis- sion, breathlessness is under-diagnosed and under-treated, although there are treatments available for controlling the symptom. We have developed a tailored implementation strategy directed to medical staff to promote the application of these pharmacological and non-pharmacological tools in dealing with dyspnea. The primary aim is to decrease the rate of patients that do not receive an adequate relief of dyspnea. This is a four-stage quasi-experimental study. The intervention consists in two teaching talks that will be taught in Cardiology and Respiratory Medicine Departments. The contents will be prepared by Palliative Care specialists, based on available tools for management of dyspnea and patients＇ needs. A cross-sectional study of dyspnea in hospitalized patients will be performed before and after the intervention to ascertain an improvement in dyspnea intensity due to changes in medical practices. The last phase consists in the creation of consensus protocols for dyspnea management based in our experience. The results of this study are expected to be of great value and may change clinical practice in the near future and promote a changing for the better of dyspnea care.