Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association

Outcomes of Elderly Patients With Acute Myocardial Infarction and Heart Failure Who Undergo Percutaneous Coronary Intervention

Background: As life expectancy rises, percutaneous coronary intervention (PCI) is being performed more frequently, even in elderly patients with acute myocardial infarction (AMI). This study evaluated outcomes of elderly patients with AMI complicated by heart failure (AMIHF), as defined by Killip Class ≥2 at admission, who undergo PCI. Methods and Results: We retrospectively analyzed 185 patients with AMIHF aged ≥80 years (median age 85 years) who underwent PCI between 2009 and 2019. The median follow-up period was 572 days. The rates of in-hospital major bleeding (Bleeding Academic Research Consortium Type 3 or 5) and in-hospital all-cause mortality were 20.5% and 25.9%, respectively. The proportion of frail patients increased during hospitalization, from 40.6% at admission to 59.2% at discharge (P<0.01). The cumulative incidence of all-cause mortality was 36.3% at 1 year and 44.1% at 2 years. After adjusting for confounders, advanced age, Killip Class 4, final Thrombolysis in Myocardial Infarction flow grade <3, and longer door-to-balloon time were associated with higher mortality, whereas higher left ventricular ejection fraction and cardiac rehabilitation were associated with lower mortality (all P<0.05). Progression of frailty during hospitalization was an independent risk factor for long-term mortality in hospital survivors (P<0.01). Conclusions: The management of patients with AMIHF aged ≥80 years who undergo PCI remains challenging, with high rates of in-hospital major bleeding, frailty progression, and mortality.

Multimodality Imaging of Sudden Cardiac Death and Acute Complications in Acute Coronary Syndrome

Sudden cardiac death (SCD) is a potentially fatal event usually caused by a cardiac arrhythmia, which is often the result of coronary artery disease (CAD). Up to 80% of patients suffering from SCD have concomitant CAD. Arrhythmic complications may occur in patients with acute coronary syndrome (ACS) before admission, during revascularization procedures, and in hospital intensive care monitoring. In addition, about 20% of patients who survive cardiac arrest develop a transmural myocardial infarction (MI). Prevention of ACS can be evaluated in selected patients using cardiac computed tomography angiography (CCTA), while diagnosis can be depicted using electrocardiography (ECG), and complications can be evaluated with cardiac magnetic resonance (CMR) and echocardiography. CCTA can evaluate plaque, burden of disease, stenosis, and adverse plaque characteristics, in patients with chest pain. ECG and echocardiography are the first-line tests for ACS and are affordable and useful for diagnosis. CMR can evaluate function and the presence of complications after ACS, such as development of ventricular thrombus and presence of myocardial tissue characterization abnormalities that can be the substrate of ventricular arrhythmias.

Making a Painless Drain: Proof of Concept

Chest tubes account for a large proportion of postoperative pain after cardiothoracic operations. The objective of this study was to develop a novel, cost-effective, easy-to-use, lidocaine-eluting coating to reduce pain associated with postoperative chest tubes. A lidocaine-eluting hydrogel was developed by dispersing lidocaine-loaded nanoparticles in an aqueous solution containing gelatin (5%). Glutaraldehyde (1%) was added to crosslink the gelatin into a hydrogel. The hydrogel was dehydrated, resulting in a thin, stable polymer. Sterile lidocaine hydrogel-coated silicone discs and control discs were prepared and surgically implanted in the subcutaneous space of C57B6 mice. Using von Frey filaments, mice underwent preoperative baseline pain testing, followed by pain testing on post-procedure day 1 and 3. On post-procedure day 1, mice implanted with control discs demonstrated no change in pain tolerance compared to baseline, while mice implanted with 20 mg and 80 mg lidocaine-loaded discs demonstrated a 2.4-fold (P = 0.36) and 4.7-fold (P = 0.01) increase in pain tolerance, respectively. On post-procedure day 3, mice implanted with control discs demonstrated a 0.7-fold decrease in pain tolerance compared to baseline, while mice implanted with 20 mg and 80 mg lidocaine-loaded discs demonstrated a 1.8-fold (P = 0.88) and 8.4-fold (P = 0.02) increase in pain tolerance, respectively. Our results demonstrate successful development of a lidocaine-eluting chest tube with hydrogel coating, leading to improved pain tolerance in vivo. The concept of a drug-eluting drain coating has significant importance due to its potential universal application in a variety of drain types and insertion locations.

Geriatric Cardiology: Coming of Age

Older adults with cardiovascular disease (CVD) contend with deficits across multiple domains of health due to age-related physiological changes and the impact of CVD. Multimorbidity, polypharmacy, cognitive changes, and diminished functional capacity, along with changes in the social environment, result in complexity that makes provision of CVD care to older adults challenging. In this review, we first describe the history of geriatric cardiology, an orientation that acknowledges the unique needs of older adults with CVD. Then, we introduce 5 essential principles for meeting the needs of older adults with CVD: 1) recognize and consider the potential impact of multicomplexity; 2) evaluate and integrate constructs of cognition into decision-making; 3) evaluate and integrate physical function into decision-making; 4) incorporate social environmental factors into management decisions; and 5) elicit patient priorities and health goals and align with care plan. Finally, we review future steps to maximize care provision to this growing population.

Development and Evaluation of a Risk Prediction Model for Left Ventricular Aneurysm in Patients with Acute Myocardial Infarction in Northwest China

Purpose

Left ventricular aneurysm (LVA) is a severe and common mechanical comorbidity with acute myocardial infarction (AMI) that can present high mortality and serious adverse outcomes. Accordingly, there is a need for early identification and prevention of patients at risk of LVA. The aim of this study was to develop and validate a risk prediction model for LVA among AMI patients in Northwest China.

Methods

A total of 509 patients with AMI were retrospectively collected between January 2018 and August 2021. All patients were randomly divided into a training group (n=356) and a validation group (n=153). Potential risk factors for LVA were screened for predictive modelling using least absolute shrinkage and selection operator regression, multivariate logistic regression, clinical relevance, and represented by a comprehensive nomogram. Receiver operating characteristic curve, calibration curve, and decision-curve analysis (DCA) were used to assess the discrimination capacity, calibration, and clinical validity, respectively.

Results

Seven predictors were finally identified for the establishment of prediction model, including age, cardiovascular disease history, left ventricular ejection fraction, ST-segment elevation, percutaneous coronary intervention history, mean platelet volume, and aspartate aminotransferase. The prediction model achieved acceptable areas under the curves of 0.901 (95% confidence interval [CI]=0.868–0.933) and 0.908 (95% CI=0.861–0.956) in the training and validation groups, respectively, and the calibration curves fit well in our model. The DCA result indicated that this nomogram exhibited a favorable performance in terms of clinical utility.

Conclusion

An accurate prediction model for LVA development established, which can be applied to rapidly assess the risk of LVA in patients with AMI. Our findings will aid clinical decision-making to reduce the incidence of LVA in high-risk patients, and counteract adverse cardiovascular outcomes.

Facing the challenge of polypharmacy when prescribing for older people with cardiovascular disease. A review by the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy

Population ageing has resulted in an increasing number of older people living with chronic diseases (multimorbidity) requiring five or more medications daily (polypharmacy). Ageing produces important changes in the cardiovascular system and represents the most potent single cardiovascular risk factor. Cardiovascular diseases (CVDs) constitute the greatest burden for older people, their caregivers, and healthcare systems. Cardiovascular pharmacotherapy in older people is complex because age-related changes in body composition, organ function, homeostatic mechanisms, and comorbidities modify the pharmacokinetic and pharmacodynamic properties of many commonly used cardiovascular and non-cardiovascular drugs. Additionally, polypharmacy increases the risk of adverse drug reactions and drug interactions, which in turn can lead to increased morbi-mortality and healthcare costs. Unfortunately, evidence of drug efficacy and safety in older people with multimorbidity and polypharmacy is limited because these individuals are frequently underrepresented/excluded from clinical trials. Moreover, clinical guidelines are largely written with a single-disease focus and only occasionally address the issue of coordination of care, when and how to discontinue treatments, if required, or how to prioritize recommendations for patients with multimorbidity and polypharmacy. This review analyses the main challenges confronting healthcare professionals when prescribing in older people with CVD, multimorbidity, and polypharmacy. Our goal is to provide information that can contribute to improving drug prescribing, efficacy, and safety, as well as drug adherence and clinical outcomes.

Clinically Interpretable Machine Learning Models for Early Prediction of Mortality in Older Patients with Multiple Organ Dysfunction Syndrome (MODS): An International Multicenter Retrospective Study

BACKGROUND

Multiple organ dysfunction syndrome (MODS) is associated with a high risk of mortality among older patients. Current severity scores are limited in their ability to assist clinicians with triage and management decisions. We aim to develop mortality prediction models for older patients with MODS admitted to the ICU.

METHODS

The study analyzed older patients from 197 hospitals in the US and one hospital in the Netherlands. The cohort was divided into the young-old (65-80 years) and old-old (≥80 years), which were separately used to develop and evaluate models including internal, external and temporal validation. Demographic characteristics, comorbidities, vital signs, laboratory measurements, and treatments were used as predictors. We used the XGBoost algorithm to train models, and the SHAP method to interpret predictions.

RESULTS

34,497 young-old (11.3% mortality) and 21,330 old-old (15.7% mortality) patients were analyzed. Discrimination AUROC of internal validation models in 9,046 U.S. patients was as follows: 0.87 and 0.82, respectively; Discrimination of external validation models in 1,905 EUR patients was as follows: 0.86 and 0.85, respectively; and of temporal validation models in 8,690 U.S. patients: 0.85 and 0.78, respectively. These models outperformed standard clinical scores like SOFA and APSIII. The GCS, Charlson Comorbidity Index, and Code Status emerged as top predictors of mortality.

CONCLUSIONS

Our models integrate data spanning physiologic and geriatric-relevant variables that outperform existing scores used in older adults with MODS, which represents a proof of concept of how machine learning can streamline data analysis for busy ICU clinicians to potentially optimize prognostication and decision making.

Braden Skin Score Subdomains Predict Mortality Among Cardiac Intensive Care Patients

BACKGROUND

The Braden Skin Score (BSS) is a bedside nursing assessment that may be a measure of frailty and predicts mortality among patients in the cardiac intensive care unit (CICU). We examined the association between each of the 6 individual BSS subscores with hospital mortality in patients in the CICU. We hypothesized that BSS subscores reflecting patient frailty would have a stronger association with outcomes.

METHODS

Retrospective cohort study of unique adult patients admitted to the Mayo Clinic CICU from 2007 to 2018 with BSS documented on admission. Primary outcome was all-cause hospital mortality. Odds ratios (ORs) were determined using multivariable logistic regression.

RESULTS

The 11,954 included patients had a mean age of 67.4 ± 15.2 years (37.8% women). Each individual BSS subscore was lower among patients who died in the hospital (all P < .001). The total BSS was inversely associated with in-hospital mortality across admission diagnoses and among patients with coma or mechanical ventilation; each individual subscore was inversely associated with in-hospital mortality. On multivariable regression, all subscores were inversely associated with hospital mortality after full adjustment. Shear had the strongest association (adjusted OR 0.59), followed by nutrition (adjusted OR 0.67), skin moisture (adjusted OR 0.76), mobility (adjusted OR 0.76), sensory perception (adjusted OR 0.82), and activity level (adjusted OR 0.85).

CONCLUSION

BSS can serve as a rapid noninvasive screening tool for identifying poor outcomes in patients in the CICU. BSS subdomains that are more strongly associated with mortality appear to reflect physical frailty. Insofar as the BSS and its subscores measure frailty, a low BSS may identify frail patients.

Surgical management for mechanical complications of acute myocardial infarction: a systematic review of long-term outcomes

BACKGROUND

Mechanical complications following acute myocardial infarction (AMI), though rare, are associated with significant morbidity and mortality. Surgical management remains a mainstay of therapy for these complications. The purpose of this review is to evaluate long-term outcomes data of surgical management for postinfarction free wall rupture, ventricular septal defect, papillary muscle rupture, and pseudoaneurysm.

METHODS

An electronic literature search was performed to identify original studies reporting long-term outcomes data of surgical management of one of the four mechanical complications following AMI. Studies were considered to have long-term outcomes if they at minimum included survival or mortality data up to one year.

RESULTS

A total of 285 studies were identified from the literature search. Of these, 29 studies with long-term survival data on surgically managed mechanical complications of AMI are included in the review. The majority of these are retrospective cohort studies or single-center case series. Five studies are included on free wall rupture, 18 on ventricular septal defect, 4 on papillary muscle rupture, and 2 on pseudoaneurysm. Detailed results are tabulated according to complication.

CONCLUSIONS

Long-term surgical outcomes of postinfarction mechanical complications remain understudied. Outcomes for ventricular septal defect repair are better represented in the literature than are outcomes for other mechanical complications, though available studies are still limited by small sample sizes and retrospective design. Further research is warranted, particularly for outcomes of acute pseudoaneurysm repair.

The influence of heart failure on clinical and economic outcomes among older adults ≥75 years of age with acute myocardial infarction

BACKGROUND

We aimed to evaluate the influence of heart failure (HF) on clinical and economic outcomes among older adults ≥75 years of age during their acute myocardial infarction (AMI) admission in large population-based study from the United States. We also evaluated the clinical characteristics associated with the presence of HF and the predictors of mortality, healthcare utilization, and cost among older adults with AMI.

METHODS

From January 1, 2000, to December 31, 2016, AMI admission was identified using the primary diagnosis and concomitant HF was identified using any non-primary diagnoses in the Premier Healthcare Database.

RESULTS

Of the 468,654 patients examined, 42,946 (9%) had concomitant HF during their AMI admission. These patients were older, more often female, and were more likely to be White. Patients with concomitant HF were more likely to be frail than non-HF patients (59% vs 15%, P < .001). The mean (SD) Elixhauser comorbidity index was 2.6 (2.5) vs 0.4 (1.1), P < .001 in the AMI with HF vs AMI only group. The use of percutaneous coronary intervention in those with AMI and HF was lower than those with AMI only (15% vs 31%, P < .001). The overall mortality rate for those with HF was 12%, the median [IQR] hospital length of stay was 5 [3,9] days, and only 25% of patients were discharged home. A higher proportion of patients were discharged to rehabilitation or hospice if they had AMI and HF (Rehabilitation: 33% vs 20%, P < .001; Hospice: 5% vs 3%, P < .001). The mean unadjusted cost of an AMI hospitalization in patients with concomitant HF was lower ($12,411 ± $14,860) than in those without HF ($15,828 ± $19,330). After adjusting for age, gender, race, hypertension, frailty, revascularization strategy, and death, the average cost of hospitalization attributed to concomitant HF was +$1,075 (95% CI +876 to $1,274) when compared to AMI patients without HF.

CONCLUSION

In patients ≥75 years of age, AMI with concomitant HF carries higher risk of death, but at ages ≥85 years, the risk difference diminishes due to other competing risks. HF was also associated with longer hospital length of stay and higher likelihood of referral to hospice and rehabilitation facilities when compared to older patients without HF. Care for these older adults is associated with increased hospitalization costs. Measures to identify HF in older adults during their AMI admission are necessary to optimize health outcomes, care delivery, and costs.

Acute Myocardial Infarction and Cardiogenic Shock Interventional Approach to Management in the Cardiac Catheterization Laboratories

Despite advances in early reperfusion and a technologic renaissance in the space of Mechanical Circulatory Support (MCS), Cardiogenic Shock (CS) remains the leading cause of in-hospital mortality following Acute Myocardial Infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patients without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive, evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated into the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trials designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.

The Aftermath of the COVID-19 Crisis in Saudi Arabia: Respiratory Rehabilitation Recommendations by Physical Therapists

Since late 2019, the number of COVID-19 patients has gradually increased in certain regions as consecutive waves of infections hit countries. Whenever this wave hits the corresponding areas, the entire healthcare system must respond quickly to curb the diseases, morbidities, and mortalities in intensive care settings. The healthcare team involved in COVID-19 patients' care must work tirelessly without having breaks. Our understanding of COVID-19 is limited as new challenges emerge with new COVID-19 variants appearing in different world regions. Though medical therapies are finding solutions to deal with the disease, there are few recommendations for respiratory rehabilitation therapies. A group of respiratory rehabilitation care professionals in Saudi Arabia and international experts have agreed with the World Health bodies such as the World Health Organization (WHO) on the treatment and rehabilitation of patients with COVID-19. Professionals participating in COVID-19 patient treatment, rehabilitation, and recovery formulated respiratory rehabilitation guidelines based on the DELPHI Method, combining scientific research and personal practical experience. As a result, it is envisaged that the number of individuals in the region suffering from respiratory ailments due to post-COVID-19 will decrease. This narrative review and clinical expertise guidelines may give physiotherapists acceptable and standard clinical guideline protocols for treating COVID-19 patients.

Temporal Trends in Post Myocardial Infarction Heart Failure and Outcomes Among Older Adults

BACKGROUND

We sought to determine national trends and long term outcomes of post myocardial infarction (MI) heart failure. An MI can be complicated by heart failure; there are limited data describing the contemporary patterns and clinical implications of post-MI heart failure.

METHODS AND RESULTS

We studied patients with an MI aged 65 years or older from 2000 to 2013 in a Medicare database. New-onset heart failure after an MI was defined as either heart failure during the index MI admission or a hospitalization for heart failure within 1 year of the index MI event. A trend analysis of the incidence of heart failure was performed, and differences were examined by Gray tests. The 5-year mortality rates were evaluated and differences among heart failure cohorts were ascertained by Gray tests. There were a total of 1,531,638 patients with an MI and 565,291 patients had heart failure (36.0%). The rate of heart failure during index admission was 32.3% and the frequency of heart failure hospitalization within 1 year was 10.4%. Patients with heart failure were older (81 years vs 77 years). The temporal trend from 2001 to 2012 suggested a decrease in the incidence of heart failure during index admission (2001: 34.7%, 2012: 31.2%, P_trend < .01), as well as heart failure hospitalization within 1 year (2001: 11.3%, 2012: 8.7%, P_trend < .01). The 5-year mortality rate among patients without heart failure was 38.4% and for patients with any heart failure it was 68.7%.

CONCLUSIONS

Post-MI heart failure in older adults occurs in 1 in 3 patients within 1 year; heart failure portends significantly higher long-term mortality.

Trends, Predictors and In-Hospital Outcomes of the Next Day Discharge Approach After Transcatheter Mitral Valve Repair

Early discharge strategies are associated with lower cost and resource utilization during hospitalization, as such we sought to evaluate trends, predictors and outcomes of the next day discharge (NDD) approach after transcatheter mitral valve repair (TMVR) procedures with the MitraClip device. The National Inpatient Sample (NIS) was queried between 2013 and 2018 for patients undergoing TMVR using the International Classification of Diseases (ICD) 9 procedure code '3597' and ICD-10 procedure code '02UG3JZ'. Patients undergoing TMVR were stratified into two groups, determined by hospital length of stay (LOS) [≤1 day, NDD versus >1-day, non-NDD]. Overall, 22,035 patients underwent TMVR with 35.7% (n  = 7,870) belonging to the NDD group (mean age 78.1 ± 9.7 years, women 45%). From 2013 to 2018, the proportion of patients being discharged using the NDD approach trended upward from 18.3% to 46.0%. Amongst demographic and social factors, female sex, black race, and low median household income were predictive of non-NDD (p <0.05 for all). Amongst clinical factors, anemia, iron deficiency anemia, major depressive disorder, thrombocytopenia, obesity and end stage renal disease were some predictors of non-NDD (p <0.05 for all). In the non-NDD group there was a downward trend of pooled post-procedure complications, post procedure cardiogenic shock, vascular complications, acute kidney injury, mechanical circulatory support use, acute respiratory distress and postoperative ischemic stroke and (p for trend <0.001 for all). Despite the overall downward trend, complications began increasing in 2017-18. In conclusion, these trends may reflect improving operator experience, advancement in vascular access device closures and techniques, and prioritization of decreasing length of stay. Ideally, the feasibility and safety of this approach should be confirmed in larger-sized multicenter, randomized trials.

Frailty and cardiovascular outcomes in the National Health and Aging Trends Study

AIMS

Physical frailty is a commonly encountered geriatric syndrome among older adults without coronary heart disease (CHD). The impact of frailty on the incidence of long-term cardiovascular outcomes is not known.We aimed to evaluate the long-term association of frailty, measured by the Fried frailty phenotype, with all-cause-mortality and MACE among older adults without a history of CHD at baseline in the National Health and Aging Trends Study.

METHODS AND RESULTS

We used the National Health and Aging Trends Study, a prospective cohort study linked to a Medicare sample. Participants with a prior history of CHD were excluded. Frailty was measured during the baseline visit using the Fried physical frailty phenotype. Cardiovascular outcomes were assessed during a 6-year follow-up.Of the 4656 study participants, 3259 (70%) had no history of CHD 1 year prior to their baseline visit. Compared to those without frailty, subjects with frailty were older (mean age 82.1 vs. 75.1 years, P < 0.001), more likely to be female (68.3% vs. 54.9%, P < 0.001), and belong to an ethnic minority. The prevalence of hypertension, falls, disability, anxiety/depression, and multimorbidity was much higher in the frail and pre-frail than the non-frail participants. In a Cox time-to-event multivariable model and during 6-year follow-up, the incidences of death and of each individual cardiovascular outcomes were all significantly higher in the frail than in the non-frail patients including major adverse cardiovascular event (MACE) [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.53, 2.06], death (HR 2.70, 95% CI 2.16, 3.38), acute myocardial infarction (HR 1.95, 95% CI 1.31, 2.90), stroke (HR 1.71, 95% CI 1.34, 2.17), peripheral vascular disease (HR 1.80, 95% CI 1.44, 2.27), and coronary artery disease (HR 1.35, 95% CI 1.11, 1.65).

CONCLUSION

In patients without CHD, frailty is a risk factor for the development of MACEs. Efforts to identify frailty in patients without CHD and interventions to limit or reverse frailty status are needed and, if successful, may limit subsequent adverse cardiovascular events.

Prevalence and Prognosis Impact of Frailty Among Older Adults in Cardiac Intensive Care Units

Background

Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the outcomes of elderly patients admitted to a cardiac intensive care unit (CICU) remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted to a CICU.

Methods

This prospective single-centre observational study was conducted among patients aged ≥ 80 years admitted to a CICU in a tertiary centre. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS-score of 0-3, EFS-score of 4-6, and EFS-score > 7.

Results

A total of 199 patients were included, and median follow-up duration was 365 days. The mean age was 84.8 years, and 50 patients (25.1%) died during the follow-up period. In all, 45 (22.6%), 60 (30.2%), and 94 patients (47.2%) had an EFS-score of 0-3, 4-6, and ≥ 7, respectively. The all-cause mortality rate was 4.4%, 27.1%, and 37.2% in the 0-3, 4-6, and ≥ 7 EFS-score groups, respectively (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: hazard ratio was 2.60 (95% confidence interval 0.54-12.45) within the 4-6 EFS-score group, and 5.46 (95% confidence interval 1.23-24.08) within the ≥ 7 EFS-score group.

Conclusions

Frailty is highly prevalent in older adults admitted to the population hospitalized in a CICU and represents a strong prognostic factor for 1-year all-cause mortality.

The management of multi-morbidity in elderly patients: Ready yet for precision medicine in intensive care?

There is ongoing demographic ageing and increasing longevity of the population, with previously devastating and often-fatal diseases now transformed into chronic conditions. This is turning multi-morbidity into a major challenge in the world of critical care. After many years of research and innovation, mainly in geriatric care, the concept of multi-morbidity now requires fine-tuning to support decision-making for patients along their whole trajectory in healthcare, including in the intensive care unit (ICU). This article will discuss current challenges and present approaches to adapt critical care services to the needs of these patients.

Cardiovascular care of older adults

Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.

Mechanical ventilation at the time of heart transplantation and associations with clinical outcomes

AIMS

The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality.

METHODS AND RESULTS

We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P < 0.001). At 1 year, the mortality was 33.7% (n = 484) for ventilated patients and 11.7% (n = 6967) for those not ventilated at the time of transplantation (log-rank P < 0.001). After multivariable adjustment, patients requiring MV continued to have a substantially higher 90-day [odds ratio (OR) 3.20, 95% confidence interval (CI): 2.79-3.66, P < 0.001] and 1-year mortality (OR 2.67, 95% CI: 2.36-3.03, P < 0.001). For those that survived to 90 days, the adjusted mortality at 1 year continued to be higher (OR 1.48, 95% CI: 1.16-1.89, P = 0.002).

CONCLUSION

We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.

Management of acute coronary syndromes in older adults

Older patients are underrepresented in prospective studies and randomized clinical trials of acute coronary syndromes (ACS). Over the last decade, a few specific trials have been conducted in this population, allowing more evidence-based management. Older adults are a heterogeneous, complex, and high-risk group whose management requires a multidimensional clinical approach beyond coronary anatomic variables. This review focuses on available data informing evidence-based interventional and pharmacological approaches for older adults with ACS, including guideline-directed management. Overall, an invasive approach appears to demonstrate a better benefit-risk ratio compared to a conservative one across the ACS spectrum, even considering patients' clinical complexity and multiple comorbidities. Conversely, more powerful strategies of antithrombotic therapy for secondary prevention have been associated with increased bleeding events and no benefit in terms of mortality reduction. An interdisciplinary evaluation with geriatric assessment should always be considered to achieve a holistic approach and optimize any treatment on the basis of the underlying biological vulnerability.

[Geriatric patients in the intensive care unit]

The percentage of geriatric patients treated in intensive care units continues to increase, comprising up to 30%. Age per se is not of great relevance for the outcome of intensive care treatment. Functional status and geriatric syndromes are crucial for prognosis. Frailty and delirium are very important and should be screened using the Clinical Frailty Scale (CFS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), respectively. Furthermore, age-physiological organ changes as well as multimorbidity and associated polypharmacy play an important role. The latter should be assessed at the time of admission. Another goal of intensive care treatment of geriatric patients is to maintain and improve the nutritional status, which can be assessed with the help of an established tool (e.g. NRS 2002). In the treatment of critically ill geriatric patients with coronavirus disease 2019 (COVID-19), frailty is also crucial. It is particularly important in the intensive medical treatment of critically ill geriatric patients to clarify the question whether the patient benefits from each intensive care therapy, e.g., whether a desired therapeutic goal can be achieved, whether intensive care is in the (presumed) patient's will and whether the burdens during treatment are justified by the perspective of life. Furthermore, interdepartmental cooperation plays an important role in the intensive medical care of geriatric patients.

Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association

Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.

Eight Weeks of High-Intensity Interval Static Strength Training Improves Skeletal Muscle Atrophy and Motor Function in Aged Rats via the PGC-1α/FNDC5/UCP1 Pathway

Background

Sarcopenia is a syndrome characterized by the loss of skeletal muscle mass and strength. Most studies have focused on dynamic resistance exercises for preventing muscular decline and maintaining the muscle strength of older individuals. However, this training mode is impractical for older people with osteoarthritis and a limited range of motion. The static strength training mode is more suitable for older people. Therefore, a determination of the effect and mechanism of static strength training on sarcopenia is critical.

Methods

In this study, we developed a training device designed to collect training data and evaluate the effects of static training on the upper limbs of rats. The expression of PGC-1α was locally blocked by injecting a siRNA at the midpoint of the biceps to determine whether PGC-1α signal transduction participates in the effects of high-intensity interval static training on muscle strength. Then, the rat’s motor capacity was measured after static strength training. Immunohistochemistry and Western blotting were applied to determine PGC-1α/FNDC5/UCP1 expression levels in the muscle and adipose tissue. The serum irisin level was also detected using an enzyme-linked immunosorbent assay (ELISA).

Results

Increased levels of serum irisin and local expression of FNDC5, PGC-1α, and UCP1 were observed in the biceps brachii and surrounding fatty tissue after static strength training. Static strength training showed an advantage in reducing body weight and white fat accumulation while increasing the muscle fiber volume, which resulted in a longer training time and shorter rest time.

Conclusion

Overall, these results indicated that high-intensity interval static training prevents skeletal muscle atrophy and improves the motor function of aged rats through the PGC-1α/FNDC5/UCP1 signaling pathway.

Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality

BACKGROUND

Current cardiac intensive care unit (CICU) practice has seen an increase in patient complexity, including an increase in noncardiac organ failure, critical care therapies, and comorbidities. We sought to describe the changing epidemiology of noncardiac multimorbidity in the CICU population.

METHODS

We analyzed consecutive unique patient admissions to 2 geographically distant tertiary care CICUs (n = 16,390). We assessed for the prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities (diabetes, chronic lung, liver, and kidney disease, cancer, and stroke/transient ischemic attack) and their associations with hospital and postdischarge 1-year mortality using multivariable logistic regression.

RESULTS

The prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities was 37.7%, 31.4%, 19.9%, and 11.0%, respectively. Increasing noncardiac comorbidities were associated with a stepwise increase in mortality, length of stay, noncardiac indications for ICU admission, and increased utilization of critical care therapies. After multivariable adjustment, compared with those without noncardiac comorbidities, there was an increased hospital mortality for patients with 1 (odds ratio [OR] 1.30; 95% confidence interval [CI], 1.10-1.54, P = .002), 2 (OR 1.47; 95% CI, 1.22-1.77, P < .001), and ≥3 (OR 1.79; 95% CI, 1.44-2.22, P < .001) noncardiac comorbidities. Similar trends for each additional noncardiac comorbidity were seen for postdischarge 1-year mortality (P < .001, all).

CONCLUSIONS

In 2 large contemporary CICU populations, we found that noncardiac multimorbidity was highly prevalent and a strong predictor of short- and long-term adverse clinical outcomes. Further study is needed to define the best care pathways for CICU patients with acute cardiac illness complicated by noncardiac multimorbidity.

Physical Frailty Phenotype and the Development of Geriatric Syndromes in Older Adults with Coronary Heart Disease

BACKGROUND

Frailty, a clinical state of vulnerability, is associated with subsequent adverse geriatric syndromes in the general population. We examined the long-term impact of frailty on geriatric outcomes among older patients with coronary heart disease.

METHODS

We used the National Health and Aging Trends Study, a prospective cohort study linked to a Medicare sample. Coronary heart disease was identified by self-report or International Classification of Diseases (ICD) codes 1-year prior to the baseline visit. Frailty was measured using the Fried physical frailty phenotype. Geriatric outcomes were assessed annually during a 6-year follow-up.

RESULTS

Of the 4656 participants, 1213 (26%) had a history of coronary heart disease 1-year prior to their baseline visit. Compared to those without frailty, subjects with frailty were older (ages ≥75: 80.9% vs 68.9%, P < 0.001), more likely to be female, and belong to an ethnic minority. The prevalence of hypertension, stroke, falls, disability, anxiety/depression, and multimorbidity were much higher in the frail, than nonfrail, participants. In a discrete time survival model, the incidence of geriatric syndromes during 6-year follow-up including 1) dementia, 2) loss of independence, 3) activities of daily living disability, 4) instrumental activities of daily living disability, and 5) mobility disability were significantly higher in the frail than in the nonfrail older patients with coronary heart disease.

CONCLUSION

In patients with coronary heart disease, frailty is a risk factor for the accelerated development of geriatric outcomes. Efforts to identify frailty in the context of coronary heart disease are needed, as well as interventions to limit or reverse frailty status for older patients with coronary heart disease.

Influence of age and shock severity on short-term survival in patients with cardiogenic shock

AIMS

Cardiogenic shock (CS) is associated with poor outcomes in older patients, but it remains unclear if this is due to higher shock severity. We sought to determine the associations between age and shock severity on mortality among patients with CS.

METHODS AND RESULTS

Patients with a diagnosis of CS from Mayo Clinic (2007-15) and University Clinic Hamburg (2009-17) were subdivided by age. Shock severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock stages. Predictors of 30-day survival were determined using Cox proportional-hazards analysis. We included 1749 patients (934 from Mayo Clinic and 815 from University Clinic Hamburg), with a mean age of 67.6 ± 14.6 years, including 33.6% females. Acute coronary syndrome was the cause of CS in 54.0%. The distribution of SCAI shock stages was 24.1%; C, 28.0%; D, 33.2%; and E, 14.8%. Older patients had similar overall shock severity, more co-morbidities, worse kidney function, and decreased use of mechanical circulatory support compared to younger patients. Overall 30-day survival was 53.3% and progressively decreased as age or SCAI shock stage increased, with a clear gradient towards lower 30-day survival as a function of increasing age and SCAI shock stage. Progressively older age groups had incrementally lower adjusted 30-day survival than patients aged <50 years.

CONCLUSION

Older patients with CS have lower short-term survival, despite similar shock severity, with a high risk of death in older patients with more severe shock. Further research is needed to determine the optimal treatment strategies for older CS patients.

The Effect of Aging Physiology on Critical Care

Older patients experience a decline in their physiologic reserves as well as chronic low-grade inflammation named "inflammaging." Both of these contribute significantly to aging-related factors that alter the acute, subacute, and chronic response of these patients to critical illness, such as sepsis. Unfortunately, this altered response to stressors can lead to chronic critical illness followed by dismal outcomes and death. The primary goal of this review is to briefly highlight age-specific changes in physiologic systems majorly affected in critical illness, especially because it pertains to sepsis and trauma, which can lead to chronic critical illness and describe implications in clinical management.

A new multi-national network studying Very old Intensive care Patients (VIPs)

In Europe there are increasing numbers of old (more than 65 years old) and very old (more than 80 years old) patients (very old intensive care patients - VIPs) (Figure 1). In addition to combinations of chronic conditions (multi-morbidity), there are geriatric disabilities and functional limitations, with a profound impact on management in the ICU and afterwards [1].

Intensive Care Unit Nursing Priorities in the United States

This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.

Influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction in the United States

Background

There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI).

Objective

To assess the influence of insurance status on STEMI outcomes.

Methods

Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample database (2000–2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes of interest included in-hospital mortality, use of coronary angiography and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition.

Results

Of the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53–57 years), more often female (46% vs. 20–36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1–6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11–1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94–0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72–0.75]) and other insurance (aOR 0.91 [95% CI 0.88–0.94]); all p<0.001. Coronary angiography (60% vs. 77–82%) and PCI (45% vs. 63–70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home.

Conclusions

Compared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.

Impact of Prior Coronary Artery Bypass Grafting in Patients ≥75 Years Old Presenting With Acute Myocardial Infarction (From the National Readmission Database)

Patients ≥75 years old presenting with acute myocardial infarction (AMI) have complex coronary anatomy in part due to prior coronary artery bypass grafting (CABG), percutaneous coronary interventions (PCI), calcific and valvular disease. Using the National Readmission Database from January 2016 to November 2017, we identified hospital admissions for acute myocardial infarction in patients ≥75 years old and divided them based on a history of CABG. We evaluated in-hospital outcomes, 30-day mortality, 30-day readmission and predictors of PCI in cohorts. Out of a total of 296,062 patients ≥75 years old presenting with an AMI, 42,147 (14%) had history of previous CABG. Most presented with a non-ST segment elevation myocardial infarction, and those with previous CABG had higher burden of co-morbidities and were more commonly man. The in-hospital mortality was significantly lower in those with previous CABG (6.7% vs 8.8%, adjusted odds ratio, 0.88, 95% confidence interval, 0.82 to 0.94). Medical therapy was more common in those with previous CABG and 30-day readmission rates were seen more frequently in those with prior CABG. Predictors of not undergoing PCI included previous PCI, female, older ager groups, heart failure, dementia, malignancy, and higher number of co-morbidities. In conclusion, in patients ≥75 years old with AMI the presence of prior CABG was associated with lower odds of in-hospital and 30-day mortality, as well as lower complications rates, and a decreased use of invasive strategies (PCI, CABG, and MCS). However, 30-day MACE readmission was higher in those with previous CABG.

Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans

BACKGROUND

Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use.

METHODS

We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA₂ DS₂ -VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]).

RESULTS

In this study of 779 participants with AF (median age = 80 years; median CHA₂ DS₂ -VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = -3.7%; 95% confidence interval = -1.4% to -5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia.

CONCLUSION

Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.

Impact of Prior Ischemic Stroke on Outcomes in Patients With Heart Failure - A Propensity-Matched Study

BACKGROUND

Whether ischemic stroke per se, rather than older age or additional comorbidities, accounts for the adverse prognosis of heart failure (HF) is uncertain. The present study examineed the intrinsic association of ischemic stroke with outcomes in a propensity-matched cohort.

METHODS AND RESULTS

Of 1,351 patients hospitalized with HF, 388 (28.7%) had prior ischemic stroke. Using propensity score for prior ischemic stroke, estimated for each patient, a matched cohort of 379 pairs of HF patients with and without prior ischemic stroke, balanced on 32 baseline characteristics was assembled. At 30 days, prior ischemic stroke was associated with significantly higher risks of the combined endpoint of all-cause death or readmission (hazard ratio [HR]: 1.91; 95% confidence interval [CI]: 1.38 to 2.65; P<0.001), all-cause death (HR: 2.08; 95% CI: 1.28 to 3.38; P=0.003), all-cause readmission (HR: 2.67; 95% CI: 1.78 to 4.01; P<0.001), and HF readmission (HR: 2.11; 95% CI: 1.19 to 3.72; P=0.010). Prior ischemic stroke was associated with a significantly higher risk of all 4 outcomes at both 6 months and 1 year.

CONCLUSIONS

Prior ischemic stroke was a potent and persistent risk predictor of death and readmission among patients with HF after accounting for clinical characteristics.

Age and shock severity predict mortality in cardiac intensive care unit patients with and without heart failure

AIMS

Age is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in-hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF.

METHODS AND RESULTS

We retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007-2015 and stratified patients by age and SCAI shock stage. The association between age and in-hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co-morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In-hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2-1.4, P < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2-1.3, P < 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P < 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage.

CONCLUSIONS

Age is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in-hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.

Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies

Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.

Sarcopenia and health-related quality of life in older adults after transcatheter aortic valve replacement

BACKGROUND

Skeletal muscle wasting, or sarcopenia, affects a significant proportion of patients undergoing transcatheter aortic valve replacement (TAVR). However, its influence on post-TAVR recovery and 1-year health-related quality of life (HR-QOL) remains unknown. We examined the relationship between skeletal muscle index (SMI), post-TAVR length of hospital stay (LOS), and 1-year QOL.

METHODS

The study sample consisted of 300 consecutive patients undergoing TAVR from 2012 to 2018 who had pre-TAVR computed tomographic scans suitable for analysis of body composition. Skeletal muscle mass was quantified as cm² of skeletal mass per m² of body surface area from the cross-sectional computed tomographic image at the third lumbar vertebra. Sarcopenia was defined using established sex-specific cutoffs (women: SMI < 39 cm²/m²; men: < 55 cm²/m²). Multivariable linear regression analysis was used to determine the relationship between SMI, LOS, and HR-QOL using the Kansas City Cardiomyopathy Questionnaire.

RESULTS

Sarcopenia was present in most (59%) patients and associated with older age (82 vs 76 years; P < .001) and lower body mass index (27 vs 33 kg/m²; P < .001). There were no other differences in baseline clinical or echocardiographic characteristics among the 4 quartiles of SMI. SMI was positively correlated with LOS and 1-year QOL. After adjusting for age, gender, race, and body mass index, SMI remained a significant predictor of both LOS (P = .01) and 1-year QOL (P = .012). For every 10 cm²/m² higher SMI, there was an 8-point increase in Kansas City Cardiomyopathy Questionnaire score, a difference that is clinically meaningful.

CONCLUSIONS

Sarcopenia is prevalent in TAVR patients. Higher SMI is associated with shorter LOS and better 1-year HR-QOL. To achieve optimal TAVR benefits, further study into how body composition influences post-TAVR recovery and durable improvement in QOL is warranted.

Assessment of Sensory Processing and Executive Functions at the School: Development, Reliability, and Validity of EPYFEI-Escolar

The aim of this study was to determine the psychometric properties of the Assessment of Sensory Processing and Executive Functions at the School (EPYFEI-Escolar), a questionnaire designed to assess the sensory processing and executive functions as underlying processes for school participation. The total sample consisted of 536 children aged between 3 and 11 years old who lived in Spain. A total of 103 teachers completed the questionnaire. An exploratory factor analysis was conducted, which showed five main factors: (1) initiation, organization, execution, and supervision of the action; (2) inhibitory control; (3) sensory processing; (4) emotional self-regulation and play; and (5) self-competence. Some of these factors were similar to those found in the EPYFEI for parents in the home context. The reliability of the analysis was high, both for the whole questionnaire and for the factors it is composed of. The results provide evidence of the potential usefulness of the EPYFEI-Escolar in school contexts for determining academic needs and difficulties of children; moreover, this tool can also be used to plan intervention programs in the school environment according to the needs of each child and school.

Muscle weakness assessment in older intensive care unit patients

INTRODUCTION: After long periods of hospitalization, older adults may develop muscle weakness that can affect their functional independence after discharge. OBJECTIVE: To assess muscle weakness in older patients admitted to an ICU. METHOD: This cross-sectional, descriptive study with a quantitative approach assessed functional independence with the Katz Index and post-ICU muscle strength with a handgrip strength (HS) test and the Medical Research Council (MRC) sum-score. The sample consisted of 60 patients with an average age of 76 (60–99) years, 36 (60%) of whom were female. RESULTS: Post-ICU, 86.7% of the patients were functionally dependent. Female patients had significantly lower HS than males: 7 (0–24) vs. 17 (1–37) (p < 0.001). Female patients who received mechanical ventilation (MV) or sedation had significantly lower HS and MRC scores than those who did not (p < 0.001): HS MV 1 (0–13) vs. 11 (0–24) p < 0.001; MRC MV 35 (14–48) vs. 43 (27–57) p < 0.001; HS sedation 0 (0–12) vs. 9 (0–24) p < 0.001; MRC sedation 34 (14–36) vs. 42 (22–57) p < 0.001, respectively. Finally, there was an inversely proportional correlation between HS, MRC scores, and ICU length of stay, Spearman’s rho = -0.267 (p = 0.0039) and Spearman’s rho = -0.347 (p = 0.007), respectively. CONCLUSION: Older women who received mechanical ventilation and sedation have lower muscle strength than those who did not. As the ICU length of stay increases, muscle strength decreases.