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Chen D, Zhang Y, Ji Z, Zhou Y, Liang Z. Association between frailty and the progression trajectories of stroke and dementia comorbidity: insights from observational and genetic analyses. Arch Gerontol Geriatr 2025; 134:105862. [PMID: 40262338 DOI: 10.1016/j.archger.2025.105862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2025] [Revised: 03/17/2025] [Accepted: 04/14/2025] [Indexed: 04/24/2025]
Abstract
BACKGROUND The relationship between frailty and the progression trajectories of stroke-dementia comorbidity remains inconclusive. This study aimed to determine whether there are associations between frailty and the progression trajectories of stroke-dementia comorbidity, including the transitions from enrollment to incident stroke/dementia, progression to stroke-dementia comorbidity, and ultimately to mortality. METHODS This prospective study was conducted based on the UK Biobank cohort. Frailty was assessed using the frailty index (FI) and categorized as robust (FI ≤ 0.10), prefrail (0.10 < FI ≤ 0.25), or frail (FI > 0.25). We used multi-state models and one-sample Mendelian randomization (MR) to investigate the relationships between frailty and the progression trajectories of stroke-dementia comorbidity. Population attributable fraction (PAF) analyses were conducted to assess the attributable risks of frailty and its components. RESULTS The final analysis included 459,924 participants. In comparison to the robust, the frail group significantly elevated the risk of transitioning from enrollment to stroke [HR(95 %CI): 2.32(2.19-2.45)], from enrollment to dementia [2.56(2.31-2.83)], from enrollment to mortality [2.32(2.23-2.42)], from stroke to stroke-dementia comorbidity [1.59(1.23-2.05)], from dementia to stroke-dementia comorbidity [1.79(1.29-2.48)], and from stroke to mortality [1.25(1.11-1.40)]. MR analyses revealed that genetically predicted FI was causally associated with higher risks of stroke-dementia comorbidity. PAF analyses indicated that hypertension, diabetes, lung disease, and visual impairment were significant contributors to the risk of progression to stroke-dementia comorbidity. CONCLUSION Our findings revealed that frailty status increases the risk of post-stroke dementia, offering important insights for the clinical management and public health strategies.
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Affiliation(s)
- Dongze Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Genetics, Peking University Cancer Hospital & Institute, Beijing 100142, China; Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing 100191, China.
| | - Yali Zhang
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing 100191, China
| | - Zhiqiang Ji
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing 100191, China
| | - Yi Zhou
- Department of Third Research, Shenzhen Health Development Research and Data Management Center, Shenzhen 518000, China
| | - Zhisheng Liang
- Department of Global Health, School of Public Health, Peking University, Beijing 100191, China
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Rasalam R, Sindone A, Deed G, Audehm RG, Atherton JJ. State of precision medicine for heart failure with preserved ejection fraction in a new therapeutic age. ESC Heart Fail 2025; 12:1544-1557. [PMID: 39844745 PMCID: PMC12055434 DOI: 10.1002/ehf2.15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Revised: 11/08/2024] [Accepted: 12/13/2024] [Indexed: 01/24/2025] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is defined by heart failure (HF) with a left ventricular ejection fraction (LVEF) of at least 50%. HFpEF has a complex and heterogeneous pathophysiology with multiple co-morbidities contributing to its presentation. Establishing the diagnosis of HFpEF can be challenging. Two algorithms, the 'Heavy, 2 or more Hypertensive drugs, atrial Fibrillation, Pulmonary hypertension, Elderly age >60, elevated Filling pressures' (H2FPEF) and the 'Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final aetiology' (HFA-PEFF), can help to determine the likelihood of HFpEF in individuals with symptoms of HF. Phenotype clusters defined largely by the total number and types of co-morbidities may delineate groups of patients with HFpEF with different management needs. It is important to recognize alternative diagnoses or HFpEF mimics such as infiltrative cardiomyopathies, coronary artery disease, lung disease, anxiety, depression, anaemia, severe obesity, and physical deconditioning, among others. Treatment with sodium-glucose co-transporter 2 inhibitors (dapagliflozin and empagliflozin) is recommended for all patients with HFpEF unless contraindicated. Future research should consider alternative approaches to guide the initial diagnosis and treatment of HFpEF, including phenotype clustering models and artificial intelligence, and consider whether LVEF is the most useful distinguishing feature for categorizing HF. Ongoing clinical trials are evaluating novel pharmacological and device-based approaches to address the pathophysiological consequences of HFpEF.
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Affiliation(s)
- Roy Rasalam
- Endocrinology and Diabetes DepartmentAlfred HealthMelbourneVictoriaAustralia
- Faculty of MedicineUniversity of MelbourneMelbourneVictoriaAustralia
| | - Andrew Sindone
- Concord HospitalUniversity of SydneySydneyNew South WalesAustralia
| | - Gary Deed
- HealthCarePlus Medical CentreCarindaleQueenslandAustralia
- Monash UniversityMelbourneQueenslandAustralia
| | - Ralph G. Audehm
- Faculty of MedicineUniversity of MelbourneMelbourneVictoriaAustralia
| | - John J. Atherton
- Faculty of Medicine, Royal Brisbane and Women's HospitalUniversity of QueenslandHerstonQueenslandAustralia
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Yesilyurt-Dirican ZE, Qi C, Wang YC, Simm A, Deelen L, Hafiz Abbas Gasim A, Lewis-McDougall F, Ellison-Hughes GM. SGLT2 inhibitors as a novel senotherapeutic approach. NPJ AGING 2025; 11:35. [PMID: 40348751 PMCID: PMC12065912 DOI: 10.1038/s41514-025-00227-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 04/23/2025] [Indexed: 05/14/2025]
Abstract
Cellular senescence is the permanent cessation of cell proliferation and growth. Senescent cells accumulating in tissues and organs with aging contribute to many chronic diseases, mainly through the secretion of a pro-inflammatory senescence-associated secretory phenotype (SASP). Senotherapeutic (senolytic or senomorphic) strategies targeting senescent cells or/and their SASP are being developed to prolong healthy lifespan and treat age-related pathologies. Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a new class of anti-diabetic drugs that promote the renal excretion of glucose, resulting in lower blood glucose levels. Beyond their glucose-lowering effects, SGLT2 inhibitors have demonstrated protective effects against cardiovascular and renal events. Moreover, SGLT2 inhibitors have recently been associated with the inhibition of cell senescence, making them a promising therapeutic approach for targeting senescence and aging. This review examines the latest research on the senotherapeutic potential of SGLT2 inhibitors.
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Affiliation(s)
- Zeynep Elif Yesilyurt-Dirican
- Department of Pharmacology, Faculty of Pharmacy, Gazi University, Ankara, Türkiye
- School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, Guy's Campus, King's College London, London, SE1 1UL, UK
| | - Ce Qi
- School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, Guy's Campus, King's College London, London, SE1 1UL, UK
| | - Yi-Chian Wang
- School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, Guy's Campus, King's College London, London, SE1 1UL, UK
| | - Annika Simm
- School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, Guy's Campus, King's College London, London, SE1 1UL, UK
| | - Laura Deelen
- Department of Life Sciences, Faculty of Natural Sciences, Imperial College London, London, UK
- Centre for Microvascular Research, William Harvey Research Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Alia Hafiz Abbas Gasim
- Centre for Microvascular Research, William Harvey Research Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Fiona Lewis-McDougall
- Centre for Microvascular Research, William Harvey Research Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Georgina M Ellison-Hughes
- School of Basic and Medical Biosciences, Faculty of Life Sciences & Medicine, Guy's Campus, King's College London, London, SE1 1UL, UK.
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Yamashita I, Fujisaki T, Romeo FJ, Sueta D, Yamamoto E, Tsujita K. Comparing the Efficacy of Sodium-Glucose Cotransporter 2 Inhibitors Among Nonolder and Older Patients: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol 2025; 85:329-337. [PMID: 39665425 DOI: 10.1097/fjc.0000000000001659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 11/26/2024] [Indexed: 12/13/2024]
Abstract
ABSTRACT Large scale randomized trials have shown that sodium-glucose cotransporter 2 (SGLT2) inhibitors can reduce cardiovascular events in patients with cardiovascular disease or with increased risks of cardiovascular disease. However, the evidence from older patients is limited. To compare the efficacy of SGLT2 inhibitors among nonolder and older patients, we have searched PubMed, Cochrane Central, and Embase until February 2023 for randomized controlled trials investigating SGLT2 inhibitors in older (age ≥65 years) patients with diabetes mellitus, chronic kidney disease, and chronic heart failure. The primary outcome was a composite outcome of cardiovascular death, acute myocardial infarction, and stroke. The secondary outcomes were exacerbation of heart failure, kidney disease progression, and a composite of cardiovascular death and heart failure. Our search identified 11 randomized controlled trials with a total of 79,370 patients. SGLT2 inhibitors were associated with a reduced risk of the primary outcome in the total cohort [hazard ratio (HR): 0.91; confidence intervals (CI), 0.84-0.99] with concordant results in both nonolder and older populations (HR: 0.96; CI, 0.88-1.05, HR: 0.87; CI, 0.75-1.01, respectively) without subgroup differences ( P = 0.23), and a reduced risk of developing the composite of cardiovascular death and heart failure exacerbation in both nonolder and older populations (HR: 0.77; CI, 0.67-0.87, HR: 0.76; CI, 0.71-0.82, respectively) without subgroup differences ( P = 0.96). A meta-analysis could not be performed for the other outcomes. These results suggested that SGLT2 inhibitors were similarly associated with reduced risks of cardiovascular events across the spectrum of nonolder and older patients with risk factors for developing cardiovascular disease.
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Affiliation(s)
- Izuki Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan ; and
| | - Francisco J Romeo
- Department of Cardiovascular Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
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5
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Del Buono MG, Filomia S, Saponara G, Sanna T. SGLT2 Inhibitors in the Elderly: Redefining Cardiac Care Beyond Age. J Cardiovasc Pharmacol 2025; 85:316-318. [PMID: 39928698 DOI: 10.1097/fjc.0000000000001680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2025]
Affiliation(s)
- Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy ; and
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simone Filomia
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy ; and
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gianluigi Saponara
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy ; and
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Sanna
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy ; and
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Prokopidis K, Nortcliffe A, Okoye C, Venturelli M, Lip GYH, Isanejad M. Length of stay and prior heart failure admission in frailty and heart failure: A systematic review and meta-analysis. ESC Heart Fail 2025. [PMID: 40205981 DOI: 10.1002/ehf2.15300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Revised: 01/30/2025] [Accepted: 03/26/2025] [Indexed: 04/11/2025] Open
Abstract
AIMS The aim of this study was to compare the differences in length of stay (LoS) and prior hospitalization due to heart failure (HHF) in patients with HF and frailty versus without frailty. METHODS AND RESULTS From inception until August 2024, PubMed, Scopus, Web of Science and Cochrane Library were searched. To examine the association related to LoS and HHF in patients with HF, a meta-analysis using a random-effects model was conducted (CRD42024570604). Our main analysis demonstrated a significantly increased LoS in patients with frailty versus those without frailty [n = 10; mean difference (MD): 3.67; 95% CI: 2.26-5.08, I2 = 93%, P < 0.01]. Likewise, patients with frailty had significantly increased odds of HHF [n = 17; odds ratio (OR): 1.76; 95% CI: 1.50-2.07, I2 = 81%, P < 0.01]. Risk of bias assessment of the included studies was overall fair, while Egger's test showed publication bias regarding studies that examined LoS (P = 0.02). CONCLUSIONS Patients with frailty have longer LoS and more frequent HHF, underscoring the need for early, targeted interventions to manage frailty that may be attributed primarily to ageing and comorbidity-related status.
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Affiliation(s)
- Konstantinos Prokopidis
- Department of Musculoskeletal and Ageing Science Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Amy Nortcliffe
- Department of Musculoskeletal and Ageing Science Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Chukwuma Okoye
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm University, Solna, Sweden
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Acute Geriatric Unit, IRCCS Foundation San Gerardo dei Tintori Monza, Monza, Italy
| | - Massimo Venturelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Masoud Isanejad
- Department of Musculoskeletal and Ageing Science Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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7
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Patel L, Segar MW, Subramanian V, Singh S, Betts T, Lokesh N, Keshvani N, Patel K, Pandey A. Frailty, age, and treatment effect of surgical coronary revascularization in ischemic cardiomyopathy: a post hoc analysis of the STICHES trial. GeroScience 2025; 47:1945-1955. [PMID: 39424698 PMCID: PMC11979079 DOI: 10.1007/s11357-024-01377-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 10/02/2024] [Indexed: 10/21/2024] Open
Abstract
Frailty is common among older patients with heart failure (HF). The efficacy of coronary artery bypass grafting (CABG) on the risk of mortality among frail patients with ischemic cardiomyopathy and HF is uncertain, and whether frailty burden modifies the treatment benefits of CABG among these patients is unknown. We performed a post hoc analysis of the STICHES trial, a randomized trial of CABG with medical therapy vs medical therapy alone among participants with ischemic cardiomyopathy with ejection fraction ≤ 35%. Baseline frailty was assessed through a Rockwood Frailty Index (FI), and based on FI cut-offs from prior HF studies, participants with FI ≥ 0.311 were classified as more frail, and those with FI < 0.311 were classified as less frail. A multivariable Cox proportional hazard model with multiplicative interaction terms was constructed to evaluate whether frailty status modified the treatment effect of CABG on mortality in the overall trial cohort and among those < 60 vs ≥ 60 years of age. Of 1187 participants (12.4% female, 2.6% Black, median FI = 0.33 [IQR 0.27-0.39]), 678 were characterized as more frail. Frailty burden did not modify the efficacy of CABG on the risk of all-cause death in the overall cohort (Pint CABG × frailty = 0.2). In age stratified analysis, Baseline frailty status did not modify the treatment effect of CABG on the risk of all-cause mortality among younger (< 60 years, Pint CABG × frailty = 0.2) as well as older participants (≥60 years, Pint CABG × frailty = 0.6). In this post hoc analysis of the STICHES trial, baseline frailty status did not modify the efficacy of CABG in the overall cohort as well as among younger or older participants. Frailty alone should not be used as a criterion to determine the utilization of CABG among patients with ischemic cardiomyopathy.
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Affiliation(s)
- Lajjaben Patel
- Division of Cardiology, Department of Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA
| | - Matthew W Segar
- Division of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Vinayak Subramanian
- Division of Cardiology, Department of Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA
| | - Sumitabh Singh
- Division of Cardiology, Department of Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA
| | - Traci Betts
- Division of Cardiology, Department of Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA
| | - Nidhish Lokesh
- Division of Cardiology, Department of Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA
| | - Kershaw Patel
- Division of Cardiology, Houston Methodist, Houston, TX, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9047, USA.
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Camafort M, Kasiakogias A, Agabiti-Rosei E, Masi S, Iliakis P, Benetos A, Jeong JO, Lee HY, Muiesan ML, Sudano I, Tsioufis C. Hypertensive heart disease in older patients: considerations for clinical practice. Eur J Intern Med 2025; 134:75-88. [PMID: 39955235 DOI: 10.1016/j.ejim.2024.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Revised: 12/21/2024] [Accepted: 12/30/2024] [Indexed: 02/17/2025]
Abstract
Appropriate management of older people with hypertension is essential to reduce the burden of hypertensive heart disease and further cardiovascular sequelae but there may be challenges given the presence of concurrent senescent changes, comorbidities and impairment in functionality. It is recommended that frailty level and functional status are assessed periodically to understand patient needs and to guide treatment decisions. Office blood pressure should be measured with an appropriate cuff as per standard guidelines. There should be a high index of suspicion for orthostatic hypotension and white coat/masked hypertension, both common in older individuals. Cardiac imaging often identifies age-related changes that may not result from hypertension alone, including smaller ventricular volumes, a sigmoid septum and non-ischaemic fibrosis. Diastolic dysfunction is common and other pathologies, including cardiac amyloidosis, may need to be considered in the presence of red flags. Screening for atrial fibrillation during blood pressure evaluation is advised. Decisions for blood pressure management should follow current recommendations and take into consideration the patient's age and tolerance. There is limited evidence regarding heart failure management in older patients, however, disease-modifying therapy as per guidelines should be pursued. Sufficient outcome data are lacking for this patient group and a multidisciplinary approach is often needed to design optimal therapy.
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Affiliation(s)
- Miguel Camafort
- Hypertension Unit, Department of Internal Medicine, Hospital Clinic, University of Barcelona, Spain; Biomedical Research Network Center for the Pathophysiology of Obesity and Nutrition (CIBER-OBN), Carlos III Health Institute, Spain
| | - Alexandros Kasiakogias
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece.
| | - Enrico Agabiti-Rosei
- Department of Clinical and Experimental Sciences, University of Brescia, Italy and IRCCS Multimedica, Milan, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Panagiotis Iliakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Athanase Benetos
- Department of Geriatric Medicine and INSERM DCAC, CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, Centro per la Prevenzione e Cura dell'ipertensione Arteriosa, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Isabella Sudano
- University Hospital Zurich University Heart Center, Cardiology and University of Zurich, Zurich, Switzerland
| | - Costas Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Kitai T, Kohsaka S, Kato T, Kato E, Sato K, Teramoto K, Yaku H, Akiyama E, Ando M, Izumi C, Ide T, Iwasaki YK, Ohno Y, Okumura T, Ozasa N, Kaji S, Kashimura T, Kitaoka H, Kinugasa Y, Kinugawa S, Toda K, Nagai T, Nakamura M, Hikoso S, Minamisawa M, Wakasa S, Anchi Y, Oishi S, Okada A, Obokata M, Kagiyama N, Kato NP, Kohno T, Sato T, Shiraishi Y, Tamaki Y, Tamura Y, Nagao K, Nagatomo Y, Nakamura N, Nochioka K, Nomura A, Nomura S, Horiuchi Y, Mizuno A, Murai R, Inomata T, Kuwahara K, Sakata Y, Tsutsui H, Kinugawa K. JCS/JHFS 2025 Guideline on Diagnosis and Treatment of Heart Failure. J Card Fail 2025:S1071-9164(25)00100-9. [PMID: 40155256 DOI: 10.1016/j.cardfail.2025.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2025]
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10
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Nguyen TN, Yu J, Perkovic V, Jardine M, Mahaffey KW, Chow CK, Arnott C, Lindley RI. The Efficacy and Safety of Canagliflozin by Frailty Status in Participants of the CANVAS and CREDENCE Trials. J Am Geriatr Soc 2025. [PMID: 40105285 DOI: 10.1111/jgs.19444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 12/29/2024] [Accepted: 02/16/2025] [Indexed: 03/20/2025]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to improve renal and cardiovascular outcomes in patients with type 2 diabetes. Limited evidence exists about the efficacy and safety of SGLT2 inhibitors in patients with frailty. METHODS This was a post hoc pooled, participant-level data analysis of the CANVAS Program (CANVAS and CANVAS-R) and the CREDENCE trial. We examined the effect of canagliflozin on: (1) Major adverse cardiovascular events (MACE), (2) Cardiovascular mortality, (3) all-cause mortality, and (4) key safety outcomes. Frailty was defined by a Frailty Index (FI) based on a deficit accumulation approach (FI > 0.25: frail). Cox proportional-hazard models were used to estimate the efficacy and safety of canagliflozin overall and according to frailty status. RESULTS There were 14,543 participants (10,142 from the CANVAS Program, 4401 from the CREDENCE trial). Their mean age was 63.2 years; 35.3% were female. Frailty was present in 56% of the study participants. The benefits of canagliflozin were observed in both the frail and non-frail subgroups: HRs for MACE 0.80 (95% CI 0.70-0.90) in the frail versus 0.91 (95% CI 0.75-1.09) in the non-frail (p for interaction = 0.27); HRs for cardiovascular mortality 0.79 (95% CI 0.67-0.95) in the frail versus 0.94 (95% CI 0.70-1.27) in the non-frail (p for interaction = 0.38); HRs for all-cause mortality 0.81 (95% CI 0.70-0.94) in the frail versus 0.93 (95% CI 0.74-1.16) in the non-frail (p for interaction = 0.39). Adverse events were similar among frail and non-frail participants, except for osmotic diuresis (HRs 1.67, 95% CI 1.22-2.28 in the frail vs. 3.05, 95% CI 2.13-4.35 in the non-frail, p for interaction = 0.01). CONCLUSIONS Canagliflozin improved cardiovascular and mortality endpoints in participants with type 2 diabetes irrespective of frailty status, with a similar safety profile. Our findings, in addition to those from other recent studies, provide evidence to support the introduction of SGLT2 inhibitor therapy in patients perceived to be frail. TRIAL REGISTRATION ClinicalTrials.gov CANVAS: NCT01032629; CANVAS-R: NCT01989754; CREDENCE: NCT02065791.
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Affiliation(s)
- Tu N Nguyen
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jie Yu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia
- Hunter Medical Research Institute, University of Newcastle, Newcastle, New South Wales, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Meg Jardine
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, California, USA
| | - Clara K Chow
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Richard I Lindley
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Aliberti MJR, Arteaga-Vargas DF, Avelino-Silva TJ. Frailty Matters-Why Isn't It Guiding Clinical Decisions? J Am Geriatr Soc 2025. [PMID: 40105286 DOI: 10.1111/jgs.19443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2025] [Accepted: 02/23/2025] [Indexed: 03/20/2025]
Affiliation(s)
- Márlon Juliano Romero Aliberti
- Laboratorio de Investigacao Medica Em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Thiago Junqueira Avelino-Silva
- Laboratorio de Investigacao Medica Em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Division of Geriatrics, Department of Medicine, University of California san Francisco, San Francisco, California, USA
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12
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Uchmanowicz I, Lisiak M, Lomper K, Czapla M, Kurpas D, Jedrzejczyk M, Wleklik M. State of the Art in Measuring Frailty in Patients With Heart Failure: from Diagnosis to Advanced Heart Failure. Curr Heart Fail Rep 2025; 22:11. [PMID: 40056318 PMCID: PMC11890372 DOI: 10.1007/s11897-025-00699-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2025] [Indexed: 03/10/2025]
Abstract
PURPOSE OF REVIEW This review aims to present the current state of the art in measuring frailty in patients with heart failure (HF), covering the entire spectrum from diagnosis to advanced stages of the disease. Frailty is a critical factor that significantly impacts outcomes in heart failure, and accurate assessment is essential for guiding treatment and improving prognosis. RECENT FINDINGS Frailty is increasingly recognized as a key determinant of morbidity and mortality in HF patients. Various tools are available for assessing frailty, but there is no consensus on the optimal method. The assessment of frailty needs to be multidimensional, incorporating physical, cognitive, and social domains. Early detection of frailty, coupled with personalized interventions, has the potential to improve patient outcomes. Integrating routine frailty assessments into the clinical care of heart failure patients is essential for optimizing treatment. Future research should focus on standardizing frailty assessment tools and integrating innovative technologies, such as artificial intelligence, to enhance the precision and applicability of these assessments in clinical practice.
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Affiliation(s)
- Izabella Uchmanowicz
- Division of Research Methodology, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Bartla 5, Wroclaw, 51-618, Poland
- Centre for Cardiovascular Health, Edinburgh Napier University, Sighthill Campus, Edinburgh, EH11 4DN, UK
| | - Magdalena Lisiak
- Division of Research Methodology, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Bartla 5, Wroclaw, 51-618, Poland
- Institute of Heart Diseases, University Hospital, Wrocław, 50-566, Poland
| | - Katarzyna Lomper
- Division of Research Methodology, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Bartla 5, Wroclaw, 51-618, Poland.
- Institute of Heart Diseases, University Hospital, Wrocław, 50-566, Poland.
| | - Michał Czapla
- Institute of Heart Diseases, University Hospital, Wrocław, 50-566, Poland
- Division of Scientific Research and Innovation in Emergency Medical Service, Department of Emergency Medical Service, Faculty of Nursing and Midwifery, Wroclaw Medical University, Wroclaw, 51-618, Poland
- Group of Research in Care (GRUPAC), Faculty of Health Sciences, University of La Rioja, Logroño, 26006, Spain
| | - Donata Kurpas
- Division of Research Methodology, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Bartla 5, Wroclaw, 51-618, Poland
| | - Maria Jedrzejczyk
- Division of Research Methodology, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Bartla 5, Wroclaw, 51-618, Poland
| | - Marta Wleklik
- Division of Research Methodology, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Bartla 5, Wroclaw, 51-618, Poland
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13
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Tersalvi G, Beltrani V, Peronti M, Furlan L, Foy A, Biasco L. Deprescribing strategies in older patients with heart failure. Intern Emerg Med 2025; 20:599-609. [PMID: 39406965 DOI: 10.1007/s11739-024-03791-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Accepted: 10/01/2024] [Indexed: 03/28/2025]
Abstract
Older patients with heart failure are particularly vulnerable due to a wide range of associated comorbidities, disability, and frailty. This population often receives multiple prescriptions, increasing the risk of adverse drug reactions, non-adherence, and drug interactions. Deprescribing, which involves reducing the number of medications to the lowest clinically reasonable limit, has the potential to decrease the risk of drug interactions and enhance patients' quality of life. Moreover, simplifying medication regimens may improve adherence to essential heart failure therapies. This scientific review aims to comprehensively examine deprescribing strategies in older patients with heart failure. It explores the rationale, challenges, benefits, and potential approaches to optimizing medication regimens in this vulnerable population. Furthermore, the review suggests a practical, step-by-step approach for performing deprescribing in older patients with heart failure.
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Affiliation(s)
- Gregorio Tersalvi
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Mendrisio, Switzerland.
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Vittorio Beltrani
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Mendrisio, Switzerland
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Marco Peronti
- Division of Geriatrics, Ente Ospedaliero Cantonale, Mendrisio, Switzerland
| | - Ludovico Furlan
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Andrew Foy
- Division of Cardiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Luigi Biasco
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Azienda Sanitaria Locale Torino 4, Ciriè, Turin, Italy
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14
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Singh AK, Singh A, Singh R. Have SGLT-2 inhibitors DELIVERed an EMPhatic win in heart failure and chronic kidney disease? Expert Opin Pharmacother 2025; 26:457-472. [PMID: 39918955 DOI: 10.1080/14656566.2025.2464905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2024] [Revised: 02/02/2025] [Accepted: 02/05/2025] [Indexed: 02/09/2025]
Abstract
INTRODUCTION Major global guidelines currently recommend sodium-glucose co-transporter-2 inhibitors (SGLT-2i) as the first-line agent in people with type 2 diabetes (T2D) who have either established cardiovascular disease (eCVD), heart failure (HF), or chronic kidney disease (CKD), regardless of baseline glycated hemoglobin (HbA1c). Moreover, SGLT-2i are currently included in guideline-directed medical therapy as one of the pillars for people with HF and CKD, regardless of T2D. These recommendations are based on positive cardio-renal outcomes from several randomized controlled trials (RCTs). AREAS COVERED Following an extensive search in electronic databases of PubMed, Google Scholar, and clinicaltrials.gov, we critically analyzed the RCTs that assessed cardio-renal outcome trials of SGLT-2i and put a perspective on how SGLT-2i delivered an emphatic win for people with HF and CKD, with or without T2D. EXPERT OPINION From thirteen high-quality RCTs, including five cardiovascular outcome trials, five HF outcome trials, three renal outcome trials, and a pooled meta-analysis, it is evident that SGLT-2i has delivered an emphatic win in people with HF and CKD, with or without T2D, with an acceptable safety profile. Ongoing RCTs shall further enlighten whether SGLT-2i will be effective in polycystic kidney disease, lupus nephritis, vasculitis, end-stage CKD with or without hemodialysis, and renal transplant.
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Affiliation(s)
- Awadhesh Kumar Singh
- Department of Diabetes & Endocrinology, G. D Hospital & Diabetes Institute, Kolkata, India
- Department of Diabetes & Endocrinology, Sun Valley Hospital & Diabetes Research Center, Guwahati, India
- Department of Medicine, Horizon Life Line Multispecialty Hospital, Kolkata, India
- Department of Diabetes & Endocrinology, Institute of Medical Science & SUM Hospital, Bhubaneswar, India
| | - Akriti Singh
- Department of Medicine, KPC Medical College & Hospital, Jadavpur, India
| | - Ritu Singh
- Department of Medicine, Horizon Life Line Multispecialty Hospital, Kolkata, India
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15
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Abassi NK, Nouhravesh N, Elmegaard M, Austreim M, Zahir D, Garred CH, Butt JH, Andersen CF, Strange JE, Sindet‐Pedersen C, Christensen DM, Fosbøl E, Andersson C, Køber L, Schou M. Temporal Trends in Mortality and Hospitalization Risk in Patients With Heart Failure According to the Hospital Frailty Risk Score. J Am Heart Assoc 2025; 14:e037973. [PMID: 39895527 PMCID: PMC12074740 DOI: 10.1161/jaha.124.037973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Accepted: 12/31/2024] [Indexed: 02/04/2025]
Abstract
BACKGROUND Heart failure (HF) and frailty often coexist. However, it is unknown how the interplay between HF and frailty at HF onset impacts prognosis of frail patients with HF and how this has evolved over time. METHODS AND RESULTS We identified 131 235 patients with new-onset HF (median age 74 years, 39.7% women) from Danish nationwide registers in 1999 to 2017. Stratification according to the Hospital Frailty Risk Score resulted in (1) 102 635 (78%) nonfrail, (2) 26 054 (20%) moderately frail, and (3) 2609 (2%) severely frail patients. The proportion of moderately frail patients increased from 13.2% to 24.9%. Five-year absolute risks of all-cause mortality, HF hospitalization, and non-HF hospitalization were calculated using the Kaplan-Meier and Aalen-Johansen estimators. From 1999 to 2002 to 2003 to 2017, all-cause mortality risk (95% CI) declined from 56.4% (55.8%-57.0%) to 33.3% (32.6%-34.1%), 79.8% (78.5%-81.0%) to 58.6% (57.2%-60.1%), and 90.8% (85.6%-96.0%) to 79.8% (76.4%-83.2%) in nonfrail, moderately frail, and severely frail patients, respectively. HF hospitalization risk remained almost constant over the study period. Non-HF hospitalization risk declined from 74.0% (73.5%-74.5%) to 65.8% (65.0%-66.5%) in nonfrail patients and remained stable overall in moderately frail and severely frail patients over the study period. CONCLUSIONS We observed an increase in frail patients. Mortality decreased for all frailty groups but remained high for severely frail patients. These findings indicate the need for further evidence on the optimization of care for frail patients with HF, and future research should address the development of comprehensive management strategies, integrating frailty assessment into standard clinical care and focused care for older patients with HF.
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Affiliation(s)
- Noor K. Abassi
- Department of CardiologyHerlev‐Gentofte University HospitalCopenhagenDenmark
| | - Nina Nouhravesh
- Department of CardiologyHerlev‐Gentofte University HospitalCopenhagenDenmark
| | - Mariam Elmegaard
- Department of CardiologyHerlev‐Gentofte University HospitalCopenhagenDenmark
| | - Marte Austreim
- Department of CardiologyHerlev‐Gentofte University HospitalCopenhagenDenmark
| | - Deewa Zahir
- Department of CardiologyHerlev‐Gentofte University HospitalCopenhagenDenmark
| | | | - Jawad H. Butt
- Department of CardiologyRoskilde HospitalRoskildeDenmark
- Department of Cardiology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | | | - Jarl E. Strange
- Department of CardiologyHerlev‐Gentofte University HospitalCopenhagenDenmark
| | | | | | - Emil Fosbøl
- Department of Cardiology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Charlotte Andersson
- Cardiovascular DivisionBrigham & Women’s hospital and Harvard Medical SchoolBostonMAUSA
| | - Lars Køber
- Department of Cardiology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Morten Schou
- Department of CardiologyHerlev‐Gentofte University HospitalCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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16
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Hashemi A, Kwak MJ, Goyal P. Pharmacologic Management of Heart Failure with Preserved Ejection Fraction (HFpEF) in Older Adults. Drugs Aging 2025; 42:95-110. [PMID: 39826050 DOI: 10.1007/s40266-024-01165-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2024] [Indexed: 01/20/2025]
Abstract
There are several pharmacologic agents that have been touted as guideline-directed medical therapy for heart failure with preserved ejection fraction (HFpEF). However, it is important to recognize that older adults with HFpEF also contend with an increased risk for adverse effects from medications due to age-related changes in pharmacokinetics and pharmacodynamics of medications, as well as the concurrence of geriatric conditions such as polypharmacy and frailty. With this review, we discuss the underlying evidence for the benefits of various treatments in HFpEF and incorporate key considerations for older adults, a subpopulation that may be at higher risk for adverse drug events. Key considerations for older adults include: the use of loop diuretics, mineralocorticoid receptor antagonists (MRAs), and sodium glucose co-transporter-2 (SGLT2) inhibitors for most; angiotensin receptor blockers/ angiotensin receptor-neprilysin inhibitors (ARB/ARNIs) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) as add-on therapies for some, though risk of geriatric conditions such as falls, malnutrition, and/or sarcopenia must be considered; and beta blockers for a smaller subset of patients (with consideration of deprescribing for some, though data are lacking on this approach). Naturally, when making clinical decisions for older adults with cardiovascular disease, it is critical to consider the complexity of their conditions, including cognitive and physical function and social and environmental factors, and ensure alignment of care plans with the patient's health goals and priorities.
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Affiliation(s)
- Ashkan Hashemi
- Program for the Care and Study of the Aging Heart, Department of Medicine, Weill Cornell Medicine, 420 East 70th St, New York, NY, LH-36510063, USA
| | - Min Ji Kwak
- Division of Geriatric and Palliative Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
| | - Parag Goyal
- Program for the Care and Study of the Aging Heart, Department of Medicine, Weill Cornell Medicine, 420 East 70th St, New York, NY, LH-36510063, USA.
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17
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Theodorakis N, Hitas C, Vamvakou G, Kalantzi S, Spyridaki A, Kollia Z, Feretzakis G, Nikolaou M. Complexities in Geriatric Cardiology: Clinical Dilemmas and Gaps in Evidence. J Geriatr Cardiol 2025; 22:190-209. [PMID: 40151630 PMCID: PMC11937829 DOI: 10.26599/1671-5411.2025.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2025] Open
Abstract
Cardiovascular diseases (CVD) are undoubtedly the leading cause of morbidity and mortality in the elderly. Population aging is a global phenomenon. In developed countries, by the year 2050 one in four people will be aged 65+ years. This ongoing growth of the aging population leads to an increasing burden of CVD. The management of CVD in geriatric patients requires specific considerations. Aging is associated with complex pathophysiology due to decreased organ reserve, which is clinically described as frailty. Additionally, the aging population is extremely heterogenous and frequently characterized by a combination of unique features, including atypical disease presentation, multimorbidity, polypharmacy, altered pharmacokinetics, cognitive impairment, renal impairment, dysautonomia, elevated risk of falls, sarcopenia, and frailty. Furthermore, significant gaps in evidence exist largely due to the limited representation of the very elderly, and especially frail patients, in randomized controlled trials. When combined with issues related to life expectancy, goals of care, bioethics, and patients' preferences, these factors pose intricate challenges for healthcare providers. This literature review summarizes selected clinical scenarios that often introduce dilemmas in the management of elderly patients in cardiology practice, emphasizing the intersection of geriatric medicine and cardiology. These include blood pressure management, management of dyslipidemia, anticoagulation in atrial fibrillation, medical and device treatment of heart failure, antiplatelet and interventional management of acute coronary syndromes, and peri-procedural considerations in severe aortic stenosis. The above will provide guidance for clinical practice, as well as implications for health policies and future research in the field of geriatric cardiology.
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Affiliation(s)
- Nikolaos Theodorakis
- Department of Cardiology, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
- School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527 Athens, Greece
| | - Christos Hitas
- Department of Cardiology, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
| | - Georgia Vamvakou
- Department of Cardiology, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
| | - Sofia Kalantzi
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
- Department of Internal Medicine, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
| | - Aikaterini Spyridaki
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
- Department of Internal Medicine, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
| | - Zoi Kollia
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
| | - Georgios Feretzakis
- School of Science and Technology, Hellenic Open University, 18 Aristotelous Str., 26335 Patras, Greece
| | - Maria Nikolaou
- Department of Cardiology, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
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18
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Sinclair AJ, Abdelhafiz AH. The Use of SGLT-2 Inhibitors and GLP-1RA in Frail Older People with Diabetes: A Personalised Approach Is Required. Metabolites 2025; 15:49. [PMID: 39852391 PMCID: PMC11767933 DOI: 10.3390/metabo15010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Revised: 12/30/2024] [Accepted: 01/11/2025] [Indexed: 01/26/2025] Open
Abstract
Background: Frailty is an increasingly recognised complication of diabetes in older people and should be taken into consideration in management plans, including the use of the new therapies of sodium glucose cotransporter-2 (SGLT-2) inhibitors and glucagon like peptide-1 receptor agonists (GLP-1RA). The frailty syndrome appears to span across a spectrum, from a sarcopenic obese phenotype at one end, characterised by obesity, insulin resistance, and prevalent cardiovascular risk factors, to an anorexic malnourished phenotype at the other end, characterised by significant weight loss, reduced insulin resistance, and less prevalent cardiovascular risk factors. Therefore, the use of the new therapies may not be suitable for every frail older individual with diabetes. Objectives: To review the characteristics and phenotype of frail older people with diabetes who should benefit from the use of SGLT-2 inhibitors or GLP-1RA. Methods: A narrative review of the studies investigating the benefits of SGLT-2 inhibitors and GLP-1RA in frail older people with diabetes. Results: The current evidence is indirect, and the literature suggests that the new therapies are effective in frail older people with diabetes and the benefit appears to be proportional with the severity of frailty. However, frail patients described in the literature who benefited from such therapy appeared to be either overweight or obese, and to have a higher prevalence of unfavourable metabolism and cardiovascular risk factors such as dyslipidaemia, gout, and hypertension compared to non-frail subjects. They also have a higher prevalence of established cardiovascular disease compared with non-frail individuals. In absolute terms, their higher cardiovascular baseline risk meant that they benefited the most from such therapy. The characteristics of this group of frail patients fulfil the criteria of the sarcopenic obese frailty phenotype, which is likely to benefit most from the new therapies due to the unfavourable metabolic profile of this phenotype. There is no current evidence to suggest the benefit of the new therapies in the anorexic malnourished phenotype, which is underrepresented or totally excluded from these studies, such as in patients living in care homes. This phenotype is likely to be intolerant to such therapy due to its associated risk of inducing further weight loss, dehydration, and hypotension. Conclusions: Clinicians should consider the early use of the new therapies in frail older people with diabetes who are either of normal weight, overweight, or obese with prevalent cardiovascular risk factors, and avoid their use in those frail subjects who ae underweight, anorexic, and malnourished.
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Affiliation(s)
- Alan J. Sinclair
- King’s College, London WC2R 2LS, UK;
- Foundation for Diabetes Research in Older People (fDROP), Diabetes Frail Ltd., Droitwich Spa WR9 0QH, UK
| | - Ahmed H. Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK
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19
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Nguyen TN, Ahmad F, Lindley RI. Frailty in clinical drug trials: Frailty assessments, subgroup analyses and outcomes. Br J Clin Pharmacol 2025; 91:8-22. [PMID: 38509766 PMCID: PMC11671326 DOI: 10.1111/bcp.16034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/23/2023] [Accepted: 01/18/2024] [Indexed: 03/22/2024] Open
Abstract
With population ageing, drug trials are increasingly turning their attention to including older, frailer people. This review aimed to provide an overview of how frailty was assessed in published studies related to clinical pharmacological trials, and on the interaction of frailty on the efficacy of the treatments. We searched MEDLINE, EMBASE and Cochrane for clinical drug trials in older people. A total of 4031 abstracts were screened and 17 relevant studies were included in this review. We summarized the findings of these 17 trials into five main clinical areas: cardiovascular (eight studies), cognition (one study), vaccination (two studies), cancer (four studies) and other (two studies). Frailty was assessed retrospectively in most of the studies. Frailty was treated as an ordinal variable (with different levels of frailty) or binary variable (frail/non-frail) using cut-offs in some studies, and as a continuous in some other studies. The effect of frailty on the treatment efficacy was not consistent among the studies. While several trials, such as the Action in Diabetes and Vascular Disease-Preterax and Diamicron Modified Release Controlled Evaluation trials, the Systolic Blood Pressure Intervention Trial and the Aspirin in Reducing Events in the Elderly trial, showed some reduced effects of the treatment in frail patients, most of the trials showed that the benefits of the treatment are not affected by frailty. Some trials even showed that the benefits of the treatment were more significant in frailer patients (the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure and the Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure trials). The results of this review suggest that routine measurement of frailty in participants in clinical drug trials would improve our knowledge of the effect of treatment in the frail and identify those who have more or least to gain from treatment.
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Affiliation(s)
- Tu N. Nguyen
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
| | - Fahed Ahmad
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
| | - Richard I. Lindley
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
- George Institute for Global HealthSydneyNew South WalesAustralia
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20
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Goyal P, Chen L, Lau JD, Rosenson RS, Levitan EB. Reductions in renin-angiotensin system inhibitors following hospitalization for heart failure. ESC Heart Fail 2024; 11:3862-3871. [PMID: 39030944 PMCID: PMC11631335 DOI: 10.1002/ehf2.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 04/29/2024] [Accepted: 06/23/2024] [Indexed: 07/22/2024] Open
Abstract
AIMS Limited data are available that evaluate the efficacy of renin-angiotensin system inhibitor (RASI) dose-reduction in older adults with heart failure with reduced ejection fraction following a heart failure hospitalization. METHODS AND RESULTS We examined a 5% random sample of Medicare beneficiaries with prescription coverage who were discharged to home following a hospitalization for heart failure with reduced ejection fraction between 1 January 2007 and 30 June 2018 and were treated with RASI prior to hospitalization. We classified patients into three mutually exclusive groups based on RASI dosage before (prescription fills up to 90 days prior to) and after a hospitalization (prescription fills up to 365 days that were most proximate to the discharge date as possible)-same/increased dose, dose-reduction, and discontinuation. We examined associations between RASI prescribing patterns and outcomes (mortality and all-cause readmission at 30 days and 1 year) using Cox proportional hazards models. Among 12 794 unique older adults, 36.8% experienced a RASI reduction following their hospitalization for HFrEF-15.7% had a dose-reduction and 21.1% had a discontinuation. Neither dose-reduction nor discontinuation was associated with 30-day mortality. Discontinuation was associated 1-year mortality, 30-day all-cause readmission, and 1-year all-cause readmission, whereas dose-reduction was not. CONCLUSION RASI dose-reduction occurs in 1 out of 7 HF hospitalizations. In contrast to RASI discontinuation, RASI dose-reduction was not associated with adverse short or long-term outcomes. These findings indicate that RASI dose-reduction is preferred over RASI discontinuation in selected situations where RASI reduction is needed.
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Affiliation(s)
- Parag Goyal
- Department of MedicineWeill Cornell MedicineNew YorkNYUSA
| | - Ligong Chen
- Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamALUSA
| | | | | | - Emily B. Levitan
- Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamALUSA
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21
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Zhong L, Thanapluetiwong S, Xu K, Ko D, Kim DH. Assessing Frailty-Specific Treatment Effect in Cardiovascular Disease: A Systematic Review. Drugs Aging 2024; 41:945-958. [PMID: 39585601 PMCID: PMC11884329 DOI: 10.1007/s40266-024-01157-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2024] [Indexed: 11/26/2024]
Abstract
BACKGROUND Clinicians are increasingly considering using frailty assessments to individualize treatment for older patients. It remains uncertain whether interventions to reduce cardiovascular disease (CVD) events offer similar benefits between older adults with and without frailty. METHODS A systematic literature search was undertaken in PubMed and Embase, adhering to PRISMA guidelines. Key inclusion criteria were randomized controlled trials published between January 2007 and September 2024 with CVD outcomes as an endpoint and data on frailty-specific treatment effects. Data were collected for population characteristics, intervention, follow-up time, frailty measure, outcome rates, and frailty subgroup treatment effect. Due to heterogeneity among the studies, the results were not pooled. RESULTS The search identified 151 unique studies, of which 18 were included. Using Cochrane Risk of Bias 2.0, 12 out of the 18 studies have low risk of bias. The intervention was more effective in frail participants than in non-frail counterparts in two studies (e.g., aerobic exercise), less effective in frail participants in three studies (e.g., intensive lifestyle intervention), similarly effective across frailty levels in seven studies (e.g., prasugrel), and inconclusive in six studies (e.g., edoxaban). Some treatments were similarly effective across frailty level by hazard ratio but had a greater reduction in absolute risk for frail versus non-frail patients. CONCLUSIONS Cardiovascular interventions may provide differential benefits by patients' frailty. These findings suggest the potential utility of frailty assessment for optimizing cardiovascular interventions.
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Affiliation(s)
- Lily Zhong
- University of Connecticut School of Medicine, Farmington, CT, USA.
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA.
| | - Saran Thanapluetiwong
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Kailin Xu
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
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22
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Wang C, Guan L, Han S, Tong F, Li Y, Li Z, Sun H, Sun Z. Systematic review and meta-analysis to predict mortality in heart failure with preserved ejection fraction: Development and validation of the HF-DANAS score. ESC Heart Fail 2024; 11:4104-4115. [PMID: 39118428 PMCID: PMC11631325 DOI: 10.1002/ehf2.15008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 06/25/2024] [Accepted: 07/15/2024] [Indexed: 08/10/2024] Open
Abstract
AIMS The morbidity and mortality of heart failure with preserved ejection fraction (HFpEF) continue to increase with the accelerating global aging process. During the past decade, the pathophysiology, diagnostic methods, and prognostic prediction of HFpEF have been revolutionized, resulting in new and effective management strategies. Dynamic prognostic assessment facilitates systematic clinical management of patients, and the aim of this study was to investigate the risk factors for mortality in patients with HFpEF and to develop a risk prediction assessment model. METHODS AND REULTS Data for the derivation cohort were obtained from three databases, PubMed, Embase, and Cochrane. The validation cohort was obtained from the Chinese Heart Failure Center database. The β-coefficient was calculated based on the risk ratio (RR) and 95% confidence intervals (CI) corresponding to each risk factor to construct a mortality risk assessment model. A total of 30 studies were included in the meta-analysis: 22 prospective cohort studies and 8 retrospective cohort studies, including 34 196 HFpEF patients. Seven predictors of all-cause mortality in HFpEF patients were derived. Considering the need for feasibility in clinical practice, we performed subgroup and sensitivity analyses and determined the following cutoff values: age > 75 years (RR: 2.07, 95% CI: 1.83-2.35; P < 0.001), male sex (RR: 1.36, 95% CI: 1.17-1.59; P < 0.001), DM (RR: 1.23, 95% CI: 1.11-1.36; P < 0.001), anaemia (RR: 1.53, 95% CI: 1.41-1.67; P < 0.001), albumin concentration < 3.2 g/dL (RR: 1.29, 95% CI: 1.14-1.47; P < 0.001), AF (RR: 1.27, 95% CI: 1.12-1.43; P < 0.001), and NYHA class III/IV (RR: 1.63, 95% CI: 1.43-1.87; P < 0.001). The area under the receiver operating characteristic (ROC) curve (AUC) for this model was 71.3% (95% CI: 0.696-0.736), with an optimal cut-off value of 10.75. The sensitivity and specificity were 0.778 and 0.566, respectively. According to this risk score, we divided patients into three risk classes (low, moderate, and high risk), the numbers of patients who died by the end of the 1-year follow-up were 23 (1.87%), 82 (5.62%), and 382 (15.52%) in these three groups, and the 5-year mortality rates were 9.82%, 20.68%, and 43.28%, respectively. CONCLUSIONS This study developed an HF-DANAS scoring system for the HFpEF mortality risk containing seven predictors, providing clinicians with a simple assessment tool that can help improve clinical management.
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Affiliation(s)
- Chuanhe Wang
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Lin Guan
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Su Han
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Fei Tong
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Ying Li
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Zhichao Li
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
| | - Hao Sun
- Department of Clinical Epidemiology and Evidence‐Based MedicineThe First Hospital of China Medical UniversityShenyangChina
| | - Zhijun Sun
- Department of CardiologyShengjing Hospital of China Medical UniversityShenyangChina
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23
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Woodford HJ, McKenzie D, Pollock LM. Appropriate management of heart failure in older people with frailty. BMJ 2024; 387:e078188. [PMID: 39592163 DOI: 10.1136/bmj-2023-078188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2024]
Affiliation(s)
- Henry John Woodford
- Elderly Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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24
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Sargeant JA, Ahmad E, James E, Baker L, Bilak JM, Coull NA, Gulsin GS, King JA, Khunti K, Redman E, Rowlands A, Watson E, Wormleighton JV, McCann GP, Yates T, Davies MJ. Impact of exercise training in combination with dapagliflozin on physical function in adults with type 2 diabetes mellitus: study protocol for the Dapagliflozin, Exercise Training and physicAl function (DETA) randomised controlled trial. BMJ Open 2024; 14:e084482. [PMID: 39592159 PMCID: PMC11590848 DOI: 10.1136/bmjopen-2024-084482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 10/21/2024] [Indexed: 11/28/2024] Open
Abstract
INTRODUCTION Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are associated with weight loss, diverse cardiorenal benefits and improved glycaemic control. However, the effects of SGLT2i on physical function and fitness are uncertain. The Dapagliflozin, Exercise Training and physicAl function trial investigates whether the SGLT2i dapagliflozin, alone or in combination with structured exercise training, improves physical function compared with diet-induced weight loss in adults with type 2 diabetes mellitus (T2DM), overweight/obesity and impaired physical function. METHODS AND ANALYSIS This single-centre randomised controlled trial will assign 1:1:1, 135 adults with T2DM and low physical function to receive one of three treatments: (1) dapagliflozin (10 mg once-daily) alone, (2) dapagliflozin (10 mg once-daily) plus structured exercise training or (3) diet control (where participants are supported to achieve 3% weight loss, equivalent to estimated weight loss with dapagliflozin treatment). Primary and secondary outcomes will be assessed at baseline, 12 and 24 weeks. The primary outcome is the difference in physical function, assessed using the modified Physical Performance Test, between the treatment groups and diet control at 24 weeks. Secondary outcomes include MRI-measured cardiac structure and function, maximal aerobic capacity, resting metabolic rate, device-measured physical activity and sleep, body composition, haemoglobin A1c and cardiovascular risk markers. ETHICS AND DISSEMINATION The Heath Research Authority (HRA) and the Medicines and Healthcare Products Regulatory Authority (MHRA) Research Ethics Committee have approved the study. The findings of the study will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN11459997. EUDRACT NUMBER 2019-004586-41.
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Affiliation(s)
- Jack A Sargeant
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Ehtasham Ahmad
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Emily James
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Luke Baker
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Joanna M Bilak
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Nicole A Coull
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Gaurav Singh Gulsin
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - James A King
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- National Centre of Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| | - Kamlesh Khunti
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- NIHR Applied Research Collaboration East Midlands, Leicester, UK
| | - Emma Redman
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Alex Rowlands
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Emma Watson
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joanne V Wormleighton
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gerry P McCann
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Thomas Yates
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Melanie J Davies
- NIHR Leicester Biomedical Research Centre, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
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Kim DH. Unleashing frailty from laboratory into real world: A critical step toward frailty-guided clinical care of older adults. J Am Geriatr Soc 2024; 72:3299-3314. [PMID: 39166879 PMCID: PMC11560722 DOI: 10.1111/jgs.19151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/21/2024] [Accepted: 06/30/2024] [Indexed: 08/23/2024]
Abstract
Understanding patients' degree of frailty is crucial for tailoring clinical care for older adults based on their physiologic reserve and health needs ("frailty-guided clinical care"). Two prerequisites for frailty-guided clinical care are: (1) access to frailty information at the point of care and (2) evidence to inform decisions based on frailty information. Recent advancements include web-based frailty assessment tools and their electronic health records integration for time-efficient, standardized assessments in clinical practice. Additionally, database frailty scores from administrative claims and electronic health records data enable scalable assessments and evaluation of the effectiveness and safety of medical interventions across different frailty levels using real-world data. Given limited evidence from clinical trials, real-world database studies can complement trial results and help treatment decisions for individuals with frailty. This article, based on the Thomas and Catherine Yoshikawa Award lecture I gave at the American Geriatrics Society Annual Meeting in Long Beach, California, on May 5, 2023, outlines our group's contributions: (1) developing and integrating a frailty index calculator (Senior Health Calculator) into the electronic health records at an academic medical center; (2) developing a claims-based frailty index for Medicare claims; (3) applying this index to evaluate the effect of medical interventions for patients with and without frailty; and (4) efforts to disseminate frailty assessment tools through the launch of the eFrailty website and the forthcoming addition of the claims-based frailty index to the Centers for Medicare and Medicaid Services Chronic Conditions Data Warehouse. This article concludes with future directions for frailty-guided clinical care.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Alsuwayh AF, Altawili M, Alhazmi MF, Alotaibi DFM, Rashed AO, Obaid Abdullah AH, Alkenani AAN, Almohammdi RAS, Alotaibi HFM, Mohamed Alsharif FEA. Potential of Sodium-Glucose Cotransporter-2 Inhibitors in the Management of Heart Failure With Preserved Ejection Fraction: A Narrative Review. Cureus 2024; 16:e73906. [PMID: 39697908 PMCID: PMC11653976 DOI: 10.7759/cureus.73906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2024] [Indexed: 12/20/2024] Open
Abstract
Heart failure with preserved ejection fraction presents a major clinical challenge due to its complex pathophysiology and limitations in its therapeutic options. This comprehensive review explores the comparative effectiveness of sodium-glucose cotransporter-2 inhibitors, focusing on their impact on diabetic versus non-diabetic patients, individuals with chronic kidney disease, and the elderly. A comprehensive literature search identified randomized controlled trials, meta-analyses, and clinical studies that evaluated the role of sodium-glucose cotransporter-2 inhibitors in managing heart failure with preserved ejection fraction. Findings indicate that sodium-glucose cotransporter-2 inhibitors significantly reduce heart failure hospitalizations and cardiovascular mortality. Among chronic kidney disease patients with heart failure with preserved ejection fraction, sodium-glucose cotransporter-2 inhibitors showed a decrease in the risk of cardiovascular mortality and hospitalization. Furthermore, their use in elderly patients was associated with improved health-related quality of life and cognitive function, with no notable increase in adverse events. Clinical guidelines increasingly recommend sodium-glucose cotransporter-2 inhibitors as part of heart failure with preserved ejection fraction management. However, further research is required to refine patient-specific strategies and explore additional benefits, such as their cardioprotective role post-myocardial infarction. This review highlights the effectiveness of sodium-glucose cotransporter-2 inhibitors in managing heart failure with preserved ejection fraction across various subgroups. Additionally, integrating these agents into clinical practice has significant potential to improve patient outcomes.
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27
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Mayne KJ, Hanlon P, Lees JS. Detecting and managing the patient with chronic kidney disease in primary care: A review of the latest guidelines. Diabetes Obes Metab 2024; 26 Suppl 6:43-54. [PMID: 38699995 DOI: 10.1111/dom.15625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
Chronic kidney disease (CKD) is a major global health problem, affecting about 9.5% of the population and 850 million people worldwide. In primary care, most CKD is caused by diabetes and/or hypertension, but a substantial proportion of cases may have alternative causes. During the early stages, CKD is asymptomatic, and many people are unaware that they are living with the disease. Despite the lack of symptoms, CKD is associated with elevated risks of cardiovascular disease, progressive kidney disease, kidney failure and premature mortality. Risk reduction strategies are effective and cost-effective but require early diagnosis through testing of the estimated glomerular filtration rate and albuminuria in high-risk populations. Once diagnosed, the treatment of CKD centres around lifestyle interventions, blood pressure and glycaemic control, and preventative treatments for cardiovascular disease and kidney disease progression. Most patients with CKD should be managed with statins, renin-angiotensin-aldosterone system inhibitors and sodium-glucose cotransporter-2 inhibitors. Additional treatment options to reduce cardiorenal risk are available in patients with diabetes, including glucagon-like peptide-1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists. The Kidney Failure Risk Equation is a new tool that can support the identification of patients at high risk of progressive kidney disease and kidney failure and can be used to guide referrals to nephrology. This review summarizes the latest guidance relevant to managing adults with, or at risk of, CKD and provides practical advice for managing patients with CKD in primary care.
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Affiliation(s)
- Kaitlin J Mayne
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Peter Hanlon
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jennifer S Lees
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, NHS Greater Glasgow and Clyde, Glasgow, UK
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28
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van Deutekom C, Hendriks JML, Myrstad M, Van Gelder IC, Rienstra M. Managing elderly patients with atrial fibrillation and multimorbidity: call for a systematic approach. Expert Rev Cardiovasc Ther 2024; 22:523-536. [PMID: 39441182 DOI: 10.1080/14779072.2024.2416666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 10/10/2024] [Indexed: 10/25/2024]
Abstract
INTRODUCTION Atrial fibrillation (AF) is often accompanied by comorbidities. Not only cardiovascular but also non-cardiovascular comorbidities have been associated with AF. Multimorbidity is therefore a common finding in patients with AF, especially in elderly patients. Multimorbidity is associated with adverse outcomes, adds complexity to AF management, and poses a significant burden on healthcare costs. It is expected that the prevalence of elderly patients with multimorbidity will increase significantly. It is therefore crucial to outline implications for clinical practice and guide comprehensive multimorbidity management. AREAS COVERED This perspective article outlines multimorbidity in AF and the importance of comprehensive comorbidity management. It addresses current clinical practice guided by international guidelines and the need for integrated care including a patient-centered focus, comprehensive AF management, coordinated multidisciplinary care, and supporting technology. Moreover, it proposes a novel model of care delivery following a systematic approach to multimorbidity management. EXPERT OPINION Providing comprehensive care by means of a multidisciplinary team and patient engagement is crucial to provide optimal personalized care for elderly patients with AF and multimorbidity. A systematic integrated care approach seems promising, but further studies are needed to investigate the feasibility of a systematic approach and prioritization of comorbidity management in patients with multimorbidity.
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Affiliation(s)
- Colinda van Deutekom
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jeroen M L Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Marius Myrstad
- Department of Internal Medicine, Bærum Hospital Vestre Viken Hospital Trust, Gjettum, Norway
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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29
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Mayne KJ, Sardell RJ, Staplin N, Judge PK, Zhu D, Sammons E, Cherney DZ, Cheung AK, Maggioni AP, Nangaku M, Rossello X, Tuttle KR, Ihara K, Iwata T, Wanner C, Emberson J, Preiss D, Landray MJ, Baigent C, Haynes R, Herrington WG. Frailty, Multimorbidity, and Polypharmacy: Exploratory Analyses of the Effects of Empagliflozin from the EMPA-KIDNEY Trial. Clin J Am Soc Nephrol 2024; 19:1119-1129. [PMID: 40179340 PMCID: PMC11390031 DOI: 10.2215/cjn.0000000000000498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/24/2024] [Indexed: 07/03/2024]
Abstract
Background Sodium-glucose cotransporter-2 inhibitors are recommended treatment for adults with CKD, but uncertainty exists regarding their use in patients with frailty and/or multimorbidity, among whom polypharmacy is common. We derived a multivariable logistic regression model to predict hospitalization (reflecting frailty) and assessed empagliflozin's risk–benefit profile in a post hoc analysis of the double-blind, placebo-controlled EMPA-KIDNEY trial. Methods The EMPA-KIDNEY trial randomized 6609 patients with CKD (eGFR ≥20 to <45 ml/min per 1.73 m2, or ≥45 to <90 ml/min per 1.73 m2 with urinary albumin-to-creatinine ratio ≥200 mg/g) to receive either empagliflozin 10 mg daily or matching placebo and followed them for 2 years (median). Additional characteristics analyzed in subgroups were multimorbidity, polypharmacy, and health-related quality of life at baseline. Cox regression analyses were performed with subgroups defined by approximate thirds of each variable. Results The strongest predictors of hospitalization were N-terminal prohormone of brain natriuretic peptide, poor mobility, and diabetes and then eGFR and other comorbidities. Empagliflozin was generally well tolerated independent of predicted risk of hospitalization. In relative terms, allocation to empagliflozin reduced the risk of the primary outcome of kidney disease progression or cardiovascular death by 28% (hazard ratio, 0.72; 95% confidence interval, 0.64 to 0.82) and all-cause hospitalization by 14% (hazard ratio, 0.86; 95% confidence interval, 0.78 to 0.95), with broadly consistent effects across subgroups of predicted risk of hospitalization, multimorbidity, polypharmacy, or health-related quality of life. In absolute terms, the estimated benefits of empagliflozin were greater in those at highest predicted risk of hospitalization (reflecting frailty) and outweighed potential serious harms. Conclusions These findings support the use of sodium-glucose cotransporter-2 inhibitors in CKD, irrespective of frailty, multimorbidity, or polypharmacy.
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Affiliation(s)
- Kaitlin J. Mayne
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Rebecca J. Sardell
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Natalie Staplin
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Parminder K. Judge
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Doreen Zhu
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Emily Sammons
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | | | - Aldo P. Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Centre, Florence, Italy
| | | | - Xavier Rossello
- Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain
| | - Katherine R. Tuttle
- University of Washington, Seattle, Washington
- Providence Inland Northwest Health, Spokane, Washington
| | - Katsuhito Ihara
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd., Tokyo, Japan
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Christoph Wanner
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jonathan Emberson
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - David Preiss
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Martin J. Landray
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Colin Baigent
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Richard Haynes
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - William G. Herrington
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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30
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Hilmer SN, Schwartz J, Petrovic M, Walker LE, Thürmann P, Le Couteur DG. Addressing the gaps in evaluation of new drugs for older adults: Strategies from the International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee. J Am Geriatr Soc 2024; 72:2942-2950. [PMID: 38485461 DOI: 10.1111/jgs.18826] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 09/03/2024]
Abstract
The International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee aims to improve the use of drugs in older adults and develop new therapeutic approaches for the syndromes and diseases of old age through advocacy, education, and research. In the present paper, we propose strategies relevant to drug development and evaluation, spanning preclinical and the full range of clinical studies. Drugs for older adults need to consider not only age, but also other characteristics common in geriatric patients, such as multimorbidity, polypharmacy, falls, cognitive impairment, and frailty. The IUPHAR Geriatric Committee's position statement on 'Measurement of Frailty in Drug Development and Evaluation' is included, highlighting 12 key principles that cover the spectrum of translational research. We propose that where older adults are likely to be major users of a drug, that frailty is measured at baseline and as an outcome. Preclinical models that replicate the age, frailty, duration of exposure, comorbidities, and co-medications of the proposed patients may improve translation. We highlight the potential application of recent technologies, such as physiologically based pharmacokinetic-pharmacodynamic modeling informed by frailty biology, and Artificial Intelligence, to inform personalized medicine for older patients. Considerations for the rapidly aging populations in low- and middle-income countries related to health-care and clinical trials are outlined. Involving older adults, their caregivers and health-care providers in all phases of research should improve drug development, evaluation, and outcomes for older adults internationally.
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Affiliation(s)
- Sarah N Hilmer
- Kolling Institute, The University of Sydney and Northern Sydney Local Health District, St Leonards, New South Wales, Australia
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
| | - Janice Schwartz
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Divisions of Geriatrics and Clinical Pharmacology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Mirko Petrovic
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Lauren E Walker
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK
| | - Petra Thürmann
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Helios University Hospital Wuppertal, Chair of Clinical Pharmacology, University Witten/Herdecke, Witten, Germany
| | - David G Le Couteur
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Centre for Education and Research on Ageing, University of Sydney and Concord RG Hospital, Concord, New South Wales, Australia
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31
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Yang M, Kondo T, Anand IS, de Boer RA, Campbell RT, Køber L, Lam CSP, Maggioni AP, Martinez FA, O'Meara E, Packer M, Sabatine MS, Kerr Saraiva JF, Shah SJ, Zannad F, Zile MR, Jhund PS, Solomon SD, McMurray JJV. Clinical characteristics and outcomes of patients aged 80 years and over with heart failure: Need for better treatment. Eur J Heart Fail 2024. [PMID: 39169481 DOI: 10.1002/ejhf.3417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 06/28/2024] [Accepted: 07/21/2024] [Indexed: 08/23/2024] Open
Abstract
AIMS Although the prevalence of heart failure (HF) increases markedly with advancing age, surprisingly little is known about HF in the very elderly. The aim of this study was to describe the clinical characteristics and outcomes of octogenarians with HF. METHODS AND RESULTS Individual participant meta-analysis of patients with HF and reduced, mildly reduced, and preserved ejection fraction (HFrEF, HFmrEF, and HFpEF, respectively) enrolled in eight large randomized trials. Overall, the proportion of octogenarians was 1518 of 20 168 patients (7.5%) with HFrEF, 610 of 4609 (13.2%) with HFmrEF, and 3130 of 15 354 (20.4%) with HFpEF. Regardless of HF phenotype, octogenarian patients were more often female and had more comorbidities, more symptoms and signs of congestion, and worse health status (but not quality of life), in comparison to patients aged <80 years. The incidence (per 100 person-years) of the composite of cardiovascular death or HF hospitalization was 13.3 (95% confidence interval [CI] 12.7-14.0) in octogenarians versus 9.5 (95% CI 9.3-9.7) in non-octogenarians (adjusted hazard ratio [aHR] 1.40, 95% CI 1.32-1.48). Each component of the composite was more frequent in octogenarians with rates of cardiovascular mortality of 7.0 (95% CI 6.5-7.4) per 100 person-years versus 4.9 (95% CI 4.8-5.1) in non-octogenarians (aHR 1.60, 95% CI 1.48-1.72, p < 0.001). Octogenarians received less evidence-based therapy, especially mineralocorticoid receptor antagonists, than younger patients. CONCLUSION Despite worse health status and higher hospitalization and mortality rates, octogenarians were undertreated compared to younger patients.
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Affiliation(s)
- Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Inder S Anand
- Department of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ross T Campbell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore, Singapore
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | | | - Eileen O'Meara
- Montreal Heart Institute Department of Medicine (Cardiology) and Research Centre, Université de Montréal, Montreal, QC, Canada
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jose F Kerr Saraiva
- Cardiovascular Division, Instituto de Pesquisa Clínica de Campinas, Campinas, Brazil
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Faiez Zannad
- Inserm CIC 1433 and Université de Lorraine, Centre Hospitalier Régional Universitaire, Nancy, France
| | - Michael R Zile
- RHJ Department of Veterans Affairs Medical Center, Medical University of South Carolina, Charleston, SC, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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32
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Ko D, Evans PT, Lin KJ, Pande AN, Cervone A, Lee SB, Cheng S, Tsacogianis T, Glynn RJ, Kim DH. Frailty and Clinical Outcomes of Ticagrelor Versus Clopidogrel in Older Adults With Acute Myocardial Infarction. J Am Heart Assoc 2024; 13:e034529. [PMID: 39056329 PMCID: PMC11964041 DOI: 10.1161/jaha.124.034529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Ticagrelor is recommended over clopidogrel in acute coronary syndrome based on the results of the PLATO (Study of Platelet Inhibition and Patient Outcomes) trial. We aimed to emulate PLATO in older adults with and without frailty and with acute coronary syndrome treated with percutaneous coronary intervention. METHODS AND RESULTS We created a new-user cohort of Medicare fee-for-service beneficiaries aged ≥65 years hospitalized for acute coronary syndrome from 2014 to 2018 and initiated ticagrelor or clopidogrel following percutaneous coronary intervention. Frailty was defined using a validated claims-based frailty index ≥0.25. Coprimary outcomes were major adverse cardiovascular events and major bleeding. Follow-up began on the date of first outpatient prescription for ticagrelor or clopidogrel and ended on the earliest date for an outcome event, death, discontinuation of the index drug, or disenrollment from Medicare. The study included 42 843 older adults; 23% were frail. After propensity score matching, the rates of major adverse cardiovascular events per 100 person-years comparing ticagrelor versus clopidogrel groups were 7.8 and 7.3 in the frail cohort (hazard ratio [HR], 1.07 [95% CI, 0.84-1.36]) and 3.7 and 4.2 in the nonfrail cohort (HR, 0.87 [95% CI, 0.75-1.02]). The corresponding rates of major bleeding were 4.3 and 3.8 in the frail cohort (HR, 1.12 95% CI, [0.80-1.56]) and 2.2 and 1.8 in the nonfrail cohort (HR, 1.22 [95% CI, 0.98-1.51]). CONCLUSIONS There was a trend toward a modest reduction in risk of major adverse cardiovascular events and a trend toward a modest increase in risk of major bleeding with ticagrelor compared with clopidogrel in the nonfrail cohort. There was insufficient evidence for the benefit of ticagrelor in frail older adults.
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Affiliation(s)
- Darae Ko
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeBostonMA
- Section of Cardiovascular MedicineBoston Medical CenterBostonMA
| | - Peter T. Evans
- Section of Cardiovascular MedicineBoston Medical CenterBostonMA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women’s HospitalBostonMA
- Division of General Internal Medicine, Department of MedicineMassachusetts General HospitalBostonMA
| | - Ashvin N. Pande
- Section of Cardiovascular MedicineBoston Medical CenterBostonMA
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women’s HospitalBostonMA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women’s HospitalBostonMA
| | - Susan Cheng
- Department of CardiologyCedars‐Sinai Medical CenterLos AngelesCA
| | - Theodore Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women’s HospitalBostonMA
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women’s HospitalBostonMA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeBostonMA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women’s HospitalBostonMA
- Division of Gerontology, Department of MedicineBeth Israel Deaconess Medical CenterBostonMA
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33
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Kittipibul V, Vaduganathan M, Ikeaba U, Chiswell K, Butler J, DeVore AD, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, Linganathan KK, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Fonarow GC, Greene SJ. Cause-Specific Health Care Costs Following Hospitalization for Heart Failure and Cost Offset With SGLT2i Therapy. JACC. HEART FAILURE 2024; 12:1409-1421. [PMID: 38727651 DOI: 10.1016/j.jchf.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Little is known regarding differences in cause-specific costs between heart failure (HF) with ejection fraction (EF) ≤40% vs >40%, and potential cost implications of sodium glucose co-transporter 2 inhibitor (SGLT2i) therapy. OBJECTIVES This study sought to compare cause-specific health care costs following hospitalization for HF with EF ≤40% vs >40% and estimate the cost offset with implementation of SGLT2i therapy. METHODS This study examined Medicare beneficiaries hospitalized for HF in the Get With The Guidelines-Heart Failure registry from 2016 to 2020. Mean per-patient total (excluding drug costs) and cause-specific costs from discharge through 1-year follow-up were calculated and compared between EF ≤40% vs >40%. Next, risk reductions on total all-cause and HF hospitalizations were estimated in a trial-level meta-analysis of 5 pivotal trials of SGLT2is in HF. Finally, these relative treatment effects were applied to Medicare beneficiaries eligible for SGLT2i therapy to estimate the projected cost offset with implementation of SGLT2i, excluding drug costs. RESULTS Among 146,003 patients, 50,598 (34.7%) had EF ≤40% and 95,405 (65.3%) had EF >40%. Mean total cost through 1 year was $40,557. Total costs were similar between EF groups overall but were higher for EF ≤40% among patients surviving the 1-year follow-up period. Patients with EF >40% had higher costs caused by non-HF and noncardiovascular hospitalizations, and skilled nursing facilities (all P < 0.001). Trial-level meta-analysis of the 5 SGLT2i clinical trials estimated 11% (rate ratio: 0.89; 95% CI: 0.84-0.93; P < 0.001) and 29% (rate ratio: 0.71; 95% CI: 0.66-0.76; P < 0.001) relative reductions in rates of total all-cause and HF hospitalizations, respectively, regardless of EF. Reductions in all-cause and HF hospitalizations were projected to reduce annual costs of readmission by $2,451 to $2,668 per patient with EF ≤40% and $1,439 to $2,410 per patient with EF >40%. CONCLUSIONS In this large cohort of older U.S. adults hospitalized for HF, cause-specific costs of care differed among patients with EF ≤40% vs >40%. SGLT2i significantly reduced the rate of HF and all-cause hospitalizations irrespective of EF in clinical trials, and implementation of SGLT2i therapy in clinical practice is projected to reduce costs by $1,439 to $2,668 per patient over the 1 year post-discharge, excluding drug costs.
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Affiliation(s)
- Veraprapas Kittipibul
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karen E Joynt Maddox
- Cardiology Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | | | - Anjali Tiku Owens
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Scott D Solomon
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota, USA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA.
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Gharagozloo K, Mehdizadeh M, Heckman G, Rose RA, Howlett J, Howlett SE, Nattel S. Heart Failure With Preserved Ejection Fraction in the Elderly Population: Basic Mechanisms and Clinical Considerations. Can J Cardiol 2024; 40:1424-1444. [PMID: 38604339 DOI: 10.1016/j.cjca.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) refers to a clinical condition in which the signs of heart failure, such as pulmonary congestion, peripheral edema, and increased natriuretic peptide levels, are present despite normal ejection fractions and the absence of other causes (eg, pericardial disease). The ejection fraction cutoff for the definition of HFpEF has varied in the past, but recent society guidelines have settled on a consensus of 50%. HFpEF is particularly common in the elderly population. The aim of this narrative review is to summarize the available literature regarding HFpEF in elderly patients in terms of evidence for the age dependence, specific clinical features, and underlying mechanisms. In the clinical arena, we review the epidemiology, discuss distinct clinical phenotypes typically seen in elderly patients, the importance of frailty, the role of biomarkers, and the role of medical therapies (including sodium-glucose cotransport protein 2 inhibitors, renin-angiotensin-aldosterone system blockers, angiotensin receptor/neprilysin inhibitors, diuretics, and β-adrenergic receptor blockers). We then go on to discuss the basic mechanisms implicated in HFpEF, including cellular senescence, fibrosis, inflammation, mitochondrial dysfunction, enhanced production of reactive oxygen species, abnormal cellular calcium handling, changes in microRNA signalling, insulin resistance, and sex hormone changes. Finally, we review knowledge gaps and promising areas of future investigation. Improved understanding of the specific clinical manifestations of HFpEF in elderly individuals and of the fundamental mechanisms that contribute to the age-related risk of HFpEF promises to lead to novel diagnostic and treatment approaches that will improve outcomes for this common cardiac disorder in a vulnerable population.
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Affiliation(s)
- Kimia Gharagozloo
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada
| | - Mozhdeh Mehdizadeh
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada
| | - George Heckman
- Schlegel Research Institute for Aging and University of Waterloo, Waterloo, Ontario, Canada
| | - Robert A Rose
- Department of Cardiac Sciences, Department of Physiology and Pharmacology, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan Howlett
- Libin Cardiovascular Institute and Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan E Howlett
- Departments of Pharmacology and Medicine (Geriatric Medicine), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stanley Nattel
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany.
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35
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Zahir Anjum D, Strange JE, Fosbøl E, Garred CH, Elmegaard M, Andersson C, Jhund PS, McMurray JJV, Petrie MC, Kober L, Schou M. Use of medical therapy and risk of clinical events according to frailty in heart failure patients - A real-life cohort study. Eur J Heart Fail 2024; 26:1717-1726. [PMID: 38700461 DOI: 10.1002/ejhf.3249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/21/2024] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
AIMS Although recent randomized clinical trials have demonstrated the advantages of heart failure (HF) therapy in both frail and not frail patients, there is insufficient information on the use of HF therapy based on frailty status in a real-world setting. The aim was to examine how frailty status in HF patients associates with use of HF therapy and with clinical outcomes. METHODS AND RESULTS Patients with new-onset HF between 2014 and 2021 were identified using the nationwide Danish registers. Patients across the entire range of ejection fraction were included. The associations between frailty status (using the Hospital Frailty Risk Score) and use of HF therapy and clinical outcomes (all-cause mortality, HF hospitalization, and non-HF hospitalization) were evaluated using multivariable-adjusted Cox models adjusting for age, sex, diagnostic setting, calendar year, comorbidities, pharmacotherapy, and socioeconomic status. Of 35 999 participants (mean age 69.1 years), 68% were not frail, 26% were moderately frail, and 6% were severely frail. The use of HF therapy was significantly lower in frailer patients. The hazard ratio (HR) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation was 0.74 (95% confidence interval 0.70-0.77) and 0.48 (0.43-0.53) for moderate frailty and severe frailty, respectively. For beta-blockers, the corresponding HRs were 0.74 (0.71-0.78) and 0.51 (0.46-0.56), respectively, and for mineralocorticoid receptor antagonists, 0.83 (0.80-0.87) and 0.58 (0.53-0.64), respectively. The prevalence of death and non-HF hospitalization increased with frailty status. The HR for death was 1.55 (1.47-1.63) and 2.32 (2.16-2.49) for moderate and severe frailty, respectively, and the HR for non-HF hospitalization was 1.37 (1.32-1.41) and 1.82 (1.72-1.92), respectively. The association between frailty status and HF hospitalization was not significant (HR 1.08 [1.02-1.14] and 1.08 [0.97-1.20], respectively). CONCLUSION In real-world HF patients, frailty was associated with lower HF therapy use and with a higher incidence of clinical outcomes including mortality and non-HF hospitalization.
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Affiliation(s)
- Deewa Zahir Anjum
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Jarl E Strange
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Mariam Elmegaard
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Charlotte Andersson
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Rakisheva A, Soloveva A, Shchendrygina A, Giverts I. Heart Failure With Preserved Ejection Fraction and Frailty: From Young to Superaged Coexisting HFpEF and Frailty. INTERNATIONAL JOURNAL OF HEART FAILURE 2024; 6:93-106. [PMID: 39081641 PMCID: PMC11284337 DOI: 10.36628/ijhf.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/01/2024] [Accepted: 06/14/2024] [Indexed: 08/02/2024]
Abstract
Being commonly diagnosed in elderly women and associated with comorbidities as well as ageing-related cardio-vascular changes, heart failure with preserved ejection fraction (HFpEF) has been recently considered as a distinct cardiogeriatric syndrome. Frailty is another frequent geriatric syndrome. HFpEF and frailty share common underlying mechanisms, often co-exist, and represent each other's risk factors. A threshold of 65 years old is usually used to screen patients for both frailty and HFpEF in research and clinical settings. However, both HFpEF and frailty are very heterogenous conditions that may develop at younger ages. In this review we aim to provide a broader overview on the coexistence of HFpEF and frailty throughout the lifetime. We hypothesize that HFpEF and frailty patients' profiles (young, elderly, superaged) represent a continuum of the common ageing process modified by cumulative exposure to risk factors resulting to a presentation of HFpEF and frailty at different ages. We believe, that suggested approach might stimulate assessment of frailty in HFpEF assessment and vice versa regardless of age and early implementation of targeted interventions. Future studies of pathophysiology, clinical features, and outcomes of frailty in HFpEF by age are needed.
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Affiliation(s)
| | - Anzhela Soloveva
- Department of Cardiology, Almazov Almazov National Medical Research Centre, Saint Petersburg, Russia
| | | | - Ilya Giverts
- Maimonides Medical Center, Brooklyn, NY, USA
- Massachusetts General Hospital, Boston, MA, USA
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37
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Kim DH, Park CM, Ko D, Lin KJ, Glynn RJ. Assessing the Benefits and Harms of Pharmacotherapy in Older Adults with Frailty: Insights from Pharmacoepidemiologic Studies of Routine Health Care Data. Drugs Aging 2024; 41:583-600. [PMID: 38954400 PMCID: PMC11884328 DOI: 10.1007/s40266-024-01121-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 07/04/2024]
Abstract
The objective of this review is to summarize and appraise the research methodology, emerging findings, and future directions in pharmacoepidemiologic studies assessing the benefits and harms of pharmacotherapies in older adults with different levels of frailty. Older adults living with frailty are at elevated risk for poor health outcomes and adverse effects from pharmacotherapy. However, current evidence is limited due to the under-enrollment of frail older adults and the lack of validated frailty assessments in clinical trials. Recent advancements in measuring frailty in administrative claims and electronic health records (database-derived frailty scores) have enabled researchers to identify patients with frailty and to evaluate the heterogeneity of treatment effects by patients' frailty levels using routine health care data. When selecting a database-derived frailty score, researchers must consider the type of data (e.g., different coding systems), the length of the predictor assessment period, the extent of validation against clinically validated frailty measures, and the possibility of surveillance bias arising from unequal access to care. We reviewed 13 pharmacoepidemiologic studies published on PubMed from 2013 to 2023 that evaluated the benefits and harms of cardiovascular medications, diabetes medications, anti-neoplastic agents, antipsychotic medications, and vaccines by frailty levels. These studies suggest that, while greater frailty is positively associated with adverse treatment outcomes, older adults with frailty can still benefit from pharmacotherapy. Therefore, we recommend routine frailty subgroup analyses in pharmacoepidemiologic studies. Despite data and design limitations, the findings from such studies may be informative to tailor pharmacotherapy for older adults across the frailty spectrum.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA.
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Harvard Medical School, Boston, MA, USA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Harvard Medical School, Boston, MA, USA
- Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Boston, MA, USA
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Moras E, Zaid S, Gandhi K, Barman N, Birnbaum Y, Virani SS, Tamis-Holland J, Jneid H, Krittanawong C. Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population. Curr Atheroscler Rep 2024; 26:231-248. [PMID: 38722473 DOI: 10.1007/s11883-024-01203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE OF REVIEW To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population. RECENT FINDINGS Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.
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Affiliation(s)
- Errol Moras
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Syed Zaid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Kruti Gandhi
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nitin Barman
- Cardiac Catheterization Laboratory, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Yochai Birnbaum
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX, USA
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Beishon L, Jayasinghe R, Roshan-Zamir S, Barton C. Reducing heart failure deaths by 25% in 25 years: the '25in25' heart failure summit. THE BRITISH JOURNAL OF CARDIOLOGY 2024; 31:022. [PMID: 39555464 PMCID: PMC11562576 DOI: 10.5837/bjc.2024.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2024]
Abstract
Heart failure (HF) is a major cause of morbidity and mortality in older people, and 80% of people with HF are aged over 60 years. HF is the end point for almost all common cardiovascular diseases, as well as many non-cardiovascular diseases. Despite this, HF remains underdetected and undertreated. Detection and treatment of HF has improved significantly in recent years, with several novel treatments developed in the last decade improving outcomes for patients. Therefore, earlier detection and improved treatment of HF has the potential to reduce morbidity and mortality for older people, particularly given the shift in ageing demographics anticipated over the coming decades. The British Geriatrics Society Cardiovascular Specialist Interest Group recently participated in the British Society for Heart Failure (BSH) '25in25' Heart Failure Summit, which aims to reduce deaths due to HF by 25% in the next 25 years. The 2023 summit comprised experts from over 45 top health organisations across Europe, Canada and the US. The summit brought together cross-disciplinary expertise to support the implementation of strategies to improve outcomes for people living with HF, and, in this commentary, we reflect upon the priorities identified. We discuss the current barriers to the early detection and management of HF, and the particular challenges and complexity of managing HF in older people. Finally, we discuss the role of patient empowerment and how this can lead to improved care for older people living with HF.
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Affiliation(s)
- Lucy Beishon
- NIHR Academic Clinical Lecturer NIHR Leicester Biomedical Research Centre, BHF Cardiovascular Research Centre, Glenfield Hospital, Groby Road, Leicester, LE3 9QP
| | | | - Shahbaz Roshan-Zamir
- Consultant Physician and Geriatrician Department of Ageing and Health, St. Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH
| | - Carys Barton
- Heart Failure Nurse Consultant Department of Cardiology, Imperial College Healthcare NHS Trust, St. Mary’s Hospital, Praed Street, London, W2 1NY
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Villaschi A, Chiarito M, Pagnesi M, Stolfo D, Baldetti L, Lombardi CM, Adamo M, Loiacono F, Sammartino AM, Colombo G, Tomasoni D, Inciardi RM, Maccallini M, Gasparini G, Montella M, Contessi S, Cocianni D, Perotto M, Barone G, Merlo M, Vitale C, Rosano GMC, Cappelletti AM, Sinagra G, Metra M, Pini D. Frailty according to the 2019 HFA-ESC definition in patients at risk for advanced heart failure: Insights from the HELP-HF registry. Eur J Heart Fail 2024; 26:1399-1407. [PMID: 38741569 DOI: 10.1002/ejhf.3234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 03/05/2024] [Accepted: 03/27/2024] [Indexed: 05/16/2024] Open
Abstract
AIMS Frailty is highly prevalent in patients with heart failure (HF), but a concordant definition of this condition is lacking. The Heart Failure Association of the European Society of Cardiology (HFA-ESC) proposed in 2019 a new multi-domain definition of frailty, but it has never been validated. METHODS AND RESULTS Patients from the HELP-HF registry were stratified according to the number of HFA-ESC frailty domains fulfilled and to the cumulative deficits frailty index (FI) quintiles. Prevalence of frailty and of each domain was reported, as well as the rate of the composite of all-cause death and HF hospitalization, its single components, and cardiovascular death in each group and quintile. Among 854 included patients, 37 (4.3%), 206 (24.1%), 365 (42.8%), 217 (25.4%), and 29 (3.4%) patients fulfilled zero, one, two, three, or four domains, respectively, while 179 patients had a FI < 0.21 and were considered not frail. The 1-year risk of adverse events increased proportionally to the number of domains fulfilled (for each criterion increase, all-cause death or HF hospitalization: hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.27-1.62; all-cause death: HR 1.72, 95% CI 1.46-2.02, HF hospitalizations: subHR 1.21, 95% CI 1.04-1.31; cardiovascular death: HR 1.77, 95% CI 1.45-2.15). Consistent results were found stratifying the cohort for FI quintiles. The FI as a continuous variable demonstrated higher discriminative ability than the number of domains fulfilled (area under the curve = 0.68 vs. 0.64, p = 0.004). CONCLUSION Frailty in patients at risk for advanced HF, assessed via a multi-domain approach and the FI, is highly prevalent and identifies those at increased risk of adverse events. The FI was found to be slightly more effective in identifying patients at increased risk of mortality.
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Affiliation(s)
- Alessandro Villaschi
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Mauro Chiarito
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giada Colombo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marta Maccallini
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Gaia Gasparini
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Marco Montella
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Stefano Contessi
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniele Cocianni
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Maria Perotto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Giuseppe Barone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Merlo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Cristiana Vitale
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | | | | | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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McNally T, Tumelty E, Chung I, Hussain S, Mookerjee S, Ali MA, Anderson L, Rosano G, Banerjee D. Investigating the relationship between FRailty And Quality of LIfe in patients with heart faiLure and CKD (FRAIL study). ESC Heart Fail 2024; 11:1411-1421. [PMID: 38320815 PMCID: PMC11098643 DOI: 10.1002/ehf2.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 05/18/2024] Open
Abstract
AIMS Patients with chronic kidney disease (CKD) or heart failure (HF) are disproportionally affected by frailty, an independent predictor of morbidity. The prevalence of frailty and its impact on quality of life (QoL) in a unique population of patients with both CKD and HF (CKD-HF) is unclear. The aim of this study was to investigate the association between frailty and QoL in patients with CKD-HF. METHODS AND RESULTS Patients were identified from a tertiary care cardiorenal clinic. Eligible patients had CKD-HF with a stable estimated glomerular filtration rate of <60 mL/min/1.732. Data were collected from each participant at one point in time using surveys delivered by study personnel between 14 July 2022 and 31 March 2023. Frailty was defined as Modified Frailty Phenotype (MFP) score ≥3. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to assess QoL. Demographic data were retrospectively collected from electronic patient records. Demographics and QoL were compared between frail and non-frail cohorts using Pearson's R and Student's t-test (two-tailed, alpha-priori = 0.05). One hundred five participants consented, and 103 completed the questionnaires in full. Amongst the 103 participants, 49.5% (n = 51) were frail. Frailty was related to sex (P = 0.021) and medication count (P = 0.007), however not to other clinical measures, including estimated glomerular filtration rate (P = 0.437) and ejection fraction (P = 0.911). Frail patients reported poorer QoL across physical functioning (P < 0.001), general health (P < 0.001), bodily pain (P = 0.004), social functioning (P < 0.001), and energy levels (P < 0.001), however not emotional wellbeing (P = 0.058); 51.5% cited 'better quality of life' as their healthcare priority, over longer survival (23.3%) or avoiding hospital admissions (22.3%). This was consistent across frail and non-frail groups. CONCLUSIONS A large proportion of CKD-HF patients are frail, regardless of disease severity, and more susceptible to significantly poorer QoL across physical and social domains. Improving QoL is the priority of patients across both frail and non-frail cohorts, further emphasizing the need for prompt recognition of frailty as well as possible intervention and prevention.
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Affiliation(s)
- Thomas McNally
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Ella Tumelty
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Isaac Chung
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Sabba Hussain
- St George's University Hospitals NHS Foundation TrustLondonUK
| | | | | | - Lisa Anderson
- St George's University Hospitals NHS Foundation TrustLondonUK
| | | | - Debasish Banerjee
- St George's University Hospitals NHS Foundation TrustLondonUK
- St George's University of LondonLondonUK
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Yao A, Gao L, Zhang J, Cheng JM, Kim DH. Frailty as an Effect Modifier in Randomized Controlled Trials: A Systematic Review. J Gen Intern Med 2024; 39:1452-1473. [PMID: 38592606 PMCID: PMC11169165 DOI: 10.1007/s11606-024-08732-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/15/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The effect of clinical interventions may vary by patients' frailty status. Understanding treatment effect heterogeneity by frailty could lead to frailty-guided treatment strategies and reduce overtreatment and undertreatment. This systematic review aimed to examine the effect modification by frailty in randomized controlled trials (RCTs) that evaluate pharmacological, non-pharmacological, and multicomponent interventions. METHODS We searched PubMed, Web of Science, EMBASE, and ClinicalTrial.gov, from their inception to 8 December 2023. Two reviewers independently extracted trial data and examined the study quality with senior authors. RESULTS Sixty-one RCTs that evaluated the interaction between frailty and treatment effects in older adults were included. Frailty was evaluated using different tools such as the deficit accumulation frailty index, frailty phenotype, and other methods. The effect of several pharmacological interventions (e.g., edoxaban, sacubitril/valsartan, prasugrel, and chemotherapy) varied according to the degree of frailty, whereas other treatments (e.g., antihypertensives, vaccinations, osteoporosis medications, and androgen medications) demonstrated consistent benefits across different frailty levels. Some non-pharmacological interventions had greater benefits in patients with higher (e.g., chair yoga, functional walking, physical rehabilitation, and higher dose exercise program) or lower (e.g., intensive lifestyle intervention, psychosocial intervention) levels of frailty, while others (e.g., resistance-type exercise training, moderate-intensive physical activity, walking and nutrition or walking) produced similar intervention effects. Specific combined interventions (e.g., hospital-based disease management programs) demonstrated inconsistent effects across different frailty levels. DISCUSSION The efficacy of clinical interventions often varied by frailty levels, suggesting that frailty is an important factor to consider in recommending clinical interventions in older adults. REGISTRATION PROSPERO registration number CRD42021283051.
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Affiliation(s)
- Aaron Yao
- VillageMD Research Institute, Chicago, IL, USA.
- Virginia Commonwealth University, Richmond, VA, USA.
| | | | - Jiajun Zhang
- Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Joyce M Cheng
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Seidu S, Alabraba V, Davies S, Newland-Jones P, Fernando K, Bain SC, Diggle J, Evans M, James J, Kanumilli N, Milne N, Viljoen A, Wheeler DC, Wilding JPH. SGLT2 Inhibitors - The New Standard of Care for Cardiovascular, Renal and Metabolic Protection in Type 2 Diabetes: A Narrative Review. Diabetes Ther 2024; 15:1099-1124. [PMID: 38578397 PMCID: PMC11043288 DOI: 10.1007/s13300-024-01550-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/06/2024] [Indexed: 04/06/2024] Open
Abstract
A substantial evidence base supports the use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in the treatment of type 2 diabetes mellitus (T2DM). This class of medicines has demonstrated important benefits that extend beyond glucose-lowering efficacy to protective mechanisms capable of slowing or preventing the onset of long-term cardiovascular, renal and metabolic (CVRM) complications, making their use highly applicable for organ protection and the maintenance of long-term health outcomes. SGLT2is have shown cost-effectiveness in T2DM management and economic savings over other glucose-lowering therapies due to reduced incidence of cardiovascular and renal events. National and international guidelines advocate SGLT2i use early in the T2DM management pathway, based upon a plethora of supporting data from large-scale cardiovascular outcome trials, renal outcomes trials and real-world studies. While most people with T2DM would benefit from CVRM protection through SGLT2i use, prescribing hesitancy remains, potentially due to confusion concerning their place in the complex therapeutic paradigm, variation in licensed indications or safety perceptions/misunderstandings associated with historical data that have since been superseded by robust clinical evidence and long-term pharmacovigilance reporting. This latest narrative review developed by the Improving Diabetes Steering Committee (IDSC) outlines the place of SGLT2is within current evidence-informed guidelines, examines their potential as the standard of care for the majority of newly diagnosed people with T2DM and sets into context the perceived risks and proven advantages of SGLT2is in terms of sustained health outcomes. The authors discuss the cost-effectiveness case for SGLT2is and provide user-friendly tools to support healthcare professionals in the correct application of these medicines in T2DM management. The previously published IDSC SGLT2i Prescribing Tool for T2DM Management has undergone updates and reformatting and is now available as a Decision Tool in an interactive pdf format as well as an abbreviated printable A4 poster/wall chart.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
| | - Vicki Alabraba
- Leicester Diabetes Centre, University Hospitals Leicester NHS Trust, Leicester, UK
| | | | | | | | - Stephen C Bain
- Diabetes Research Group, Swansea University Medical School, Swansea University, Swansea, UK
- Department of Diabetes and Endocrinology, Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Jane Diggle
- College Lane Surgery, Ackworth, West Yorkshire, UK
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | - June James
- Leicester Diabetes Centre, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Naresh Kanumilli
- Brooklands Northenden Primary Care Network, Manchester, UK
- Manchester University Foundation Trust, Manchester, UK
| | - Nicola Milne
- Brooklands Northenden Primary Care Network, Manchester, UK
| | - Adie Viljoen
- Borthwick Diabetes Research Unit, Lister Hospital, Stevenage, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, Aintree University Hospital, University of Liverpool, Liverpool, UK.
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Zhang N, Qu X, Kang L, Liu X, Zhu W. Mapping Knowledge Landscapes and Emerging Trends of the Links Between Frailty and Heart Failure: A Bibliometric Analysis From 2000 to 2023. Cureus 2024; 16:e60511. [PMID: 38764704 PMCID: PMC11101057 DOI: 10.7759/cureus.60511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 05/21/2024] Open
Abstract
Background Frailty, within the context of heart failure (HF), is strongly linked to poor patient outcomes. Investigating the vulnerable condition of individuals with HF is crucial, not only for medical reasons but also as a significant public health challenge, especially among the elderly population where both HF and frailty are common. Therefore, it is essential to prioritize HF patients with frailty over those without such symptoms. To begin, promptly assessing the impact of academic research in this area is crucial, considering factors such as geographical regions, authors, journals, and institutions. Additionally, it is important to explore current topics and identify potential areas that could inspire future researchers to conduct further studies to advance public health. Methodology We conducted a search in the Web of Science Core Collection database to identify articles and reviews in the English language focusing on frailty and HF which were published from January 1, 2000, to December 31, 2023. To perform bibliometric analysis, VOSviewer (v.1.6.18) and CiteSpace (v.6.1.R2) were utilized. Results A total of 1,381 original English-language articles were gathered, comprising 1,162 articles and 219 reviews. The quantity of research publications in this area has experienced significant growth since 2013. Among all countries, the United States has contributed the largest number of publications, accounting for 409 articles (29.62% of the total). Additionally, the United States has received the highest number of citations, being cited a total of 13,329 times, as well as boasting the greatest total link strength. Duke University stands out as the institution with the highest number of research papers, having published 40 articles (2.90% of the total). It has also received the most citations, with a total of 2,455 times, and possesses the highest total link strength, which amounts to 212. Within the realm of prolific authors, Kentaro Kamiya from Kitasato University emerges as the most productive, having authored 28 articles (2.03% of the total). When considering scholarly journals, "Esc Heart Failure" contains the highest number of articles pertaining to frailty and HF, publishing a noteworthy 36 articles (2.61% of the total). Noteworthy keywords within this field encompass frailty, heart failure, elderly, mortality, and cardiovascular disease. Over the past five years, the most popular keywords have centered around "frailty syndrome," "sarcopenia," and "therapeutic interventions." Conclusions Research on frailty and HF at a global scale has experienced substantial growth between 2000 and 2023, demonstrating a prospective field for further exploration with potential advantages from ongoing progress. Prospective studies could prioritize the enhancement of cardiac rehabilitation for patients coping with HF and frailty while ensuring the preservation of their overall quality of life.
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Affiliation(s)
- Ning Zhang
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
| | - Xuan Qu
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
| | - Lin Kang
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
| | - Xiaohong Liu
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
| | - Wenling Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
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Tumelty E, Chung I, Hussain S, Ali MA, Addada H, Banerjee D. An Updated Review of the Management of Chronic Heart Failure in Patients with Chronic Kidney Disease. Rev Cardiovasc Med 2024; 25:144. [PMID: 39076544 PMCID: PMC11264008 DOI: 10.31083/j.rcm2504144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 07/31/2024] Open
Abstract
Chronic kidney disease (CKD) is common in patients with heart failure (HF) and is associated with high morbidity and mortality. There has been remarkable progress in the treatment of HF over recent years with the establishment of guideline-directed medical therapies including: (1) Beta-blockers, (2) renal angiotensin aldosterone system (RAAS) inhibition (i.e., angiotensin-converting enzyme inhibitor [ACEi], aldosterone receptor blocker [ARB] or angiotensin receptor-neprilysin inhibitor [ARNI]); (3) mineralocorticoid receptor antagonists (MRA), and (4) sodium-glucose cotransporter-2 inhibitors (SGLT2i). However, there are challenges to the implementation of these medications in patients with concomitant CKD due to increased vulnerability to common side-effects (including worsening renal function, hyperkalaemia, hypotension), and most of the pivotal trials which provide evidence of the efficacy of these medications excluded patients with severe CKD. Patients with CKD and HF often have regular healthcare encounters with multiple professionals and can receive conflicting guidance regarding their medication. Thus, despite being at higher risk of adverse cardiovascular events, patients who have both HF and CKD are more likely to be under-optimised on evidence-based therapies. This review is an updated summary of the evidence available for the management of HF (including reduced, mildly reduced and preserved left ventricular ejection fraction) in patients with various stages of CKD. The review covers the evidence for recommended medications, devices such as implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), intravenous (IV) iron, and discusses how frailty affects the management of these patients. It also considers emerging evidence for the prevention of HF in the cohort of patients with CKD. It synthesises the available evidence regarding when to temporarily stop, continue or rechallenge medications in this cohort. Chronic HF in context of CKD remains a challenging scenario for clinicians to manage, which is usually complicated by frailty, multimorbidity and polypharmacy. Treatment should be tailored to a patients individual needs and management in specialised cardio-renal clinics with a multi-disciplinary team approach has been recommended. This review offers a concise summary on this expansive topic.
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Affiliation(s)
- Ella Tumelty
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Isaac Chung
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Sabba Hussain
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Mahrukh Ayesha Ali
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Harshavardhani Addada
- Cardiovascular and Genetics Research Institute St George’s University of London, SW17 0QT London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
- Cardiovascular and Genetics Research Institute St George’s University of London, SW17 0QT London, UK
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Tian J, Li W, Zeng L, Li Y, Du J, Li Y, Li B, Su G. HBI-8000 improves heart failure with preserved ejection fraction via the TGF-β1/MAPK signalling pathway. J Cell Mol Med 2024; 28:e18238. [PMID: 38509729 PMCID: PMC10955178 DOI: 10.1111/jcmm.18238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/18/2024] [Accepted: 02/09/2024] [Indexed: 03/22/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of total heart failure patients and is characterized by peripheral circulation, cardiac remodelling and comorbidities (such as advanced age, obesity, hypertension and diabetes) with limited treatment options. Chidamide (HBI-8000) is a domestically produced benzamide-based histone deacetylase isoform-selective inhibitor used for the treatment of relapsed refractory peripheral T-cell lymphomas. Based on our in vivo studies, we propose that HBI-8000 exerts its therapeutic effects by inhibiting myocardial fibrosis and myocardial hypertrophy in HFpEF patients. At the cellular level, we found that HBI-8000 inhibits AngII-induced proliferation and activation of CFs and downregulates the expression of fibrosis-related factors. In addition, we observed that the HFpEF group and AngII stimulation significantly increased the expression of TGF-β1 as well as phosphorylated p38MAPK, JNK and ERK, whereas the expression of the above factors was significantly reduced after HBI-8000 treatment. Activation of the TGF-β1/MAPK pathway promotes the development of fibrotic remodelling, and pretreatment with SB203580 (p38MAPK inhibitor) reverses this pathological change. In conclusion, our data suggest that HBI-8000 inhibits fibrosis by modulating the TGF-β1/MAPK pathway thereby improving HFpEF. Therefore, HBI-8000 may become a new hope for the treatment of HFpEF patients.
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Affiliation(s)
- Jing Tian
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Wenjing Li
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Lu Zeng
- Research Center of Translational Medicine, Jinan Central HospitalShandong First Medical UniversityJinanShandongChina
| | - Yang Li
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Jiamin Du
- Department of Cardiology, Jinan Central Hospital, Cheeloo College of MedicineShandong UniversityJinanShandongChina
| | - Ying Li
- Research Center of Translational Medicine, Jinan Central HospitalShandong First Medical UniversityJinanShandongChina
| | - Bin Li
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
- Research Center of Translational Medicine, Jinan Central HospitalShandong First Medical UniversityJinanShandongChina
| | - Guohai Su
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
- Research Center of Translational Medicine, Jinan Central HospitalShandong First Medical UniversityJinanShandongChina
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Kuthi LK, Schwertner WR, Veres B, Merkel ED, Masszi R, Behon A, Kovács A, Osztheimer I, Zima E, Molnár L, Gellér L, Kosztin A, Merkely B. The prevalence of frailty and its effect on the outcome in cardiac resynchronization therapy patients. GeroScience 2024; 46:2671-2679. [PMID: 38127223 PMCID: PMC10828248 DOI: 10.1007/s11357-023-01023-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023] Open
Abstract
Frailty is a complex clinical syndrome associated with aging and comorbidities, which correlates with unfavorable outcomes. However, in heart failure patients, frailty is very common, data is scarce about those, who are eligible for Cardiac Resynchronization Therapy (CRT) implantation. We investigated the incidence of frailty and the association of Frailty Index (FI) with the outcome. Thirty baseline clinical parameters were used by the Rockwood cumulative deficit method to determine patients' FI in our single-center cohort. Based on previous studies, patients with FI ≤ 0.210 were considered as non-frail, those with FI 0.10-0.210 were classified in Frail-1, with FI > 0.10 in Frail-2 groups, respectively. Echocardiographic response after 12 months and all-cause mortality were investigated by frailty groups. Among 1004 included patients, 75 (7%) were considered Non-frail, 271 (27%) grouped in Frail-1, and 658 (66%) in Frail-2 with a median FI of 0.36 (0.28-0.43). Patients in Frail-2 group were older, with more comorbidities compared with non-frail patients or those in Group Frail-1. During the median follow-up time of 4.8 years, 29 (39%) patients died in the Non-frail, 140 (52%) in Frail-1, and 471 (72%) in the Frail-2 groups (log-rank p < 0.001). Group Frail-2 showed an unfavorable outcome compared to the non-frail (HR 2.49, 95%CI 1.92-3.22; p < 0.001) and the Frail-1 group (1.83, 95%CI 1.55-2.16; p < 0.001). In our HFrEF patients eligible for CRT implantation, patients were exceedingly vulnerable with a high prevalence of frailty. The calculated frailty index was associated with outcome and proved to be prevalent in individual risk stratification.
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Affiliation(s)
- Luca Katalin Kuthi
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | | | - Boglárka Veres
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Eperke Dóra Merkel
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Richard Masszi
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Anett Behon
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - István Osztheimer
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Levente Molnár
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Annamária Kosztin
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary.
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Beussink-Nelson L, Freed BH, Chirinos JA, Brubaker PH, Kitzman DW, Yeboah J, Rosas SE, Hu M, Lima JAC, Pandit J, Bertoni AG, Shah SJ. Multi-Ethnic Study of Atherosclerosis Early Heart Failure Study: Rationale, Design, and Baseline Characteristics. Circ Heart Fail 2024; 17:e010289. [PMID: 38456289 PMCID: PMC11073782 DOI: 10.1161/circheartfailure.122.010289] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/20/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Current prevalence estimates of heart failure (HF) are primarily based on self-report or HF hospitalizations. There is an unmet need to define the prevalence and pathogenesis of early symptomatic HF, which may be undiagnosed and precedes HF hospitalization. METHODS The MESA (Multi-Ethnic Study of Atherosclerosis) Early HF study was conducted during MESA exam 6 to determine the prevalence of early HF and investigate the transition from risk factors to early HF in a diverse population-based cohort of older adults. Between 2016 and 2018, 3285 MESA participants from 6 field centers underwent comprehensive speckle-tracking echocardiography with passive leg raise maneuver, Kansas City Cardiomyopathy Questionnaire, 6-minute walk test, arterial stiffness assessment, and proteomics (including NT-proBNP [N-terminal pro-B-type natriuretic peptide]). RESULTS Median age was 73 (25th-75th percentile 67-81) years, 53.2% were female, 25.6% were Black, 12.8% were Chinese, and 40.0% were White. The prevalence of HF risk factors was high: hypertension, 61.9%; former or current smoking, 53.7%; obesity 34.8%; diabetes; 24.7%; and chronic kidney disease; 22%. Overt cardiovascular disease, which ranged from 2.1% (HF) to 13.6% (atrial fibrillation), was less common. Of the 3285 participants, 96% underwent proteomics, 94% Kansas City Cardiomyopathy Questionnaire, 93% speckle-tracking echocardiography with passive leg raise, 82% arterial stiffness exam, and 77% 6-minute walk test. Feasibility of resting speckle-tracking echocardiography (87%-99% across cardiac chambers) and passive leg raise Doppler/speckle-tracking echocardiography (>84%) measurements was high. A total of 120 unique echocardiographic indices were measured. CONCLUSIONS The MESA Early HF study is a key resource for cardiovascular researchers who are interested in improving the epidemiological and phenotypic characterization of early HF. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00005487.
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Affiliation(s)
- Lauren Beussink-Nelson
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
| | - Benjamin H Freed
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
| | - Julio A Chirinos
- Division of Cardiology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania and Perelman Center for Advanced Medicine, Philadelphia (J.A.C.)
| | - Peter H Brubaker
- Wake Forest School of Medicine (P.H.B., D.W.K., J.Y., A.G.B.), Harvard Medical School, Boston, MA
| | - Dalane W Kitzman
- Wake Forest School of Medicine (P.H.B., D.W.K., J.Y., A.G.B.), Harvard Medical School, Boston, MA
| | - Joseph Yeboah
- Wake Forest School of Medicine (P.H.B., D.W.K., J.Y., A.G.B.), Harvard Medical School, Boston, MA
| | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center (S.E.R.), Harvard Medical School, Boston, MA
| | - Mo Hu
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
| | - João A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD (J.A.C.L.)
| | - Jay Pandit
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
| | - Alain G Bertoni
- Wake Forest School of Medicine (P.H.B., D.W.K., J.Y., A.G.B.), Harvard Medical School, Boston, MA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
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49
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Aliberti MJR, Tavares CAM, Pajewski NM. Awaiting the verdict: Statins and the road ahead for primary prevention in older adults. J Am Geriatr Soc 2024; 72:332-336. [PMID: 38217414 PMCID: PMC10922889 DOI: 10.1111/jgs.18764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/15/2024]
Abstract
This editorial comments on the article by Orkaby et al. in this issue.
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Affiliation(s)
- Márlon Juliano Romero Aliberti
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Caio A M Tavares
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Geriatric Cardiology Unit, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Vart P, Butt JH, Jongs N, Schechter M, Chertow GM, Wheeler DC, Pecoits-Filho R, Langkilde AM, Correa-Rotter R, Rossing P, McMurray JJV, Heerspink HJL. Efficacy and Safety of Dapagliflozin in Patients With Chronic Kidney Disease Across the Spectrum of Frailty. J Gerontol A Biol Sci Med Sci 2024; 79:glad181. [PMID: 37527836 PMCID: PMC10809037 DOI: 10.1093/gerona/glad181] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND A sizeable proportion of patients with chronic kidney disease (CKD) are reported to be frail. Here we examined the safety and efficacy of dapagliflozin in patients with CKD by frailty level. METHODS Adults with CKD, with/without type 2 diabetes, with an estimated glomerular filtration rate (eGFR) of 25-75 mL/min/1.73 m2, and urinary albumin-to-creatinine ratio 200-5 000 mg/g were randomized to dapagliflozin (10 mg/day) or placebo. The primary endpoint was a composite of sustained ≥50% eGFR decline, end-stage kidney disease (ESKD), or death from kidney or cardiovascular (CV) causes. RESULTS Frailty index (FI), assessed by Rockwood cumulative deficit approach, was calculable in 4 303/4 304 (99.9%) patients: 1 162 (27.0%) in not-to-mildly frail (FI ≤0.210), 1 642 (38.2%) in moderately frail (FI 0.211-0.310), and 1 499 (34.8%) in severely frail categories (FI >0.311). Dapagliflozin reduced the risk of the primary composite endpoint across all FI categories (hazard ratios [95% confidence interval {CI}]: 0.50 [0.33-0.76], 0.62 [0.45-0.85], and 0.64 [0.49--0.83], respectively; p-interaction = 0.67). Results were similar for secondary outcomes including kidney composite outcome (sustained ≥50% eGFR decline, ESKD or death from kidney cause; p-interaction = 0.44), CV endpoint (heart failure hospitalization or CV death; p-interaction = 0.63), and all-cause mortality (p-interaction p = .42). Results were consistent when using FI as a continuous variable. Occurrence of serious adverse events was numerically lower in patients receiving dapagliflozin versus placebo in all FI categories (16.9% vs 20.1%, 26.3% vs 30.7%, and 42.9% vs 47.8%, in not-to-mildly, moderately, and severely frail categories, respectively). CONCLUSIONS The relative benefit of dapagliflozin for all outcomes was consistent across all frailty categories, with no difference in associated safety.
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Affiliation(s)
- Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jawad H Butt
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Meir Schechter
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | | | - Ricardo Correa-Rotter
- The National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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