Probiotics in the gastrointestinal diseases of the elderly

Changes of the gut microflora in elderly appear to involve a reduction in numbers of healthy bacteria (lactobacilli and bifidobacteria) and an increase in numbers of potentially pathogenic species. These changes are generally described as gastrointestinal disorders and infections. This review analyses benefits of probiotics in old people, with particular interesting for the latest researches relevant to elderly people, e.g. trials examining enteric infections, antibiotic-associated diarrhea and Clostridium difficile associated diarrhea, functional bowel problems (constipation and irritable bowel syndrome), inflammatory bowel diseases, stimulation of the immune system and prevention of cancer. A growing number of researches indicates that some probiotic strains may help to maintain the health in old people, suggesting both health and cost-saving benefits in offering fermented dairy products. These benefits include: establishment of balanced intestinal microflora; improving colonization resistance and or prevention of diarrhea; reduction of fecal enzymes; reduction of serum cholesterol; reduction of potential mutagenes; reduction of lactose intolerance; synthesis of vitamins; predigestion of proteins.

Safety and efficacy of carvedilol in very elderly diabetic patients with heart failure

OBJECTIVE

Beta-blockers are often cautiously prescribed to older heart failure diabetics because of the paucity of published data and their perceived unfavourable effects on glucose metabolism, in spite of the evidence of their effectiveness and safety in middle-aged diabetic patients. The aim of this study was to compare the safety, tolerability and efficacy of long-term administration of carvedilol in a group of elderly patients with chronic heart failure, with and without concomitant diabetes.

METHODS

Two hundred and fifty-two patients aged > or =70 years with heart failure and left ventricular ejection fraction < or =40% were followed in specialised heart failure clinics. Diabetes was present in 29.7%. Carvedilol was associated with conventional optimised treatment in 64% of diabetics and 65% of non-diabetics (P = NS).

RESULTS

At baseline, diabetics presented with a longer duration of symptoms, higher Charlson comorbidity index, more frequent renal dysfunction and smaller left ventricular volumes than non-diabetics. New York Heart Association functional class and ejection fraction were similar in the two groups. At 1-year follow-up, tolerability (93.7 vs. 92.2%) and mean daily dose (24 +/- 17 vs. 23 +/- 14 mg/day) of carvedilol were similar in diabetics and non-diabetics. No worsening of fasting glucose, glycosylated haemoglobin and creatinine levels as well as the incidence of deaths and hospitalisations was observed in diabetics treated with carvedilol. Similar improvements in New York Heart Association class and mitral regurgitation severity were observed in diabetic and non-diabetic patients taking carvedilol. Ejection fraction showed a significant improvement, more pronounced in non-diabetics than in diabetics (+10 vs. +7 points; improvement of at least 10 points: 15 vs. 36%, P = 0.03).

CONCLUSIONS

Similarly to younger ones, also in older patients, diabetes does not negatively influence the safety, tolerability and efficacy of carvedilol. However, diabetes remains a strong prognostic factor limiting the reversibility of left ventricular systolic dysfunction and the effect of treatment on subsequent outcome.

Carotid intima–media thickness, carotid distensibility and mitral, aortic valve calcification: a useful diagnostic parameter of systemic atherosclerotic disease

BACKGROUND

Mitral (MAC) and aortic (AVC) calcification are observed more frequently in the elderly and are associated with coronary artery disease, aortic atheroma and peripheral arterial atherosclerotic disease. Common carotid intima-media thickness (cIMT) and distensibility (cDIST) are also independent predictors of adverse cardiovascular outcomes. We examined the relationship between the degree of MAC-AVC and cIMT and cDIST.

METHODS AND RESULTS

One hundred and forty-three patients referred for transthoracic echocardiography and carotid artery echo-Doppler were evaluated; the variables measured were: systemic blood pressure, pulse pressure; body mass index, traditional risk factors, cIMT, cDIST (cDIST = [(csD - cdD)/PP]/csD; where csD and cdD were systolic and diastolic carotid diameters, respectively). MAC and AVC score, based on acoustic densitometry, were: 1 = absence of annular/valvular (av) sclerosis/calcification; 2 = av sclerosis; 3 = av calcification; 4 = av calcification; 5 = av calcification with no recognition of the leaflets; the resulting score was the highest for either valvular annulus. Mean cIMT increased linearly with increasing valvular calcification score (P < 0.0001) whereas cDIST decreased for scores 1 to 5 (P < 0.0001). Distribution of cIMT quartiles showed that 75% of the patients in the lowest quartile had a score of 1 and 70% of patients in the highest quartile had a score of 5; 47% of the patients in the highest quartile of cDIST had a score of 1, whereas 60% of patients in the lowest quartile of cDIST had a score of 4.

CONCLUSIONS

The MAC and AVC score identifies subgroups of patients with different cIMT and cDIST. These data may confirm MAC-AVC as a useful important diagnostic parameter of systemic atherosclerotic disease.

Two-year outcome of a prospective, controlled study of a disease management programme for elderly patients with heart failure

OBJECTIVE

Elderly heart failure patients are at high risk of events. Available studies and systematic reviews suggest that elderly patients benefit from disease management programmes (DMPs). However, important questions remain open, including the optimal follow-up intensity and duration and whether such interventions are cost-effective during long-term follow-up and in different healthcare systems. The aim of this study was to determine the long-term efficacy of a hybrid DMP in consecutive older outpatients.

METHODS

Intervention consisted in combined hospital-based (cardiologists and nurse-coordinators from two heart failure clinics) and home-based (patient's general practitioner visits) care. The components of the DMP were the following: discharge planning, education, therapy optimisation, improved communication, early attention to signs and symptoms. Intensive follow-up was based on scheduled hospital visits (starting within 14 days of discharge), nurse's phone call and home general practitioner visits.

RESULTS

A group of 173 patients aged > or =70 years (mean age 77 +/- 6 years, 48% women) was randomly assigned to DMP (n = 86) or usual care (n = 87). At 2-year follow-up, a 36% reduction in all-cause death and heart failure hospital admissions was observed in DMP vs. usual care. All-cause and heart failure admissions as well as the length of hospital stay were also reduced. DMP patients reported, compared to baseline, significant improvements in functional status, quality of life and beta-blocker prescription rate. The intervention was cost-effective with a mean saving of euro 982.04 per patient enrolled.

CONCLUSIONS

A hybrid DMP for elderly heart failure patients improves outcomes and is cost-effective over a long-term follow-up.

Aortic correlates of clinical markers of large artery structure and function. Effects of aging and hypertension

BACKGROUND AND AIMS

Non-invasive measures of large artery structure and function--such as aorto-femoral pulse wave velocity (PWV), arterial compliance (AC) and common carotid intima-media thickness (CCA IMT)--can predict new CV events, independently of traditional CV risk factors. However, neither their relations with aorta properties nor the effects of aging and hypertension on those relations are yet clear.

METHODS AND RESULTS

40 subjects (18 M, 22 F; mean age 60+/-16 yrs, range 21-83 yrs) free of any acute CV event, valve disease or atrial fibrillation, were studied. Aortic IMT, diastolic diameter (D) and distensibility (Dist) were measured by transesophageal echocardiography at three different levels: ascending aorta (AA), distal aortic arch (Aarc) and descending aorta (DA). PWV was measured by Complior. AC was measured as the ratio of stroke volume to pulse pressure. CCA IMT was measured by ultrasonography in diastole. The Dist, IMT, and D of each aortic segment were introduced alternatively into the regression models. After controlling for age, sex, traditional risk factors and prevalent CV disease, AC showed a significant positive association with the distensibility of proximal aortic segments, but no significant association with properties of distal aorta; PWV showed a significant positive association with proximal aorta wall thickness and a negative association with distal aorta distensibility; CCA IMT was positively associated with distal aorta wall thickness, but not with any explored property of the proximal aorta. None of these relationships differed between younger or older, normotensive or hypertensive subjects.

CONCLUSIONS

Non-invasive measures of large artery structure and function are not equivalent with respect to their relations with aortic properties, so that AC seems to reflect proximal aorta function, PWV proximal aorta structure and distal aorta function, and CCA IMT distal aorta structure. Future studies are needed to confirm whether these relations identify a common pathogenetic mechanism, which may be the target for new therapeutic strategies.

Systo-diastolic ventricular function in patients with hypertension: an echocardiographic tissue doppler imaging evaluation study

BACKGROUND

Tissue Doppler imaging (TDI) has evolved to become a useful non invasive method that can complement other echocardiographic techniques in the assessment of left ventricular function in different clinical conditions. Spectral pulsed TDI can provide measurements of regional systolic and diastolic myocardial velocities and is particularly useful in detecting abnormalities of left ventricular systolic and diastolic function. We investigated the presence of systo-diastolic dysfunction in patients (pts) with hypertension compared with pts affected by hypertensive cardiomyopathy and normal control subjects.

METHODS

We evaluated 214 pts with traditional echocardiography and TDI: 69 normal control subjects (Group A); 145 pts with hypertension, divided according to base echocardiographic evaluation in 74 with no evidence of hypertensive cardiomyopathy (diastolic dysfunction and ventricular hypertrophy, Group B), and 71 with evidence of hypertensive cardiomyopathy (Group C). Pts groups were matched for age, sex, heart rate, smoking status and body surface area.

RESULTS

There were no significant differences in ventricular diameters, volumes, shortening and ejection fraction values; TDI showed a progressive systolic wave peak reduction from Group A to B and from Group B to C. Routinely Doppler diastolic function did not show any significant difference between Group A and B; TDI showed progressive E wave peak velocity decrease and A wave peak velocity increase from Group A to B and C and from Group B to C.

CONCLUSIONS

TDI evaluation showed a ventricular systolic dysfunction in pts with hypertensive cardiomyopathy; in addition, an early mild systo-diastolic dysfunction was detected in subjects with hypertension but no evidence of hypertensive cardiomyopathy.

Association of mitral annulus calcification, aortic valve calcification with carotid intima media thickness

Background

Mitral annular calcification (MAC) and aortic annular calcification (AVC) may represent a manifestation of generalized atherosclerosis in the elederly. Alterations in vascular structure, as indexed by the intima media thickness (IMT), are also recognized as independent predictors of adverse cardiovascular outcomes.

Aim

To examine the relationship between the degree of calcification at mitral and/or aortic valve annulus and large artery structure (thickness).

Methods

We evaluated 102 consecutive patients who underwent transthoracic echocardiography and carotid artery echoDoppler for various indications; variables measured were: systemic blood pressure (BP), pulse pressure (PP=SBP-DBP), body mass index (BMI), fasting glucose, total, HDL, LDL chlolesterol, triglycerides, cIMT. The patients were divided according to a grading of valvular/annular lesions independent scores based on acoustic densitometry: 1 = annular/valvular sclerosis/calcification absence; 2 = annular/valvular sclerosis; 3 = annular calcification; 4 = annular-valvular calcification; 5 = valvular calcification with no recognition of the leaflets.

Results

Patient score was the highest observed for either valvular/annulus. Mean cIMT increased linearly with increasing valvular calcification score, ranging from 3.9 ± 0.48 mm in controls to 12.9 ± 1.8 mm in those subjects scored 5 (p < 0.0001). In the first to fourth quartile of cIMT values the respective maximal percentual of score were: score 1: 76.1%, score 2: 70.1%, score 4: 54.3% and score 5: 69.5% (p > 0.0001).

Conclusion

MAC and AVC score can identify subgroups of patients with different cIMT values which indicate different incidence and prevalence of systemic artery diseases. This data may confirm MAC-AVC as a useful important diagnostic parameter of systemic atherosclerotic disease.

Aortic Ectasia with Hemiazygos Vein Dilatation: A Mimicker of Aortic Dissection

Infrahepatic interruption of the inferior vena cava (IVC) is a rare but well-documented finding. In this condition, the IVC between renal and hepatic vein is absent and the hepatic veins directly empty into the right atrium; because of the enlargement of the azygos-hemiazygos vein system, this condition could mimic aortic pathology. We will describe a case of aortic arch enlargement with dilatation of hemiazygos vein, which was initially misdiagnosed by two-dimensional transesophageal echocardiography (TEE) as aortic dissection. TEE-Doppler identified the real condition, which was confirmed by computed tomography.

[Angiotensin II antagonists: new therapeutic perspectives]

First experimental data regarding potential effects of renin-angiotensin-aldosterone system modulation and their usefulness in clinical management of cardiovascular diseases have been reported more than 30 years ago. The two principals pharmacologic innovations are represented by the solid established angiotensin converting enzyme inhibitors, and angiotensin II receptor blockers, lately introduced and not enough tested in well-conducted trials; in particular, it's very interesting the hypothesis of their impact in clinical practice not only in case of angiotensin converting enzyme inhibitors intolerance but as first choice or associated therapy in the treatment of heart failure, a very complex physiopathologic condition in which renin-angiotensin-aldosterone system plays an important role and so its both enzymatic and receptorial inhibition could be particularly useful. With this review we present an up to date of knowledges, completed trials results and ongoing trials perspectives, to redefine actual indications and to profile main future develops of this drugs.

[The elderly patient with heart failure at hospital cardiology units]

The majority of patients hospitalized for heart failure are elderly. In order to point out the clinical characteristics and the quality of care of elderly heart failure patients we evaluated available data from national databases and observational studies. Elderly patients have more severe clinical manifestations, multiple etiologies and comorbid diseases, frequent hospital admissions and a worse prognosis. As many as 30-50% of elderly patients with heart failure may have normal systolic function. In the elderly, evidence-based treatments are relatively underused with often inappropriately low doses. However, this "underuse" largely depends on the higher "frailty" of these patients (i.e. multiple coexisting diseases, disability, socio-environmental factors) and the lack of definite evidence on efficacy and safety of treatments in the very elderly. Thus, there are opportunities to improve quality in many aspects of care, such as instrumental and multidimensional assessment and out-of-hospital management. Targeted clinical trials and rigorous observational studies to favor the implementation of specific guidelines into clinical practice in the elderly are needed.

Clinical features and outcomes of elderly outpatients with heart failure followed up in hospital cardiology units: data from a large nationwide cardiology database (IN-CHF Registry)

BACKGROUND

Congestive heart failure (HF) represents a major public health problem with an age-related increasing prevalence. Despite the high mortality and morbidity in elderly patients with HF, limited clinical and prognostic data are available for development of appropriate prevention and treatment strategies.

METHODS

A cohort of 3327 outpatients consecutively enrolled in the Registry of Italian Network on Congestive Heart Failure by 133 cardiology centers was studied. Univariate and multivariate analyses were performed to compare patients <70 and > or =70 years old and to evaluate associations between clinical variables and the 1-year mortality rate and hospitalizations.

RESULTS

With respect to the 2294 patients <70 years old, the 1033 (31%) elderly patients were significantly more likely to be female, to be in New York Heart Association (NYHA) class III-IV, and to have preserved left ventricular systolic function (ejection fraction >40%), an ischemic/valvular etiology, and atrial fibrillation/flutter. Elderly patients received angiotensin-converting enzyme inhibitors, beta-blockers, and anticoagulants less frequently than younger patients did. The 1-year mortality rate was significantly higher in patients > or =70 years old (22% vs 13.7%, P <.001). Age was an independent predictor of 1-year mortality, increasing 2.8% by each year of age. Independent predictors of 1-year mortality in elderly patients were (1) > or =1 hospital admission in the previous year (relative risk [RR] 2.09, 95% CI 1.51-2.87), (2) systolic blood pressure (RR 0.98, 95% CI 0.97-0.99), (3) NYHA class III-IV (RR 1.57, 95% CI 1.20-2.07), and (4) age (RR 1.028, 95% CI 1.001-1.056).

CONCLUSIONS

Our study confirms that elderly patients (1) are seen in a more advanced stage of HF, (2) are less likely to receive evidence-based treatments, (3) show more frequently preserved systolic function, and (4) have a worse prognosis. Consequently, there is a need to develop more effective and targeted management strategies for this escalating health problem.

Blood lipid changes in hypertensive, dyslipidemic patients under long term quinapril treatment

OBJECTIVE

The present study aimed at verifying Quinapril effects on both pressure and lipid profile in 15 patients (5 M, 10 F), aged 45 to 80 years (63 +/- 9), complaining for mild to moderate hypertension and dyslipidemia (total cholesterol > 200 mg/dl and triglycerides > 200 mg/dl). No relevant associated disease was present, including diabetes mellitus not any lipid lowering drugs were given.

METHOD

After a wash-out period of one week, all patients, who had been hypertensive for 2 to 120 months (33 +/- 11), were given Quinapril 20 mg orally once a day for 6 months and kept on a low lipid diet from before treatment to the end of the study. Lipid profile we assessed at three-month intervals.

RESULTS

Blood pressure, monitored at two-week intervals, significantly decreased on the 1st month (p < 0.001), and kept lower thereafter. Mean total cholesterol, triglycerides and low density lipoprotein cholesterol levels, after 6 months of therapy, were reduced by 44 mg/dl (p < 0.001), 29 mg/dl (p < 0.001) and 39 mg/dl (p < 0.002) respectively.

CONCLUSIONS

Our results seen indicate that Quinapril antihypertensive effects are accompanied by a significant improvement of the lipid profile.

[Cutaneous microcirculation and diabetic disease. A functional and flowmetry study in subjects with diabetes mellitus type 2]

Laser-Doppler single fingertip skin blood flow has been evaluated in 41 euglycemic type II diabetic patients under basal conditions and after dynamic testing (both ischemia and thermal stress). The same subjects have also undergone tests for the assessment of the degree of autonomic nervous system (ANS) dysfunction. The results have been compared to those obtained in 38 age-matched healthy subjects. In diabetic patients: baseline flow levels were much higher; the post-ischemic flow increase was less evident; a shorter hyperemic phase followed ischemia; a longer latency period was noticed, during thermal stress, together with a lower and slower hyperemic peak level. According to the results of ANS dynamic tests, diabetic subjects were divided into 3 groups: Group 1 (subjects with negative results); Group 2 (subjects with only one positive result); Group 3 (subjects with more than one positive test). Microcirculation disturbances were more often found in Group 3. These results show that a correlation exists between diabetic microangiopathy and ANS dysfunction. They also support the hypothesis, already pointed out by other research groups, of a similar mechanism causing diabetic neurologic and vascular complications.

[The incidence and clinical significance of the echocardiographic finding of false chordae tendineae]

The presence of false tendons (FT) with M-mode and 2-D echocardiography in a consecutive series of 916 patients (520 men--396 women) with a wide age range (9-83 y) was investigated, and a possible correlation with heart systolic murmurs and/or heart arrhythmias evaluated. The problems that FT cause in differential diagnosis with other intraventricular structures were also considered. FT were observed in 53 subjects (5.8%), 30 men--23 women, and in an additional 51 cases (96%) in the left ventricular cavity. A clear prevalence of FT was observed during childhood and adolescence (26.1%), with the preferential location at the top of the ventricular chamber. No relevant correlation between FT and heart systolic murmurs and/or cardiac rhythm disorders was found. Although our results show that FT constitute an occasional finding, with no anatomic or functional relevance, they should always be held in due consideration in case of diagnostic uncertainty with other pathological structures, in particular intracavitary thrombi.

[Relation between the blood potassium and blood glucose responses and electrocardiographic changes, specifically the T wave, during the oral glucose tolerance test]

As previously showed by the Authors, serum K+ levels significantly decrease during OGTT. Moreover, two possible patterns were separated: a) monophasic decrease ("M" type curve) causing a mild but continuous down-slope, possibly physiologically more relevant, and b) polyphasic decrease ("O" type curve) causing a sharp down-slope followed by a rebound to normal K+ levels. In 10 of 12 M type subjects (83%) electrocardiographic changes were shown after OGTT, comparative to only 9 out of 16 O type subjects. The Authors believe this to be suggestive of a heavier impact of kaliemic changes on to myocardial function in M type curves. The hypothesis needs further analysis.

[Influence of blood potassium variations on changes in electrocardiographic patterns during oral glucose tolerance test]

In 45 apparently healthy subjects an OGTT was performed and glucose, insulin, potassium and sodium were measured at fixed intervals. A standard EKG was recorded at the beginning and at the end of the trial. K+ levels steadily decreased reaching their lowest value 60 to 120 min after insulin peak. Na+ levels did not change. In those subjects whose final EKG showed some worsening, the ratio final to initial K+ levels, unlike glucose levels, significantly decreased (p less than 0,01). The hypothesis is given that many clinical pictures of coronary heart disease, so often encountered during OGTTs, may depend on K+, rather than glucose, unbalance.