Original Article
Characteristics of acute heart failure in very elderly patients — EVE study (EAHFE very elderly)

https://doi.org/10.1016/j.ejim.2014.04.002Get rights and content

Highlights

  • Presentation of acute heart failure (AHF) in very elder is similar from youngest.

  • There are no differences in management in Emergency Departments of AHF in elderly.

  • There are few identifiable predictors of early mortality in elderly with AHF.

  • NTproBNP and troponins provide important prognostic information in these patients.

  • Incorporating NTproBNP and troponin should be considered for very elderly with AHF.

Abstract

Objectives

To determine the characteristics and prognostic factors of early death in the very elderly with acute heart failure (AHF).

Patients and methods

We performed a prospective, observational study of AHF patients attended in Emergency Departments (ED), analyzing 45 variables collected in ED and studying troponin, natriuretic peptides and echocardiographies, not always available in the ED. The patients were divided into 2 groups: nonagenarian (age ≥ 90 years) and controls (age < 90 years). The study variables were mortality and death or reconsultation to the ED for AHF within 30 days after inclusion.

Results

We included 4700 patients (nonagenarians: 520, 11.1%). The 30-day mortality was 21.5% and 8.7% (p < 0.01), respectively with a combined event of 33.3% and 26.7% (p = 0.001). Age ≥ 90 years was maintained in all the models associated with death (OR: 1.94, CI 95%: 1.40–2.70). In nonagenarians, chronic kidney insufficiency (OR: 2.07, CI95%: 1.16–3.69), severe functional dependence (OR: 2.18, CI95%; 1.30–3.64) and basal oxygen saturation < 90% (OR: 1.97, CI95%: 1.17–3.32) and hyponatremia < 135 mEq/L (OR: 1.89, CI95%: 1.05–3.42) were predictive variables of mortality. We observed an association between elevated troponin levels and natriuretic peptide values > 5180 pg/mL and mortality (OR: 4.26, CI95%: 1.83–9.89; and OR: 3.51, CI95%: 1.45–8.48; respectively).

Conclusions

The profile of nonagenarians with AHF differs from that of younger patients. Although very advanced age is an independent prognostic factor of mortality, these patients have fewer predictive factors of mortality, being only functional deterioration, basal kidney disease, hyponatremia and respiratory insufficiency on arrival at the ED and probably troponin values and elevated natriuretic peptides.

Introduction

In industrialized countries a gradual aging of the population is taking place leading to increasingly more patients of advanced age consulting in emergency departments (ED). Heart failure represents the first cause of hospitalization and consultation in the ED in developed countries among patients over the age of 65 years [1], [2], with the prevalence rising with age [1], [3].

Patients with a very advanced age are very seldom represented in clinical trials [4] and the prevalence of risk factors and cardiovascular comorbidity [5], [6], [7], [8], [9], [10], [11], [12] differs from that of younger patients. Many of these studies have the limitation of being undertaken only in patients attended or admitted to cardiology, internal medicine or geriatric units or are analyses performed in patients included in clinical trials [5] and as such provide only a partial image of this problem since patients with acute heart failure (AHF) are not always admitted to the hospital.

The first study of the EAHFE project (Epidemiology Acute Heart Failure Emergency) [13] which was carried out in 10 Spanish EDs demonstrated that more than half of the patients attended in the ED for AHF were entirely managed in these departments: one part of the patients in the short stay units and another part were discharged directly from the ED without admission. Analysis of octogenarian patients in the same series [8] demonstrated that despite different basal characteristics between the patients over 80 years of age and the remaining patients, the mortality was similar, and in contrast to what occurs in most of the previous studies, it was not possible to identify predictive factors of mortality or reconsultation to the ED in this group of subjects over 80 years of age. It is possible that in this study the cut off age of 80 years was not sufficient to identify patients with a clearly increased fragility and who present a different profile from the remaining population since the general advances in health in the last few decades, particularly in the treatment of cardiovascular diseases, have substantially increased the prognosis and survival of the population [14]. Nonetheless, the lack of studies on the management and results of patients with AHF and a very elderly age makes it difficult to use evidence-based medicine to estimate the prognosis of these groups of extreme age.

With these precedents the hypothesis of the present study was that very elderly patients with AHF, that is, those with an age ≥ 90 years, have an increased risk of death or reconsultation to the ED in the short-term compared with patients of a younger age, and additionally, it is possible to define the profile of those presenting a greater risk of death or reconsultation.

Section snippets

Type of study

The EAHFE project [13] is a prospective, evaluative, multicentric, cohort study without intervention, with consecutive inclusion of all the patients attended for AHF in Spanish EDs. The inclusion criteria was in fulfillment of the Framingham diagnostic criteria. During the design phase of the EAHFE project, the authors considered performing different studies based on data registry. One study was the analysis of very elderly patients (≥ 90 years of age) which was denominated EAHFE-VERY ELDER (EVE

Results

Of the 4897 individuals, 197 were excluded due to loss to follow-up. The patients excluded did not present differences compared with those included with respect to the demographic variables, cardiovascular comorbidity and form of presentation of the AHF episode (data not shown). Of the 4700 patients finally analyzed, 520 (11.1%) corresponded to the nonagenarians.

Table 1 shows the analysis of all the variables collected in the study, both globally and compared between the two groups. Females

Discussion

The EVE study is the first carried out in the usual clinical practice in the ED including a population group of very elderly patients and in which more than 15% of the patients in this age group were directly discharged home after ED care. This demonstrates a wider range of very elderly patients with AHF, not only those who were hospitalized [5], [17], [18], [19], and the results may be extrapolated to the usual ED practice. The population of such an elderly age with AHF is scarcely represented

Learning points

  • Very elderly patients with acute heart failure have fewer prognostic markers than younger patients.

  • In very elderly patients, mortality does not depend only on advanced age.

  • Severe functional dependence is one of the clinical variables with the greatest predictive capacity and also presents great interaction with age.

  • In very elderly patients, probably NTproBNP and troponin biomarkers could be of value in determining prognosis. The NTproBNP and troponin biomarkers probably have prognostic value in

Conflict of interests

The authors state that they have no conflicts of interest.

Acknowledgments

This study was carried out within the projects PI10/01918 and PI11/01021 of the Instituto de Salud Carlos III and received financial support from Fondos FEDER. The Group of Investigation in Emergency Medicine “Emergency care: processes and diseases” of the IDIBAPS receives financial support from the Generalitat de Catalunya for Consolidated Groups of Investigation (GRC 2009/1385).

Members of EAHFE Registry of the Work Group ICA-SEMES. Marta Fuentes (University Hospital of Salamanca). José Vallés

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