Differential clinical characteristics and outcome predictors of acute heart failure in elderly patients

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Abstract

Objective

We determined the clinical-epidemiological characteristics and prognostic factors of early mortality and re-consultation in an elderly population attending the hospital emergency department (HED) for acute heart failure (AHF).

Patients and methods

A prospective, observational, non interventional study including all the patients with AHF attended in the Spanish's HED. Two groups were defined: elderly (≥ 80 years) and controls (< 80 years). Variables: demographic characteristics, comorbidity, degree of cardiac involvement, previous treatment, symptoms and signs of the AHF episode, precipitating factors, treatment in the HED and outcome. Outcome variables: mortality and re-consultation within 30 days.

Results

Of the 942 patients included, 455 of whom were elderly (48.3%). In this elderly population female sex, auricular fibrillation and a history of ictus and a poor functional status predominated. The type of ventricular dysfunction was unknown in 70%. No main differences in the presentation of AHF were found between the two groups. Mortality and re-consultation to the HED within 30 days were similar in both groups. While several factors were identified to be related to mortality or re-consultation in control group, in the elderly group it was more difficult to identify patients who will die or re-consult to the HED within the following 30 days. Only respiratory insufficiency on arrival to the HED was found to predict a greater probability of death (OR 3.55; CI95% 1.39–9.11).

Conclusions

AHF in elderly patients presents some differential characteristics and, most importantly, it is more difficult to identify which of these patients will die or re-consult in the short-term.

Introduction

Heart failure (HF) is a syndrome with a high morbimortality [1] and represents the first cause of hospitalisation and consultation in the hospital emergency departments (HED) in patients over the age of 65 years in developed countries [2]. The prevalence of this syndrome increases markedly with age being found in more10% of the population from 70 to 80 years of age and 50% of the patients diagnosed with HF die within 4 years after diagnosis [1]. In Spain, the prevalence of HF is of around 7–8%, reaching 16% on considering only persons over the age of 75 [3]. There are few studies on populations of advanced age with this disease in the literature [4], [5], [6], with differences in the presence of risk factors, form of presentation of HF and clinical management having been reported. Nonetheless, as indicated by their authors, these studies have the limitation of only including patients attended or admitted to departments of cardiology, internal medicine, geriatrics, etc. and therefore, provide only a partial image of this problem since patients with decompensate insufficiency are not always admitted to hospital. Thus, the EAHFE-1 (Epidemiology Acute Heart Failure Emergency) [7] project, carried out in 10 Spanish hospitals, demonstrated that 58.8% of the patients attended in the HED for acute heart failure (AHF) were managed wholly in these departments.

The hypothesis of the present study was that elderly patients with AHF have their own clinical-epidemiological characteristics and prognostic factors of mortality different from those of patients of younger age and from the characteristics reported in the studies published including only individuals who had been hospitalised. To avoid this latter bias, the EAHFE-ELDER sub-study was designed and was carried out with the database of the EAHFE-1 with the objectives of determining the clinical-epidemiological characteristics and prognostic factors of mortality and re-consultation differentiating this elderly population from younger patients.

Section snippets

Subjects and methods

The EAHFE (Epidemiology Acute Heart Failure Emergency) project [7] is a multicentre, evaluational, prospective, non interventional study consecutively including all the patients attended for AHF in the HED of 10 Spanish hospitals. The design of the study was mainly transversal. For the variables of mortality and re-consultation and for some of the objectives specified, a cohort design study was performed to follow the evolution of the patients [8].

The first phase of the EAHFE covered a period

Results

Of the 1017 patients included in the EAHFE study, 75 were excluded from the present study due to the absence of the variable of age, including a total of 942 individuals in the EAHFE-ELDER sub-study. One hundred forty-two patients (15.1%) were lost to follow up.

The age of the total sample was of 77.78 (SD 9.99) years, with a median of 79 years, a minimum of 35 years and a maximum of 99. Of the 942 subjects, 455 (48.3%) were included in the group of elderly patients (80 years of age or greater) and

Discussion

The EAHFE-ELDER sub-study is the first to analyse a very elderly population (greater than 80 years of age) with AHF attended in the setting of an HED, which implies that the segment of population analysed was greater than that of only hospitalised subjects. This cut-off was chosen for age because the life expectancy in our country is of 8.02 years [12], thereby implying that these patients had already surpassed their life expectancy.

In the latter type of study an important loss of patients

Limitations

Firstly, the difficulty in diagnosing HF within the setting of emergency department care should be pointed out. This diagnosis should be fundamentally clinical and may have led to loss of inclusion of patients during the study period. Secondly, at the time of patient recruitment the determination of certain markers which reportedly influence the prognosis of these patients such as type B natriuretic peptides or troponines were not available or systematically recorded in some of the

Conclusion

The study of AHF with patients attended in the emergency department confers a more global view than that obtained from samples obtained with hospitalised patients or those controlled by specialists [23]. When approached from this perspective, AHF in elderly patients of 80 years of age or more presents some differential characteristics compared to the remaining population and, importantly, it is more difficult to identify those who will die or re-consult within the following 30 days after having

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [24].

References (24)

  • K. Dickstein et al.

    ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008

    Eur Heart J

    (2008)
  • J. Rodríguez-Artalejo et al.

    Epidemiología de la Insuficiencia Cardiaca

    Rev Esp Cardiol

    (2004)
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      Citation Excerpt :

      No differences were found in PF between the groups. Herrero et al. [24] assessed older and younger patients recruited in the Emergency Room and followed over the next 30 days. Respiratory infections were the only different PF, more common in the group of older adults but no evidence was found for a prognostic value of none of PF.

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    1

    Annex 1. Members of the EAHFE group:

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      González Armengol JJ, González del Castillo J. Hospital Clinico San Carlos, Madrid, Spain.

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      Llopis F, Álvarez A, Iglesias L, Palom X. Hospital Universitario de Bellvitge, Barcelona, Spain.

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      Laghzoui F, Diéguez S, Carbajosa JF, Murcia J. Hospital General Universitario de Alicante, Alicante, Spain.

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      Pavón J, Sánchez Nayra, Casal LM, Lubillo JT, Medina J. Hospital Dr. Negrín, Las Palmas de Gran Canaria, Spain.

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      Pozo A, Álvaro E, Valles JM, García A. Hospital La Fe, Valencia, Spain.

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      González C, Martín JM, Diego F, Alario MJ, Grande S. Hospital Universitario de Salamanca, Salamanca, Spain.

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      Gil V, Perelló R, Escoda R. Hospital Clinic, Barcelona, Spain.

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      Vázquez-Álvarez J, Gil-Román JJ, Antuña-Montes L, González-Méndez A. Hospital Universitario Central de Asturias, Oviedo, Spain.

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      Iglesias L, Pérez G, Gómez-Ullate F, Díaz JM. Hospital Marqués de Valdecilla, Santander, Spain.

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