Aged – ABC CARDIOL

IJCS

Editorial

From Right to Left Radial Access in Older Patients: Are We Witnessing the Next Procedural Shift?

Sandro Cadaval Gonçalves

The steady rise in percutaneous coronary interventions performed in older patients reflects not only demographic trends but also the growing body of evidence supporting the effectiveness of invasive strategies in this population. Three decades ago, the femoral approach was the undisputed standard. Early reports of transradial access in the early 1990s were met with skepticism, mainly due to concerns about procedural complexity and unfamiliarity with the required technical adjustments. Over time, radial access became the preferred approach. The transition from radial to femoral access offered elderly patients a clear reduction in bleeding and vascular complications. Operators naturally shifted from right femoral to right radial access, remaining on the same side of the patient and often overlooking the more distant left side. As a result, right radial access (RRA) became the default. The choice between RRA and left radial access (LRA) is often driven by habit, operator ergonomics, equipment availability, and catheterization laboratory setup. Emerging evidence suggests this decision warrants closer consideration. In older patients, atherosclerotic and tortuous changes in the subclavian and brachiocephalic arteries are disproportionately more common on the right side. A left radial approach may reduce technical challenges, potentially shortening procedure time and lowering radiation exposure and contrast volume.^,

In this issue of the International Journal of Cardiovascular Sciences, Gonçalves et al. shed light on this important topic. In an elegant and technically well-performed systematic review and meta-analysis, including 1,094 patients from three randomized trials and one observational study, the authors provide compelling evidence to reconsider the choice of radial access in elderly patients. While numerous previous reviews have compared LRA and RRA, this study is unique in its exclusive focus on the elderly population. The analysis included studies involving patients aged ≥70 years undergoing diagnostic or therapeutic coronary procedures, comparing RRA and LRA, and reporting at least one of three outcomes: fluoroscopy time, contrast volume, and procedural difficulty.

[…]

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Original Article

Diagnostic Value of Serum sCD40L, CCL3, and NT-ProBNP Levels in Detection of Lower Limb Venous Thrombosis among Elderly Patients with Heart Failure

Xuelian Liu et al. Lina Mu Shasha Ma Huijing Zhang

Abstract

Background:

The serum levels of soluble CD40 ligand (sCD40L), cytokine ligand 3 (CCL3), and N-terminal pro-brain natriuretic peptide (NT-proBNP) are closely associated with heart failure (HF).

Objective:

This study evaluated the predictive value of serum sCD40L, CCL3, and NT-proBNP levels for lower limb venous thrombosis (LLVT) in elderly patients with HF.

Methods:

A total of 200 patients with HF were retrospectively included and equally divided into thrombus and non-thrombus groups based on lower limb vein ultrasound findings. Serum levels of sCD40L, CCL3, and NT-proBNP were measured and analyzed. A p-value < 0.05 was considered statistically significant.

Results:

Serum sCD40L, CCL3, and NT-proBNP levels were significantly higher in the thrombus group compared with the non-thrombus group (p < 0.05). Multivariate logistic regression analysis demonstrated that elevated serum sCD40L, CCL3, and NT-proBNP levels are risk factors for LLVT in patients with HF (p < 0.05). The area under the receiver operating characteristic (ROC) curve (AUC) for the combined serum sCD40L, CCL3, and NT-proBNP levels was greater than that of each individual marker (Z values: sCD40L = 3.337, CCL3 = 2.303, and NT-proBNP = 5.156; p < 0.001, p < 0.001, and p = 0.021, respectively).

Conclusion:

Elevated serum sCD40L, CCL3, and NT-proBNP levels were associated with LLVT in elderly patients with HF. The combination of these markers provides high diagnostic value for the detection of LLVT in this population.

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IJCS

Original Article

Left Versus Right Radial Access in Elderly Patients for Coronary Procedures: A Systematic Review and Meta-Analysis

Anna Loise da Cruz Gonçalves et al. Deivyd Vieira Silva Cavalcante Brenda de Adonai Rodrigues Martins Caroline de Oliveira Fischer Bacca … Júlia Gonçalves Gadelha Suelen Queiroz Gabriel Erzinger Octávio Drummond Guina

Abstract

Background:

Radial artery access is widely used in coronary procedures, but the optimal choice between left (LRA) and right (RRA) radial access remains controversial, especially in older patients.

Objective:

Compare LRA and RRA in patients ≥ 70 years undergoing coronary procedures.

Methods:

This study conducted a systematic review and meta-analysis of observational studies and randomized clinical trials (RCTs), adopting a significance level of 5% for all statistical analyses. We searched PubMed, Embase, and Cochrane Central for studies comparing LRA and RRA in patients aged ≥ 70 years. The main outcomes were fluoroscopy time, contrast volume, and procedure difficulty.

Results:

We included 1,094 patients from 4 studies, of which 3 were RCTs. Among them, 821 (75%) patients underwent the procedure via RRA. The LRA group showed a significantly shorter fluoroscopy time (standard mean difference [MD]: −0.41; 95% confidence interval [CI]: −0.67 to −0.42; p < 0.01; I² = 80%), and there was a significant reduction in the contrast volume between the groups, favoring LRA (MD: −13.04 milliliters; 95% CI: −18.0 to −8.20; p < 0.01; I² = 0%). However, there was no significant difference in the perceived difficulty level between the groups (risk ratio [RR]: 1.03; 95% CI: 0.61 to 1.73; p = 0.92; I² = 0%).

Conclusion:

LRA is associated with a significantly shorter fluoroscopy time, suggesting a greater efficiency in terms of radiation exposure. These findings imply that, while LRA may offer some efficiency benefits, the choice between LRA and RRA should consider other clinical and technical factors, such as operator preference and experience.

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Editorial

Influenza Vaccine Adherence in Older Adults – Reflections and Perspectives

Bruna Moretti Luchesi

Influenza vaccination in Brazil was implemented in 1999 with the goal of vaccinating at least 70% of the population aged 65 or over. In 2000, the age limit was lowered to 60 years; in 2010, new risk groups were included as eligible to receive the vaccine; in 2008, the vaccination target was raised to 80%; and in 2017, to 90%, a target that remains to this day.

Older people are considered a risk group for vaccination because they are more susceptible to serious illnesses and complications from influenza. Within this group, those with cardiovascular comorbidities are even more vulnerable.

[…]

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IJCS

Original Article

Analysis of the Prevalence of Metabolic Syndrome and NCEP ATP III Criteria in Older People

João Pedro de Sousa Palmeira et al. Mateus Cardoso Oliveira Emille Silva Santos Renata Sigler … Lorena Andrade Nunes Cézar Augusto Casotti

Abstract

Background:

Metabolic syndrome (MS) is a cluster of conditions, including hypertension, dyslipidemia, and abdominal obesity, associated with increased cardiovascular risk. In the elderly population, the prevalence of MS varies widely depending on region, lifestyle, and diagnostic criteria. Understanding the components that contribute most to MS can aid in targeted health interventions.

Objective:

This study aimed to investigate the prevalence of MS and identify which components most influence its diagnosis among older adults.

Methods:

This is an epidemiological, cross-sectional study conducted from January to December 2022, with people aged 60 or over, of both sexes. Data were obtained in three steps (interviews, clinical examinations, and laboratory tests). Data were entered in duplicate and analyzed using PAST software. The criteria and cutoff points adopted to diagnose MS were those proposed by NCEP ATP III.

Results:

This study evaluated 127 older people, 63% female. The prevalence of MS was 40%, and the most prevalent component was arterial hypertension. Hypertriglyceridemia, waist circumference, and high blood glucose were the components of MS that contributed to 68.2% of the diagnosis of this condition.

Conclusions:

The prevalence of MS was high in the population assessed. Hypertension was the most prevalent component, and hypertriglyceridemia was the component that most explained it.

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IJCS

Original Article

Percutaneous Patent Foramen Ovale Occlusion in Patients Over 60 Years of Age with History of Stroke

Marcelo Sabedotti et al. Luciano da Silva Selistre Agda Mezzomo Fabio Eduardo Camazzola … Ramiro Caldas Degrazia Bibiana Guimarães Maggi Sara Voltolini

Abstract

Background:

The prevalence of patent foramen ovale (PFO) is 27%. PFO is related to paradoxical embolism, which can cause ischemic stroke. Ischemic stroke without an identifiable cause is common, accounting for up to 40% of cases, and PFO is frequently found in these patients. The prevalence of PFO is almost 3 times higher in elderly patients with ischemic stroke without identified etiology, suggesting that these patients may also benefit from PFO closure.

Objectives:

The primary objective was to assess the recurrence of ischemic stroke or transient ischemic attack during clinical follow-up. The secondary objective was to assess the occurrence of procedural complications, onset of atrial fibrillation, and reduced anticoagulant use.

Methods:

This retrospective cohort study included 36 patients over 60 years of age with prior ischemic stroke who underwent PFO closure. Survival analysis was performed using the Kaplan-Meier model. Independence tests between categorical variables were performed using the chi-square test and Fisher’s exact test, adopting a significance level of 0.05.

Results:

The patients’ mean age was 69.6 ± 6.5 years, and 55.5% were men. No complications occurred during the procedures. Echocardiography was performed 30 days after the intervention, showing no residual shunts. During the follow-up of 58.9 ± 42.7 months, there were no cases of ischemic stroke, transient ischemic attack, or atrial fibrillation related to the procedure. The use of anticoagulants decreased from 41.7% to 5.6% (p = 0.03).

Conclusions:

Percutaneous PFO occlusion for the prevention of cerebrovascular events in individuals over 60 years of age with prior ischemic stroke is effective and safe, with a low risk of complications, and it can reduce the risk of bleeding by reducing the use of anticoagulants.

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Original Article

Uptake of Influenza Vaccine among Older Adults with Cardiovascular Comorbidities

Rodrigo S. Aguilar et al. Ana Paula Rosim Giraldes Maria Paula Barbieri Delia Meliza Goi Roscani Henrique Pott

Abstract

Background

Influenza vaccination reduces illness and fatality in older adults, especially those with cardiovascular comorbidities.

Objective

To investigate influenza vaccination uptake among community-dwelling older Brazilian patients with cardiovascular comorbidities.

Methods

This cross-sectional study analyzed data from the ELSI-Brazil Second wave (2019-2021), involving 9,949 older adults. Participants with cardiovascular conditions provided data on influenza vaccination from the previous year. Vaccination-associated factors were identified, with subgroup analyses for each cardiovascular comorbidity. An exploratory analysis investigated the primary reasons for non-vaccination. Statistical significance was determined with a two-sided P-value < 0.05.

Results

This study included 5,296 individuals. Of these, 76.6% reported receiving the influenza vaccine within the year before data collection. Vaccinated individuals were generally older females, widowed, and non-smokers with healthier habits and private healthcare access, although they had higher frailty and cardiovascular comorbidities. Age significantly influenced the likelihood of vaccination across subgroups. In hypertension, private healthcare and good health status increased the odds, while smoking and alcohol consumption reduced them. The most common reasons for not receiving the influenza vaccine were fear of adverse reactions (18.2%), belief in a low-risk infection (14.9%), vaccine unavailability (13.9%), and lack of confidence in its effectiveness (12%).

Conclusion

About 24% of older Brazilian adults with cardiovascular conditions remain unvaccinated against influenza, posing severe health risks. Strategies addressing personal beliefs, improving access, and enhancing healthcare provider engagement are crucial. Tailored interventions should align with the population’s demographic and health characteristics to overcome these barriers effectively.

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Original Article

Characteristics Associated with Prevalent Atrial Fibrillation and Risk Profile for Incident Atrial Fibrillation an Elderly Population from ELSA-Brasil

Bernardo Boccalon et al. Murilo Foppa Luisa C.C Brant Marcelo M. Pinto-Filho … Antonio L. Ribeiro Bruce B. Duncan Angela Barreto Santiago Santos

Abstract

Background

Atrial fibrillation (AF) is an arrhythmia causing significant symptoms and raising the risk of complications.

Objectives

To evaluate the association of clinical, electrocardiographic, and echocardiographic parameters with prevalent atrial fibrillation or flutter (AFF) and assess the risk profile for incident AFF using the AF prediction scores CHARGE-AF and EHR in an elderly population from a developing country.

Methods

We included all participants in ELSA-Brasil aged 60 and over whose diagnosis of AFF could be defined through self-report or electrocardiogram and who had echocardiography performed at the study’s baseline. For statistical analysis, results with p values < 0.05 were considered statistically significant.

Results

Among the 2,088 participants (65 ± 4.1 years; 53% women), 88 (4.2%) had AFF. Those with AFF were older and had higher rates of heart failure (HF), previous myocardial infarction, left bundle branch block (LBBB), prolonged QT interval, supraventricular extrasystoles, and sinus bradycardia. They also had larger left atrial and left ventricular dimensions, and lower left ventricular ejection fraction (LVEF). Multivariable analysis showed that HF, LBBB, larger left atrium, and lower LVEF were independently associated with AFF. The 5-year risk for incident AFF was low ( 5%) in 12% of individuals according to the CHARGE-AF score, and low in 67% and high in 13% according to the EHR.

Conclusion

AFF was found in 4.2% of this older Brazilian cohort. AFF was linked to HF history, LBBB, left atrial dilation, and reduced LVEF. Additionally, 12% to 13% of patients in sinus rhythm were at high risk for AFF. Monitoring clinical, electrocardiographic, and echocardiographic parameters can aid in early identification of high-risk individuals.

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IJCS

Original Article

Agreement Between a Portable Cholesterol Device and Laboratory-Based Testing in Older Adults

Odilon Abrahin et al. Naicha Stefanie Félix Souza Rejane P. Abrahin Alex Harley Crisp

Abstract

Background:

It is crucial to monitor blood lipid levels accurately in older adults to assess cardiovascular risk. Although several portable strip-based devices are commercially available, their accuracy has not been well established.

Objective:

To evaluate the agreement of the Mission Cholesterol device and standard laboratory method results, using samples from older adults.

Methods:

Forty-nine patients (42 females) with an average age of 70 ± 8 years were included. The participants were instructed to fast for 12 hours before undergoing venous and capillary blood sampling for lipid analysis (total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], and triglyceride [TG] levels). The agreement between the Mission Cholesterol device and laboratory test results was assessed using the concordance correlation coefficient (CCC) and Bland–Altman plots. The accuracy levels were assessed based on the percentage bias recommended by the National Cholesterol Education Program (NCEP).

Results:

The TC measurement had a better accuracy level (bias = 10.91%; CCC = 0.89) than other lipid measurements. However, none of them met the NCEP’s acceptable standards for bias and concordance (CCC ≥ 0.90). Furthermore, the device demonstrated modest overall agreement in classifying lipid risk according to clinical reference values (agreement rates: TC, 67.3%; HDL-C, 65.3%; LDL-C, 49.0%; and TG, 61.2%).

Conclusion:

The Mission Cholesterol device exhibited insufficient agreement levels for effective lipid profile monitoring and screening in older adults.

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Editorial

Hypertension and Cardiovascular Risk: Direct Association with Blood Pressure Values

Hypertension (AH) is one of the main risk factors for cardiovascular (CV) diseases, mainly stroke, coronary artery disease, heart failure, and peripheral vascular insufficiency. Adequate control of blood pressure (BP) levels significantly reduces the appearance of all these harmful events.

As BP is a continuous biological variable, the definition of normality is not yet a universal consensus. The latest Brazilian AH guideline published in 2020 considers individuals with BP ≥140/90 mmHg (systolic/diastolic) to be hypertensive. However, we know that CV risk begins to increase at BP values well below those considered normal.

[…]

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Original Article

The Association of Blood Pressure Defined by the 2017 ACC/AHA Guidelines and Cardiovascular Disease Risk for Middle-Aged and Elderly People in China: A Cohort Study

Qingyang Lu et al. Haijing Xie Xuefeng Gao

Abstract

Background

Cardiovascular disease (CVD) is a series of diseases affecting the heart or blood vessels.

Objectives

To assess the relationship between blood pressure (BP) levels defined by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline and CVD/atherosclerotic cardiovascular disease (ASCVD) risk for middle-aged and elderly people in China.

Methods

A total of 6,644 middle-aged and elderly people from the China Health and Retirement Longitudinal Study (CHARLS) were finally included. According to the 2017 ACC/AHA guideline, all subjects were divided into four groups: normal BP, elevated BP, stage 1 hypertension, and stage 2 hypertension. The outcome of this study was considered as the risk of CVD and ASCVD. Univariate and multivariate COX regression models were adopted to examine the relationship of the 2017 ACC/AHA BP classification with the risk of CVD. Univariate and multivariate logistic regression models were used to investigate the association between BP levels and ASCVD risk. Subgroup analyses based on age, gender, and use of antihypertensive drugs were performed. P<0.05 was accepted as statistically significant.

Results

After adjusting all covariates, compared to middle-aged and elderly patients with normal BP, we found that patients with stage 1/2 hypertension were associated with a higher risk of CVD, separately. Simultaneously, we also observed a positive association between individuals with elevated BP, stage 1 hypertension, stage 2 hypertension, and higher ASCVD risk in the fully adjusted model. The result of subgroup analyses implied that the relationship between stage 1/2 hypertension and CVD/ high ASCVD was robust in different ages and genders, and participants without using antihypertensive drugs.

Conclusion

BP classification under the 2017 ACC/AHA BP guidelines may apply to the Chinese population.

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IJCS

Original Article

Feasibility of the Two-Minute Walk Test in Elderly Patients After Acute Myocardial Infarction: A Cross-Sectional Study

André Luiz Lisboa Cordeiro et al. Luiz Anselmo Santos Lucas Oliveira Ana Cristina Almeida … Damaris Alves Hanna Beatriz de Melo Moraes e Silva Fernanda Francisco Souza André Raimundo França Guimarães

Abstract

Background

Pathologies involving the heart are still the main causes of death, and acute myocardial infarction (AMI) is consistently present in this index. The two-minute walk test (2MWT) is ideal for assessing the functional capacity of this patient.

Objective

To describe the feasibility of the 2MWT in older people after AMI.

Methods

This is a cross-sectional study. At hospital discharge, patients were invited to perform the 2MWT. Before starting the test, systolic blood pressure (SBP), diastolic blood pressure (DBP), peripheral oxygen saturation (SpO₂), heart rate (HR) and the Double Product (DP) were checked. After checking the vital signs, the patients were accompanied by an examiner, who was positioned laterally to ensure safety and verbally encouraged during the test; after the completion of the test, all vital signs were reassessed in two moments, at the immediate end and after 20 minutes of rest. ANOVA was used for the comparison of pre and post-test and pre and recovery. A p<0.05 was considered significant.

Results

We evaluated 51 patients, 4 (80%) males with a mean age of 67±8 years. The distance walked on the 2MWT had a mean of 157 ± 22 meters. The SBPmmHg Pre-Test 112±21 vs 131±15 Post-Test (p=0.24) and 119±22 at Recovery (p = 0.34) and HR (bpm) Pre-Test 75±15 vs 89±19 Post-Test (p=0.15) and 79±15 at Recovery (p = 0.59). After a rest, all variables analyzed followed the same pattern, returning to values close to the pre-test moment.

Conclusion

The performance of the 2MWT in the hospital environment presents good feasibility in the evaluation of submaximal capacity in elderly patients after AMI.

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Original Article

Temporal Trends in Transcatheter Aortic Valve Implantation: 10-Year Analysis of the TAVIDOR Registry

Vinicius Esteves et al. Pedro Beraldo de Andrade Cleverson Neves Zukowski Edmur Araujo … Cristiano Guedes Bezerra Adriano Dourado Oliveira Eduardo Pessoa de Melo Gustavo Gama Rodrigo Cantarelli Luiz Alberto Piva e Mattos Angelo Tedeschi Vitor Alves Loures Vitor Vahle Guilherme Barreto Gameiro Silva Miguel Antonio Neves Rati Augusto Celso Lopes Nilson de Moura Fé Filho Gustavo Alves Sérgio Costa Tavares Filho Sergio Kreimer Marden Tebet Felipe Maia Maurício Sales de Oliveira Alberto Fonseca Angelina Camiletti Denilson Campos de Albuquerque Olga Ferreira de Souza

Abstract

Background

Transcatheter aortic valve implantation (TAVI) has established itself as the preferential strategy to approach severe aortic stenosis. Information on procedural improvements and nationwide results obtained with the technique throughout the past decade are unknown.

Objectives

To assess the temporal variation of the demographic profile, procedural characteristics, and in-hospital outcomes of patients undergoing TAVI procedures at the Rede D’Or São Luiz.

Methods

Observational registry comprising 29 national institutions, comparing the characteristics of the TAVI procedures performed from 2012 to 2017 (Group 1) to those performed from 2018 to 2023 (Group 2). The statistical significance level adopted was p < 0.05.

Results

This study assessed 661 patients, 95 in Group 1 and 566 in Group 2, with a mean age of 81.1 years. Group 1 patients had a higher prevalence of New York Heart Association functional class III or IV and STS risk score > 8%. In addition, they more often underwent general anesthesia, transesophageal echocardiographic monitoring, and access through femoral dissection. Group 2 patients had a higher success rate of the TAVI procedure (95.4% versus 89.5%; p = 0.018), lower mortality (3.9% versus 11.6%; p = 0.004), and less often needed permanent pacemaker implantation (8.5% versus 17.9%; p = 0.008).

Conclusions

The 10-year temporal trends analysis of the TAVIDOR Registry shows a reduction in patients’ clinical complexity over time. Furthermore, the advance to minimalistic implantation techniques, added to the technological evolution of the devices, may have contributed to the favorable outcomes observed among those whose implantation occurred in the last 5 years studied.

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Letter to the Editor

Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years: Commentary

Sérgio Renato da Rosa Decker et al. Luiza Duarte Pittol Regis Goulart Rosa Marciane Maria Rover

Dear Editor,

In the edition of Arquivos Brasileiros de Cardiologia, Mengjin Hu et al. evaluated the benefit of early invasive strategy for elderly patients with non-ST-elevation myocardial infarction (NSTEMI), concluding that this strategy yields positive results in reducing myocardial infarction, major adverse cardiac events, and urgent revascularization outcomes. However, we have concerns regarding the authors’ claim of superiority and the relevance of the chosen outcomes for this specific population. Firstly, these outcomes (ischemia-driven outcomes) are mostly surrogate endpoints based on troponin levels. To establish the surrogacy of one outcome to another, several factors need to be considered, including biological plausibility, associations in observational studies, and, most importantly, proof of concept through trials where improving the surrogate endpoint also enhances clinical outcomes. In this sense, evidence shows that the association between nonfatal myocardial infarction and all-cause or cardiovascular mortality meets the first two levels; however, a meta-analysis of randomized clinical trials did not establish nonfatal myocardial infarction as a surrogate for all-cause or cardiovascular mortality. Indeed, this is a reproducible relationship in short and long term outcomes; the metanalysis of FRISC-II, ICTUS, and RITA-3 showed that, after five years, early invasive strategy for patients with NSTEMI did not result in reduced mortality despite the benefits seen in ischemia-driven outcomes.

[…]

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Case Report

Substrate-Based Ablation of Purkinje-Related Ventricular Fibrillation in an Elderly Patient with Ischemic Cardiomyopathy

Nurullah Çetin et al. Mustafa Özcan Soylu Batuhan Özbaş Özgür Bayturan Uğur Kemal Tezcan

Introduction

Fatal ventricular arrhythmias have an increased incidence in the case of structural heart diseases such as ischemic cardiomyopathy. It is known that ventricular premature contractions (PVCs) originating from Purkinje fibers can induce polymorphic ventricular tachycardia (PMVT) and, subsequently, ventricular fibrillation (VF) in patients with ischemic cardiomyopathy.^, Ventricular arrhythmias associated with Purkinje usually do not respond to conventional antiarrhythmic drugs. Catheter ablation is a favorable and life-saving treatment strategy for VF triggered by Purkinje fibers.

[…]

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Editorial

Improving Meta-analyses

Fernando Mendes Sant’Anna et al. Mariana Bonacossa Sant’Anna Lucas Bonacossa Sant’Anna

The meta-analysis (MA) by Meng-jin et al., published in this issue of the journal, brings important information about the invasive treatment of elderly patients (≥ 75 years old) with acute myocardial infarction without ST-segment elevation (NSTEMI) versus conservative treatment.

Even aware of the benefits of early revascularization in both elderly and young patients, in the first group, the concern with the risks of complications in invasive procedures are known to reduce the number of interventions in this group. On the other hand, with the rapid growth of the elderly population in the world, World Health Organization predicts a significant increase in mortality from coronary artery disease in the coming decades, making it essential to develop effective treatment strategies in elderly patients with NSTEMI.

[…]

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Original Article

Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years

Mengjin Hu et al. Xiaosong Li Yuejin Yang

Abstract

Background

The efficiency of invasive management in older patients (≥75 years) with non-ST-segment elevation myocardial infarction (NSTEMI) remains ambiguous.

Objectives

To assess the efficiency of invasive management in older patients with NSTEMI based on meta-analysis and trial sequential analysis (TSA).

Methods

Relevant randomized controlled trials (RCT) and observational studies were included. The primary outcomes were all-cause death, myocardial infarction, stroke, and major bleeding. Pooled odd ratio (OR) and 95% confidence interval (CI) were calculated. P <0.05 was considered statistically significant.

Results

Five RCTs and 22 observational studies with 1017374 patients were included. Based on RCT and TSA results, invasive management was associated with lower risks of myocardial infarction (OR: 0.51; 95% CI: 0.40-0.65; I²=0%), major adverse cardiovascular events (MACE; OR: 0.61; 95% CI: 0.49-0.77; I²=27.0%), and revascularization (OR: 0.29; 95% CI: 0.15-0.55; I²=5.3%) compared with conservative management. Pooling results from RCTs and observational studies with multivariable adjustment showed consistently lower risks of all-cause death (OR: 0.57; 95% CI: 0.50-0.64; I²=86.4%), myocardial infarction (OR: 0.63; 95% CI: 0.56-0.71; I²=0%), stroke (OR: 0.59; 95% CI: 0.51-0.69; I²=0%), and MACE (OR: 0.64; 95% CI: 0.54-0.76; I²=43.4%). The better prognosis associated with invasive management was also observed in real-world scenarios. However, for patients aged ≥85 years, invasive management may increase the risk of major bleeding (OR: 2.68; 95% CI: 1.12-6.42; I²=0%).

Conclusions

Invasive management was associated with lower risks of myocardial infarction, MACE, and revascularization in older patients with NSTEMI, yet it may increase the risk of major bleeding in patients aged ≥85 years.

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Editorial

Sepsis, Atrial Fibrillation, and Aging: A Dangerous Association

Evandro José Cesarino et al. Marildes Luiza de Castro Carolina Baraldi Araujo Restini

Atrial fibrillation (AF) is a common heart rhythm disorder often identified during sepsis’s progression.

Its prevalence increases in the general population with age, reaching 18% in the elderly over 85 years old.

[…]

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IJCS

Original Article

Clinical Aspects Of Hypertensive Patients With COVID-19 Hospitalized In A Campaign Hospital In Northeast Brazil

Luan George Xavier et al. Renato Sampaio Mello Neto Marcos Henrique de Oliveira Morais Pedro Jorge Cronemberger … Maria do Carmo Carvalho Martins Marta Rosal

Abstract

Background

In view of the absence of effective therapy for COVID-19, many studies have been conducted seeking to identify determining factors for the development of severe forms, aiming to direct efforts to avoid the worst outcomes in patients susceptible to severe conditions. One of the main comorbidities associated with complicated forms of the disease is systemic arterial hypertension (SAH).

Objective

To assess aspects of the clinical, demographic, laboratory, and radiological characteristics of hypertensive patients with COVID-19 to contribute to the knowledge of the relationship between the presence of this comorbidity and the severity of the disease.

Methods

A total of 380 patients with a diagnosis of acute SARS-CoV-2 infection hospitalized between June and August 2020 were included. Patients were divided into two groups according to the presence or absence of a previous diagnosis of hypertension. For comparison between groups, a significant difference was established if p < 0.05.

Results

Of the total of 380 patients, 202 (53.16%) had a clinical diagnosis of SAH. Hypertensive patients were significantly older (p < 0.01) and had more comorbidities (p < 0.01) than the non-hypertensive group. In laboratory tests, hypertensive patients had higher levels of blood glucose (p = 0.014), creatinine (p = 0.002), and urea (p = 0.003), while values for alanine aminotransferase (ALT) (p < 0.01), aspartate aminotransferase (AST) (p = 0.006), and sodium (p = 0.024) were lower. There was no difference between groups in radiographic parameters.

Conclusions

This study showed that, although the hypertensive group had some laboratory alterations that elicited severe disease, these patients did not have worse outcomes.

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Research Letter

Orthotopic Heart Transplantation in a Covid-19 Recipient

Leonardo Rufino Garcia et al. André Monti Garzesi Julia Bazzo Sinatora Rejane Maria Tommasini Grotto … Andréia Cristina Passaroni Nelson Leonardo Kerdahi Leite de Campos Antônio Sérgio Martins Marcello Laneza Felicio Flávio de Souza Brito

Introduction

The coronavirus pandemic has affected more than 480 million people around the world. Solid organ recipients constitute a highly vulnerable group due to the need for immunosuppression and the various comorbidities that may be associated, many of which persist even after transplantation.

Transplanted patients can present a spectrum of clinical manifestations resulting from COVID-19: from asymptomatic, mild symptoms or acute respiratory failure and death. Some studies suggest that in the case of conditions with a favorable outcome, previous immunization and irreplaceable post-transplantation immunosuppression contribute to a response of less exacerbated inflammation and, consequently, less organic damage.^, Nonetheless, some reports and literature reviews show worse prognosis in transplanted patients, possibly due to comorbidities, advanced age, and lymphopenia often present.^,,

[…]

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IJCS

Viewpoint

Frailty in Patients With Valve Disease: How to Assess?

David Provenzale Titinger et al. Vitor Emer Egypto Rosa Marcelo Eidi Ochiai Tarso Augusto Accorsi … João Ricardo Cordeiro Fernandes Roney Orismar Sampaio Flávio Tarasoutchi

Introduction

Valvular heart disease contributes to an important portion of hospital admissions. It can progress to heart failure and death, and it ranks eighth among the causes of mortality due to cardiovascular diseases in Brazil. From the moment that a valve disease becomes anatomically important and has clinical repercussions, only interventional treatment (conventional surgery or transcatheter technique) is able to alter the natural course of the disease.^, The choice of intervention leads to the need for individualized evaluation of the patient, exposing associated clinical conditions that may impact the final result, such as frailty.^,

Frailty, as a clinical syndrome, is characterized by decreased physiological reserve and reduced capacity after a stressor event, causing vulnerability to diseases. It is related to decreased muscle strength, resistance, and functionality, resulting in greater dependence for daily activities and increased mortality. Some commonly associated conditions include sarcopenia, malnutrition, and hormonal disorders.

[…]

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Editorial

Diabetes Mellitus, Physical Exercise and Heart Rate Variability

Gustavo Augusto Ferreira Mota et al. Mariana Gatto Luana Urbano Pagan Suzana Erico Tanni Marina Politi Okoshi

The prevalence of diabetes mellitus (DM) has grown in recent decades.Risk factors for developing DM have been well established in clinical studies. Among these, sedentary lifestyles, aging and obesity stand out.DM, defined by increased plasma glucose concentration, is commonly accompanied by cardiovascular alterations such as hypertension, coronary disease, heart failure, and cardiac autonomic neuropathy.As cardiovascular diseases are currently the main causes of death and morbidity, studies aimed at better understanding the pathophysiological mechanisms inherent in DM are of great importance.

Cardiac autonomic neuropathy is characterized by changes in fibers that innervate the heart and blood vessels.^,In this condition, changes in nerve function lead to reduced heart rate variability and altered baroreflex sensitivity.Physical exercise is considered an important non-pharmacological therapy to help prevent and control DM and its clinical consequences.Researchers have recently observed that exercise can also prevent and treat cardiac autonomic neuropathy.

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ABC

Editorial

Pharmacoinvasive Strategy in ST-elevation Myocardial Infarction: Particularities in the Elderly

Fernando Cesena

Managing myocardial infarction (MI) in older people differs from treating younger individuals. In the elderly, MI presentation is often atypical, more complex, and has a worse prognosis. Not only do the disease severity and the prevalence of comorbidities tend to be higher in the elderly, but adverse events from treatments are also more frequent, particularly bleeding facilitated by different antithrombotic medications. Moreover, decreased renal function and the higher susceptibility to drug interactions due to the concomitant use of multiple medications potentiate the chance of bad outcomes.

In ST-elevation MI (STEMI), fibrinolysis followed by the early percutaneous coronary intervention (PCI) to optimize coronary reperfusion, the so-called pharmacoinvasive strategy, is a guideline-recommended therapy when timely PCI is not available.^–

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IJCS

Editorial

Correlation of Diuretic use and Sarcopenia in Elderly Patients with Hypertension

Lídia Zytynski Moura et al. Camila Hartmann

Hypertension is a chronic disease with high prevalence in Brazil and worldwide. It is estimated that approximately 31% of the world population has blood pressure levels ≥ 140/90 mmHg or uses antihypertensive medication. Hypertension is also the main risk factor with an independent, linear, and continuous association for cardiovascular diseases. Cardiovascular diseases, in turn, are the leading cause of death, hospitalizations, and outpatient care worldwide, including in developing countries such as Brazil.

With aging, hypertension becomes an even more significant health problem. Around 61% of individuals over 60 years old have hypertension. In Brazil, the epidemiological transition with the increase in the number of elderly people (≥ 60 years) in the next decades will lead to a substantial increase in the prevalence of hypertension and its complications. Aging is still associated with other health disorders, including sarcopenia. As with hypertension, the prevalence of sarcopenia is higher in the elderly. It varies from 5% to 13% in people between 60 and 70 years of age, and from 11% to 50% in people ≥ 80 years of age.

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