New research on heart failure, elderly surgery at AHA Scientific Sessions

New research on heart failure, elderly surgery at AHA Scientific Sessions.

Heart failure, surgery in the elderly and health care disparities were a few of the many research topics presented recently at the annual American Heart Association Scientific Sessions conference in New Orleans.

One study tried to determine whether elderly heart failure patients prefer an improved quality of life or prolonged survival, and which factors might affect their preferences. Researchers studied 622 heart failure patients from 15 centers in Europe who were 60 to 97 years old and had been hospitalized in the last year. Using standardized questionnaires that measure quality of life and end-of-life preferences, researchers asked patients if they would accept a shorter life span if it meant they could live without symptoms. Researchers also asked if the patients would want to be resuscitated if the situation arose.

Paul Ridker MD Providers could prevent 250000 deaths in five years by expanding statin use
Paul Ridker, MD: Providers could prevent 250,000 deaths in five years by expanding statin use.

About 74% of patients said they preferred a longer life to a better quality of life, while 51% said they would want to be resuscitated. Results differed based on a person's individual circumstances, however. Older patients, women, people who lived alone, and people with higher depression scores were more likely to say they didn't want to be resuscitated. People age 75 and older were more likely to prefer quality of life to longer survival, as were those with a history of depression and those who lived alone.

Resuscitation may become more of an issue for hospitalists, as new research found heart failure hospitalizations rose dramatically in the elderly after 1990. Researchers looked at more than 2 million patients age 65 and older from the National Hospital Discharge Survey from 1980 to 2006. Between 1980 and 2005, the estimated annual percentage increase for heart failure hospitalizations was 1.2% in men and 1.55% in women. However, between 2002 and 2006, the relative risk of being hospitalized for heart failure was 1.37 times that of subjects in 1980-1984.

“Both the number of patients hospitalized with a primary diagnosis of heart failure and age-adjusted hospitalization rates have increased dramatically,” said study author Longjian Liu, MD, associate professor of epidemiology and medicine at Drexel University. “Heart failure has become an epidemic.”

Heart failure treatment

Unfortunately, there was disappointing research on treatment for heart failure, including the HF-ACTION study, which found structured exercise training doesn't reduce death or hospitalization rates for heart failure patients compared with usual care. The regimen in the study involved 36 supervised sessions of 30 minutes of exercise, three times a week. At the 18th session, patients began to transition into exercising at home for 40 minutes, five times a week, on a treadmill or exercise bike. All patients received optimal medical therapy.

Despite the lackluster results, the finding may ease the minds of physicians and patients who are wary of exercise for heart failure patients, for fear of bad consequences. The study found no more adverse events (heart attack, angina or arrhythmia) in patients who exercised compared to those who didn't, noted study author Christopher O’Connor, MD, of Duke University Medical Center.

A sub-study of HF-ACTION also found that the patients in the exercise group reported significantly better health status (quality of life, symptoms and physical/social limitations) at three months, and the difference lasted for three years. HFACTION involved 2,331 heart failure patients (average age, 59 years) who were followed for about 2.5 years.

A separate study looked at the subset of heart failure patients with an ejection fraction of greater than or equal to 45%, for whom there has historically been no good treatment. Researchers tested whether irbesartan (Avapro) might decrease death and hospitalizations for heart failure, myocardial infarction, stroke and arrhythmia. They studied 4,128 patients and followed them for 4.5 years, with the average patient age at the start being 72 years—appropriate given that this condition mostly affects older people.

Though there was a difference in those who took irbesartan versus placebo, it wasn't significant. Again the researchers were left with pointing out that at least the study showed the drug was safe, which means it could be a good substitute for patients who can't tolerate other hypertension drugs.

Good news for the elderly

Two studies reported good news about surgery outcomes in the very elderly. One examined 1,062 patients age 80 years and older who had undergone coronary artery bypass grafting, and found that half lived for six years or more and about a quarter lived for 10 years. The researchers concluded that, since the operative mortality is about the same as that of the overall population, CABG can be performed on octogenarians.

A second study of octogenarians undergoing aortic valve replacement without CABG found that more than half were still alive nearly 11 years later, compared with nine years later for those who had valve replacement with CABG. The study looked at 8,796 patients in New England and found that while both sets of patients had an early “upfront” risk of death, they usually survived at least six years after the procedure. Adding CABG to the valve replacement slightly reduced the likelihood of survival. For more on these studies, see the related article.

Life after JUPITER

Not surprisingly, the just-released JUPITER trial was a much-discussed topic at the conference, with physicians debating the consequences of its finding that rosuvastatin lowers heart attack, stroke and death risk in patients with normal LDL cholesterol but high C-reactive protein (CRP) levels. Generally, about half of stroke events and heart attacks are in patients whose cholesterol seems fine.

The results indicate that not only are statins safe, but providers could prevent 250,000 deaths over a five-year period by expanding their use, said lead study author Paul Ridker, MD, director of the Center for Cardiovascular Disease Prevention at Brigham and Women's Hospital in Boston. Yet others at the conference urged caution, noting that cost needs to be taken into account and more research needs to be done to determine who, precisely, should be screened for CRP.

“I do think we need to review the guidelines of where CRP sits in risk evaluation,” said Andrew Tonkin, MD, head of cardiovascular research at Monash University in Melbourne, Australia. “But we need to see what the absolute risk reduction is in various subgroups before we can figure out who to screen.”

It's not clear whether the statins in the study successfully reduced events because they lowered CRP, because they lowered LDL, or both, noted Timothy Gardner, MD, president of the American Heart Association, as did others.

“This was not a trial that compared a CRP strategy to a non- CRP strategy; it was a statin trial,” agreed Ramachandran Vasan, MD, associate professor at Boston University School of Medicine. “Still, JUPITER does provide food for thought.”

Racial disparities

Several studies presented at the conference looked at disparities in care. Hispanic patients are 57% less likely than white patients to have coronary artery bypass surgery a year after successful angioplasty, one study found. They were also significantly more likely to have hypertension, diabetes and insulin-treated diabetes— which one might expect would lead to higher rates of restenosis, not lower, said study author Shailja V. Parikh, MD, a cardiology fellow at the University of Texas Southwestern Medical Center in Dallas.

“It's possible that a referral bias exists,” Dr. Parikh said. “Or there may be mediating factors intrinsic to the Hispanic patient that could be protective toward restenosis.”

Another study offered a speck of hope in the usual dismal news about racial disparities. After reviewing data on 291,009 Pennsylvania patients admitted for CABG after heart attack, researchers found that disparities between African Americans and whites had declined between 1997 and 2006.

While African Americans were less likely to have invasive cardiac procedures done during any time period, the gap narrowed from 59% in 1995-1997 to 38% in 2004-2006. Gaps between lower- and higher-income patients narrowed as well, the study found.