Cardiovascular

Introduction

Treating hypertension in older patients (>65y) remains controversial given limited evidence around optimising blood pressure in frailty. Although studies suggest improved cardiovascular benefit, NICE guidelines emphasise the need for careful clinical decisions to balance benefits and risks. This local audit assessed the appropriateness of antihypertensive regimens prescribed for older patients against NICE guidelines and STOPP/START criteria. Secondary aims assessed admissions related to antihypertensive medication, polypharmacy reviews during inpatient stays, and management of postural hypotension.

Methods

Retrospective chart analysis of 29 patients including adults > 65y admitted under Ageing and Complex Medicine consultants with diagnosis synonymous to hypertension, postural hypotension, or falls.

Results

A third of the cohort were on inappropriate antihypertensive medications on admission; 56% of these being contraindicated STOPP criteria drugs. 78% majority had medications reviewed, resulting in an improvement from 69% to 89% of patients being on appropriate antihypertensives from admission to discharge.  The admission diagnosis’ of at least 55% of patient cohort were related to antihypertensive medication. There was better compliance of checking lying and standing blood pressure (LSBP) within 48h admission but lower value of 36% was observed within 48 hours prior to discharge. Of those measured, a significant 74% and 50% of patients demonstrated positive postural drops on admission and discharge.  18% of all patients re-attended hospital within six months with similar diagnosis’.

Conclusion

Many older adults in the local area are admitted to hospital whilst on inappropriate antihypertensive regimens. Those admitted due to falls often experience symptoms caused by their medication effects. There is substandard dynamic assessment of lying-standing blood pressure during antihypertension management which likely contributes towards high rate of hospital readmission. Quality improvement measures such as targeted teaching sessions have since been undertaken to improve competence and confidence in clinicians managing hypertension. Further interventions to improve LSBP monitoring, primary care education and patient information provision are ongoing.

Introduction:

The sign of Frank or sign of the cleft lobe has been associated with the existence of a disorganization of the elastic fibers and a thickening of the arterioles that causes a vascular sclerosis and a chronic local ischemia of the lobe of the ear.

Objectives:

To determine the relationship of the split lobe sign with cardiovascular diseases in geriatrics patients of the Internal Medicine service of a Southamerican hospital 2017 to July-2018.

Methodology:

A descriptive and cross-sectional observational study of cases and controls to establish a relationship between the sign of the diseased lobe and cardiovascular disease.

Results:

We observed Smoking is a risk factor directly associated with the presence of the cleft lobe sign p (0.047), there being a greater tendency to appear when the intensity of smoking is higher. The presence of the lobe sign generates a relative risk of 2.062 times in terms of cardiovascular events compared to those who do not. Conclusions: We consider that the association found between the sign of the cleft lobe, smoking and cardiovascular diseases, give us an easily identifiable tool for a population at higher risk for the development of these pathologies.

Introduction: Ischaemic stroke has a poor prognosis, and hemorrhagic transformation after intravenous thrombolysis may increase morbidity and mortality in these patients. Methods: By means of a retrospective analysis, related risk factors were recruited for the analyses, including: smoking, alcohol, hyperlipidemia, and diabetes, among others. The statistical analysis was performed by ANOVA for quantitative variables and the Chi-square test for qualitative variables. Results: The study was carried out on 52 patients with acute ischaemic stroke treated with recombinant tissue-type plasminogen activator (rt-PA) within 4.5 hours after symptom onset. Results showed that factors like age ≥70, smoking, atrial fibrillation, NIHSS score before thrombolysis ≥20 and systolic pressure on admission and at 2h after thrombolysis of ≥160mmHg, increased the risk of hemorrhagic transformation after rt-PA administration. Conclusions: Haemorrhagic transformation after thrombolysis is a complication of acute ischaemic stroke. However, a better characterization of Latin American patients will allow us to direct population strategies in these cohorts in a more individualised way, considering that the predictive factors of this event are not entirely clear in different population groups. The aim is to encourage the development of studies of this type in our latitudes in order to reduce the morbimortality of these patients and stratify them appropriately based on their characteristics.

Introduction

Postural BP readings are important in assessing older people, but are infrequently measured (1) The National Audit of Inpatient Falls (NAIF) 2022 has shown measurement of lying standing blood pressure (LSBP) remains below 50% (2)  

NICE guidelines suggest checking LSBP in patients with:  

1) Hypertension and postural hypotension symptoms  

2) Hypertension and Type 2 diabetes  

3) Hypertension and age ≥ 80 years (3)  

4) Patients presenting with falls (4).  

We aimed to update local data for LSBP recording and investigate LSBP measurements in hypertensive patients.

Method   

Data was collected across 4 wards in University Hospital of Wales between 22^nd May and 9^th June. Patient notes and NEWS charts were reviewed to establish whether an LSBP was necessary and carried out according to NICE guidelines (2) and whether appropriate reasons were documented.   

Results   

The table below shows the number of patients required and completed LSBPs.  

Total Number of Patients  98  

Number of Patients requiring a LSBP  76 

Total number of postural measurements completed 18 (16 LSBP, 2 sit/stand) 

Number of acceptable reasons for not completing postural BP reading  12 

All categories of patient requiring a LSBP have <40% completion; no LSBP’s were completed in patients that were hypertensive and diabetic.

 Conclusion  

Results indicate that local LSBP measurement requires improvement, with only 24% of requiring patients having a postural reading completed. Significant variations in guidelines (NAIF (2), MFRA (4), Cardiff and Vale Falls Policy (5)) have been highlighted as a potential factor, hence clearer guidance is needed on when LSBP is required, to improve detection of postural hypotension and therefore improve falls prevention and hypertension management.  

 References  

1. Detecting Risk of Postural hypotension. BMJ. 2020  
2. National Audit of Inpatient Falls report 2022.  
3. NICE. Hypertension in adults 2022  
4. NICE. Falls in older people 2013. 
5. CAVUHB. Falls Policy 2021  

Introduction

Over 250 medications are reported to cause postural hypotension, associated with serious adverse outcomes in older adults. Studies in the literature and guidelines suggest a harmful cumulative risk of postural hypotension with multiple medication use. However, there is limited evidence on the potential for harm in practice, particularly which drugs are co-prescribed and may increase risk of postural hypotension.

Methods

Retrospective cohort study and cluster analysis using general practice data from IQVIA Medical Research Data (IMRD) in patients aged ≥50 contributing data between 1 Jan 2018 and 31 Dec 2018. Thirteen drug groups known to be associated with postural hypotension by mechanism were analysed and clusters generated by sex and age-band.

Results

602,713 individuals aged ≥50 with 283,912 (47%) men and 318,801 (53%) women were included. The most prevalent prescriptions that might contribute to postural hypotension were angiotensin converting enzyme (ACE) inhibitors, calcium-channel blockers, beta-blockers, selective serotonin reuptake inhibitors and uroselective alpha-blockers. We identified distinct clusters of cardiovascular system (CVS) drugs in men and women at all ages. CVS plus psychoactive drug clusters were common in women at all ages, and in men aged ≤70. CVS plus uroselective alpha-blockers were identified in men aged ≥70.

Conclusion

Distinct clusters of drugs associated with postural hypotension are commonly prescribed in practice, which change over the life course in men and women. Our findings highlight potentially harmful drug combinations that may cause a cumulative risk of postural hypotension in older people. This may guide clinicians about the potential of synergistic harm and to monitor for postural hypotension if using such combinations – particularly in patients aged ≥70 or at high-risk due to comorbidity.

Background: Hospital Electronic Health Records (EHRs) increasingly capture health and functional deficits. We report outcomes for acute cardiac patients in relation to an automated frailty measure derived from these EHR data.

Methods: We conducted a retrospective observational cohort study of consecutive cardiology admissions aged ≥70 years between April 2016 and August 2020, to three hospitals across Edinburgh, Scotland. The Continuous Dynamic Evaluation of Frailty (CODE-f) is an automated score between 0 (no markers present) and 1 (all present) representing 12 deficits generated from 31 admission EHR data points. This includes measures of cognition, functional dependence, mobility and falls risk. The primary outcome was mortality at 1 year. The secondary outcome was days alive and out of hospital (‘home time’) in the year after discharge for hospital survivors. In a nested cohort of 318 consecutive patients, the Clinical Frailty Scale (CFS) was determined from manual EHR review blinded to CODE-f scores.

Results: 2,406 patients were included (mean 79±6 years old, 60% male). A CODE-f score could be generated in 2,158 (90%) patients, with a median score of 0.13 (IQR 0–0.33). There were 352 (15%) deaths by 1 year. Patients in the highest CODE-f quartile (>0.35) had three times greater risk of death at one year than in the lowest quartile after adjustment for age and sex (27% versus 9%, adjusted odds ratio 3.44, 95% CI 2.47–4.82, p<.001). 16% of patients from the highest CODE-f quartile lost>90 days home time in the year after discharge, compared to 6% in the lowest two quartiles (p<.001). CODE-f scores correlated moderately well with CFS (spearman’s r="0.50," 95% ci 0.41–0.58, p<0.001).

Conclusion: An automated EHR measure can identify older adults at risk of death and poorer recovery after acute cardiac illness. This could inform treatment decisions future care planning.

Funding: Chief Scientist Office (pcl />18/05)

Introduction:

Co-morbidities and frailty are common in older heart failure patients. The aim of this study is to explore the relationship between co-morbidity, frailty and ejection fraction (EF) in older heart failure inpatients.

Methods:

A cross-sectional, observational, retrospective analysis of consecutive patients aged 60 years and over who were admitted with heart failure in a UK hospital. Patients with incomplete data were excluded. Carlson’s comorbidity index (CCI) was used to compute comorbidity, and the Rockwood Clinical Frailty Scale (CFS) was used to measure frailty. The EF was calculated as the midpoint of the ranges measured by echocardiography. IBM SPSS 28 software was used for statistical analysis. Descriptive statistics were used to measure baseline characteristics, and Pearson’s correlation coefficient and linear regression were used to calculate the correlation.

Results and discussion:

101 patients were analysed; 48 males and 53 females. The mean age was 81.2 years (SD 9.98). The mean CCI was 6.97 (SD 1.63), and the mean CFS was 5.09 (SD 1.14).

There was a statistically significant positive correlation between CCI and CFS (r= 0.232; p= .01).

There was a statistically significant inverse correlation between CCI and EF (r= -.277; p=. 005).

When taking into account the level of frailty, the correlation between CCI and EF was much stronger in non-frail than in frail patients (r= -.612; p=. 035 and r= -.216; p= .047, respectively).

There was no correlation between CFS and EF (r= .095; p=.26).

Conclusion:

There was a positive correlation between multi-morbidity and frailty in older inpatients admitted with heart failure. There was a statistically significant inverse correlation between CCI and ejection fraction, but there was no correlation between frailty and ejection fraction.

Introduction:

Postural Hypotension is a very common presentation in the elderly population. Appropriate knowledge to record postural hypotension & non-medicinal management for this is very important among MDT members working in the care of the elderly wards.

Method:

We set out a questionnaire to assess the knowledge among MDT ( multidisciplinary) members. An educational programme was initiated to improve the knowledge among MDT members. A complete audit cycle was done and the knowledge was reassessed with the same questionnaire based on the principles of the PDSA (Plan, Do, Study & Act) cycle.

Results:

It showed that the correct way of checking for postural blood pressure improved from 52.4% to 92% in recording the blood pressure. Correct identification of postural blood pressure improved from 33.3% to 88%. Self-rating of confidence to identify correctly postural blood pressure improved from 47.6% to 64% among the MDT Members. It was difficult to compare the answers about non-medicinal methods and exercises to help postural hypotension as there was heterogeneity in answers. It was also not possible to compare the impact of individual interventions on the alleviation of postural blood pressure.

Conclusion:

Good improvement in the recording and non-medicinal management of Postural hypotension was observed in both the wards among the MDT Members. It is very important to have good knowledge and understanding in the management of this common condition as it helps in the identification and better management.

Introduction

Heart failure (HF) is a common problem managed in our West Lothian multi-disciplinary hospital at home (HaH) service, however significant variation in practice was noted with considerable resource implications. We aimed to standardise and improve this by developing a dedicated protocol.

Methods

We developed a protocol to guide the assessment and management of HF within HaH. We collected baseline (n=25) and follow-up data (n=10) after protocol introduction from patients referred to HaH with heart failure. Outcomes reviewed included anticipatory care planning (ACP) decisions, length of stay (LOS) and treatment strategy. We held staff education sessions and surveyed staff confidence regarding HF management.


Results

ACP discussion rates improved after protocol introduction, with decision rates improving for both escalation of care (28% to 80%) and resuscitation (44% to 60%). LOS reduced after protocol introduction (mean 6.3 days to 5.9 days). Titration of oral diuretics alone (71%) was associated with a shorter LOS (mean 5.4 days) compared to IV (29%, mean 8.1 days), with no difference in 28 day outcome. In those with HF with reduced ejection fraction, the rates of beta-blocker prescription increased (57% to 80%) however ACE-inhibitor prescription decreased (29% to 20%). Use of add-on therapy (e.g. thiazide diuretics) increased (12% to 30%) with a decrease in complication rates (12% to 0%). All staff found the protocol helpful with an improvement in confidence levels.


Conclusions

Through introducing a standardised protocol, we observed an improvement in anticipatory care discussion rates and a trend towards shorter LOS. Oral diuretic titration was less resource intensive without an adverse impact on outcome. Future plans include ongoing education and data collection, trialling a joint multi-disciplinary meeting with cardiology for discussion of complex patients and embedding a treatment strategy of oral diuretic titration with a ‘discharge with planned review' approach in appropriate patients.