Feasibility of frailty screening among patients with advanced heart failure.

BACKGROUND: Frailty is common among patients with advanced heart failure (HF), and screening for frailty to guide care is recommended. Although multiple tools are available to screen for frailty, the feasibility of routinely incorporating frailty screening into daily clinical practice among hospitalised advanced HF patients has not been rigorously tested. METHODS: This was a prospective, single-centre, quality improvement study. Two brief frailty screening tools were incorporated into palliative care consultations for all patients ≥50 years from August 2021 to October 2022. In the first phase, the Clinical Frailty Scale (CFS) was implemented, followed by the Study of Osteoporotic Fracture (SOF) tool or a modified SOF (mSOF) version in the second phase. The primary outcome was feasibility (%) of performing frailty screenings for this high-risk population. RESULTS: A total of 212 patients (mean age 69±10 years, 69% male, 79% white, 30% with ischaemic HF) were referred for palliative care consultation during the study period. Overall, frailty screens were completed in 86% (n=183) of patients. CFS and mSOF reached >80% of adoption, while SOF adoption was 54%. Altogether, 52% of the population screened frail by use of CFS and 52% also by mSOF. All clinicians (n=6) participating in the study reported that frailty screening tools were useful and acceptable, and 83% reported plans for continued utilisation in future clinical practice. CONCLUSIONS: Frailty screening with CFS or mSOF tools was feasible in hospitalised patients with advanced HF. Tools that require physical assessment were more challenging to implement. These data support the feasibility of incorporating questionnaire-based frailty screening in a busy hospital setting.

Outcomes after coronary artery bypass grafting and percutaneous coronary intervention in diabetic and non-diabetic patients.

AIMS: To assess the prognosis of patients with coronary heart disease (CHD) after first myocardial revascularisation procedure in real-world practice and to compare the differences in outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) among diabetic and non-diabetic patients. METHODS AND RESULTS: A database was compiled from the national hospital discharge register to collect data on all cardiac revascularisations performed in Finland in 2000-2015. The outcomes (all-cause deaths, cardiovascular (CV) deaths, major CV events and need for repeat revascularisation) after the first revascularisation were identified from the national registers at 28 day, 1 year, and 3 year time points.A total of 139 242 first-time revascularisations (89 493 PCI and 49 749 CABG) were performed during the study period. Of all the revascularised patients, 24% had diabetes, and 76% were non-diabetic patients. At day 28, the risk of fatal outcomes was lower after PCI than after CABG among non-diabetic patients, whereas no difference was seen among diabetic patients. In long-term follow-up the situation was reversed with PCI showing higher risk compared with CABG for most of the outcomes. In particular, at 3 year follow-up the risk of all-cause deaths was elevated among diabetic patients [HR 1.30 (95% CI 1.22-1.38) comparing PCI with CABG] more than among non-diabetic patients [HR 1.09 (1.04-1.15)]. The same was true for CV deaths [HR 1.29 (1.20-1.38) among diabetic patients, and HR 1.03 (0.98-1.08) among non-diabetic patients]. CONCLUSION: Although PCI was associated with better 28 day prognosis, CABG seemed to produce better long-term prognosis especially among diabetic patients.

Clinical practice patterns in revascularization of diabetic patients with coronary heart disease: nationwide register study.

Aims: To compare diabetic patients with coronary heart disease (CHD) needing revascularization to corresponding non-diabetic patients in terms of revascularization methods, comorbidities and urgency of procedure. We also examined the impact of patient characteristics and comorbidities on the revascularization method.Methods: We identified all diabetic (n = 33,018) and non-diabetic (n = 106,224) patients with first-ever, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) from electronic health records in Finland between 2000 and 2015.Results: Overall, PCI was the most common revascularization method. PCI outnumbered CABG in women and men both in diabetic and non-diabetic patients. However, diabetic patients were more likely to undergo CABG than PCI (OR 1.30; 95% CI 1.27-1.34, adjusted for age, gender, region of residence and procedure year). Moreover, 26.9% of diabetic patients' urgent procedures were CABG compared to 21.6% in non-diabetic patients (p<.001). Among diabetic patients, prior myocardial infarction was associated with increased odds of CABG, whereas female gender, atrial fibrillation, congestive heart failure, hypertension and later procedure year were associated with lower odds of CABG.Conclusions: CABG has been performed more frequently in diabetic than in non-diabetic CHD patients. Nevertheless, PCI was the dominant revascularization method over CABG both in diabetic and non-diabetic patients. KEY MESSAGESPCI was the dominant revascularization method in both diabetic and non-diabetic patients. Diabetic patients were more likely to undergo CABG than PCI when compared to non-diabetic patients (OR: 1.30; CI 1.27-1.34).Diabetic patients underwent urgent CABG procedures more often than non-diabetic patients and had more comorbidities compared to non-diabetic patients.

Does the clinical spectrum of incident cardiovascular disease differ between men and women?

BACKGROUND: Cardiovascular diseases (CVDs) are the main cause of death and disability in the western world. Women are known to be older at the time of first CVD event, but the main types of CVD events and their relative importance and differences compared with men are not well known. Our aim was to evaluate gender differences in the clinical presentation of incident major adverse cardiovascular events (MACE). DESIGN: A population-based study with prospective follow-up. METHODS: We used data from the population-based National FINRISK Surveys from years 1992, 1997, 2002 and 2007. People with prevalent cardiovascular disease were excluded. In total, 27,897 participants (53, 2% women) aged 25-74 years were included in the analyses. RESULTS: During the 292,316 person-years of follow-up, 2573 MACE were identified. MACE were more frequent in men than women (1318; 95% CI 1252-1388 in men vs. 736; 686-789 in women). Men had four times more fatal coronary heart disease (CHD) events (149; 126-174 vs. 39; 28-53) and three times more non-fatal CHD events (512; 471-555 vs. 164; 141-189) than women. Stroke incidence was higher in men than women (268; 238-301 vs. 169; 145-195). Heart failure (HF) incidence did not differ between genders. The relative proportions of MACE categories differed substantially between genders: HF was the most common type among women (50% vs. 30% in men), whereas the most common type among men was CHD (50% vs. 28% in women). CONCLUSIONS: Incident MACE were more common in men than women. HF was the dominant type of MACE in women, whereas CHD dominated in men.

Effects of acute and one-week fatty acid lowering on cardiac function and insulin sensitivity in relation with myocardial and muscle fat and adiponectin levels.

BACKGROUND/AIM: We tested the hypothesis that a persistent reduction in free fatty acid (FFA) levels improves cardiac function and systemic insulin sensitivity via a reduction in the myocardial and skeletal muscle adiposities and a modulation in adipokine release. METHODS: Study subjects (body mass index 22-30 kg/m(2), 57 ± 3 yr old) underwent magnetic resonance imaging and spectroscopy to measure the cardiac function and the amounts of fat inside and around the myocardium and skeletal muscle, before (n = 10) and after acute (n = 8) and 1 wk (n = 7, one excluded from analysis) lowering of circulating FFA by acipimox. Circulating adipokines (leptin, adiponectin, resistin, TNFα, IL-6, IL-8, plasminogen activator inhibitor-I, macrophage chemoattractant protein-1) were measured. RESULTS: The ejection fraction (62 ± 2 vs. 56 ± 1%, P = 0.0035), cardiac output (6.6 ± 0.3 vs. 5.5 ± 0.2 liters/min, P = 0.0018), and forward work (708 ± 49 vs. 539 ± 44 mm Hg × liters/min, P = 0.018) were significantly lower after 1 wk of FFA lowering. In the six subjects undergoing all sessions, the stroke and end-diastolic volumes were also reduced, insulin sensitivity was increased by 33%, and adiponectinemia was decreased (-26%, P = 0.03). No change in intracellular cardiac and skeletal muscle triglyceride levels was observed. Metabolic changes correlated with the lowering of FFA. The reduction in cardiac function was related with changes in glycemia and insulin sensitivity, whereas the deflection in left ventricular work was correlated with the decline in FFA, lipid, and blood pressure levels. CONCLUSIONS: A 1-wk FFA depletion suppressed cardiac function and improved insulin sensitivity. Intracellular triglyceride deposits in the heart and skeletal muscle played no role in the observed changes. Our data show that FFA participate in the physiological regulation of adipokine levels.

Gender differences in the prevalence, causes and treatment of high cardiovascular risk: findings from the FINRISK Survey.

BACKGROUND: Concerns have been raised that high cardiovascular (CVD) risk is not always recognized in women and treated effectively enough. We aimed to analyze, whether there are differences between men and women in the prevalence, underlying causes and treatment of high CVD risk. DESIGN: A cross-sectional analysis of data from population-based health examination surveys was conducted. METHODS: Pooled data from the population-based National FINRISK Surveys from the years 1992, 1997, 2002 and 2007 were used. Subjects with any of the following were considered as having high-risk: history of a major CVD event, prevalent diabetes or 10-year risk of CVD ≥ 20% calculated according to the Framingham equation. RESULTS: We identified 835 (46.0% women) high-risk subjects in the age group 25-54 years and 3587 (27.3% women) in the age group 55-74 years. In the younger age group men had more often prevalent CVD (29.3% vs 7.8%, p < 0.001) and were more likely to be smokers (46.3% vs 21.4%, p < 0.001), whereas women had more diabetes (94.0 % vs 60.5%, p < 0.001). Younger women were less likely to achieve the recommended total cholesterol level of <4.5 mmol/l (14.3 % vs 17.3 %, p = 0.03) and had a lower rate of hypolipidaemic therapy (9.6% vs 21.2%, p < 0.001) and acetylsalicylic acid therapy (8.3% vs 27.7%, p < 0.001). CONCLUSION: Among young individuals, high CVD risk was almost as common in women as in men. It appears that the high-risk situation is not always recognized and treated adequately in young women.

Sex differences in short- and long-term case-fatality of myocardial infarction.

Declining trends in case fatality (CF) of MI events have been generally reported in western countries. It is, however, not clear whether the development has been equally beneficial in both sexes. Data from two large population based registers, FINAMI and the Finnish National Cardiovascular Disease Register (CVDR) were used to determine whether the CF of incident MI events has declined less in women than in men. All patients aged 35 and over were included. CF was calculated for different time periods after the onset of the MI event, the main emphasis was in pre-hospital, 28-day, and 1-year CF. Figures were compared between two study periods: 1994-1996 and 2000-2002. A total of 6,342 incident MI events were recorded in FINAMI and 117,632 events in CVDR during the study periods. Comparison between the two study periods showed that the CF was generally declining. However, a slower decline in short-term CF was seen among young (aged<55 years) women (P for sex by study period interaction in pre-hospital CF=0.028 in FINAMI and 0.003 in CVDR, and for 28-day CF P=0.016 in FINAMI and <0.0001 in CVDR). In conclusion, the short and long-term prognosis of MI events has improved in both sexes. Pre-hospital CF has declined less among younger women than among men and among older women. This slower decline in early CF was responsible for the slower improvement in 28-day and 1-year prognosis in young women.

Contribution of glucose tolerance and gender to cardiac adiposity.

CONTEXT AND OBJECTIVE: To examine whether pericardial and myocardial fat depots may contribute to the association between diabetes and cardiovascular risk, including sex-related differences, and the role of adiponectin, we evaluated data in patients with obesity and without diabetes [nondiabetic (ND)] or with impaired glucose tolerance or type 2 diabetes and in lean ND controls. METHODS: Magnetic resonance imaging and spectroscopy were used to measure left ventricular (LV) function and abdominal sc and visceral fat areas to estimate respective masses, pericardial fat depots, and myocardial triglyceride content in 53 subjects (10 lean ND, 25 obese ND, six impaired-glucose-tolerance, and 12 type 2 diabetic patients with macrovascular disease); gender effects and adiponectin levels were evaluated in the available subset of subjects. RESULTS: Myocardial and pericardial fat increased progressively across study groups. They were lower in obese women than men (P = 0.002), but cardiac steatosis caught up in hyperglycemic women (+81% vs. ND, P = 0.01). Adiponectin was inversely related with both fat depots (P < 0.01) and LV mass (P = 0.003) and positively with LV function (P = 0.03). In multiple regression analysis, myocardial and pericardial fat were independently related with plasma glucose levels, only pericardial fat mass was associated with visceral adiposity and myocardial fat with cardiac output and work. CONCLUSIONS: We conclude that glycemia, gender, adiponectin, and cardiac workload are associated with, and hyperglycemia and male gender are independent positive predictors of, heart adiposity. Once glucose tolerance becomes impaired, the evolution of cardiac steatosis is more pronounced in women.

The lowering of hepatic fatty acid uptake improves liver function and insulin sensitivity without affecting hepatic fat content in humans.

Lipolysis may regulate liver free fatty acid (FFA) uptake and triglyceride accumulation; both are potential causes of insulin resistance and liver damage. We evaluated whether 1) systemic FFA release is the major determinant of liver FFA uptake in fasting humans in vivo and 2) the beneficial metabolic effects of FFA lowering can be explained by a reduction in liver triglyceride content. Sixteen healthy subjects were subdivided in two groups of similar characteristics to undergo positron emission tomography with [(11)C]acetate and [(11)C]palmitate to quantify liver FFA metabolism (n = 8), or magnetic resonance spectroscopy (MRS) to measure hepatic fat content (n = 8), before and after the acute lowering of circulating FFAs by using the antilipolytic agent acipimox. MRS was again repeated after a 1-wk treatment period. Acipimox suppressed FFA levels while stimulating hepatic fractional extraction of FFAs (P < 0.05). As a result, fasting liver FFA uptake was decreased by 79% (P = 0.0002) in tight association with lipolysis (r = 0.996, P < 0.0001). The 1-wk treatment induced a significant improvement in systemic (+30%) and liver (+70%) insulin sensitivity (P < 0.05) and decreased circulating triglycerides (-20%, P = 0.06) and liver enzymes (ALT -20%, P = 0.03). No change in liver fat content was observed after either acute or sustained FFA suppression. We conclude that acute and sustained inhibitions of lipolysis and liver FFA uptake fail to deplete liver fat in healthy human subjects. Liver FFA uptake was decreased in proportion to FFA delivery. As a consequence, liver and systemic insulin sensitivity were improved, together with liver function, independently of changes in hepatic triglyceride accumulation.

Are coronary event rates declining slower in women than in men - evidence from two population-based myocardial infarction registers in Finland?

BACKGROUND: Studies have suggested that the prevention and treatment of coronary heart disease may not have been as effective in women as in men. Therefore, we aimed to examine whether the incidence, attack rate and mortality of myocardial infarction (MI) events have declined less in women than in men. METHODS: Two large population-based MI registers, the FINAMI register and the Finnish Cardiovascular Disease Register (CVDR) were used for comparing the event rates among men and women aged > or =35 years in two time periods, 1994-1996 and 2000-2002. RESULTS: In the FINAMI register a total of 5,252 events were recorded in men and 4,898 in women. Corresponding numbers in the CVDR were 78,709 and 70,464. Both FINAMI and CVDR data suggested smaller declines in incidence and attack rate of MI events in women than in men. In CVDR data the decline in mortality was also smaller in women than in men, while in FINAMI data this difference did not reach statistical significance. In the large CVDR data set, negative binomial regression models revealed smaller declines in incidence (p = 0.006), attack rate (p = 0.008) and mortality (p = 0.04) in women than in men aged <55 years. In persons > or =55 years no difference was observed between women and men. CONCLUSION: The incidence and attack rate of MI events have declined less in women aged <55 than in men of similar age. In older persons no significant differences were observed. Further studies are warranted to find out the reasons why the development has been less favourable for young women than for men.

Myocardial triglyceride content and epicardial fat mass in human obesity: relationship to left ventricular function and serum free fatty acid levels.

CONTEXT AND OBJECTIVE: Ectopic fat accumulation within and around the myocardial wall has been implicated in the pathogenesis of heart disease in obesity. We evaluated myocardial and epicardial fat, left ventricular (LV) function, and metabolic risk factors in nine (five lean, four moderately obese) men. METHODS: Myocardial fat percent was quantified in the septum by proton magnetic resonance spectroscopy. Reproducibility was assessed by triplicate systolic and diastolic measurements. LV parameters and epicardial fat were determined by magnetic resonance imaging. Waist-to-hip ratio and liver enzymes (alanine transaminase) were used as surrogate markers of visceral and liver fat contents. RESULTS: Myocardial fat (2.1 +/- 0.5 vs. 0.8 +/- 0.1, P = 0.03) and epicardial fat (120 +/- 33 vs. 55 +/- 12 g, P = 0.08) were higher in obese than lean subjects. Individuals with above-median alanine transaminase values had a 4-fold elevation in myocardial fat. The coefficient of variation of repeated myocardial fat percent determinations was 17 +/- 3 and 23 +/- 3% in systole and diastole, respectively. Myocardial fat was correlated with free fatty acid (FFA) levels (r = 0.76; P = 0.017), epicardial fat (r = 0.69; P = 0.042), and waist-to-hip ratio (r = 0.70; P = 0.035), and it showed a tendency to associate positively with LV work. Epicardial fat was associated with peripheral vascular resistance (positively) and the cardiac index (negatively). FFA levels were significantly correlated with LV mass (r = 0.72; P = 0.030) and forward work (r = 0.74; P = 0.023). CONCLUSIONS/INTERPRETATION: The accumulation of triglyceride in and around the myocardium of moderately obese individuals is significant, and it is related to FFA exposure, generalized ectopic fat excess, and peripheral vascular resistance. These changes precede LV overload and hypertrophy.