- Email: [email protected]
Nonagenarians presenting to the diagnostic heart failure clinic
European Geriatric Medicine 7 (2016) 28–33
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Nonagenarians presenting to the diagnostic heart failure clinic S.J. Allison, C.M. Orton, A. Al-Mohammad * Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 July 2015 Accepted 23 November 2015 Available online 17 December 2015
Background: The prevalence of heart failure (HF) and the complexities of its management increase with age. Our city serves a population of 551,800 inhabitants with a growing elderly population. The size of the 90 years and above age group has increased by 26% since 2001 to 4300 people. Methods: Patients with suspected HF and a natriuretic peptide (NTproBNP) greater than 400 pg/mL undergo an echo and are reviewed by a HF cardiologist. We characterised the patients aged 90–99 years presenting to the diagnostic HF clinic between March 2012 and September 2014 by the diagnoses, comorbidities, symptoms and whether the clinic changed their management. Results: Of 1785 patients seen, 144 patients (9%) were nonagenarians with HF. The male to female ratio was 1:1.38. The diagnoses were HF due to left ventricular systolic dysfunction (HF-LVSD) (44%), heart failure with preserved ejection fraction (HFPEF) (38%), pulmonary hypertension (12%), valve disease (5%) and heart failure due to right ventricular systolic dysfunction (HF-RVSD) in 1 patient (< 1%). The average number of co-morbidities was four. The majority of patients (62%) had mild symptoms (New York Heart Association Class II). Management was changed in 92.4% of patients. Further follow-up was offered to 14% of patients at a HF nurse-led clinic and 9% at a cardiologist-led clinic. Conclusions: HF-LVSD, and not HFPEF, is the most common HF diagnosis amongst nonagenarians presenting to the diagnostic HF clinic. Beyond making detailed diagnosis, the clinic changed the management of 92.4% of patients. ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Nonagenarians Heart failure Diabetes Hypertension
1. Introduction The burden of heart failure and the complexities of management increase with advancing age with a prevalence of 10–20% in those over 80 years old [1]. This is significant, as Sheffield is a city with 551,800 inhabitants and a growing elderly population – the size of the 90+ years age group has increased by 26% since 2001 to 4300 people [2]. The majority of acute admissions with decompensated heart failure are in the elderly. A study by McMurray estimated that 1–2% of total NHS expenditure is spent on managing heart failure, with patients over 70 years old accounting for two thirds of this budget [3]. One can differentiate heart failure into patients who have impaired left ventricular systolic function (HF-LVSD), otherwise referred to as heart failure with reduced ejection fraction (HFREF), and patients with preserved systolic function (heart failure with preserved ejection fraction, HFPEF). The Olmsted County study found that 43% of patients with congestive cardiac failure had a left ventricular ejection fraction of greater than 50% [4]. Wong et al. * Corresponding author. E-mail address: [email protected] (A. Al-Mohammad).
found that in patients hospitalised for heart failure, 41% of patients older than 70 years had normal systolic function compared to only 6% in patients aged less than 60 years [5]. This distinction between subclasses is important, as it has implications on both management and prognosis. The evidence-based treatment for patients with heart failure due to left ventricular systolic impairment (HFREF) include beta blockers, angiotensin converting enzyme inhibitors and aldosterone antagonists. On the other hand the evidence base for treatment in patients with HFPEF is rather limited. In addition, some older patients may not tolerate guideline-suggested medical therapy. There are important co-morbidities to take into account when managing an elderly patient with heart failure. Managing these comorbidities becomes the cornerstone of management in the patients with HFPEF [6]. Female gender, ischaemic heart disease, diabetes mellitus, hypertension and obesity are more commonly associated with HFPEF. Several of the latter factors score significantly lower on a Hospital Anxiety and Depression Score (HADS) [7]. The Cardiovascular Health Study found that heart failure had the strongest association with frailty (odds ratio = 7.5), which is a complex syndrome with poor clinical outcomes in itself [8]. The co-existing morbidity in the elderly population may limit
http://dx.doi.org/10.1016/j.eurger.2015.11.008 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
S.J. Allison et al. / European Geriatric Medicine 7 (2016) 28–33
the choice of therapy as drug interactions and the implications of polypharmacy must be taken into consideration. Early referral and correct diagnosis of heart failure are likely to improve the mortality rate and reduce morbidity. Prompt initiation of treatment can prevent or reduce the need for hospitalisation. In Sheffield we provide a diagnostic heart failure clinic following the chronic heart failure clinical guidelines by the National Institute of Health and Clinical Excellence (NICE CG 1082010). Patients with suspected heart failure and a raised natriuretic peptide (NTproBNP) are referred by their general practitioner for an outpatient echocardiogram and a heart failure cardiologist review [6]. 1.1. Purpose of the study Through a review of our service we describe the characteristics of patients aged between 90 and 99 years of age who present to the Diagnostic Heart Failure Clinic in Sheffield, and evaluate the efficacy of the service. We wanted to determine the proportion of nonagenarians amongst the patients referred to the service, the extent of their co-morbidities, the principal diagnoses and the factors that may affect their treatment. The study was approved by the local Sheffield Teaching Hospitals NHS Trust Clinical Effectiveness Unit.
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3.2. Heart failure diagnoses We analysed our patients by assigning them to the following types of heart failure: HF-LVSD (or HFREF), HFPEF, HF due to valve disease, HF due to pulmonary hypertension or HF due to right ventricular systolic dysfunction. Overall 63 patients had HF-LVSD (HFREF) (43.75%) and 55 patients had HFPEF (38.19%), as shown in Tables 1 and 2. HF-LVSD was more common than HFPEF (43.75% vs 38.19%) amongst the nonagenarian patients. HF due to pulmonary hypertension alone was the problem in fifteen patients with heart failure (10.42%), HF due to valve disease alone was present in seven patients (4.86%), HF due to both pulmonary hypertension and valve disease in three patients (2.08%) and HF due to RVSD alone in one patient (0.69%). However, pulmonary hypertension was present as an additional heart failure diagnosis in a large number of the nonagenarian patients. Pulmonary hypertension was associated with HF-LVSD (11 patients), HFPEF (11 patients), HF due to valve disease (3 patients), HF-RVSD (3 patients) or with both HF-LVSD and valve disease (13 patients). Thus, 68 of the patients (47%) had a degree of pulmonary hypertension as either the sole diagnosis of their heart failure or as an associated diagnosis. 3.3. Co-morbidities
2. Methods Patients with suspected heart failure and a raised natriuretic peptide (NTproBNP) above 400 pg/mL undergo an echocardiogram and receive clinical assessment by a heart failure cardiologist. We interrogated the diagnostic heart failure clinic database for patients attending between March 2012 and September 2014. Inclusion criteria were any patient aged between 90 and 99 years of age attending the Heart Failure clinic within the specified period, who were given a diagnosis of heart failure. The only exclusion criterion was absence of heart failure. 2.1. Subjects A total of 160 patients out of a total of 1785 patients seen during that period were aged between 90 and 99 years (9%). We included 144 patients, as 16 patients (10%) did not have heart failure. We classified the patients by heart failure diagnoses, co-morbidities, symptom burden and whether or not attendance in clinic led to a change in management.
3.3.1. Renal disease The majority of 90–99 years old patients seen in the Diagnostic Heart Failure Clinic had chronic kidney disease (CKD) stage 3 (87/ 144; 60%), with only 12% of patients having normal renal function (Fig. 1). 3.3.2. Cardiovascular disease Atrial fibrillation was present in 56/144 (39%) of the nonagenarians with HF (Fig. 2). A total of 97 out of 144 patients (67%) had a past medical history of hypertension (Tables 3 and 4). Of the patients with a past medical history of hypertension, 37 patients had evidence of HFLVSD (out of a total of 63 patients with HF-LVSD; 59%) and 41 patients had evidence of HFPEF (out of a total of 55 patients with HFPEF; 75%). The odds ratio for patients with HFPEF having a Table 1 Number of patients with heart failure with left ventricular systolic dysfunction (HFLVSD). Number of patients
2.2. Analysis Data were entered into an Excel spreadsheet and analysed using mean, median and modes. We used Stata Statistical Software to perform descriptive statistical analysis [9]. Chi2 tests were used to examine the potential differences in the observed prevalence of HFPEF, HF-LVSD (or HFREF) among the patients presenting to the clinic. We also looked at the differences between the groups in terms of their co-morbidities especially hypertension, ischaemic heart disease (IHD) and diabetes mellitus. The odds ratio (OR) and 95% confidence intervals (95% CI) are reported. Statistical significance was considered to be P < 0.05.
HF-LVSD alone LVSD with other diagnoses Pulmonary hypertension Valve disease Pulmonary hypertension and valve disease Pulmonary hypertension and RVSD Pulmonary hypertension, valve disease and RVSD RVSD Total number of patients with HF-LVSD
Of the 144 nonagenarian patients with heart failure, 60 patients were male (42%) and 84 patients were female (58%). The mean and median age was 92.33 years 2.09 SD.
11 3 13 3 5 1 63/144 (43.75%)
LVSD: left ventricular systolic dysfunction; RVSD: right ventricular systolic dysfunction. Table 2 Number of patients with heart failure with preserved ejection fraction (HFPEF).
3. Results 3.1. Demographics
27
Number of patients HFPEF alone HFPEF with other diagnoses Pulmonary hypertension Valve disease Pulmonary hypertension and valve disease Total number of patients with HFPEF
34 11 3 7 55/144 (38.19%)
S.J. Allison et al. / European Geriatric Medicine 7 (2016) 28–33
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Percentage of Patients (%)
Number of Patients 100 90 80 70 60 50 40 30 20 10 0 0
1
2
3
4
Stage of CKD Fig. 1. Incidence of Chronic Kidney Disease (CKD) in nonagenarians presenting to the Diagnostic Heart Failure Clinic.
90 80
Number of Patients
70 60 50 40 30 20 10 0 Normal sinus rhythm
Atrial fibrillation Atrial flutter ECG Findings
Paced
Fig. 2. ECG findings in patients presenting to the Diagnostic Heart Failure Clinic.
diagnosis of hypertension compared to patients with HF-LVSD is 2.06 (95% CI 0.92–4.59; P = 0.0714). Sixty patients (42%) had a past medical history of ischaemic heart disease (IHD) including 20 patients who had a previous myocardial infarction. Of the patients with IHD, 35 patients had a diagnosis of HF-LVSD (56% of all patients with HF-LVSD) and 21 patients had evidence of HFPEF (38% of all patients with HFPEF). This equates to an odds ratio of having IHD of 0.49 for the HFPEF group compared to the LVSD group (95% CI 0.23–1.05; P = 0.0605).
Table 3 Incidence of hypertension, ischaemic heart disease and diabetes by diagnosis and odds ratio. Co-morbidity
Number of patients HF-LVSD
HFPEF
Hypertension Ischaemic heart disease Diabetes mellitus
37 (59%) 35 (56%) 6 (9.5%)
41 (75%) 21 (38%) 10 (18%)
Unadjusted odds ratio (95% CI; P value)
2.06 (0.92–4.59; 0.0714) 0.49 (0.23–1.05; 0.0605) 2.11 (0.7–6.33; 0.1724)
HF-LVSD: heart failure with left ventricular systolic dysfunction; HFPEF: heart failure with preserved ejection fraction.
3.3.3. Diabetes and endocrine Twenty-two patients (15%) had diabetes mellitus. Of these patients, ten patients had HFPEF (18% of all patients with HFPEF) and six had HF-LVSD (9.5% of all patients with HF-LVSD), with an odds ratio of 2.11 for patients with HFPEF compared to patients with HF-LVSD (95% CI 0.7–6.33; P = 0.1724).
Table 4 Incidence of co-morbidities in patients attending the diagnostic heart failure clinic. Co-morbidity
Number of patients Male
Female
Total (%)
Hypertension Ischaemic heart disease Previous myocardial infarction Significant valvular disease Diabetes mellitus TIA or stroke Peripheral vascular disease Cognitive impairment Hearing impairment Visual impairment
38 28 11 22 9 14 2 5 8 17
59 32 9 27 13 16 5 12 8 20
97 60 20 49 22 30 7 17 16 37
TIA: trans-ischaemic attack.
(67) (42) (14) (34) (15) (21) (12) (12) (11) (26)
Number of Patients
S.J. Allison et al. / European Geriatric Medicine 7 (2016) 28–33
35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0
0
1
2
3
4
5
6
7
8
9
31
10
11
12
Number of Co-Morbidities Fig. 3. Number of co-morbidities.
Twelve patients had a past medical history of hypothyroidism, one patient had a past medical history of hyperparathyroidism and two patients had had a previous thyroidectomy. 3.3.4. Respiratory disease Fifteen patients (10.42%) had chronic obstructive airways disease (COPD). Three patients had pulmonary fibrosis, three patients had bronchiectasis and seven patients had asthma. 3.3.5. Malignancy Nine patients had a past medical history of skin malignancy. These included: basal cell carcinoma (5 patients) and squamous cell carcinoma (4 patients). Nineteen patients had a past medical history of other types of malignancy that included colon, breast, prostate, bladder, stomach, parotid and vulval cancers. 3.3.6. Neurological disease Thirty patients had a past medical history of previous stroke or transient ischaemic attacks (21%). Three patients had had a previous subarachnoid haemorrhage and two patients had epilepsy. 3.3.7. Peripheral vascular disease Four patients had previous abdominal aortic aneurysm and seven patients had peripheral vascular disease. 3.3.8. Cognitive and sensory impairment Of the 144 patients seen in clinic, only seventeen patients were known to have cognitive impairment. Over a quarter of patients had visual impairment (37/144; 26%) and around 11% had hearing impairment. Six patients were frail. Eleven patients (7.64%) had a previous history of falls and these were often recurrent. 3.4. Average number of co-morbidities Patients had a mean and median of four co-morbidities (Fig. 3).
3.5. Symptom burden The majority of patients (89 patients; 62%) had mild symptoms of heart failure (New York Heart Association NYHA functional class II). Only 23 patients (23%) had NYHA functional classes III or IV. Nineteen patients (13%) had angina. 3.6. Natriuretic peptide levels The range of NTproBNP was from 416 to 29,611 pg/mL, with a mean of 3925 pg/mL and did not appear to correlate to NYHA class. 3.7. Management We looked at the medications that patients were already prescribed prior to their review in clinic and the changes made. For this part of the review, the patients were divided into those with HF-LVSD and those with no evidence of HF-LVSD. The reason for this division is that the evidence-based pharmacological interventions are only available for those patients with HF-LVSD. These medications may have in some of the cases been prescribed by the general practitioner for either the heart failure or for the comorbidities that the patients have. 3.7.1. Beta blockers The majority of patients were not on a beta blocker at presentation to clinic. Fifty patients had been started on one by their GP (35%). A further 21 patients with HF-LVSD were commenced on beta blockers after attendance at clinic, compared to only four patients who had no evidence of HF-LVSD (Table 5). 3.7.2. Angiotensin converting enzyme (ACE) inhibitors At presentation to the Heart Failure Diagnostic clinic, 43 patients were already on an ACE inhibitor (30%). Fifteen patients (10%) – of whom six had HF-LVSD – were already on or recommended to commence an angiotensin receptor blocker (ARB) instead of an ACE inhibitor (Table 5).
S.J. Allison et al. / European Geriatric Medicine 7 (2016) 28–33
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Table 5 Number of patients taking beta blockers, angiotensin converting enzyme (ACE) inhibitors and spironolactone before and after attending the diagnostic heart failure clinic. Medication
Beta blocker ACE inhibitor Spironolactone
Number of patients taking medication (n) LVSD (any) = 63 patients
Non-LVSD = 81 patients
Before clinic
After clinic
Before clinic
After clinic
20 (32%) 18 (29%) 3 (5%)
41 (65%) 36 (57%) 36 (57%)
30 (37%) 25 (31%) 5 (6%)
34 (42%) 27 (33%) 16 (20%)
LVSD: left ventricular systolic dysfunction.
3.7.3. Spironolactone Eight patients were on spironolactone at the time of presentation to the Heart Failure Diagnostic Clinic (5.5%). A significant number of patients were commenced on spironolactone as a result of attending clinic (44 patients, 30.6%) (Table 5). 3.8. Where changes to medical therapy made or not? One hundred and thirty-two patients (92.4%) had a change in their management after attending the Heart Failure Diagnostic Clinic. Other changes included referral to another speciality – this was to gastroenterology for two patients and respiratory medicine for one patient. In addition, other interventions included: support stockings, listing for a left heart catheter (LHC) or right heart catheter (RHC), referral for transcatheter aortic valve implantation (TAVI) assessment, referral for device therapy and in one case admission to the ward for further assessment and management. Twenty patients (14%) were referred to the HF nurses for further management. Thirteen patients (9%) were planned for further follow-up in clinic again, but the majority were discharged after the first attendance, a truly one stop clinic (131/144; 91%). In the patients whose management was not changed they all had no or mild symptoms, although their NTproBNP was between 432 and 2033 pg/mL with one exception at 8771 pg/mL. All these patients had HFPEF. 4. Discussion This study illustrates that the most common cause of heart failure in nonagenarians who were non-selectively referred to our Diagnostic Heart Failure Clinic is HF-LVSD, rather than HFPEF (which is classically linked to advanced age). In addition, the majority of these nonagenarian patients (68%) had pulmonary hypertension, mainly as an associated diagnosis. The majority of patients were female (58%) and the mean age of patients was 92 years old. This complex group of patients had a mean of four co-morbidities, with the most common being hypertension and ischaemic heart disease. Hypertension was more commonly associated with HFPEF than HF-LVSD, but this was not a statistically significant difference. However our sample size was relatively small. It was interesting that the percentage of patients with HFPEF and diabetes mellitus is almost double the percentage for patients with HF-LVSD, although the difference was not statistically significant. A history of ischaemic heart disease was more common in patients with HF-LVSD. Only 12% of patients had normal renal function, with the majority of patients having CKD stage 3. It is not surprising to see increased incidence of hypertension, diabetes mellitus and ischaemic heart disease amongst the patients with HFPEF. At the time of presentation to clinic, the majority of patients had mild symptoms (NYHA Class II) with only 4% having NYHA Class IV
symptoms. In addition, it was interesting that 13% of patients were symptomatic of angina. When referred to the clinic, 35% of patients were started on beta blockers, 30% were on an ACE inhibitor and 5.5% were on spironolactone. Following the establishment of the diagnosis by echocardiography and specialist clinical assessment, there were changes in the management of 92.4% of patients. For the majority of these nonagenarian patients, the clinic served as a one-stop clinic where the clinical assessment, the discussion of the diagnosis and the management plan were all completed during one visit. A very small proportion of the patients required further follow-up with either the heart failure nurses or the consultant cardiologist. An interesting observation was that only 10% of the nonagenarians referred to the heart failure diagnosis and management clinic with suspected heart failure and raised NTproBNP levels were found not to have heart failure. This differs from the total cohort in our clinic, where 22% of the referred patients did not have heart failure [10]. Amongst the nonagenarian patients with heart failure seen in the clinic, a larger proportion of patients have HF-LVSD than those with HFPEF. In addition, there seems to be a high proportion (68%) of the nonagenarians with heart failure who have pulmonary hypertension, usually in combination with other heart failure diagnosis. These observations are important because they contradict the frequently held belief that the majority of the elderly patients with heart failure have HFPEF. It is true that the HFPEF is probably more prevalent in older people than in younger patients; however HF-LVSD remains the most common type of heart failure in the octogenarians [11], and now in the nonagenarians. Another observation in our cohort was that the majority of the nonagenarians seen in the clinic had only mild symptoms. This may be explained by the other observation from clinical practice that nonagenarians with NYHA III-IV are hospitalised. In addition, some nonagenarians with more severe symptoms who are likely to have other co-morbidities, may have been assigned to a palliative pathway and not felt by their primary care physicians to benefit from further investigations or intervention. It would on the other hand be interesting to systematically investigate whether those nonagenarians who have achieved survival for many decades will have less severe disease by virtue of other mechanisms. This interesting question cannot be tackled through this simple observational study. One can appreciate why primary care physicians would not rush into commencing these patients on treatment for heart failure. On the one hand a primary care physician would be concerned that the patient may not have heart failure, or may not have HF-LVSD. In both those scenarios, the patient may not derive benefit from being commenced on the evidence-based therapy for HF-LVSD, and may indeed be harmed if they were to develop side effects or complications. However, adding a diuretic to a symptomatic patient with breathlessness or peripheral oedema is eminently reasonable and appropriate pending the confirmation of whether the patient has HF or not, and the determination of the type of HF they may have. An important message from this observational study is that a nonagenarian presenting with suspected HF whose NTproBNP is raised is highly likely (90%) to have one form of HF or another and may well benefit from the introduction of diuretics pending more certainty of the diagnosis after echocardiography and specialist clinical assessment. With the majority of the nonagenarians having chronic kidney disease of less than stage IV, and with many of them having HFLVSD or a form of HF associated directly or indirectly with pulmonary hypertension, it is not impossible to speculate that a loop diuretic may temporarily be combined with aldosterone
S.J. Allison et al. / European Geriatric Medicine 7 (2016) 28–33
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antagonist until the diagnosis is confirmed. This is a matter of opinion rather than being based on strong evidence-based statement [6,12].
Funding
4.1. Study limitations and future work
Ethical statement
This is an observational, retrospective single centre study which has several limitations. One may suspect lack of unification of the diagnostic criteria used by different consultant cardiologists. However, the consultant cardiologists who saw the patients were on the whole following the current NICE and European Society of Cardiology guidelines [6,13]. Besides, the vast majority of the patients in the cohort of this study were seen by one consultant cardiologist. Thus the likelihood of variability is low. This service review does not include patients diagnosed with heart failure in the community and treated along the palliative care pathway, or those admitted directly to hospital with severe symptoms. Although our findings were not statistically significant given a relatively small sample size, it may appear that diabetes and hypertension are more commonly associated with HFPEF than LVSD. A larger study would be needed to determine whether this association is significant. It is unclear whether dementia affected the decision of the primary care physician to refer the patient to this service. We have certainly seen some patients with cognitive impairment (12%) which is not very far from the incidence of all cause dementia in the 90–94 years old group (at 12.7% per year) according to the ‘‘90+ study’’ [14]. However, in the latter study all-cause dementia incidence rate rises to 21.2% per year for the group aged 95 to 99 years old, raising some concern as to whether dementia at least in the 95–99 years old might have led to under-referring of patients [1]. Frailty has been listed as a co-morbidity subjectively on a judgement of the activities and abilities of each patient rather than following a firm clinical definition of frailty. It would be ideal to conduct a study in the community to assess these factors further. This could potentially identify training needs and areas for service development.
The study was approved by the local Sheffield Teaching Hospitals NHS Trust Clinical Effectiveness Unit.
5. Conclusions Nonagenarians with HF represent one of every 10 patients attending the Heart Failure Diagnostic Clinic in Sheffield. HF-LVSD seems to occur more commonly in these unselected nonagenarians with heart failure, than HFPEF. Although, this group of patients poses many challenges for management given the number of comorbidities they have, there appears to be significant potential for implementing changes to their management in the majority of the cases.
No Funding for this Service review.
Disclosure of interest The authors declare that they have no competing interest. Acknowledgements We would like to thank Louisa Yates for helping us with access to the Infoflex database and Sophie Orton for help with our statistical analysis. References [1] Kannel WB, Belanger AJ. Epidemiology of heart failure. Am Heart J 1991;121: 951–7. [2] Sheffield City Council. Sheffield population estimates [Online]; 2014 [Available at: https://www.sheffield.gov.uk/your-city-council/sheffield-profile/ population-and-health/population-estimates.html. Accessed 26 November 14]. [3] McMurray J, Hart W, Rhodes G. An evaluation of the cost of heart failure to the National Service in the UK. Br J Health Econ 1993;6:99–110. [4] Senni M, Tribouilley CM, Rodeheffer RJ. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minesota, 1991. Circulation 1998;98:2282–9. [5] Wong WF, Gold S, Fukuyama O, Blanchete PL. Diastolic dysfunction in elderly patients with congestive heart failure. Am J Cardiol 1989;63:1526–8. [6] Al-Mohammad A, Mant J. The diagnosis and management of chronic heart failure: review following the publication of the NICE guidelines. Heart 2011;97:411–6 [Published erratum: Heart 2011;97:605, doi:10.1136/ hrt.2010.214999corr1]. [7] O’Mahoney S, Victor Sim MF, Ho SF, et al. Diastolic heart failure in older people. Age Ageing 2003;32:519–24. [8] Newman AB, Gottdiener JS, McBurie MA, et al. Association of subclinical cardiovascular disease with frailty. J Gerontol A Biol Sci Med Sci 2001;56: 158–66. [9] Stata Statistical Software: Release 13. StataCorp, College Station, TX; 2013. [10] Al-Mohammad A, Watt V, O’Toole L, Hall I, Yates L. Insights into the epidemiology of incident Heart Failure (HF): outcomes of rapid HF access clinic applying the NICE guidelines. Eur Heart J 2013 [abstract]. [11] Carr F, Schofield M, Al-Mohammad A. Characterisation of the octogenarians presenting to the incident heart failure clinic. Eur Heart J 2014;35:187 [Abstract Supplement]. [12] Spironolactone for heart failure with preserved ejection, fraction. N Engl J Med 2014;370(15):1383–92. [13] McMurray. et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J 2012;33:1787–847. [14] Corrada M, Brookmeyer R, Berlau D, Paganini-Hill A, Kawas C. Prevalence of dementia after age 90: results from The 90+ Study. Neurology 2008;71: 337–43.
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Nonagenarians presenting to the diagnostic heart failure clinic S.J. Allison, C.M. Orton, A. Al-Mohammad * Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 July 2015 Accepted 23 November 2015 Available online 17 December 2015
Background: The prevalence of heart failure (HF) and the complexities of its management increase with age. Our city serves a population of 551,800 inhabitants with a growing elderly population. The size of the 90 years and above age group has increased by 26% since 2001 to 4300 people. Methods: Patients with suspected HF and a natriuretic peptide (NTproBNP) greater than 400 pg/mL undergo an echo and are reviewed by a HF cardiologist. We characterised the patients aged 90–99 years presenting to the diagnostic HF clinic between March 2012 and September 2014 by the diagnoses, comorbidities, symptoms and whether the clinic changed their management. Results: Of 1785 patients seen, 144 patients (9%) were nonagenarians with HF. The male to female ratio was 1:1.38. The diagnoses were HF due to left ventricular systolic dysfunction (HF-LVSD) (44%), heart failure with preserved ejection fraction (HFPEF) (38%), pulmonary hypertension (12%), valve disease (5%) and heart failure due to right ventricular systolic dysfunction (HF-RVSD) in 1 patient (< 1%). The average number of co-morbidities was four. The majority of patients (62%) had mild symptoms (New York Heart Association Class II). Management was changed in 92.4% of patients. Further follow-up was offered to 14% of patients at a HF nurse-led clinic and 9% at a cardiologist-led clinic. Conclusions: HF-LVSD, and not HFPEF, is the most common HF diagnosis amongst nonagenarians presenting to the diagnostic HF clinic. Beyond making detailed diagnosis, the clinic changed the management of 92.4% of patients. ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Nonagenarians Heart failure Diabetes Hypertension
1. Introduction The burden of heart failure and the complexities of management increase with advancing age with a prevalence of 10–20% in those over 80 years old [1]. This is significant, as Sheffield is a city with 551,800 inhabitants and a growing elderly population – the size of the 90+ years age group has increased by 26% since 2001 to 4300 people [2]. The majority of acute admissions with decompensated heart failure are in the elderly. A study by McMurray estimated that 1–2% of total NHS expenditure is spent on managing heart failure, with patients over 70 years old accounting for two thirds of this budget [3]. One can differentiate heart failure into patients who have impaired left ventricular systolic function (HF-LVSD), otherwise referred to as heart failure with reduced ejection fraction (HFREF), and patients with preserved systolic function (heart failure with preserved ejection fraction, HFPEF). The Olmsted County study found that 43% of patients with congestive cardiac failure had a left ventricular ejection fraction of greater than 50% [4]. Wong et al. * Corresponding author. E-mail address: [email protected] (A. Al-Mohammad).
found that in patients hospitalised for heart failure, 41% of patients older than 70 years had normal systolic function compared to only 6% in patients aged less than 60 years [5]. This distinction between subclasses is important, as it has implications on both management and prognosis. The evidence-based treatment for patients with heart failure due to left ventricular systolic impairment (HFREF) include beta blockers, angiotensin converting enzyme inhibitors and aldosterone antagonists. On the other hand the evidence base for treatment in patients with HFPEF is rather limited. In addition, some older patients may not tolerate guideline-suggested medical therapy. There are important co-morbidities to take into account when managing an elderly patient with heart failure. Managing these comorbidities becomes the cornerstone of management in the patients with HFPEF [6]. Female gender, ischaemic heart disease, diabetes mellitus, hypertension and obesity are more commonly associated with HFPEF. Several of the latter factors score significantly lower on a Hospital Anxiety and Depression Score (HADS) [7]. The Cardiovascular Health Study found that heart failure had the strongest association with frailty (odds ratio = 7.5), which is a complex syndrome with poor clinical outcomes in itself [8]. The co-existing morbidity in the elderly population may limit
http://dx.doi.org/10.1016/j.eurger.2015.11.008 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
S.J. Allison et al. / European Geriatric Medicine 7 (2016) 28–33
the choice of therapy as drug interactions and the implications of polypharmacy must be taken into consideration. Early referral and correct diagnosis of heart failure are likely to improve the mortality rate and reduce morbidity. Prompt initiation of treatment can prevent or reduce the need for hospitalisation. In Sheffield we provide a diagnostic heart failure clinic following the chronic heart failure clinical guidelines by the National Institute of Health and Clinical Excellence (NICE CG 1082010). Patients with suspected heart failure and a raised natriuretic peptide (NTproBNP) are referred by their general practitioner for an outpatient echocardiogram and a heart failure cardiologist review [6]. 1.1. Purpose of the study Through a review of our service we describe the characteristics of patients aged between 90 and 99 years of age who present to the Diagnostic Heart Failure Clinic in Sheffield, and evaluate the efficacy of the service. We wanted to determine the proportion of nonagenarians amongst the patients referred to the service, the extent of their co-morbidities, the principal diagnoses and the factors that may affect their treatment. The study was approved by the local Sheffield Teaching Hospitals NHS Trust Clinical Effectiveness Unit.
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3.2. Heart failure diagnoses We analysed our patients by assigning them to the following types of heart failure: HF-LVSD (or HFREF), HFPEF, HF due to valve disease, HF due to pulmonary hypertension or HF due to right ventricular systolic dysfunction. Overall 63 patients had HF-LVSD (HFREF) (43.75%) and 55 patients had HFPEF (38.19%), as shown in Tables 1 and 2. HF-LVSD was more common than HFPEF (43.75% vs 38.19%) amongst the nonagenarian patients. HF due to pulmonary hypertension alone was the problem in fifteen patients with heart failure (10.42%), HF due to valve disease alone was present in seven patients (4.86%), HF due to both pulmonary hypertension and valve disease in three patients (2.08%) and HF due to RVSD alone in one patient (0.69%). However, pulmonary hypertension was present as an additional heart failure diagnosis in a large number of the nonagenarian patients. Pulmonary hypertension was associated with HF-LVSD (11 patients), HFPEF (11 patients), HF due to valve disease (3 patients), HF-RVSD (3 patients) or with both HF-LVSD and valve disease (13 patients). Thus, 68 of the patients (47%) had a degree of pulmonary hypertension as either the sole diagnosis of their heart failure or as an associated diagnosis. 3.3. Co-morbidities
2. Methods Patients with suspected heart failure and a raised natriuretic peptide (NTproBNP) above 400 pg/mL undergo an echocardiogram and receive clinical assessment by a heart failure cardiologist. We interrogated the diagnostic heart failure clinic database for patients attending between March 2012 and September 2014. Inclusion criteria were any patient aged between 90 and 99 years of age attending the Heart Failure clinic within the specified period, who were given a diagnosis of heart failure. The only exclusion criterion was absence of heart failure. 2.1. Subjects A total of 160 patients out of a total of 1785 patients seen during that period were aged between 90 and 99 years (9%). We included 144 patients, as 16 patients (10%) did not have heart failure. We classified the patients by heart failure diagnoses, co-morbidities, symptom burden and whether or not attendance in clinic led to a change in management.
3.3.1. Renal disease The majority of 90–99 years old patients seen in the Diagnostic Heart Failure Clinic had chronic kidney disease (CKD) stage 3 (87/ 144; 60%), with only 12% of patients having normal renal function (Fig. 1). 3.3.2. Cardiovascular disease Atrial fibrillation was present in 56/144 (39%) of the nonagenarians with HF (Fig. 2). A total of 97 out of 144 patients (67%) had a past medical history of hypertension (Tables 3 and 4). Of the patients with a past medical history of hypertension, 37 patients had evidence of HFLVSD (out of a total of 63 patients with HF-LVSD; 59%) and 41 patients had evidence of HFPEF (out of a total of 55 patients with HFPEF; 75%). The odds ratio for patients with HFPEF having a Table 1 Number of patients with heart failure with left ventricular systolic dysfunction (HFLVSD). Number of patients
2.2. Analysis Data were entered into an Excel spreadsheet and analysed using mean, median and modes. We used Stata Statistical Software to perform descriptive statistical analysis [9]. Chi2 tests were used to examine the potential differences in the observed prevalence of HFPEF, HF-LVSD (or HFREF) among the patients presenting to the clinic. We also looked at the differences between the groups in terms of their co-morbidities especially hypertension, ischaemic heart disease (IHD) and diabetes mellitus. The odds ratio (OR) and 95% confidence intervals (95% CI) are reported. Statistical significance was considered to be P < 0.05.
HF-LVSD alone LVSD with other diagnoses Pulmonary hypertension Valve disease Pulmonary hypertension and valve disease Pulmonary hypertension and RVSD Pulmonary hypertension, valve disease and RVSD RVSD Total number of patients with HF-LVSD
Of the 144 nonagenarian patients with heart failure, 60 patients were male (42%) and 84 patients were female (58%). The mean and median age was 92.33 years 2.09 SD.
11 3 13 3 5 1 63/144 (43.75%)
LVSD: left ventricular systolic dysfunction; RVSD: right ventricular systolic dysfunction. Table 2 Number of patients with heart failure with preserved ejection fraction (HFPEF).
3. Results 3.1. Demographics
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Number of patients HFPEF alone HFPEF with other diagnoses Pulmonary hypertension Valve disease Pulmonary hypertension and valve disease Total number of patients with HFPEF
34 11 3 7 55/144 (38.19%)
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Percentage of Patients (%)
Number of Patients 100 90 80 70 60 50 40 30 20 10 0 0
1
2
3
4
Stage of CKD Fig. 1. Incidence of Chronic Kidney Disease (CKD) in nonagenarians presenting to the Diagnostic Heart Failure Clinic.
90 80
Number of Patients
70 60 50 40 30 20 10 0 Normal sinus rhythm
Atrial fibrillation Atrial flutter ECG Findings
Paced
Fig. 2. ECG findings in patients presenting to the Diagnostic Heart Failure Clinic.
diagnosis of hypertension compared to patients with HF-LVSD is 2.06 (95% CI 0.92–4.59; P = 0.0714). Sixty patients (42%) had a past medical history of ischaemic heart disease (IHD) including 20 patients who had a previous myocardial infarction. Of the patients with IHD, 35 patients had a diagnosis of HF-LVSD (56% of all patients with HF-LVSD) and 21 patients had evidence of HFPEF (38% of all patients with HFPEF). This equates to an odds ratio of having IHD of 0.49 for the HFPEF group compared to the LVSD group (95% CI 0.23–1.05; P = 0.0605).
Table 3 Incidence of hypertension, ischaemic heart disease and diabetes by diagnosis and odds ratio. Co-morbidity
Number of patients HF-LVSD
HFPEF
Hypertension Ischaemic heart disease Diabetes mellitus
37 (59%) 35 (56%) 6 (9.5%)
41 (75%) 21 (38%) 10 (18%)
Unadjusted odds ratio (95% CI; P value)
2.06 (0.92–4.59; 0.0714) 0.49 (0.23–1.05; 0.0605) 2.11 (0.7–6.33; 0.1724)
HF-LVSD: heart failure with left ventricular systolic dysfunction; HFPEF: heart failure with preserved ejection fraction.
3.3.3. Diabetes and endocrine Twenty-two patients (15%) had diabetes mellitus. Of these patients, ten patients had HFPEF (18% of all patients with HFPEF) and six had HF-LVSD (9.5% of all patients with HF-LVSD), with an odds ratio of 2.11 for patients with HFPEF compared to patients with HF-LVSD (95% CI 0.7–6.33; P = 0.1724).
Table 4 Incidence of co-morbidities in patients attending the diagnostic heart failure clinic. Co-morbidity
Number of patients Male
Female
Total (%)
Hypertension Ischaemic heart disease Previous myocardial infarction Significant valvular disease Diabetes mellitus TIA or stroke Peripheral vascular disease Cognitive impairment Hearing impairment Visual impairment
38 28 11 22 9 14 2 5 8 17
59 32 9 27 13 16 5 12 8 20
97 60 20 49 22 30 7 17 16 37
TIA: trans-ischaemic attack.
(67) (42) (14) (34) (15) (21) (12) (12) (11) (26)
Number of Patients
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35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0
0
1
2
3
4
5
6
7
8
9
31
10
11
12
Number of Co-Morbidities Fig. 3. Number of co-morbidities.
Twelve patients had a past medical history of hypothyroidism, one patient had a past medical history of hyperparathyroidism and two patients had had a previous thyroidectomy. 3.3.4. Respiratory disease Fifteen patients (10.42%) had chronic obstructive airways disease (COPD). Three patients had pulmonary fibrosis, three patients had bronchiectasis and seven patients had asthma. 3.3.5. Malignancy Nine patients had a past medical history of skin malignancy. These included: basal cell carcinoma (5 patients) and squamous cell carcinoma (4 patients). Nineteen patients had a past medical history of other types of malignancy that included colon, breast, prostate, bladder, stomach, parotid and vulval cancers. 3.3.6. Neurological disease Thirty patients had a past medical history of previous stroke or transient ischaemic attacks (21%). Three patients had had a previous subarachnoid haemorrhage and two patients had epilepsy. 3.3.7. Peripheral vascular disease Four patients had previous abdominal aortic aneurysm and seven patients had peripheral vascular disease. 3.3.8. Cognitive and sensory impairment Of the 144 patients seen in clinic, only seventeen patients were known to have cognitive impairment. Over a quarter of patients had visual impairment (37/144; 26%) and around 11% had hearing impairment. Six patients were frail. Eleven patients (7.64%) had a previous history of falls and these were often recurrent. 3.4. Average number of co-morbidities Patients had a mean and median of four co-morbidities (Fig. 3).
3.5. Symptom burden The majority of patients (89 patients; 62%) had mild symptoms of heart failure (New York Heart Association NYHA functional class II). Only 23 patients (23%) had NYHA functional classes III or IV. Nineteen patients (13%) had angina. 3.6. Natriuretic peptide levels The range of NTproBNP was from 416 to 29,611 pg/mL, with a mean of 3925 pg/mL and did not appear to correlate to NYHA class. 3.7. Management We looked at the medications that patients were already prescribed prior to their review in clinic and the changes made. For this part of the review, the patients were divided into those with HF-LVSD and those with no evidence of HF-LVSD. The reason for this division is that the evidence-based pharmacological interventions are only available for those patients with HF-LVSD. These medications may have in some of the cases been prescribed by the general practitioner for either the heart failure or for the comorbidities that the patients have. 3.7.1. Beta blockers The majority of patients were not on a beta blocker at presentation to clinic. Fifty patients had been started on one by their GP (35%). A further 21 patients with HF-LVSD were commenced on beta blockers after attendance at clinic, compared to only four patients who had no evidence of HF-LVSD (Table 5). 3.7.2. Angiotensin converting enzyme (ACE) inhibitors At presentation to the Heart Failure Diagnostic clinic, 43 patients were already on an ACE inhibitor (30%). Fifteen patients (10%) – of whom six had HF-LVSD – were already on or recommended to commence an angiotensin receptor blocker (ARB) instead of an ACE inhibitor (Table 5).
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Table 5 Number of patients taking beta blockers, angiotensin converting enzyme (ACE) inhibitors and spironolactone before and after attending the diagnostic heart failure clinic. Medication
Beta blocker ACE inhibitor Spironolactone
Number of patients taking medication (n) LVSD (any) = 63 patients
Non-LVSD = 81 patients
Before clinic
After clinic
Before clinic
After clinic
20 (32%) 18 (29%) 3 (5%)
41 (65%) 36 (57%) 36 (57%)
30 (37%) 25 (31%) 5 (6%)
34 (42%) 27 (33%) 16 (20%)
LVSD: left ventricular systolic dysfunction.
3.7.3. Spironolactone Eight patients were on spironolactone at the time of presentation to the Heart Failure Diagnostic Clinic (5.5%). A significant number of patients were commenced on spironolactone as a result of attending clinic (44 patients, 30.6%) (Table 5). 3.8. Where changes to medical therapy made or not? One hundred and thirty-two patients (92.4%) had a change in their management after attending the Heart Failure Diagnostic Clinic. Other changes included referral to another speciality – this was to gastroenterology for two patients and respiratory medicine for one patient. In addition, other interventions included: support stockings, listing for a left heart catheter (LHC) or right heart catheter (RHC), referral for transcatheter aortic valve implantation (TAVI) assessment, referral for device therapy and in one case admission to the ward for further assessment and management. Twenty patients (14%) were referred to the HF nurses for further management. Thirteen patients (9%) were planned for further follow-up in clinic again, but the majority were discharged after the first attendance, a truly one stop clinic (131/144; 91%). In the patients whose management was not changed they all had no or mild symptoms, although their NTproBNP was between 432 and 2033 pg/mL with one exception at 8771 pg/mL. All these patients had HFPEF. 4. Discussion This study illustrates that the most common cause of heart failure in nonagenarians who were non-selectively referred to our Diagnostic Heart Failure Clinic is HF-LVSD, rather than HFPEF (which is classically linked to advanced age). In addition, the majority of these nonagenarian patients (68%) had pulmonary hypertension, mainly as an associated diagnosis. The majority of patients were female (58%) and the mean age of patients was 92 years old. This complex group of patients had a mean of four co-morbidities, with the most common being hypertension and ischaemic heart disease. Hypertension was more commonly associated with HFPEF than HF-LVSD, but this was not a statistically significant difference. However our sample size was relatively small. It was interesting that the percentage of patients with HFPEF and diabetes mellitus is almost double the percentage for patients with HF-LVSD, although the difference was not statistically significant. A history of ischaemic heart disease was more common in patients with HF-LVSD. Only 12% of patients had normal renal function, with the majority of patients having CKD stage 3. It is not surprising to see increased incidence of hypertension, diabetes mellitus and ischaemic heart disease amongst the patients with HFPEF. At the time of presentation to clinic, the majority of patients had mild symptoms (NYHA Class II) with only 4% having NYHA Class IV
symptoms. In addition, it was interesting that 13% of patients were symptomatic of angina. When referred to the clinic, 35% of patients were started on beta blockers, 30% were on an ACE inhibitor and 5.5% were on spironolactone. Following the establishment of the diagnosis by echocardiography and specialist clinical assessment, there were changes in the management of 92.4% of patients. For the majority of these nonagenarian patients, the clinic served as a one-stop clinic where the clinical assessment, the discussion of the diagnosis and the management plan were all completed during one visit. A very small proportion of the patients required further follow-up with either the heart failure nurses or the consultant cardiologist. An interesting observation was that only 10% of the nonagenarians referred to the heart failure diagnosis and management clinic with suspected heart failure and raised NTproBNP levels were found not to have heart failure. This differs from the total cohort in our clinic, where 22% of the referred patients did not have heart failure [10]. Amongst the nonagenarian patients with heart failure seen in the clinic, a larger proportion of patients have HF-LVSD than those with HFPEF. In addition, there seems to be a high proportion (68%) of the nonagenarians with heart failure who have pulmonary hypertension, usually in combination with other heart failure diagnosis. These observations are important because they contradict the frequently held belief that the majority of the elderly patients with heart failure have HFPEF. It is true that the HFPEF is probably more prevalent in older people than in younger patients; however HF-LVSD remains the most common type of heart failure in the octogenarians [11], and now in the nonagenarians. Another observation in our cohort was that the majority of the nonagenarians seen in the clinic had only mild symptoms. This may be explained by the other observation from clinical practice that nonagenarians with NYHA III-IV are hospitalised. In addition, some nonagenarians with more severe symptoms who are likely to have other co-morbidities, may have been assigned to a palliative pathway and not felt by their primary care physicians to benefit from further investigations or intervention. It would on the other hand be interesting to systematically investigate whether those nonagenarians who have achieved survival for many decades will have less severe disease by virtue of other mechanisms. This interesting question cannot be tackled through this simple observational study. One can appreciate why primary care physicians would not rush into commencing these patients on treatment for heart failure. On the one hand a primary care physician would be concerned that the patient may not have heart failure, or may not have HF-LVSD. In both those scenarios, the patient may not derive benefit from being commenced on the evidence-based therapy for HF-LVSD, and may indeed be harmed if they were to develop side effects or complications. However, adding a diuretic to a symptomatic patient with breathlessness or peripheral oedema is eminently reasonable and appropriate pending the confirmation of whether the patient has HF or not, and the determination of the type of HF they may have. An important message from this observational study is that a nonagenarian presenting with suspected HF whose NTproBNP is raised is highly likely (90%) to have one form of HF or another and may well benefit from the introduction of diuretics pending more certainty of the diagnosis after echocardiography and specialist clinical assessment. With the majority of the nonagenarians having chronic kidney disease of less than stage IV, and with many of them having HFLVSD or a form of HF associated directly or indirectly with pulmonary hypertension, it is not impossible to speculate that a loop diuretic may temporarily be combined with aldosterone
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antagonist until the diagnosis is confirmed. This is a matter of opinion rather than being based on strong evidence-based statement [6,12].
Funding
4.1. Study limitations and future work
Ethical statement
This is an observational, retrospective single centre study which has several limitations. One may suspect lack of unification of the diagnostic criteria used by different consultant cardiologists. However, the consultant cardiologists who saw the patients were on the whole following the current NICE and European Society of Cardiology guidelines [6,13]. Besides, the vast majority of the patients in the cohort of this study were seen by one consultant cardiologist. Thus the likelihood of variability is low. This service review does not include patients diagnosed with heart failure in the community and treated along the palliative care pathway, or those admitted directly to hospital with severe symptoms. Although our findings were not statistically significant given a relatively small sample size, it may appear that diabetes and hypertension are more commonly associated with HFPEF than LVSD. A larger study would be needed to determine whether this association is significant. It is unclear whether dementia affected the decision of the primary care physician to refer the patient to this service. We have certainly seen some patients with cognitive impairment (12%) which is not very far from the incidence of all cause dementia in the 90–94 years old group (at 12.7% per year) according to the ‘‘90+ study’’ [14]. However, in the latter study all-cause dementia incidence rate rises to 21.2% per year for the group aged 95 to 99 years old, raising some concern as to whether dementia at least in the 95–99 years old might have led to under-referring of patients [1]. Frailty has been listed as a co-morbidity subjectively on a judgement of the activities and abilities of each patient rather than following a firm clinical definition of frailty. It would be ideal to conduct a study in the community to assess these factors further. This could potentially identify training needs and areas for service development.
The study was approved by the local Sheffield Teaching Hospitals NHS Trust Clinical Effectiveness Unit.
5. Conclusions Nonagenarians with HF represent one of every 10 patients attending the Heart Failure Diagnostic Clinic in Sheffield. HF-LVSD seems to occur more commonly in these unselected nonagenarians with heart failure, than HFPEF. Although, this group of patients poses many challenges for management given the number of comorbidities they have, there appears to be significant potential for implementing changes to their management in the majority of the cases.
No Funding for this Service review.
Disclosure of interest The authors declare that they have no competing interest. Acknowledgements We would like to thank Louisa Yates for helping us with access to the Infoflex database and Sophie Orton for help with our statistical analysis. References [1] Kannel WB, Belanger AJ. Epidemiology of heart failure. Am Heart J 1991;121: 951–7. [2] Sheffield City Council. Sheffield population estimates [Online]; 2014 [Available at: https://www.sheffield.gov.uk/your-city-council/sheffield-profile/ population-and-health/population-estimates.html. Accessed 26 November 14]. [3] McMurray J, Hart W, Rhodes G. An evaluation of the cost of heart failure to the National Service in the UK. Br J Health Econ 1993;6:99–110. [4] Senni M, Tribouilley CM, Rodeheffer RJ. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minesota, 1991. Circulation 1998;98:2282–9. [5] Wong WF, Gold S, Fukuyama O, Blanchete PL. Diastolic dysfunction in elderly patients with congestive heart failure. Am J Cardiol 1989;63:1526–8. [6] Al-Mohammad A, Mant J. The diagnosis and management of chronic heart failure: review following the publication of the NICE guidelines. Heart 2011;97:411–6 [Published erratum: Heart 2011;97:605, doi:10.1136/ hrt.2010.214999corr1]. [7] O’Mahoney S, Victor Sim MF, Ho SF, et al. Diastolic heart failure in older people. Age Ageing 2003;32:519–24. [8] Newman AB, Gottdiener JS, McBurie MA, et al. Association of subclinical cardiovascular disease with frailty. J Gerontol A Biol Sci Med Sci 2001;56: 158–66. [9] Stata Statistical Software: Release 13. StataCorp, College Station, TX; 2013. [10] Al-Mohammad A, Watt V, O’Toole L, Hall I, Yates L. Insights into the epidemiology of incident Heart Failure (HF): outcomes of rapid HF access clinic applying the NICE guidelines. Eur Heart J 2013 [abstract]. [11] Carr F, Schofield M, Al-Mohammad A. Characterisation of the octogenarians presenting to the incident heart failure clinic. Eur Heart J 2014;35:187 [Abstract Supplement]. [12] Spironolactone for heart failure with preserved ejection, fraction. N Engl J Med 2014;370(15):1383–92. [13] McMurray. et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J 2012;33:1787–847. [14] Corrada M, Brookmeyer R, Berlau D, Paganini-Hill A, Kawas C. Prevalence of dementia after age 90: results from The 90+ Study. Neurology 2008;71: 337–43.