Seven-point system gauges seriousness of heart failure in elderly
A simple points system may soon help guide treatment of elderly heart failure patients. Researchers at Washington University School of Medicine in St. Louis found that by counting how many of seven easy-to-obtain health factors a patient has, physicians can estimate the patient's risk of dying.
The points system may steer doctors toward considering more aggressive treatments such as implantable defibrillators and pacemakers for those at low risk of death. However, elderly patients with a high risk may want to avoid stressful and unnecessary medical intervention and may benefit most from palliative or hospice care.
"It has typically been very difficult to predict how long a person hospitalized with heart failure may survive," says senior author Michael W. Rich, M.D., associate professor of medicine and a geriatric cardiologist at Barnes-Jewish Hospital. "That has made it hard for the treating physician to know how aggressive to be with therapy."
Heart failure afflicts about 5 million people in the United States, hospitalizing more than a million patients each year. The incidence of heart failure increases with age, and with people 65 and older becoming the fastest growing segment of the population, the personal and financial burden of heart failure will likely increase.
In their study, which followed 282 elderly heart failure patients for up to 14 years, the researchers identified seven factors that most affect patient survival:
- advanced age
- a history of dementia (contributes to a host of conditions related to the inability to properly care for oneself)
- coronary artery disease (arteries that supply blood to the heart muscle are hardened and narrowed)
- peripheral vascular disease (similar to coronary artery disease but involving blood vessels outside of the heart and brain)
- low sodium in the blood (an indication of neurohormonal imbalance)
- high urea in the blood (a reflection of poor cardiac output that affects kidney function)
- low blood pressure (a result of weakened heart function).
The study, published in the September 25th issue of the Archives of Internal Medicine, showed that patients with four or more of the risk factors had a low probability of surviving longer than six months. But if patients had none or just one of the factors, they had a good chance of living five years or more. Patients with two to three factors were likely to live at least a year. The patients in the study received a variety of treatments as determined by their physicians.
"The system is easy to use, and the variables don't require any specialized testing -- they are part of routine medical histories or basic lab tests," Rich says. "If the system can be validated by further studies, it can play a role in helping physicians tailor care to individual patients. If a person has a limited life expectancy, it may not be in his or her best interest to recommend invasive, uncomfortable or risky procedures. On the other hand, an elderly person with only one risk factor could potentially be considered a good candidate for an aggressive treatment such as a defibrillator."
Other factors that might have been expected to affect survival, such as the amount of blood the heart can eject during pumping or a patient's body mass index, didn't seem to influence survival times. Rich emphasizes that each of the factors identified has been linked in previous studies to poor prognosis in heart failure patients.
"We didn't find any new risk factors, which means there's good data to support that these factors truly are predictive," Rich says. "We've pinpointed the seven that are the most predictive and shown that the number of risk factors can give a reasonable estimate of the probability of living for six, 12 or 60 months."
The researchers next aim to better identify the heart failure patients not likely to survive six months so that they can be referred for hospice care.
"Hospice is very nurturing for both patients and family members," Rich says. "There is considerable evidence that patients derive significant benefit from it. If we can predict mortality within six months, we can more easily establish eligibility for hospice care."
Huynh BC, Rovner A, Rich MW. Long-term survival in elderly patients hospitalized for heart failure. Archives of Internal Medicine September 2006;166:1892-1898.
Funding from the Washington University School of Medicine Mentors in Medicine Program and the National Heart, Lung, and Blood Institute supported this research.
Washington University School of Medicine's full-time and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked fourth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.
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