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Background: Aim of the study was to prospectively assess the relation between atrial fibrillation, cognitive impairment, frailty and disability in older patients with chronic heart failure ., Methods: Three hundred thirty-one ambulatory community-living patients aged 70 years and older (mean 78 ± 6; range 70-93; 43% women) in stable conditions and optimized therapy were enrolled in seven heart failure cardiology clinics. Cognitive impairment was defined by a corrected Mini Mental State Examination score less than 24. Gait speed was used as marker of frailty and measured on a 4 m distance at usual pace., Results: Ninety-eight patients (30%) were on atrial fibrillation at enrolment and 20 (6%) had a history of paroxysmal/persistent atrial fibrillation. Patients with atrial fibrillation were more frequently women with severe valvular disease, preserved left ventricular ejection fraction and less frequently on beta-blockers. At multivariable analyses, atrial fibrillation emerged as independently related to cognitive impairment [odds ratio (OR) 1.909 (1.072-3.397); P = 0.028], as well as to reduced gait speed [OR 4.366 (2.104-9.060); P < 0.001]. Furthermore, atrial fibrillation was significantly associated with disability in either basic or instrumental activities of daily living. No differences were found in mortality and morbidity., Conclusion: Among patients with chronic heart failure, those with atrial fibrillation present a high prevalence of frailty, cognitive impairment and disability. The hypothetical mechanisms by which atrial fibrillation and heart failure may affect these conditions are multiple and further studies are warranted. However, screening for these variables in clinical practice is simple and inexpensive and may allow better strategies for intervention in this high-risk population.

In heart failure (HF), cardiac rehabilitation (CR) may reduce decompensations, hospitalization, and ultimately mortality in long term. Many studies over the past decade have demonstrated that aerobic exercise training is effective and safe in stable patients with HF. Exercise CR resulted in a clinically important improvement in the QOL. Several clinical and psychosocial factors are associated with decreased participation in CR programs of elderly HF patients, such as perception of exercise as tiring or painful, comorbidities, lack of physician encouragement, and opinion that CR will not improve their health status. Besides low functional capacity, and chronic deconditioning may also deter patients from participating in CR programs. Recent data suggest that current smoking, a BMI ≥30 kg/m2, diabetes mellitus, and cognitive dysfunction are associated with failure to enroll in outpatient CR in older age group. Moreover the lack of availability of CR facilities or the absence of financial refunds for enrolment of CHF patients in cardiac rehabilitation programs can play a crucial role. Many of this factors are modifiable through patient education and self care strategy instruction, health providers sensibilization, and implementing economic measures in order to make CR affordable.

In the setting of heart failure (HF) pharmacotherapy demonstrates a quantifiable improvement in exercise tolerance also in HF with preserved ejection fraction (HFpEF). For patients with HFpEF, often older, with higher prevalence of hypertension, diabetes mellitus, atrial fibrillation and other comorbidities, endpoints such as quality of life and functional capacity may be more clinically relevant. However several study show as the use of ACE-I and B-blocker were lesser than expected. Beta-blocker therapy is the keystone of pharmacotherapy of HF patients and exercise training is the essential core of rehabilitation programs, it is important to elucidate the relationship between these therapies. Exercise training improves the clinical status of HF, improving left ventricular ejection fraction and improving quality of life, but it is possible that b-blocker may attenuate exercise training adaptations. Despite this, possible adverse b-blocker effects are just presumed and not confirmed by published randomized clinical trials. Metanalysis suggests that b-blocker compared with placebo enhances improvements in cardiorespiratory performance in exercise training intervention. Despite these evidences, prescription of gold standard therapy and adherence are still suboptimal and should be a priority goal for all CR program.

Objectives: The aim of this study was to assess the relationship between gait speed and the risk for death and/or hospital admission in older patients with heart failure (HF)., Background: Gait speed is a reliable single marker of frailty in older people and can predict falls, disability, hospital admissions, and mortality., Methods: In total, 331 community-living patients ≥70 years of age (mean age 78 ± 6 years, 43% women, mean ejection fraction 35 ± 11%, mean New York Heart Association functional class 2.7 ± 0.6) in stable condition and receiving optimized therapy for chronic HF were prospectively enrolled and followed for 1 year. Gait speed was measured at the usual pace over 4 m, and cutoffs were defined by tertiles: ≤0.65, 0.66 to 0.99, and ≥1.0 m/s., Results: There was a significant association between gait speed tertiles and 1-year mortality: 38.3%, 21.9%, and 9.1% (p < 0.001), respectively. On multivariate analysis, gait speed was associated with a lower risk for all-cause death (hazard ratio: 0.62; 95% confidence interval: 0.43 to 0.88) independently of age, ejection fraction <20%, systolic blood pressure, anemia, and absence of beta-blocker therapy. Gait speed was also associated with a lower risk for hospitalization for HF and all-cause hospitalization. When gait speed was added to the multiparametric Cardiac and Comorbid Conditions Heart Failure risk score, it improved the accuracy of risk stratification for all-cause death (net reclassification improvement 0.49; 95% confidence interval: 0.26 to 0.73, p < 0.001) and HF admissions (net reclassification improvement 0.37; 95% confidence interval: 0.15 to 0.58; p < 0.001)., Conclusions: Gait speed is independently associated with death, hospitalization for HF, and all-cause hospitalization and improves risk stratification in older patients with HF evaluated using the Cardiac and Comorbid Conditions Heart Failure score. Assessment of frailty using gait speed is simple and should be part of the clinical evaluation process., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Cognitive impairment, anaemia and chronic kidney disease (CKD) are associated with mortality and disability in chronic heart failure patients. We hypothesized that anaemia and CKD are independent predictors of cognitive impairment in older patients with heart failure., Methods: One hundred and ninety community-living elderly patients aged at least 70 years, treated with optimized therapy for heart failure in stable clinical conditions, were prospectively studied. They underwent clinical and multidimensional assessment. Cognitive status was assessed by the Mini Mental State Examination. Cognitive impairment was defined as the Mini Mental State Examination score adjusted by age and educational level below 24. CKD was defined as the Cockcroft-Gault glomerular filtration rate below 60  ml/min and anaemia as haemoglobin below 12  g/dl., Results: Cognitive impairment was diagnosed in 38.9% of patients, CKD in 85.7% and anaemia in 42.6%. Age, female sex, BMI, education less than 5 years, depressive symptoms, anaemia, CKD, disability and worse quality of life were significantly associated with cognitive impairment. Cognitive impairment involved primarily global cognitive deficit, memory, mental speed, attention, calculation and language. A significant relationship between haemoglobin levels and cognitive impairment was found, with the range of 15-16.5  g/dl having the lower prevalence of cognitive impairment (19.4%). At multivariate analysis, advanced age, low education level, anaemia and CKD were independently associated with cognitive impairment. Cox analysis showed that cognitive impairment was an independent predictor of hospitalization for worsening heart failure alone and combined with all-cause death., Conclusion: Cognitive impairment is common in elderly heart failure patients and is independently associated with anaemia and renal dysfunction. Further studies are needed to assess whether optimal treatment of anaemia and CKD may prevent the development of cognitive impairment in heart failure patients.

Background: Cognitive impairment (CI) frequently complicates Heart failure (HF) and is associated with increased mortality and morbidity. Previous studies reported that nurse-lead home-based multidisciplinary program (MP) may not improve the prognosis of this high-risk group. In the present study, we analysed the relative effectiveness of an integrated hospital-based MP in patients with cognitive impairment., Methods: Consecutive (n = 173) community-living outpatients aged > 70 years (mean 77 +/- 6, 48% women) randomized to a MP (n = 86) or usual care (UC) (n = 87) were enrolled in stable clinical conditions. Cognitive status was assessed by means of Folstein Mini Mental State Examination (MMSE)., Results: CI (MMSE < or = 24) was present in 41.6% (42,5% UC vs 40.7% MP p =ns). The variables independently associated to CI were: older age, education level <5 years, anemia and severe renal dysfunction. During a 2-year follow-up, 59 patients died (31.4%) with no significant difference between intervention group. At multivariate analysis, in the entire cohort, CI was independently associated to death (HR 2,07 7[95%CI 1,097-3,931]), HF admissions (2,133[1,346-3,381]), death/HF admissions (1,784[1,132-2,811]) and all-cause admissions (1,473[1,008-2,153]. When considered according to intervention groups, CI was independently associated to all-cause death (3,603 [1,553-8,358], death/HF admissions (2,029[1,200-3,432]) and HF admissions (2,474[1,406-4,353]) but not to all-cause admissions. The assignment of patients with CI to MP was associated to a significant reduction in HF admissions vs UC (0,503[0,253-0,999] (all interaction tests p = ns)., Conclusions: This study suggests that CI is very common and associated to worse prognosis in heart failure and that hospital-based MP seems to improve outcomes in these patients through reduction of heart failure hospital admission.

Background: Disease management programs (DMP) improve outcomes in patients with heart failure. Because older heart failure patients represent a heterogeneous population, the aim of this study was to determine which patients benefit mostly from a DMP, by means of their frailty profile., Setting: Heart failure outpatient clinic., Methods: Consecutive (n = 173) patients aged more than 70 years were randomized to a multidisciplinary DMP (n = 86) or usual care (n = 87). A modified frailty score (range 1-6) was used as an index of global functional impairment., Results: Mild to moderate frailty (frailty score = 2-3) was associated with significant improvements in outcomes (death and/or heart failure admission, heart failure admissions and all-cause admissions) in DMP patients vs. usual care. Even in more frail patients (frailty score = 4-6) a significant reduction in heart failure admissions was observed. By contrast, nonfrail patients (frailty score = 1) did not derive significant benefit. In the cost-effectiveness analysis, the mean savings per patient, stratified according to their frailty score, were -1003.31 euro for frailty score 1 (95% confidence interval -3717.00-1709.00), 1104.72 euro for frailty score 2 (-280.6-2491.00), 2635.42 euro for frailty score 3 (352.60-4917.00, P = 0.025) and 419.53 euro for frailty score 4-6 (-1909.00-2749.00). Intervention was therefore significantly cost saving in moderately frail, but not in nonfrail or severely frail patients. Thus, DMP was dominant (i.e. both less costly and more effective than usual care) in moderately frail patients. At sensitivity analysis, DMP remained dominant even to changes in cost of intervention and hospitalizations., Conclusion: This suggests that an intensive, hospital-based DMP appears to be more effective in older patients with mild-to-moderate levels of frailty. Thus, a multidimensional assessment of frailty seems to be a useful tool for appropriate selection of model of care.

Background: Heart failure (HF) patients can benefit from management programmes that include education, discharge planning and structured follow-up. Therefore, it is important to evaluate the improvement of self-care as a result of these interventions. The European Heart Failure Self-care Behaviour Scale (EHFScBS) was developed as a reliable and valid instrument for self-care evaluation., Objectives: The aims were to translate and validate the Italian version of the EHFScBS and to evaluate factors related to self-care., Methods: The translation and validation were performed as follows: translation and back-translation; evaluation by four bilingual cardiologists; administration to healthy individuals of different ages and education to test language comprehension; final correction by cardiologists experienced in cognitive assessment; and administration in HF patients to test validity and internal consistency., Results: A sample of 93 HF patients (mean age 77 +/- 6 years, 53% women) was considered for the validation procedure. Fifty-four (58%) patients were already followed in the HF clinic (HFC), with previous HF education, and 39 (42%) were evaluated at baseline. The reliability analysis showed a Cronbach's alpha of 0.82. At multivariate analysis, age, not already followed in HFC and female sex were associated to worse self-care behaviour. When HFC patients were considered separately, an association between self-care and cognitive dysfunction was observed., Conclusion: The EHFScBS appears to be a valid and reliable instrument in the Italian version also. Self-care behaviour appears to depend on age and sex and a previous HF education. Mild to moderately impaired cognitive function seems to influence self-care in patients who have already received HF education.

Objective: Beta-blockers are often cautiously prescribed to older heart failure diabetics because of the paucity of published data and their perceived unfavourable effects on glucose metabolism, in spite of the evidence of their effectiveness and safety in middle-aged diabetic patients. The aim of this study was to compare the safety, tolerability and efficacy of long-term administration of carvedilol in a group of elderly patients with chronic heart failure, with and without concomitant diabetes., Methods: Two hundred and fifty-two patients aged > or =70 years with heart failure and left ventricular ejection fraction < or =40% were followed in specialised heart failure clinics. Diabetes was present in 29.7%. Carvedilol was associated with conventional optimised treatment in 64% of diabetics and 65% of non-diabetics (P = NS)., Results: At baseline, diabetics presented with a longer duration of symptoms, higher Charlson comorbidity index, more frequent renal dysfunction and smaller left ventricular volumes than non-diabetics. New York Heart Association functional class and ejection fraction were similar in the two groups. At 1-year follow-up, tolerability (93.7 vs. 92.2%) and mean daily dose (24 +/- 17 vs. 23 +/- 14 mg/day) of carvedilol were similar in diabetics and non-diabetics. No worsening of fasting glucose, glycosylated haemoglobin and creatinine levels as well as the incidence of deaths and hospitalisations was observed in diabetics treated with carvedilol. Similar improvements in New York Heart Association class and mitral regurgitation severity were observed in diabetic and non-diabetic patients taking carvedilol. Ejection fraction showed a significant improvement, more pronounced in non-diabetics than in diabetics (+10 vs. +7 points; improvement of at least 10 points: 15 vs. 36%, P = 0.03)., Conclusions: Similarly to younger ones, also in older patients, diabetes does not negatively influence the safety, tolerability and efficacy of carvedilol. However, diabetes remains a strong prognostic factor limiting the reversibility of left ventricular systolic dysfunction and the effect of treatment on subsequent outcome.

Objective: Elderly heart failure patients are at high risk of events. Available studies and systematic reviews suggest that elderly patients benefit from disease management programmes (DMPs). However, important questions remain open, including the optimal follow-up intensity and duration and whether such interventions are cost-effective during long-term follow-up and in different healthcare systems. The aim of this study was to determine the long-term efficacy of a hybrid DMP in consecutive older outpatients., Methods: Intervention consisted in combined hospital-based (cardiologists and nurse-coordinators from two heart failure clinics) and home-based (patient's general practitioner visits) care. The components of the DMP were the following: discharge planning, education, therapy optimisation, improved communication, early attention to signs and symptoms. Intensive follow-up was based on scheduled hospital visits (starting within 14 days of discharge), nurse's phone call and home general practitioner visits., Results: A group of 173 patients aged > or =70 years (mean age 77 +/- 6 years, 48% women) was randomly assigned to DMP (n = 86) or usual care (n = 87). At 2-year follow-up, a 36% reduction in all-cause death and heart failure hospital admissions was observed in DMP vs. usual care. All-cause and heart failure admissions as well as the length of hospital stay were also reduced. DMP patients reported, compared to baseline, significant improvements in functional status, quality of life and beta-blocker prescription rate. The intervention was cost-effective with a mean saving of euro 982.04 per patient enrolled., Conclusions: A hybrid DMP for elderly heart failure patients improves outcomes and is cost-effective over a long-term follow-up.

Purpose: To evaluate efficacy and indications of therapy for ventricular arrhythmias in patients with chronic congestive heart failure., Design: A review of most significant and recent clinical trials was performed., Results: In patients with severe left ventricular dysfunction, the desirable actions of antiarrhythmic drugs are attenuated and their negative inotropic and proarrhythmic actions are enhanced. Treatment should be limited to patients with malignant ventricular arrhythmias, or to patients considered at high risk. When indicated, amiodarone is usually well tolerated and safe. The prevention of sudden death in patients with heart failure should be based on optimized therapy of pump failure, reducing left ventricle work load and modulating neurohormonal systems with ACE-inhibitors and betablockers drugs. Further, an important role is held by anti-ischemic therapy, revascularization procedures, anticoagulant therapy and prevention of electrolytes unbalances. Patients with sustained of high risk arrhythmias, resuscitated from a cardiac arrest, should be considered for transvenous Implantable Cardioverter Defibrillator (ICD) implant., Conclusions: Ventricular arrhythmias are common in heart failure patients, represent an important cause of sudden death and the choice of treatment is difficult because of the complexity of underlying mechanisms, frequency of adverse reactions and the severity of left ventricular dysfunction.

An abstract of the study "Utility of multidimensional assessment in selection of elderly heart failure patients eligible for outpatients management programs," by G. Pulignano et al. is presented.

An abstract of the article "Are Disease Management Programmes Cost-Effective for All Elderly Patients With Heart Failure? Usefulness of Frailty Profile in Selection Process, a Randomised Study," by G. Pulignano and colleagues is presented.

An abstract of the study "Frailty Is Strongly Associated to Cardio-Renal-Anemia Syndrome in Elderly Community-Living Heart Failure Patients," by D. del Sindaco et al. is presented.

An abstract of the study "Carvedilol does not worsen depressive symptoms and cognitive function in very elderly patients with heart failure. A pilot study," by G. Pulignano et al, is presented.

An abstract of the study "2-Year Outcome of a Prospective, Controlled Study on the Effects of a Multidisciplinary Management Program for Elderly With Heart Failure," by D. Del Sindaco and colleagues is presented.