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Background: Vitamin D deficiency is associated with heart failure (HF) events, and in animal models vitamin D down-regulates renin-angiotensin-aldosterone system hormones., Methods: Patients with New York Heart Association (NYHA) functional class II-IV HF and a 25OH-D level ≤37.5 ng/mL received 50,000 IU vitamin D3 weekly (n = 31) or placebo (n = 33) for 6 months. Serum aldosterone, renin, echocardiography, and health status were determined at baseline and 6 months., Results: Mean age of participants was 65.9 ± 10.4 years, 48% were women, 64% were African American, mean ejection fraction was 37.6 ± 13.9%, 36% were in NYHA functional class III, and 64% were in class II. The vitamin D group increased serum 25OH-D (19.1 ± 9.3 to 61.7 ± 20.3 ng/mL) and the placebo group did not (17.8 ± 9.0 to 17.4 ± 9.8 ng/mL). Aldosterone decreased in the vitamin D group (10.0 ± 11.9 to 6.2 ± 11.6 ng/dL) and not in the placebo group (8.9 ± 8.6 to 9.0 ± 12.4 ng/dL; P = .02). There was no difference between groups in renin, echocardiographic measures, or health status from baseline to 6 months. Modeling indicated that variables which predicted change in aldosterone included receiving vitamin D, increasing age, African American race, and lower glomerular filtration rate., Conclusions: Vitamin D3 repletion decreases aldosterone in patients with HF and low serum vitamin D. Vitamin D may be an important adjunct to standard HF therapy. Further study will assess if vitamin D provides long-term benefit for patients with HF., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose of Review: The frailty syndrome is characterized by an increased vulnerability to physiologic stress. Frailty is distinct from disability and disease states; however, there is a strong relationship between frailty and heart failure and the pathophysiology's overlap. Heart failure exacerbations and hospitalizations likely accelerate the cycle of frailty. The following review summarizes the relationship between heart failure and frailty, and the utility of a frailty assessment in heart failure management., Recent Findings: A frailty assessment can help to stratify heart failure patients at high risk for adverse outcomes. Increasing availability of device therapies for patients with heart failure make prerisk assessment an important management strategy., Summary: Furthermore, studies are necessary to understand the relationship between heart failure and frailty and to devise the best care strategies for these patients.

The purpose of the study was to design and evaluate an improvement project that implemented HF management in four skilled nursing facilities (SNFs). Kotter's Change Management principles were used to guide the implementation. In addition, half of the facilities had an implementation coach who met with facility staff weekly for 4 months and monthly for 5 months. Weekly and monthly audits were performed that documented compliance with eight key aspects of the protocol. Contextual factors were captured using field notes. Adherence to the HF management protocols was variable ranging from 17% to 82%. Facilitators of implementation included staff who championed the project, an implementation coach, and physician involvement. Barriers were high staff turnover and a hierarchal culture. Opportunities exist to integrate HF management protocols to improve SNF care.

Background: Heart failure (HF) disease management can improve health outcomes for older community dwelling patients with heart failure. HF disease management has not been studied in skilled nursing facilities, a major site of transitional care for older adults., Methods and Anticipated Results: The objective of this trial is to investigate if a HF- disease management program (HF-DMP) in skilled nursing facilities (SNF)s will decrease all-cause rehospitalizations for the first 60 days post-SNF admission. The trial is a randomized cluster trial to be conducted in 12 for-profit SNF in the greater Cleveland area. The study population is inclusive of patients with HF regardless of ejection fraction but excludes those patients on dialysis and with a life expectancy of 6 months or less. The HF-DMP includes 7 elements considered standard of care for patients with HF documentation of left ventricular function, tracking of weight and symptoms, medication titration, discharge instructions, 7-day follow-up appointment post-SNF discharge, and patient education. The HF-DMP is conducted by a research nurse tasked with adhering to each element of the program and regularly audited to maintain fidelity of the program. Additional outcomes include health status, self-care management, and discharge destination., Conclusions: The SNF-Connect Trial is the first trial of its kind to assess if a HF-DMP will improve outcomes for patients in SNFs. This trial will provide evidence on the effectiveness of HF-DMP to improve outcomes for older frail HF patients undergoing postacute rehabilitation., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Opinion Statement: Heart failure readmissions (HFR) represent a personal burden for patients and a large financial burden for the healthcare system. As such, strategies to decrease HFR are avidly sought and studied. There are many reasons for HFR that challenge programs aimed to reduce the frequency of HFR. Large pharmacological and device trials often incorporate hospital admission as an endpoint, and many programs have been developed in varied settings to address HFR. Some of the most successful programs use a multidisciplinary team approach, intensive patient education and system commitment. Many risk factors for HFR have been identified although prediction tools are limited. The reduction of HFR should incorporate a multidisciplinary approach with 1) evidenced-based physician-guided medical and device therapy; 2) institutional programs for effective care transitions; 3) strategies aimed to improve disease management; and 4) engage patients in self-care.

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Objective: To investigate the effect of Vitamin D3 on physical performance in patients with HF., Background: HF is associated with functional decline and frailty. Vitamin D deficiency is associated with loss of muscle strength and poor outcomes in patients with HF., Methods: Sixty-four patients participated in a 6-month parallel design double blind RCT to test the hypothesis that oral vitamin D3 would improve physical performance. Vitamin D3 50,000 IU or placebo was given weekly; all received daily calcium. Patients were included regardless of EF and 25OHD ≤ 37.5 ng/ml. The primary outcome was peak VO2, and secondary outcomes were the 6MW, TGUG and knee isokinetic muscle strength. Between group comparisons were made using ANCOVA models that adjust for baseline measures., Results: Patients were age 65.9 ± 10.4 years old, 48% women, 64% African American, EF 37.6±13.9, 36% NYHA III, the remainder NYHA II. At baseline the vitamin D group 25OHD was 19.1 ± 9.3 ng/ml and increased to 61.7 ± 20.3 ng/ml; in the placebo group baseline 25OHD was 17.8 ± 9.0 ng/ml and decreased to 17.4 ± 9.8 ng/ml at 6 months (between groups p<0.001). There was no significant change from baseline to 6 months in peak VO2, 6MW, TGUG or isokinetic muscle strength., Conclusions: Vitamin D3 did not improve physical performance for patients with HF despite a robust increase in serum 25OHD. Vitamin D repletion in patients with HF should conform to standard adult guidelines for vitamin D supplementation.

Home telemonitoring can augment home health care services during a patient's transition from hospital to home. Home health care agencies commonly use telemonitors for patients with heart failure although studies have shown mixed results in the use of telemonitors to reduce rehospitalizations. This randomized trial investigated if older patients with heart failure admitted to home health care following a hospitalization would have a reduction in rehospitalizations and improved health status if they received telemonitoring. Patients were followed up to 180 days post-discharge from home health care services. Results showed no difference in the time to rehospitalization or emergency visit between those who received telemonitoring versus usual care. Older heart failure patients who received telemonitoring had better health status by home health care discharge than those who received usual care. Therefore, for older adults with heart failure, telemonitoring may be an important adjunct to home health care services to improve health status.

Introduction: Rehospitalization rates and transitions of care for patients with heart failure (HF) continue to be of prominent importance for hospital systems around the United States. Skilled nursing facilities (SNF) are pivotal sites for transition especially for older adults. The purpose of this study was to evaluate in SNF both the (1) current state of HF management (HF admissions, protocols, and staff knowledge) and (2) the acceptability and effect of a HF staff educational program., Methods: Four SNF participated in the project, 2 the first year and 2 the second year. SNF were surveyed by discipline as to HF disease management techniques. Staff were evaluated on HF knowledge and confidence in pre- and post-HF disease management training., Results: All-cause rehospitalization rates ranged from 18% to 43% in the 2 SNF evaluated. Overall, there was a lack of identification and tracking of HF patients in all the SNF. There were no HF-specific disease management protocols at any SNF and staff had limited knowledge of HF care. Staff pre and post test scores indicated an improvement in both staff knowledge and confidence in HF management after receiving training., Conclusion: The lack of identification and tracking of patients with HF limits SNF ability to care for patients with HF. HF education for staff is likely important to effective HF management in the SNF., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

The purpose of this pilot study was to test the initial efficacy, feasibility, and safety of a specially designed postacute care transitional rehabilitation intervention for cardiac patients. Cardiac Transitional Rehabilitation Using Self-Management Techniques (Cardiac TRUST) is a family-focused intervention that includes progressive low-intensity walking and education in self-management skills to facilitate recovery following a cardiac event. Using a randomized two-group design, exercise self-efficacy, steps walked, and participation in an outpatient cardiac rehabilitation (CR) program were compared in a sample of 38 older adults (17 Cardiac TRUST, 21 usual care). At discharge from postacute care, the intervention group trended toward higher levels of self-efficacy for exercise outcomes than the usual care group. During the 6 weeks following discharge, the intervention group had greater attendance in outpatient CR and a trend toward more steps walked during the first week. The feasibility of the intervention was better for the home health care participants than for those in the skilled nursing facility. The provision of CR during postacute care has the potential to bridge the gap in transitional services from hospitalization to outpatient CR for these patients at high risk for future cardiac events. Further evidence of the efficacy of Cardiac TRUST is warranted., (Copyright 2011, SLACK Incorporated.)

Background: Vitamin D is a fat-soluble hormone necessary for calcium homeostasis. Recently, studies have demonstrated that vitamin D may be important to the health of the cardiovascular system., Methods: Adults ≥ 50 years of age with heart failure were recruited for assessment of serum 25-hydroxyvitamin D (25OHD) concentrations. Cardiopulmonary exercise testing was used to assess functional capacity. Proximal muscle strength was evaluated with a Biodex isokinetic dynamometer [corrected] (Biodex, Shirley, NY), and health status was assessed with the Kansas City Cardiomyopathy Questionnaire. Univariate associations between physical performance and health status measures and 25OHD followed by a linear regression model were used to study associations, adjusting for other potential explanatory variables., Results: Forty adults 67.8 ± 10.9 years of age (55% women and 57.5% African American) with mean ejection fraction 40% were analyzed (New York Heart Association class II in 70% and class III in 30%). Comorbidities included 77.5% hypertension and 47.5% diabetes. The mean 25OHD concentration was 18.5 ± 9.1 ng/mL, and mean peak Vo₂, 14 ± 4 mL/kg/min. In univariate regression analysis, 25OHD was positively associated with peak Vo₂ (P = .045). Multivariable regression analysis sustained positive association between 25OHD and peak Vo₂ (P = .044) after adjusting for age, race, and respiratory exchange ratio (adjusted R² = 0.32). Association between proximal muscle strength with the 25OHD concentration was not significant. The Kansas City Cardiomyopathy Questionnaire physical limitation domain score was negatively associated with 25OHD (P = .04) but was not sustained in multivariable analysis., Conclusions: 25-Hydroxyvitamin D may be an important marker or modulator of functional capacity in patients with heart failure. Randomized controlled trials are needed to assess the effect of vitamin D repletion on functional performance., (Copyright © 2010 Mosby, Inc. All rights reserved.)

Objectives: To investigate the effects of dehydroepiandrosterone (DHEA) combined with exercise on bone mass, strength, and physical function in older, frail women., Design: Double-blind, randomized, placebo-controlled trial., Setting: A major medical institution., Participants: Ninety-nine women (mean age 76.6 ± 6.0) with low sulfated DHEA (DHEAS) levels, low bone mass, and frailty., Intervention: Participants received 50 mg/d DHEA or placebo for 6 months; all received calcium and cholecalciferol. Women participated in 90-minute twice-weekly exercise regimens., Measurements: Hormone levels, bone mineral density (BMD), bone turnover markers, body composition, upper and lower extremity strength, physical performance., Results: Eighty-seven women (88%) completed 6 months. There were no significant changes in BMD or bone turnover markers. DHEA supplementation resulted in gains in lower extremity strength (from 459 ± 121 N to 484 ± 147 N; P=.01). There was also improvement in Short Physical Performance Battery score, a composite score that focuses on lower extremity function, in those taking DHEA (from 10.1 ± 1.8 to 10.7 ± 1.9; P=.02). There were significant changes in all hormone levels, including DHEAS, estradiol, estrone, and testosterone, and a decline in sex hormone-binding globulin levels in those taking DHEA., Conclusion: DHEA supplementation improved lower extremity strength and function in older, frail women involved in a gentle exercise program of chair aerobics or yoga. No changes were found in BMD either due to small sample size, short duration of study or no effect. The physical function findings are promising and require further evaluation as frail women are at high risk for falls and fracture., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

Objective: this analysis was to investigate the effects of dehydroepiandrosterone (DHEA) on cardiovascular risk factors in older women with frailty characteristics., Design, Setting and Participants: the study was a double-blind, randomised, placebo-controlled trial of 99 women (mean 76.6 +/- 6.0 year) with the low DHEA-S level and frailty., Intervention: participants received 50 mg/day DHEA or placebo for 6 months; all received calcium (1,000-1,200 mg/day diet) and supplement (combined) and cholecalciferol (1,000 IU/day). Women participated in 90-min twice weekly exercise regimens, either chair aerobics or yoga., Main Outcome Measures: assessment of outcome variables included hormone levels (DHEA-S, oestradiol, oestrone, testosterone and sex hormone-binding globulin (SHBG)), lipid profiles (total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and triglycerides), body composition measured by dual energy absorptiometry, glucose levels and blood pressure (BP)., Results: eighty-seven women (88%) completed 6 months of study; 88% were pre-frail demonstrating 1-2 frailty characteristics and 12% were frail with > or =3 characteristics. There were significant changes in all hormone levels including DHEA-S, oestradiol, oestrone and testosterone and a decline in SHBG levels in those taking DHEA supplements. In spite of changes in hormone levels, there were no significant changes in cardiovascular risk factors including lipid profiles, body or abdominal fat, fasting glucose or BP., Conclusion: research to date has not shown consistent effects of DHEA on cardiovascular risk, and this study adds to the literature that short-term therapy with DHEA is safe for older women in relation to cardiovascular risk factors. This study is novel in that we recruited women with evidence of physical frailty.

Objectives: To identify relationships between anabolic hormones, inflammatory markers, and physical function., Design: Cross-sectional., Setting: Outpatient university heart failure program in Connecticut., Participants: Sixty patients with an ejection fraction of 40% or less., Measurements: The 6-minute walk distance and frailty phenotype were measured. The relationship between physical measures of hormones and inflammatory mediators were examined. Linear and ordinal logistic regression analyses were performed for the physical measures., Results: Forty-three men (mean age 77 +/- 9) and 17 women (mean age 78 +/- 12) participated. Longer 6-minute walk distance was correlated with higher 25-hydroxyvitamin D (25OHD) level, and a shorter walk was correlated with higher cortisol: dehydroepiandrosterone sulphate (DHEAS) ratio, high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL6), and intact parathyroid hormone (PTH) (all P<.05). Percentage of free testosterone, DHEAS alone, and N-terminal pro-brain natriuretic peptide (NTpro-BNP) did not correlate with 6-minute walk distance. Higher frailty phenotype score (more frail) was correlated with higher high-sensitivity CRP, higher IL6, and lower 25OHD levels (all P<.05). Linear regression with the 6-minute walk distance as the dependent variable and independent variables of age, sex, percentage of free testosterone, DHEAS, 25OHD, intact PTH, hsCRP, IL6, cortisol/DHEAS ratio, and NTpro-BNP, revealed age, sex, 25OHD and hsCRP to be significant (coefficient of determination=53.5%). Ordinal logistic regression with the frailty phenotype and hormonal levels revealed that age, 25OHD, and hsCRP also predicted frailty status., Conclusion: Twenty-five-hydroxyvitamin D and hsCRP levels may contribute to lower aerobic capacity and frailty in patients with heart failure. A longitudinal study will further define the role of 25OHD and hsCRP on muscle strength and functional decline.

Patients with heart failure (HF) are at increased risk for frailty, and identification is challenging. The authors assessed the distance on the 6-minute walk test (6MWT) as a measure of frailty in 60 older HF patients (ejection fraction

Aldosterone is elevated in heart failure and exerts multiple detrimental effects. In addition to playing key roles in sodium and volume regulation, aldosterone is involved in regulation of autonomic tone, endothelial dysfunction, tissue collagen turnover, myocyte fibrosis, and release of inflammatory modulators. Aldosterone receptor antagonists have proven to be a valuable treatment tool in the management of heart failure due to systolic dysfunction. Blocking the effects of aldosterone can improve many of the functions that are deranged in patients with heart failure, as well as promote excretion of sodium and water and preservation of potassium and hydrogen in the distal renal tubule. These medications can be especially effective at removing fluid from the periphery and soft tissues. Prevention of hypokalemia, which may predispose patients to arrhythmia, is an added benefit. Spironolactone and eplerenone are the two agents in this class that have been studied in patients with heart failure and left ventricular dysfunction. However, aldosterone antagonist therapy may not be appropriate for all patients with heart failure. Therefore, guidelines in managing patients on these medications should be followed to avoid serious electrolyte abnormalities and renal dysfunction. This review examines some of the mechanisms of action and the usefulness of aldosterone blockade in the management of heart failure.

Objective: To evaluate body composition changes, specifically skeletal muscle mass, in men receiving androgen deprivation with luteinizing-hormone releasing hormone-agonist (LHRH-A) for prostate cancer (PCa) in comparison with healthy controls., Design: Retrospective analysis of body composition changes in men with prostate cancer receiving LHRH-A therapy from 2 clinical trials compared to men without prostate cancer serving as a placebo-control in another clinical trial., Setting: Clinical Research Center in Connecticut., Participants: Thirty men (> 60 years) receiving 6 months of LHRH-A therapy for PCa were compared to a healthy group of 25 men without PCa., Measurements: Appendicular skeletal muscle/height2 (ASM/ht2), lean and fat mass were assessed by dual energy x-ray absorptiometry. Total testosterone levels were assessed by enzyme immunoassay., Results: At baseline, 12/30 (40%) of the treatment group and 7/25 (28%) of the control group (p = 0.11) met criteria for sarcopenia. There were no differences between control groups in ASM/ht2 or lean mass. The LHRH-A group had a higher percent body fat than the control group, 29.8 +/- 6.3 versus 26.3 +/- 4.6 (p = 0.02). ASM/ht2 and lean mass decreased in the LHRH-A group from 7.5 +/- 0.9 kg to 7.3 +/- 0.9 kg (-2.3% +/- 0.03; p < or = 0.001) and 53.5 +/- 5.4 kg to 52.3 +/- 5.3 kg (-2.1% +/- 0.03; p < or = 0.001), respectively. There was no muscle loss in the control group. At 6 months, the LHRH-A group had increased percent body fat from 29.8 +/- 6.4 to 32.2 +/- 5.8 (9.5% +/- 0.13; p < or = 0.001), whereas the control group had decreased in percent body fat from 26.6 +/- 4.6 to 25.3 +/- 5.0 (-3.8% +/- 0.08; p = 0.02)., Conclusions: Men undergoing LHRH-A treatment for PCa decreased appendicular skeletal muscle and lean tissue and increased body fat within 6 months of initiation of therapy. Lifestyle changes or medical interventions to minimize the effects of androgen deprivation therapy for PCa deserve investigation.