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Resumen Introduccion y objetivos El envejecimiento de la poblacion se asocia con una prevalencia creciente de fibrilacion auricular (FA) y demencia. Con este estudio se pretende analizar el impacto de la anticoagulacion oral en pacientes ancianos con FA y demencia de grado moderado-grave. Metodos Estudio retrospectivo unicentrico que analiza a pacientes de edad ≥ 85 anos con diagnostico de FA entre 2013 y 2018. El impacto de la anticoagulacion en la mortalidad, las embolias y las hemorragias se evaluo mediante un analisis multivariado de Cox. En los pacientes con demencia, dicho analisis se complemento con un propensity score matching en funcion de que se les prescribiera tratamiento anticoagulante o no. Resultados De los 3.549 pacientes de 85 o mas anos con FA, 221 presentaban demencia de grado moderado-grave (6,1%), de los que 88 (60,2%) fueron anticoagulados. Durante un seguimiento de 2,8 ± 1,7 anos, la anticoagulacion se asocio con menor riesgo embolico y mayor riesgo hemorragico tanto en pacientes con demencia (HRembolias = 0,36; IC95%, 0,15-0,84; HRhemorragias = 2,44; IC95%, 1,04-5,71) como sin demencia (HRembolias = 0,58; IC95%, 0,45-0,74; HRhemorragias = 1,55; IC95%, 1,21-1,98). Sin embargo, la anticoagulacion unicamente se asocio con menor mortalidad en los pacientes sin demencia (HR = 0,63; IC95%, 0,53-0,75), no en pacientes con demencia (HR ajustada = 1,04; IC95%, 0,63-1,72; p = 0,541; HR despues de propensity score matching = 0,91; IC95%, 0,45-1,83; p = 0,785). Conclusiones En pacientes de 85 o mas anos con demencia moderada-grave y FA, la anticoagulacion oral se asocio de manera significativa con menor riesgo de embolias y mayor riesgo hemorragico, sin encontrarse diferencias en cuanto a mortalidad total.

Aims Nutrition is an important determinant of health above the age of 80 years. Malnutrition in the elderly is often underdiagnosed. The aim of this study was to report the prevalence and prognostic value of malnutrition in patients ≥80 years old with atrial fibrillation (AF) with and without anticoagulant therapy. Methods and results We assessed the nutritional status of 4724 octogenarian patients with diagnoses of AF in a single centre from Spain between 2014 and 2017 with the CONUT score. Malnutrition was confirmed in 2036 patients (43.1%). Anticoagulation prescription was more frequent in patients with good nutrition than in those malnourished (79.5% vs. 71.7%, P Conclusion Malnutrition is very common in octogenarian patients with AF, being a clinical predictor for poor prognosis. For anticoagulated patients, malnutrition was associated with a negative embolic–haemorrhagic balance.

Resumen Cada vez es mayor el numero de pacientes de edad avanzada que esta siendo tratado por especialidades diferentes a la geriatria, las cuales, por las caracteristicas de sus tratamientos, necesitan conocer el pronostico que tiene su indicacion en los pacientes ancianos fragiles y optimizar la situacion de estos pacientes para mejorar dicho pronostico. Las mas frecuentes, actualmente, son oncologia y hematologia, cardiologia, cirugia general y otros servicios quirurgicos. Se entiende por geriatria transversal la ampliacion del area de conocimiento y atencion de la geriatria en sentido horizontal, fuera de sus unidades habituales, aplicando los principios de la medicina geriatrica con un enfoque multidisciplinar al terreno de otros servicios que atienden a pacientes muy mayores y fragiles con enfermedades graves, con el objetivo de ofrecer una atencion centrada en la persona y mejorar su manejo integral. La valoracion geriatrica y la deteccion de la fragilidad en estos casos aportan informacion pronostica y ayudan en la toma de decisiones y en la seleccion de un tratamiento individualizado. En algunos casos es posible mejorar la evolucion de los pacientes y la eficiencia del sistema sanitario. En este articulo se revisan estos conceptos, se describen algunos modelos existentes, se mencionan los instrumentos mas empleados para esta funcion y se resumen algunas actividades de esta nueva area de la asistencia geriatrica. Es previsible que cada vez en mas hospitales se solicite a los servicios de geriatria la implementacion de este tipo de valoraciones e intervenciones. Existe informacion basica para su puesta en marcha, pero no la suficiente como para considerar que estan respondidas todas las preguntas que se plantean. Sera, pues, en los proximos anos un nuevo reto para esta especialidad.

Introducción y objetivos: Los tratamientos actuales de la estenosis aórtica (EAo) grave incluyen el implante percutáneo de válvula aórtica (TAVI) y la cirugía de sustitución valvular aórtica (SVAo). El objetivo es describir la evolución de los pacientes con EAo grave tras la indicación de intervención, las variables que influyen en su pronóstico y los determinantes de un tiempo de espera superior a 2 meses. Métodos: Subanálisis del registro IDEAS (Influencia del Diagnóstico de Estenosis Aórtica Severa) en los pacientes a los que se indicó intervención. Resultados: De 726 pacientes con EAo grave diagnosticada en enero de 2014, se indicó intervención a 300 que son el foco del presente estudio. La media de edad era 74,0 ± 9,7 años. Se intervino a 258 pacientes (86,0%): 59 con TAVI y 199 con SVAo. Al año, 42 (14,0%) continuaban sin intervención, ya sea por seguir en espera (34) o haber fallecido (8). La mitad de los pacientes que murieron antes del procedimiento fallecieron en los primeros 100 días. El tiempo hasta la intervención fue 2,9 ± 1,6 meses para el TAVI y 3,5 ± 0,2 meses para la SVAo (p = 0,03). Los predictores de mortalidad independientes fueron el sexo masculino (HR = 2,6; IC95%, 1,1-6,0), la insuficiencia mitral moderada-grave (HR = 2,6; IC95%, 1,5-4,5), la movilidad reducida (HR = 4,6; IC95%, 1,7-12,6) y la falta de intervención (HR = 2,3; IC95%, 1,02-5,03). Conclusiones: Los pacientes con EAo grave en espera de intervención tienen alto riesgo de mortalidad. Hay indicadores clínicos asociados con peor pronóstico que podrían indicar la necesidad de una intervención precoz. Introduction and objectives: Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. Methods: Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR. Results: Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 ± 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 ± 1.6 for TAVI and 3.5 ± 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95%CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95%CI, 1.5-4.5), reduced mobility (HR, 4.6; 95%CI, 1.7-12.6), and nonintervention (HR, 2.3; 95%CI, 1.02-5.03). Conclusions: Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention. Sin financiación 4.642 JCR (2019) Q1, 30/138 Cardiac & Cardiovascular Systems 0.473 SJR (2019) Q3, 196/362 Cardiology and Cardiovascular Medicine No data IDR 2019 UEM

Resumen Introduccion y objetivos La alfabetizacion en salud (AS) se ha asociado con menor mortalidad en pacientes con insuficiencia cardiaca (IC) relativamente jovenes y de alto nivel educativo en Estados Unidos. Este estudio evalua la asociacion de la AS con el conocimiento de la enfermedad, el autocuidado y la mortalidad por cualquier causa en pacientes muy ancianos con muy bajo nivel educativo. Metodos Estudio prospectivo con 556 pacientes (media de edad, 85 anos) con mucha comorbilidad admitidos por IC en las unidades geriatricas de 6 hospitales espanoles. El 74% de los pacientes tenian estudios inferiores a los primarios y el 71%, funcion sistolica conservada. La AS se valoro con el cuestionario Short Assessment of Health Literacy for Spanish-speaking Adults; el conocimiento sobre la IC, con el cuestionario de DeWalt, y el autocuidado, con la European Heart Failure Self-Care Behaviour Scale. Resultados El conocimiento sobre la IC aumenta con la AS; comparado con el tercil inferior de AS, el coeficiente beta multivariado (IC95%) de conocimiento sobre la IC fue 0,60 (0,01-1,19) en el segundo tercil y 0,87 (0,24-1,50) en el tercil superior (p de tendencia = 0,008). Sin embargo, la AS no se asocio con el autocuidado de la IC. En los 12 meses de seguimiento hubo 189 muertes. Comparado con el tercil inferior de AS, la HR multivariable (IC95%) de mortalidad fue 0,84 (0,56-1,27) en el segundo tercil y 0,99 (0,65-1,51) en el tercil superior (p de tendencia = 0,969). Conclusiones No se observo asociacion entre la AS y la mortalidad a los 12 meses. Esto puede explicarse en parte por la falta de asociacion entre AS y autocuidado.

Background The role of frailty as a prognostic factor in non-selected patients with symptomatic severe aortic stenosis (SAS) is still uncertain. This study aims to examine the association between the frailty syndrome and mortality among very old patients with symptomatic SAS, and to assess whether the association varies with the type of SAS treatment. Methods and results Prospective study of 606 patients aged ≥75years with symptomatic SAS, recruited from February 2010 to January 2015, who were followed up through June 2015. At baseline, frailty was defined as having at least three of the following five criteria: muscle weakness, slow gait speed, low physical activity, exhaustion, and unintentional weight loss. Statistical analyses were performed with multivariate Cox regression. At baseline, 49.3% patients were frail. During a mean follow-up of 98weeks, 35.3% of patients died. The hazard ratio (95% confidence interval) of mortality among frail versus non-frail patients was 1.83 (1.33–2.51). The corresponding results were 1.58 (1.09–2.28) among patients under medical treatment, 3.06 (1.25–7.50) in those with transcatheter aortic valve replacement, and 1.97 (0.83–4.67) in those with surgical aortic valve replacement, p for interaction=0.21. When the frailty criteria were considered separately, mortality was also higher among patients with slow gait speed [1.52 (1.05–2.19)] or low physical activity [1.35 (1.00–1.85)]. Conclusions Frailty is associated with increased mortality among patients with symptomatic SAS, and this association does not vary with the type of SAS treatment. Future studies evaluating the benefits of different treatments in SAS patients should account for baseline frailty.

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Objectives Nonagenarian patients are underrepresented in clinical trials that have evaluated oral anticoagulation in patients with atrial fibrillation (AF). The aim of this study was to assess the pronostic impact of oral anticoagulation in patients with AF age ≥90 years. Design Retrospective multicenter study of nonagenarian patients with AF. Setting and participants A total of 1750 nonagenarian inpatients and outpatients with nonvalvular AF between January 2013 and December 2018 in 3 Spanish health areas were studied. Methods Patients were divided into 3 groups based on antithrombotic therapy: nonoral anticoagulants (30.5%), vitamin-K antagonists (VKAs; 28.6%), and direct oral anticoagulants (DOACs; 40.9%). During a mean follow-up of 23.6 ± 6.6 months, efficacy outcomes (death and embolic events) were evaluated using a Cox regression analysis and safety outcomes (bleeding requiring hospitalization) by competing-risk regression. Results were complemented with a propensity score matching analysis. Results During follow-up, 988 patients died (56.5%), 180 had embolic events (10.3%), and 186 had major bleeding (10.6%). After multivariable adjustment, DOACs were associated with a lower risk of death and embolic events than nonanticoagulation [hazard ratio (HR) 0.75, 95% confidence interval (CI)] 0.61‒0.92), but VKAs were not (HR 0.87, 95% CI 0.72‒1.05). These results were confirmed after propensity score matching analysis. For bleeding, both DOACs and VKAs proved to be associated with a higher risk (HR for DOAC 1.43; 95% CI 0.97‒2.13; HR for VKA 1.94; 95% CI 1.31‒2.88), although findings for DOACs were not statistically significant (P = .074). For intracranial hemorrhage (ICH), only VKAs—not DOACs—presented a higher risk of ICH (HR 4.43; 95% CI 1.48‒13.31). Conclusions and implications In nonagenarian patients with AF, DOACs led to a reduction in mortality and embolic events in comparison with nonanticoagulation. This reduction was not observed with VKAs. Although both DOACs and VKAs increased the risk of bleeding, only VKAs were associated with higher ICH rates.

Introduction and objectives Population aging is associated with an increased prevalence of atrial fibrillation (AF) and dementia. This study aimed to analyze the impact of oral anticoagulation in elderly patients with AF and moderate-severe dementia. Methods We conducted a single-center retrospective study analyzing patients aged ≥ 85 years with a diagnosis of AF between 2013 and 2018. The impact of anticoagulation on mortality, embolisms, and bleeding events was assessed by multivariate Cox analysis. In patients with dementia, this analysis was complemented by propensity score matching, depending on whether the patients were prescribed anticoagulant treatment or not. Results Of the 3549 patients aged ≥ 85 years with AF, 221 had moderate-severe dementia (6.1%), of whom 88 (60.2%) were anticoagulated. During a follow-up of 2.8 ± 1.7 years, anticoagulation was associated with lower embolic risk and higher bleeding risk both in patients with dementia (hazard ratio [HR]embolisms, 0.36; 95%CI, 0.15-0.84; HRbleeding, 2.44; 95%CI, 1.04-5.71) and in those without dementia (HRembolisms, 0.58; 95%CI, 0.45-0.74; HRbleeding, 1.55, 95%CI, 1.21-1.98). However, anticoagulation was associated with lower mortality only in patients without dementia (HR, 0.63; 95%CI, 0.53-0.75) and not in those with dementia (adjusted HR, 1.04; 95%CI, 0.63-1.72; P = .541; HR after propensity score matching 0.91, 95%CI, 0.45-1.83; P = .785). Conclusions In patients aged ≥ 85 years with moderate-severe dementia and AF, oral anticoagulation was significantly associated with a lower embolic risk and a higher bleeding risk, with no differences in total mortality.

The latest European Society of Cardiology Heart Failure (HF) guidelines define three types of HF according to the ejection fraction (EF): HF with reduced EF (HFrEF) when EF40%, HF with mid-range EF (HFmrEF), when EF 40-49%, and HF with preserved EF (HFpEF) when EF≥50%. The objective of this study was to analyse the characteristics and results of elderly patients hospitalised with HF according to the new classification using EF.A prospective study was carried out with 531 HF patients aged ≥75 years classified according to EF, and admitted in the geriatric wards of 6 hospitals in Spain. An analysis was performed on the demographic and clinical characteristics, as well as well as the morbidity and mortality at one year of follow-up.As regards EF, 17.1% had HFrEF, 10% had HFmrEF, and 72.9% had HFpEF. Patients with HFmrEF were more similar to those with HFrEF in terms of a younger age, predominance of men, and previous admission due to HF. This was also the case with the use of drugs for neurohormonal blockade. Patients with HFrEF (compared to those with HFmrEF and HFpEF), had higher mortality (35.2%, 24.5%, and 25.6%, respectively), more readmissions for HF (17.6%, 15.1%, and 14.5%, respectively), and more events (61.5%, 45.3%, and 52.5%, respectively), although there were no significant differences. There were also no differences observed in the survival analysis between the EF groups and the time-dependent outcome variables.In elderly patients hospitalised with HF, those classified as HFmrEF did not show any clear differences with respect to those with HFrEF or HFpEF. There were no differences in terms of morbidity and mortality.

Introduction and objectives: Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. Methods: Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR. Results: Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 +/- 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 +/- 1.6 for TAVI and 3.5 +/- 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95% CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95% CI, 1.5-4.5), reduced mobility (HR, 4.6; 95% CI, 1.7-12.6), and nonintervention (HR, 2.3; 95% CI, 1.02-5.03). Conclusions: Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention. (C) 2018 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

INTRODUCTION AND OBJECTIVES: Health literacy (HL) has been associated with lower mortality in heart failure (HF). However, the results of previous studies may not be generalizable because the research was conducted in relatively young and highly-educated patients in United States settings. This study assessed the association of HL with disease knowledge, self-care, and all-cause mortality among very old patients, with a very low educational level. METHODS: This prospective study was performed in 556 patients (mean age, 85 years), with high comorbidity, admitted for HF to the geriatric acute-care unit of 6 hospitals in Spain. About 74% of patients had less than primary education and 71% had preserved systolic function. Health literacy was assessed with the Short Assessment of Health Literacy for Spanish-speaking Adults questionnaire, knowledge of HF with the DeWalt questionnaire, and HF self-care with the European Heart Failure Self-Care Behaviour Scale. RESULTS: Disease knowledge progressively increased with HL; compared with being in the lowest (worse) tertile of HL, the multivariable beta coefficient (95%CI) of the HF knowledge score was 0.60 (0.01-1.19) in the second tertile and 0.87 (0.24-1.50) in the highest tertile, P-trend = .008. However, no association was found between HL and HF self-care. During the 12 months of follow-up, there were 189 deaths. Compared with being in the lowest tertile of HL, the multivariable HR (95%CI) of mortality was 0.84 (0.56-1.27) in the second tertile and 0.99 (0.65-1.51) in the highest tertile, P-trend = .969. CONCLUSIONS: No association was found between HL and 12-month mortality. This could be partly due to the lack of a link between HL and self-care.

Background Most studies on the association between the frailty syndrome and adverse health outcomes in patients with heart failure (HF) have used non-standard definitions of frailty. This study examined the association of frailty, diagnosed by well-accepted criteria, with mortality, readmission and functional decline in very old ambulatory patients with HF. Methods Prospective study with 497 patients in six Spanish hospitals and followed up during one year. Mean (SD) age was 85.2 (7.3) years, and 79.3% had LVEF >45%. Frailty was diagnosed as having ≥3 of the 5 Fried criteria. Readmission was defined as a new episode of hospitalisation lasting >24h, and functional decline as an incident limitation in any activity of daily living at the 1-year visit. Statistical analyses were performed with Cox and logistic regression, as appropriate, and adjusted for the main prognostic factors at baseline. Results At baseline, 57.5% of patients were frail. The adjusted hazard ratio (95% confidence interval) for mortality among frail versus non-frail patients was 1.93 (1.20–3.27). Mortality was higher among patients with low physical activity [1.64 (1.10–2.45)] or exhaustion [1.83 (1.21–2.77)]. Frailty was linked to increased risk of readmission [1.66 (1.17–2.36)] and functional decline [odds ratio 1.67 (1.01–2.79)]. Slow gait speed was related to functional decline [odds ratio 3.59 (1.75–7.34)]. A higher number of frailty criteria was associated with a higher risk of the three study outcomes (P trend Conclusions Frailty was associated with increased risk of 1-year mortality, hospital readmission and functional decline among older ambulatory patients with HF.

Background The aim of this study is to assess whether a simple comprehensive geriatric assessment (CGA) score predicts hospital mortality among very elderly patients admitted with heart failure (HF). Methods This is a prospective follow-up of 581 individuals aged ≥75 years admitted for decompensated HF to an acute geriatric unit from October 2006 to September 2009. A CGA score (range, 0-10) was constructed using baseline individual data on 5 domains: dependence in activities of daily living (Katz index), mobility (qualitative mobility scale), cognition (Mini-Mental State Examination), comorbidity (Charlson index), and number of prescribed medications. Results Mean age of patients was 85.8 ± 5.8 years, 67% were women, and 75% had preserved ventricular function (ejection fraction >45%). Fifty percent of patients required assistance in ≥1 activities of daily living, 66% had mobility problems, 45% had cognitive impairment, the mean Charlson index was 3.97 ± 3.01, and 36% had >7 medications prescribed. As a result, the mean CGA score was 4.8 ± 2.2. Hospital mortality was 8.2%. In multivariate analysis, variables associated with hospital mortality included New York Heart Association functional class III (odds ratio [OR] 4.1, 95% CI 1.5-10.8), class IV (OR 19.6, 95% CI 6.3-61), pulmonary edema on chest radiography (OR 3.0, 95% CI 1.3-6.6), renal failure (OR 2.8, 95% 1.2-6.2), and the CGA score (OR 1.2, 95% CI 1.02-1.4 for each point of increment). The area under the receiver operating characteristic curve was 0.856 (95% CI 0.790-0.921), and the model classified 93.4% of cases correctly. Conclusions In our cohort of very old patients with HF, a simple CGA score predicts hospital mortality.

Objectives To describe the characteristics, metabolic control and health-related quality of life (HRQL) of type 2 diabetes mellitus (T2DM) geriatric patients. Study design Cross-sectional descriptive study of consecutive patients attended at a geriatric outpatient clinic in a tertiary hospital over three months. Sociodemographic, geriatric assessment variables, HRQL (using the EuroQol instrument) and comorbidity (Charlson and CIRS-G indexes) were measured. The presence of macrovascular and microvascular complications and cardiovascular risk factors were investigated. To assess the degree of metabolic control, the European Union Geriatric Medicine Society (EUGMS) criteria were followed with patients under 80 years old being considered as young elderly and disability as dependence on more than 2 ADLs or need of aid in ambulation. Results We included 112 patients with an average age of 81.4 ± 5.7 years, a Charlson comorbidity index of 4.3 ± 1.57 and a CIRS-G index of 9.7 ± 3. Seventy four per cent of patients were dependent on none or only one ADL, 38.5% presented cognitive impairment and 40% depression. Appropriate control of basal glucose and glycosylated haemoglobin was seen in 43.2% of the patients. HRQL indicated a high frequency of involvement with a significant relationship with functional dependence, cognitive impairment, and depression but not with metabolic control. Conclusions Geriatric patients with T2DM treated on an outpatient basis have a heavy load of comorbidity and an insufficient level of metabolic control even when individually adapted to age and functional state. HRQL is greatly impaired and related to their functional, cognitive and affective derangements.

Background Although decent housing is recognized as a prerequisite for good health, very few studies in developed countries have examined the influence of housing characteristics on disease prognosis. This work examined whether housing conditions predict mortality in older adults with heart failure (HF). Methods This is a cohort study comprising 433 patients hospitalized for HF-related emergencies in 4 Spanish hospitals between January 1, 2000, and June 30, 2001. At baseline, patients reported whether their homes lacked an elevator (in an apartment building), hot water, heating, an indoor bathroom, a bathtub or shower, individual bedroom, automatic washing machine, and telephone and whether they frequently felt cold. Analyses included all-cause deaths identified prospectively until January 1, 2005. Results Among study participants, 165 (38.1%) lived in a home without one of the services considered; and 111 (25.6%) lacked ≥2 services. During follow-up, 260 deaths (60%) occurred. After adjustment for the main confounders, mortality was higher in those who lived in homes without an elevator (hazard ratio [HR] 1.39, 95% CI 1.07-1.80) and in those who frequently felt cold (HR 1.39, 95% CI 1.01-1.92). In comparison with living in a home with all the services considered, mortality was higher for persons living in a home lacking 1 service (HR 1.42, 95% CI 1.10-1.93) or ≥2 services (HR 1.94, 95% CI 1.37-2.74). Patients living in homes lacking any of the services more often had poor functional status, higher comorbidity, lower educational level, and less income. Conclusion Poor housing conditions are associated with higher mortality in HF. Patients living in these homes are especially vulnerable because they have poorer clinical situation and lower socioeconomic position.

Background The long-term prognostic influence of depression on patients hospitalized for heart failure (HF) is unknown. No previous study has examined systematically the mechanisms of the relationship between depression and mortality in HF. Methods Prospective study of 433 patients hospitalized for HF-related emergencies in 4 Spanish hospitals. Baseline depressive symptoms were assessed with the 10-item Geriatric Depression Scale (GDS). The association between depressive symptoms and mortality was summarized with hazard ratios (HRs) obtained from Cox regression, with sequential adjustment for possible mechanisms of the association. Results Of the 433 study participants, 103 (23.8%) had major depression (GDS-10 ≥5) at baseline. During a mean follow-up of 5.7 years, 305 deaths (70%) occurred. Compared with those who were not depressed, subjects with major depression showed higher mortality (age and sex-adjusted HR 1.52, 95% CI 1.15-2.01). Subsequent adjustment for comorbidity reduced the HR to 1.45 (95% CI 1.10-1.93). Additional adjustment for severity of cardiac lesion and for lifestyles, foremost physical inactivity, led to a HR of 1.27 (95% CI 0.95-1.70). After further adjustment for pharmacologic treatment of HF and particularly for disability in instrumental activities of daily living, the HR dropped almost to the null value (HR 1.10, 95% CI 0.82-1.49). Conclusions Depressive symptoms in patients hospitalized for HF are associated with higher long-term mortality; this association is largely explained by the frequent comorbidity, physical inactivity, and disability of these patients.

Sin duda alguna, la insuficiencia cardiaca (IC) es una afeccion principalmente de ancianos: la edad media al diagnostico es de 70 anos, los pacientes mayores de esta edad constituyen el 57% del total de hospitalizaciones por fallo cardiaco y casi el 20% de los mayores de 80 anos atendidos por los equipos de atencion primaria tienen un diagnostico de IC. Es precisamente en los ancianos en los que habitualmente se agregan comorbilidad, polifarmacia, deterioro cognitivo y funcional, lo que hace ineludible una valoracion integral, el trabajo en equipo interdisciplinar y la utilizacion de niveles asistenciales, es decir, los aspectos asistenciales que diferencian a la geriatria de otras especialidades. No es de extranar, por tanto, que la IC sea el principal motivo de ingreso a unidades geriatricas de agudos (1 de cada 8 casos) o que la registremos habitualmente como comorbilidad (en 1 de cada 3 pacientes geriatricos hospitalizados). Nuestros pacientes tienen un perfil clinico diferente de los manejados por los servicios de cardiologia; estos son mas jovenes y tradicionalmente presentan menor carga de enfermedad y un grado inferior de complejidad clinica. Esta comorbilidad es un factor determinante de reingreso y mortalidad. Como patologias mas relevantes para el pronostico destacan la enfermedad pulmonar obstructiva cronica, la diabetes, la anemia, la enfermedad renal cronica y la hipertension arterial. La valoracion geriatrica desempena un papel trascendental en el paciente anciano portador de IC, dada la influencia de factores como la comorbilidad, la depresion, el apoyo social insuficiente, la falta de conocimiento de la enfermedad y sus posibilidades de autocuidados, y el deterioro cognitivo y funcional. A diferencia del paciente joven, en el que la disfuncion sistolica y la cardiopatia isquemica son mas frecuentes, la funcion ventricular conservada y una historia de hipertension arterial son mas habituales en el anciano. Muchos expertos ven la dificultad en el diagnostico de la IC, especialmente aquella con funcion sistolica conservada, como una de las principales razones para la falta de resultados positivos en los ensayos clinicos, como

Delirium remains one of the most common complicating diagnoses in ailing elderly patients and a leading cause of morbidity, decreased quality of life, prolonged hospital stay, institutionalization and mortality. Despite its clinical importance and health-related costs, it often remains unrecognized or misdiagnosed. We evaluate currently available tools for the screening and diagnosis of delirium, their relevance and suitability for use in various clinical settings, as well as interobserver consistency amongst doctors and other nonclinician interviewers.Extensive clinical trial evidence has been published recently concerning advances on the three fundamental elements of delirium assessment in elderly people: identification, severity assessment and reporting of existing predisposing and precipitating factors.Despite advances on the pathophysiology and recognition of delirium, its detection relies on individual clinical expertise, a high index of suspicion and repeated cognitive testing of high-risk patients. Delirium diagnosis remains a clearly underresearched area; particularly, more work is required to adapt cognitive screening tools for use by nonclinicians, to develop cost-effective biochemical and molecular diagnostic techniques and to assess the effects of divulging updated consensus guidelines.

Background The benefit from intervention in elderly patients with symptomatic severe aortic stenosis (AS) and high comorbidity is unknown. Our aims were to establish the correlation between the Charlson comorbidity index and the prognosis of octogenarians with symptomatic sever AS and to identify patients who might not benefit from intervention. Methods We used the data from PEGASO (Pronóstico de la Estenosis Grave Aórtica Sintomática del Octogenario — Prognosis of symptomatic severe aortic stenosis in octogenarians), a prospective registry that included consecutively 928 patients aged ≥ 80 years with severe symptomatic AS. Results The mean Charlson comorbidity index was 3.0 ± 1.7, a total of 151 patients (16.3%) presented high comorbidity (index ≥ 5). Median survival was lower for patients with high comorbidity than for those without (16.7 ± 1.2 vs. 26.5 ± 0.6 months, p < 0.001). In patients without high comorbidity planned interventional management was clearly associated with prognosis (log rank p < 0.001), which was not the case in patients with high comorbidity (log rank p > 0.10). In multivariate analysis, the only variables that were independently associated with prognosis were planned medical management and Charlson index. Patients with high comorbidity presented non-cardiac death more frequently than those who had not (28.6% vs. 19.5%, p = 0.008). Conclusions One sixth of octogenarians with symptomatic severe AS have very high comorbidity (Charlson index ≥ 5). These patients have a poor prognosis in the short term and do not seem to benefit from interventional treatment. 4.638 JCR (2015) Q1, 24/124 Cardiac and cardiovascular systems UEM

This study examines the relationship between social network and hospital readmission and mortality in older patients with heart failure.Prospective study conducted with 371 patients, age 65 and older, admitted for heart failure-related emergencies at 4 Spanish hospitals. Social network was measured at baseline with a 4-item questionnaire that ascertained whether subjects were married, lived with another person(s), saw or had telephone contact with family members daily or almost daily, and were at home alone for less than 2 hours per day. Social network was deemed "high" where all 4 items were present, "moderate" where 3 were present, and "low" where 2 or fewer were present. Analyses were performed using Cox models, and adjusted for the main confounders. A total of 55% of patients had high or moderate social networks. During a median follow-up of 6.5 months, 135 (36.4%) patients underwent a first emergency rehospitalization and 68 (18.3%) died. Compared with patients with high social network, hospital readmission was more frequent among those who had moderate (hazard ratio [HR] 1.87; 95% confidence interval [CI] 1.06-3.29; P.05) and low social networks (HR 1.98; 95% CI 1.07-3.68; P.05). This relationship showed a positive dose-response (p for linear trend 0.042). The magnitude of this association was comparable to that of other important predictors of readmission, such as previous hospitalization. No relationship was observed between social network and death.A very simple questionnaire measuring social network can identify patients with a higher short-term risk of hospital readmission.

Introduccion y objetivos En este trabajo se estima la prevalencia de depresion y se identifican los factores biomedicos y psicosociales asociados en ancianos hospitalizados con insuficiencia cardiaca en Espana. Metodos Se estudio a 433 pacientes ≥ 65 anos ingresados de urgencia en 4 hospitales espanoles desde enero de 2000 hasta junio de 2001, con diagnostico principal o secundario de insuficiencia cardiaca. Se considero que habia depresion ante la presencia de 3 sintomas en la Escala de Depresion Geriatrica de 10 items. Resultados Del total de pacientes estudiados, 210 (48,5%) presentaron depresion. Las cifras correspondientes fueron 71 (37,6%) en varones y 139 (57,0%) en mujeres. La depresion fue mas frecuente en los pacientes con las siguientes caracteristicas: grado funcional III-IV de la NYHA (odds ratio ajustada [ORa] = 2,00; intervalo de confianza [IC] del 95%, 1,23-3,24); peor puntuacion en los aspectos fisicos de la calidad vida (ORa = 3,14; IC del 95%,1,98-4,99); dependencia en 1 o 2 actividades basicas de la vida diaria (ABVD) (ORa = 2,52; IC del 95%, 1,41-4,51); dependencia en 3 o mas ABVD (ORa = 2,47; IC del 95%, 1,20-5,07); limitacion en alguna actividad instrumental de la vida diaria (ORa = 2,20; IC del 95%, 1,28-3,79); hospitalizacion previa por insuficiencia cardiaca (ORa = 1,71; IC del 95%, 1,93-5,45); estaban solos en casa mas de 2 h al dia (ORa = 3,24; IC del 95%, 1,93-5,45); menor satisfaccion con el medico de atencion primaria (ORa = 1,90; IC del 95%, 1,14-3,17). Conclusiones La depresion es muy frecuente en los ancianos hospitalizados con insuficiencia cardiaca, y se asocia con varios factores biomedicos y psicosociales. Esta elevada frecuencia, el peor pronostico de la insuficiencia cardiaca en presencia de sintomas depresivos y la existencia de instrumentos diagnosticos sencillos y un tratamiento eficaz apoyan el cribado sistematico de la depression en estos pacientes.

Introduction and objectives This study provides an estimate of the prevalence of depression, and identifies associated medical and psychosocial factors, in elderly hospitalized patients with heart failure (HF) in Spain. Methods The study included 433 patients aged 65 years or more who underwent emergency admission at four Spanish hospitals between January 2000 and June 2001 and who had a primary or secondary diagnosis of HF. Depression was defined as the presence of three or more symptoms on the 10-item Geriatric Depression Scale. Results In total, 210 (48.5%) study participants presented with depression: 71 men (37.6%) and 139 women (57.0%). Depression was more common in patients with the following characteristics: NYHA functional class III-IV (adjusted odds ratio or aOR=2.00, 95% confidence interval or 95% CI, 1.23–3.24), poor score on the physical domain of the quality-of-life assessment (aOR=3.14; 95% CI, 1.98–4.99), being dependent for one or two basic activities of daily living (BADLs) (aOR=2.52; 95% CI, 1.41–4.51), being dependent for >3 BADLs (aOR=2.47; 95% CI, 1.20–5.07), being limited in at least one instrumental activity of daily living (aOR=2.20: 95% CI, 1.28–3.79), previous hospitalization for HF (aOR=1.71; 95% CI, 1.93–5.45), spending more than 2 hours/day alone at home (aOR=3.24; 95% CI, 1.93–5.45), and being dissatisfied with their primary care physician (aOR=1.90; 95% CI, 1.14–3.17). Conclusions Depression is very common in elderly hospitalized patients with HF and is associated with several medical and psychosocial factors. The high prevalence of depression, the poorer prognosis for HF in patients with depressive symptoms, and the existence of simple diagnostic tools and effective treatment argue in favor of systematic screening for depression in these patients.

Background— In older adults hospitalized for heart failure, a poor score on a comprehensive geriatric assessment (CGA) is associated with worse prognosis during hospitalization and at 1 month after discharge. However, the association between the CGA score and long-term mortality is uncertain. Methods and Results— This is a prospective study of 487 patients aged ≥75 years admitted for decompensated heart failure. At discharge, a CGA score (range, 0–10) was calculated based on limitation in activities of daily living, mobility limitation, comorbidity, cognitive decline, and previous medication use. The analysis of the association between the CGA score and 2-year subsequent mortality was performed with Cox regression and adjusted for the main confounders. A 1-point increase in the CGA score was associated with a 19% higher mortality (hazard ratio, 1.19; 95% confidence interval, 1.11–1.27). Results were similar regardless of age, sex, left ventricular ejection fraction, and the coexistence of atrial fibrillation, ischemic heart disease, or hypertensive cardiopathy. All components of the CGA score showed a consistent association with higher death risk: the hazard ratio (95% confidence interval) of mortality was 1.78 (1.25–2.54) with ≥3 versus 0 limitations in activities of daily living, 1.36 (1.0–1.86) with moderate or severe versus no or mild limitation in mobility, 1.98 (1.29–3.03) with a ≥5 versus ≤1 score on the Charlson index, 2.48 (1.84–3.34) with previous cognitive decline, and 1.77 (0.99–3.18) in those using ≥8 versus ≤3 medications. Conclusions— The score on a simple CGA is associated with long-term mortality in older patients hospitalized for heart failure.

Background: Disease management programmes (DMPs) have been shown to reduce hospital readmissions and mortality in adults with heart failure (HF), but their effectiveness in elderly patients or in those with major comorbidity is unknown. The Multicenter Randomised Trial of a Heart Failure Management Programme among Geriatric Patients (HF-Geriatrics) assesses the effectiveness of a DMP in elderly patients with HF and major comorbidity. Methods/Design: Clinical trial in 700 patients aged ≥ 75 years admitted with a primary diagnosis of HF in the acute care unit of eight geriatric services in Spain. Each patient should meet at least one of the following comorbidty criteria: Charlson index ≥ 3, dependence in ≥ 2 activities of daily living, treatment with ≥ 5 drugs, active treatment for ≥ 3 diseases, recent emergency hospitalization, severe visual or hearing loss, cognitive impairment, Parkinson’s disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), anaemia, or constitutional syndrome. Half of the patients will be randomly assigned to a 1-year DMP led by a case manager and the other half to usual care. The DMP consists of an educational programme for patients and caregivers on the management of HF, COPD (knowledge of the disease, smoking cessation, immunizations, use of inhaled medication, recognition of exacerbations), diabetes (knowledge of the disease, symptoms of hyperglycaemia and hypoglycaemia, self-adjustment of insulin, foot care) and depression (knowledge of the disease, diagnosis and treatment). It also includes close monitoring of the symptoms of decompensation and optimisation of treatment compliance. The main outcome variables are quality of life, hospital readmissions, and overall mortality during a 12- month follow-up. Discussion: The physiological changes, lower life expectancy, comorbidity and low health literacy associated with aging may influence the effectiveness of DMPs in HF. The HF-Geriatrics study will provide direct evidence on the effect of a DMP in elderly patients with HF and high comorbidty, and will reduce the need to extrapolate the results of clinical trials in adults to elderly patients, Study partially funded by the Fondo de Investigación Sanitaria, Instituto de Salud Carlos III (PI-081820), the Fondo Europeo de Desarrollo Regional (FEDER) “una manera de hacer Europa“ and by the INCITE programme of the Xunta de Galicia (08CSA063905PR).

Aims Although the vital prognosis of heart failure (HF) is generally poor, it varies substantially between patients. This study examined whether health-related quality of life (HRQoL) predicts long-term mortality in HF. It also evaluated the role of generic and disease-specific HRQoL questionnaires. Methods and results We studied 416 patients admitted for HF-related emergencies to four hospitals in Spain in 2000–2001. Health-related quality of life was measured at study baseline with a generic questionnaire, the SF-36, and with a disease-specific one, the Minnesota Living with Heart Failure (MLWHF) questionnaire. Patients were followed prospectively to 2007 to ascertain all-cause mortality. During follow-up, 290 (69.7%) patients died. After adjustment for biomedical, healthcare, and social variables, a poor mental component summary (MCS) score on the SF-36 was associated with higher mortality [hazard ratio (HR) 1.38; 95% confidence interval (CI) 1.06–1.76]. For MLWHF, a poor physical component summary (PCS) score predicted higher mortality (HR 1.31; 95% CI 1.01–1.70). In a stepwise Cox model that included the PCS scores of both the SF-36 and the MLWHF, only the PCS of the MLWHF was retained with P < 0.05. However, when both MCS scores were included, only the MCS of the SF-36 was retained with P < 0.05. Conclusion The SF-36 MCS and the MLWHF PCS predict long-term mortality in patients with HF. Future research should identify the determinants of HRQoL and refine interventions to improve it.

This study provides an estimate of the prevalence of depression, and identifies associated medical and psychosocial factors, in elderly hospitalized patients with heart failure (HF) in Spain.The study included 433 patients aged 65 years or more who underwent emergency admission at four Spanish hospitals between January 2000 and June 2001 and who had a primary or secondary diagnosis of HF. Depression was defined as the presence of three or more symptoms on the 10-item Geriatric Depression Scale.In total, 210 (48.5%) study participants presented with depression: 71 men (37.6%) and 139 women (57.0%). Depression was more common in patients with the following characteristics: NYHA functional class III-IV (adjusted odds ratio or aOR=2.00, 95% confidence interval or 95% CI, 1.23-3.24), poor score on the physical domain of the quality-of-life assessment (aOR=3.14; 95% CI, 1.98-4.99), being dependent for one or two basic activities of daily living (BADLs) (aOR=2.52; 95% CI, 1.41-4.51), being dependent foror =3 BADLs (aOR=2.47; 95% CI, 1.20-5.07), being limited in at least one instrumental activity of daily living (aOR=2.20: 95% CI, 1.28-3.79), previous hospitalization for HF (aOR=1.71; 95% CI, 1.93-5.45), spending more than 2 hours/day alone at home (aOR=3.24; 95% CI, 1.93-5.45), and being dissatisfied with their primary care physician (aOR=1.90; 95% CI, 1.14-3.17).Depression is very common in elderly hospitalized patients with HF and is associated with several medical and psychosocial factors. The high prevalence of depression, the poorer prognosis for HF in patients with depressive symptoms, and the existence of simple diagnostic tools and effective treatment argue in favor of systematic screening for depression in these patients.

GeriatricDepressionScale),medicaldiagnoses, geriatric conditions, and physical function (walking speed, grip strength, ADL) were recorded. Hospital outcomes were length of stay, in-hospital mortality, and institutionalization. Results.– Mean age of participants was 81years, 56% were women. Median length of stay was 10 (IQR 7–14) days, 41 patients died during hospital stay and 70 were institutionalized after discharge. Multivariate linear regression analyses identified metastasized cancer, renal failure, infection, number of drugs before admission, history of falls, and walking speed as independent predictors for length of stay. Malnutrition (BMI

cular risk, thewomen’s 87%. The 80.5% of the sample had associated diseases. Thirteen percent of the sample had some kind of cognitive impairment. Fifty-two percent of the sample had an obesity family background, 26.8% suffered from diabetes, 25.4% had arterial hypertension, 10.4% suffered from cognitive impairment. Conclusions.– –Obesity is associatedwith dementia inwomenwith a higher level of obesity and lower cultural background. And it is independent of age and family background. – It is important primary prevention in obese patients since high percentage had family background associated with obese pathology. –Knowing family background can help to delay the beginning of some diseases such as cognitive impairment.

ext.– Objectives.– The aim of our study was to determine the rate f systemic embolic events and adverse drug reactions in patients ndergoing treatment with DA. atients and methods.– We carried out a retrospective study of 92 atients, 62 females and 30 males, with a mean age of 84.7 years, aking DE at a daily dose of 220mg (n=83) or 150mg (n=9). esults.– After a mean follow up of 216 days, there was one troke, no other systemic embolic events and nine deaths (none elated to treatment with DE). After 12 months, 19.8% of individals had stopped dabigatran; relevant causes for discontinuation ncluded rectal bleeding (n=3) and anaemia (n=3). There were no ife-threatening bleeds but four patients suffered major bleeding reduction in the haemoglobin level of at least 20g/l or transfusion f two units of blood), four minor gastrointestinal bleeds and eight inor bleeding at other places: two haematuria, two epistaxis, one aemoptysis, one puncture site, one gingival and one conjunctial bleeding. We observed higher discontinuation rate (P=0.028) n patients treated with 75mg twice daily. Conclusions Dabigatran texilate appears to be a useful, safe and well tolerated in geriatric atients with non-valvular atrial fibrillation with no fatal compliations and only one systemic event in our cohort. This observation equires further confirmation by larger randomised studies. isclosure.– No significant relationships.

Background: We sought to examine the relationship between health-related quality of life (HRQL) and a first emergencyrehospitalizationandmortalityinpatientswith heart failure (HF) having a wide variation in ventricular ejection fraction and functional status. Methods: Prospective study conducted with 394 patients admitted for HF-related emergencies at 4 Spanish hospitals. Baseline HRQL was measured with a generic questionnaire, the Medical Outcomes Study 36-item Short Form Survey (SF-36), and with an HF-specific instrument, the Minnesota Living With Heart Failure (MLWHF)questionnaire.Coxproportionalhazardsmodels were used to calculate hazard ratios (HRs) for hospitalization and death on the basis of HRQL scores. Results: During a median follow-up of approximately 6 months, 138 patients (35.0%) underwent a first emergency rehospitalization and 70 (17.8%) died. After adjustment for biomedical, psychosocial, and health care variables, the frequency of hospital readmission was higher in patients with worse scores on the SF-36 physical functioning (HR, 1.65; 95% confidence interval [CI], 1.11-2.44; P=.01), general health (HR, 1.73; 95% CI, 1.19-2.52; P=.003), and mental health (HR, 1.65; 95% CI, 1.10-2.47;P=.02) subscales. Results were similar for the mortality end point. For the MLWHF questionnaire, worse overall and worse physical and emotional summary scores were associated with higher mortality. Conclusions: Worse HRQL is associated with hospital readmission and death in patients with HF. The magnitude of this association, for both physical and mental HRQL components, is comparable to that for other wellknownpredictorsofhospitalreadmissionanddeath,such as personal history of diabetes, previous hospitalizations, and treatment with angiotensin-converting enzyme inhibitors. Arch Intern Med. 2005;165:1274-1279

A B S T R A C T Background: Midodrine hydrochloride has been shown to be effective in the management of syncope in adults with reflex syncope, orthostatic hypotension and orthostatic intolerance syndromes; however, its use, tolerability and side effects have not been monitored specifically in the older old, particularly not over a prolonged period of time. Objectives: We aim to document changes in patients’ symptoms, drug dosages employed and adverse drug reactions to midodrine therapy in older adults with a diagnosis of neurocardiogenic syncope assessed and managed at a specialist falls and syncope outpatient unit. Methods: Prospective observational study of 135 consecutive subjects with a mean age of 84 years started on midodrine after comprehensive geriatric assessment, structured falls evaluation, positive tilt table testing (TT) or a mixed/vasodepressor response to carotid sinus massage (CSM). Results: Ninety-seven individuals (71%) commenced on midodrine treatment and followed up for a mean of 2.7 years, reported either significant improvement or abolition of symptoms across all TT/CSM diagnosis. Forty-nine percent of individuals achieved sustained clinical improvement after an initial dosage of 2.5 mg three times per day and only four patients required dosages above 7.5 mg three times daily. One hundred and one individuals (75%) continued midodrine until the end of the monitoring period, and although 19 subjects developed adverse drug reactions, most were minor and only six resulted in drug withdrawal. Conclusions: Midodrine hydrochloride appears to be safe and well tolerated in older adults and should be considered, independent of age, in the management of patients with symptomatic orthostatic hypotension, vasovagal syncope and vasodepressor or mixed carotid sinus syndrome. This observation requires further confirmation by larger multicenter randomised control studies.