Between January 1996 and July 1999, a total of 1,971 outpatients were recruited from 24 departments of geriatrics or respiratory medicine within the context of the Salute Respi-ratoria nell’Anziano (Sa.R.A.) [respiratory health in the elderly study]. Details on the Sa.R.A. project are available elsewhere; the Sa.R.A. study is a multicenter Italian project investigating various aspects of chronic airway diseases in the elderly population (age > 65 years) attending pulmonary or geriatric outpatient clinics. Participating centers were geriatric (n = 19) or respiratory medicine departments (n = 5) of university or major teaching hospitals. Researchers had specific and extensive training in respiratory function in the elderly and multidimensional geriatric assessment.
Enrollment was on a consecutive basis up to the achievement of a target number of approximately 200 COPD and 200 asthmatic patients. The study also enrolled as a control group outpatients aged > 65 years and attending the geriatric clinics for nonrespiratory conditions, the most common of which were hypertension (27.3%), arthritis (27%), diabetes mellitus (12.7%), coronary artery disease (11.4%), and cerebrovascular diseases (7%). Data from individual centers were collected by a coordinating center at the Cattedra di Malattie dell’Apparato Respira-torio of the University of Palermo, which was also responsible for the quality control, the retrieval, and the final processing of data.
Asthma in the elderly is not a rare disorder, but it is underdiagnosed because of atypical presentation and comorbidity. Up to 8% of subjects > 65 years old enrolled in the Cardiovascular Health Study had a diagnosis of definite or probable asthma, and a 7% prevalence of airways obstruction and symptoms suggestive of asthma has been reported in the Netherlands in an adult population. In elderly populations, asthma is an heterogeneous condition encompassing early and late onset forms. This can make the differential diagnosis between asthma and COPD difficult’: history of allergy is common in early onset, but not in late onset asthma, and several elderly patients with asthma have a persistent degree of airflow obstruction even when optimally treated. All this affects the quality of statistics on asthma prevalence and asthma-related death in the elderly. Factors associated with death from asthma, such as reversibility in FEV1, eosinophilia, comorbidity, and smoking, have been identified in subjects aged < 60 years.
While routine assessment of LVEF may be challenged in subjects with minimal myocardial damage as determined by novel biomarkers, our findings apply to MIs ascertained using CK/CK-MB only, as troponin was not used in Olmsted County at that time. The racial and ethnic composition of Olmsted County is becoming more diverse, but during the study period more limited diversity may limit the generalization of these data to groups underrepresented in the population. Conversely, however, the quasi totality of the population has some form of health insurance such that confounding by access to care is unlikely to explain the present results.
An ancillary survival analysis indicated that patients without LVEF assessment had worse survival. As in any observational study, residual confounding may account for this association. However, this underscores that the use of clinically indicated tests to measure the prevalence of LV dysfunction after MI and/or to ascertain outcomes is confounded by indication and will likely provide biased estimates. Indeed, estimates of the true prevalence of LV systolic dysfunction vary depending on the value of LV function in the group in whom it was not measured. To this end, we reported that the proportion of patients with preserved LVEF after MI among subjects with post-MI heart failure could vary notably, depending on assumptions for LVEF among patients without LV function measured.
Recent data underscored the association between the specialty of the ambulatory physician and the delivery of care among MI survivors. The present study extends these findings by demonstrating a positive association between the involvement of a cardiologist as a care provider and the measurements of LVEF among all consecutive patients from a geographically defined population admitted with acute MI irrespective of their hospital outcomes, such that the results are generalizable to all MI patients, not only survivors.
The results presented herein extend previously reported findings by indicating that during the last 20 years, the use of tests to measure LVEF increased dramatically during the first decade characterized by rapid incorporation of new technology in practice. Its use, however, stabilized over the last decade. Thus, the use of testing to measure LVEF did not increase appreciably since the publication of the aforementioned reports.- Furthermore, only 80% of patients underwent LVEF measurement during hospital stay, which is the optimal time to make use of the information on LVEF to optimize the use of evidence-based therapies after MI.
While some studies reported that an approximate estimation of LVEF can be performed clinically in 40% of patients after MI, the practical value of such scoring systems is limited. Indeed, stud-ies reported associations between several clinical indicators and abnormal LVEF, but these studies consisted of relatively small case series and the proposed prediction algorithms were not validated independently. In the current guidelines for the management of patients with acute MI, the ACC and AHA strongly support the measurement of LVEF after MI and underscore the value of predischarge assessment of ventricular function for risk stratifi-cation.
After adjusting for comorbidities and for other determinants of LVEF testing (including age, sex, year, peak CK, history of heart failure and comorbidity, EF measurement prior to index MI, cardiologist involved as care provider, length of stay > 10 days and reperfusion), patients who did not have an assessment of LVEF within 30 days of the index MI had an increased mortality during follow-up (relative risk of death if EF not measured, 1.69; 95% CI, 1.36 to 2.10).