Hearing Loss and Heart Failure

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At first glance, hearing impairment and heart disease seem to have very little in common. However, the relationship has been hypothesized since the 1960’s, and more recently has been established in epidemiologic studies – with a particular emphasis on heart failure. For example, a recent study by Sterling et al. examined patients in the cross-sectional NHANES Survey aged ≥70 years with a diagnosis of heart failure. The authors described the percentage with quantifiable hearing loss based on pure-tone audiometry (considered the gold standard test).

The main findings: 74% of patients with heart failure had some degree of hearing loss, which was significantly higher than those without heart failure (63%). Further, only 16% of heart failure patients wore hearing aids. Thus there was a disconnect between the burden of hearing loss, and use of a strategy (hearing aids) with proven effectiveness.

Why does this matter? According to the authors: “since patients with HF [heart failure] are frequently in noisy hospitals and clinics where they receive myriad instructions about disease management, it seems likely that untreated hearing loss could impair patient-physician communication and ultimately HF self-care.” After my recent two weeks attending on the inpatient cardiology service, I concur. We are constantly expecting our patients to provide us an accurate history, comprehend diagnostic test results, and adhere to discharge plans, all of which may be affected by hearing impairment.

What are the solutions? The first is to increase identification of hearing impairment through screening – and with advances in technology, I’d predict this can soon be easily done at the bedside with portable electronic devices. The second is to make hearing aids more accessible, including over-the-counter purchases – and recently there has been some notable advocacy work advancing laws to increase access. Through these two simple strategies, we may be able to make meaningful improvements in the health of our older cardiac patients.

Time for Action: Including Older Adults in Clinical Trials

dodson%20headshotWe recently published an editorial in the Journal of the American Geriatrics Society entitled “Time for a New Approach to Studying Older People with Ischemic Heart Disease”. This was in response to a research article by Bourgeois et al. demonstrating that of medication trials for patients with ischemic heart disease published between 2006 and 2016, over half (53%) excluded older adults. The authors’ findings underscore the continued problem of under-representation of older adults in the most rigorously conducted research studies, which makes translating these studies’ results into practice especially challenging.

This is a longstanding problem that was highlighted by the FDA over 25 years ago. In our editorial, we highlighted several potential next steps to address this issue:

  1. Design clinical research studies with no upper age limit. Alternatively, mandate an explicit lower age limit for inclusion – for example, only enroll patients age ≥75. Since there are fundamental phenotypic differences in older patients (including aging-related impairments such as frailty, sarcopenia, visual/sensory impairments, and cognitive impairment), this approach would ensure these characteristics are adequately represented.
  2. Create an Office of Geriatric Health and Aging within FDA, which would provide expertise for review of protocols on dosing, enrollment, and data collection in older patients.
  3. Add an exclusivity rule to extend patent life in drugs with proven safety and efficacy specifically in older adults, which would incentivize drug manufacturers to focus on aging. This approach has been previously described by Skolnick and Alexander.

These are just few examples of concrete steps that can be taken to address a problem that has long been recognized. With our aging population, and in light of current clinical uncertainties in cardiovascular medicine, there is a critical need for action.

 

By: John Dodson, MD

Frailty and Advanced Heart Failure

dodson%20headshotThis week we published a review in the Journal Current Cardiovascular Risk Reports  on the concept of frailty and advanced heart failure in older adults. As geriatricians have long known, frailty–defined as an increased vulnerability to physiologic stressors–is an incredibly common and often unrecognized syndrome in older patients. Cardiologists are increasingly recognizing that frailty predicts a broad range of outcomes, including mortality, in conditions such as heart failure, but also other situations such as acute myocardial infarction and transcatheter aortic valve replacement.

A few highlights from our paper:

– 80% of patients with heart failure are over age 65.

– As the heart failure population continues to age, the burden of frailty has increased.

– The estimated prevalence of frailty in advanced heart failure varies widely, with some estimates ranging up to 3 out of every 4 patients.

– It is challenging to determine causality between heart failure and frailty; they share common inflammatory pathways and one syndrome may mimic the other.

With our current technologies, one of the most pressing clinical questions is whether placement of a left ventricular assist device (LVAD) in advanced systolic heart failure can reverse the frailty phenotype, by correcting underlying physiologic derangements. Flint et al. have put forward the concept of “LVAD-responsive frailty” and “LVAD-independent frailty” – with an illustrative figure cited in our paper. Their concept emphasizes the considerable heterogeneity that exists within heart failure populations. We will need further studies to be able to predict where frailty may improve, in order to better counsel patients about their expected outcomes.

 

By: John Dodson