Unrecognized Heart Failure and Chronic Obstructive Pulmonary Disease (COPD) in Frail Elderly Detected Through a Near-Home Targeted Screening Strategy

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Figure 1.
Flow chart of inclusion. *“Other” includes cognitive problems (such as dementia) and inability to travel to the primary care physician's office. ^†Nonresponse after 2 written invitations were sent. COPD, chronic obstructive pulmonary disease; HF, heart failure; ECG, electrocardiogram.
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Figure 2.
Age- and sex-specific prevalence of heart failure (HF) (A) and chronic obstructive pulmonary disease (COPD) (B). Total prevalence included new plus already known diagnoses.

Table 1. Demographic and Baseline Characteristics of 389 Frail Elderly With Dyspnea and/or Reduced Exercise Tolerance

Age (years)	75.5 ± 6.1
Male sex	174 (44.7)
BMI (kg/m²)	28.2 ± 4.4
Heart rate/minute	69 ± 11
Respiratory rate per minute	15 ± 3
Blood pressure (mm Hg)
Systolic	139 ± 18
Diastolic	76 ± 9
Smoking	138 (35.5)
Never
Former	214 (55.0)
Current	37 (9.5)
Medical history^*
Comorbidities (number), median (IQR)	4 (3–4)
Heart failure	22 (5.7)
COPD	67 (17.2)
Asthma (persistent)	36 (9.3)
Anemia	14 (3.6)
Renal dysfunction	12 (3.1)
Thyroid dysfunction	34 (8.7)
Ischemic heart disease^{^†}	125 (32.1)
Valvular disease	23 (5.9)
Cardiac rhythm disorders^{^‡}	54 (13.9)
Hypertension	316 (81.2)
Diabetes mellitus	135 (34.7)
Stroke or TIA	44 (11.3)
Symptoms
Orthopnea^{^§}	39 (10.0)
Ankle swelling	105 (27.0)
Nocturia (≥2 times a night)	199 (51.2)
Loss of appetite	33 (8.5)
Chest pain suggestive for angina pectoris	32 (8.2)
Palpitations	109 (28.0)
Cough (>3 months a year)	66 (17.0)
Wheezing	104 (26.7)
Inhalation allergy	79 (20.3)
Bronchial hyperreactivity	76 (19.5)
Medications, median (IQR)^{^‖}	5 (4–7)
Diuretics	212 (54.5)
Spironolactone	18 (4.6)
β-Blockers	187 (48.1)
ACEIs/ARBs	239 (61.4)
Cholesterol-lowering drugs	232 (59.6)
Inhaled long-acting β2-agonists	60 (15.4)
Inhaled anticholinergics	56 (14.4)
Inhaled corticosteroids	73 (18.8)

Data are mean ± standard deviation or number (%) unless otherwise indicated.
↵* Comorbidities were based on the primary care physician's electronic medical record; actual medication use from pharmacy records was added to the diagnosis of anemia, thyroid dysfunction, and diabetes mellitus; for hypertension, the electronic medical record was extended with self-reported hypertension.
↵† Ischemic heart disease included prior myocardial infarction, angina pectoris, coronary artery bypass grafting, and percutaneous coronary intervention.
↵‡ Cardiac rhythm disorders included atrial fibrillation and pacemakers.
↵§ Orthopnea included paroxysmal nocturnal dyspnea.
↵‖ Based on actual medication use (pharmacy records); 2 instances of missing data on orthopnea and one on loss of appetite.
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BMI, body mass index; COPD, chronic obstructive pulmonary disease; IQR, interquartile range; TIA, transient ischemic attack.

Table 2. New and “New Plus Already Known” Diagnoses^* in 389 Frail Elderly With Dyspnea and/or Reduced Exercise Tolerance

Diagnosed Conditions	New Diagnoses^{^†}	New Plus Already Known Diagnoses
Cardiac diseases
Heart failure	127 (33.5)	145 (38.3)
With reduced ejection fraction	36 (9.5)	46 (12.1)
With preserved ejection fraction	89 (23.5)	97 (25.6)
Isolated right-sided	2 (0.5)	2 (0.5)
Left ventricular dysfunction^{^‡}	81 (34.6)	X
Systolic	3 (1.3)	X
Diastolic	78 (33.3)	X
Atrial fibrillation	7 (1.8)	44 (11.3)
Valvular disease^{^§}	81 (21.4)	93 (24.6)
Aortic regurgitation (≥grade 2/4)	10 (2.6)	14 (3.7)
Aortic stenosis (moderate to severe)	14 (3.7)	16 (4.2)
Mitral regurgitation (≥grade 2/4)	67 (17.7)	74 (19.6)
Pulmonary diseases
COPD	65 (16.8)	134 (34.7)
GOLD I	31 (8.2)	53 (14.0)
GOLD II	28 (7.4)	59 (15.6)
GOLD III	3 (0.8)	11 (2.9)
GOLD IV	0 (0)	0 (0)
Persisting asthma	12 (3.1)	39 (10.1)
Restriction	9 (2.3)	X
Other diseases
Hypertension	3 (0.8)	319 (82.0)
Diabetes mellitus	3 (0.8)	138 (35.5)
Anemia	49 (12.7)	63 (16.3)
Hyperthyroidism	1 (0.3)	16 (4.2)
Hypothyroidism	1 (0.3)	20 (5.2)
Renal dysfunction (mL/min/1.73 m²)	86 (22.2)	97 (25.0)
30–60	85 (21.9)	96 (24.7)
<30	1 (0.3)	1 (0.3)

Data are number (%).
↵* Patients could have more than one diagnosis.
↵† There were 525 new diagnoses detected in 297 patients: 148 had 1, 94 had 2, 38 had 3, 11 had 4, 5 had 5, and 1 had 6. Because of an incomplete screening strategy or a nonassessable test, there were 10 instances of missing data on heart failure and dysfunction, 11 on valvular disease, 1 on atrial fibrillation, 3 on COPD, 11 on GOLD classification, 4 on asthma en restriction, 3 on anemia, and 4 on hypo- and hyperthyroidism.
↵‡ Left ventricular dysfunction without signs or symptoms of heart failure.
↵§ Patients could have more than one valve disorder.
COPD, chronic obstructive pulmonary disease; GOLD, Global Inititative for Chronic Obstructive Lung Disease; X = no such diagnosis in the electronic medical file at the primary care physician's office.

Table 3

Medical Research Council Dyspnea Scale^*^{^†}	Responses (%)
0. No breathlessness	2.1
1. Not troubled by breathlessness except on strenuous exercise.	10.1
2. Short of breath when hurrying on the level or walking up a slight hill.	44.6
3. Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace.	22.2
4. Stops for breath after walking about 100 yards or after a few minutes on level ground.	16.5
5. Too breathless to leave the house or breathless when dressing or undressing.	4.6
Questionnaire to evaluate exercise tolerance^{^‡}	Yes Responses (%)
Do you have a reduced exercise tolerance compared with others of the same age?	51.9
Do you feel more tired than others of the same age?	52.7^{^§}
Do you feel you need more recovery time after exercise than others of the same age?	46.1^{^†}
Do you feel your heart is pounding or feel palpitations or feel agitated during activities such as walking, gardening, or housework?	39.9^{^‖}
Response to the above questions were all negative	23.8^{^‖}