Diuretic use, RAAS blockade and morbidity in elderly patients presenting to the Emergency Department with non-specific complaints
QUESTIONS UNDER STUDY: Up to 20% of elderly patients present to the emergency department (ED) with non-specific complaints (NSC), such as “generalised weakness”, the majority suffering from serious conditions requiring timely intervention. Little is known about the use and influence of diuretics and renin-angiotensin-aldosterone (RAAS) blockade on morbidity in those patients. The hypothesis was tested that the use of diuretics and RAAS blockade could be associated with an increased incidence of serious conditions in those patients.
METHODS: During a 23-month period, all adult non-trauma patients with an Emergency Severity Index (ESI) of 2 or 3 were prospectively enrolled. Serious conditions were defined as potentially life-threatening conditions or conditions requiring early intervention to prevent further morbidity and mortality.
RESULTS: Study population consisted of 633 patients with median age 82 years, median Charlson comorbidity index 2. 59% of all subjects suffered from a serious condition. 299 subjects (47.2%) used diuretics, of which 65.6% suffered from a serious condition. Combination therapy of RAAS blockade and diuretics was found in 158 subjects (24.9%), 70.3% of which suffered from a serious condition. The intake of two or more diuretics, loop diuretics and a combination therapy with diuretics and RAAS blockade were associated with an increased risk for serious condition (p = 0.036; p = 0.021; p = 0.004).
CONCLUSIONS: Treatment with two or more diuretics, loop diuretics, or a combination therapy with RAAS blockade and diuretics are independently associated with serious condition and therefore should be recognized as “red flags” in elderly patients presenting to the ED with NSC.
- Brenner R, Waeber B, Allemann Y. Medical treatment of hypertension in Switzerland. The 2009 Swiss Hypertension Survey (SWISSHYPE). Swiss Med Wkly. 2011;141:w13169.
- Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, et al. ACCF/AHA. Expert consensus document on hypertension in the elderly: A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents Developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Soc Hypertens. 2011;5(4):259–352.
- Heart Failure Society of America. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):e1–e2.
- Butt TF, Branch RL, Beesley L, Martin U. Managing hypertension in the very elderly: effect of adverse drug reactions (ADRs) on achieving targets. J Hum Hypertens. 2010;24(8):514–8.
- Jyrkkä J, Enlund H, Korhonen MJ, Sulkava R, Hartikainen S. Polypharmacy status as an indicator of mortality in an elderly population. Drugs Aging. 2009;26(12):1039–48.
- Prybys KM. Deadly drug interactions in emergency medicine. Emerg Med Clin North Am. 2004;22(4):845–63.
- Michenot F, Sommet A, Bagheri H, Lapeyre-Mestre M, Montastruc JL; French Network of PharmacoVigilance Centres. Adverse drug reactions in patients older than 70 years during the heat wave occurred in France in summer 2003: a study from the French PharmacoVigilance Database. Pharmacoepidemiol Drug Saf. 2006;15(10):735–40.
- Vanpee D, Swine C, Vandenbossche P, Gillet JB. Epidemiological profile of geriatric patients admitted to the emergency department of a university hospital localized in a rural area. Eur J Emerg Med. 2001;8(4):301–4.
- Banz VM, Paul K, de Moya M, Zimmermann H, Candinas D, et al. Ignoring non-specific abdominal pain in emergency department patients may be related to decreased quality of life. A follow up of an underestimated problem. Swiss Med Wkly. 2011;141:w13167.
- Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, et al. Patients presenting to the emergency department with non-specific complaints: The Basel Non-specific Complaints (BANC) Study. Acad Emerg Med. 2010;17(3):284–92.
- Safwenberg U, Terent A, Lind L. The Emergency Department presenting complaint as predictor of in-hospital fatality. Eur J Emerg Med. 2007;14(6):324–31.
- Rutschmann OT, Chevalley T, Zumwald C, Luthy C, Vermeulen B, Sarasin FP. Pitfalls in the emergency department triage of frail elderly patients without specific complaints. Swiss Med Wkly. 2005;135(9-10):145–50.
- Gilboy N, Tanabe P, Travers DA. The Emergency Severity Index Version 4: changes to ESI level 1 and pediatric fever criteria. J Emerg Nurs. 2005;31(4):357–62.
- Charlson ME, Pompei P, Ales KL, MacKenzie CR.. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.
- Olsson T, Terent A, Lind L. Charlson Comorbidity Index can add prognostic information to Rapid Emergency Medicine Score as a predictor of long-term mortality. Eur J Emerg Med. 2005;12(5):220–4.
- Aerden L, van Raak E, Boreas A, Kessels A, Lodder J. Common drugs in acute ischemic stroke and their influence on outcome: An observational study in 1,013 stroke patients. Clin Neuropharmacol. 2008;31(2):74–9. 10.1097/WNF.0b013e31811ec142.
- Rao MY, Sudhir U, Anil Kumar T, Saravanan S, Mahesh E, Punith K. Hospital-based descriptive study of symptomatic hyponatremia in elderly patients. Journal of Association of Physicians of India 2010;58:667–9.
- Hamaguchi S, Kinugawa S, Goto D, Tsuchihashi-Makaya M, Yokota T, Yamada S, et al. Predictors of long-term adverse outcomes in elderly patients over 80 years hospitalized with heart failure - A report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD)-. Circ J. 2011 Sep 22;75(10):2403-10. Epub 2011 Jul 21.
- Page RL 2nd, Linnebur SA, Bryant LL, Ruscin JM. Inappropriate prescribing in the hospitalized elderly patient: Defining the problem, evaluation tools, and possible solutions. Clin Interv Aging. 2010;5:75–87.
- Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D., STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;26(2):72–83.
- Hasselblad V, Gattis Stough W, Shah MR, Lokhnygina Y, O'Connor CM, Califf RM,, et al. Relation between dose of loop diuretics and outcomes in a heart failure population: Results of the ESCAPE Trial. Eur J Heart Fail. 2007;9(10):1064–9.
- Costanzo MR, Johannes RS, Pine M, Gupta V, Saltzberg M, Hay J, et al. The safety of intravenous diuretics alone versus diuretics plus parenteral vasoactive therapies in hospitalized patients with acutely decompensated heart failure: A propensity score and instrumental variable analysis using the Acutely Decompensated Heart Failure National Registry (ADHERE) database. Am Heart J. 2007;154(2):267–77.
- Wright JT Jr, Probstfield JL, Cushman WC, Pressel SL, Cutler JA, Davis BR, et al. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. Arch Intern Med. 2009;169(9):832–42.
- Jamerson KA, Bakris GL, Wun CC, Dahlöf B, Lefkowitz M, Manfreda S, et al. Rationale and design of the avoiding cardiovascular events through combination therapy in patients living with systolic hypertension (ACCOMPLISH) trial: The first randomized controlled trial to compare the clinical outcome effects of first-line combination therapies in hypertension. Am J Hypertens. 2004;17(9):793–801.
- ACCORD Study Group, Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575–85.
- Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA. 2002;287(3):337–44.
- Beglinger C. Ethics related to drug therapy in the elderly. Dig Dis. 2008;26(1):28–31.
- Knottnerus JA, Buntinx F, ed. The evidence base of clinical diagnosis: Theory and methods of diagnostic research. ed. B. Books. 2008.
- MeteoSwiss, F.O.o.M.a.C. Monthly homogenized values of temperature and precipitation in Basel / Binningen, Switzerland. Coordinates: 47° 32.5' N / 7° 35.0' E. 20.06.2011.