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Background A gap in evidence exists concerning the survival-benefit of neurohormonal blockade in older patients with chronic heart failure (HF). The purpose of our study was to investigate the neurohormonal modulation therapy in older HF patients. Methods We retrospectively analysed data on chronic HF patients with systolic dysfunction from January 2012 to May 2018 at a central tertiary academic hospital in Porto, Portugal. Very old (VO) patients were those ≥80 years. Endpoint under analysis: all-cause mortality; patients were followed until January 2021. The prognostic impact of beta-blockers (BBs) and renin-angiotensin system inhibitors (RASi) use was assessed with a Cox-regression analysis adjusting for confounders. Results We studied 934 patients, 65.5% male; 45.3% had ischemic HF. BBs were used in 92.2% and RASi in 83.5%; 255 (27.3%) were VO patients. VO more often presented co-morbidities, were more symptomatic, presented worse renal function and higher BNP levels. BB prescription was similar in VO and non-VO patients, however RASi were less used in VO: 74.9% versus 86.7%, respectively. During a median follow-up of 47 months, 479 (51.3%) patients died: 71.4% among VO versus 43.7% in non-VO. BBs increased survival both in non-VO and VO—multivariate adjusted HRs of 0.57 (95% CI: 0.38–0.85) and 0.59 (0.36–0.97), respectively. A survival-benefit was also observed with RASi—adjusted HR of 0.71 (0.50–1.01) and 0.59 (0.42–0.83) in non-VO and VO. Conclusions VO patients with chronic HF with systolic dysfunction have a very ominous outcome. Neurohormonal modulation therapy appears to portend survival-benefit also in this particularly vulnerable subgroup of patients.

Objective:Vasculitides are a group of rare, systemic diseases that induce inflammatory reactions in blood vessels, causing a reduction of blood flow and ischemia. In the kidney, luminal narrowing reduces blood flow and activates the renin-angiotensin-aldosterone system, causing renovascular hypertension.Design and method:Clinical case report.Results:A 47-year-old male with previous intestinal tuberculosis and hypertension diagnosed two years prior (blood pressure around 220/110 mmHg) was referred to our Hypertension Clinic. He reported self-limited episodes of lumbar pain, tender erythematous nodules in the shins and arthralgias. His mean office blood pressure was 203/118 mmHg, confirmed in home blood pressure monitoring, without medication. He had left ventricular concentric hypertrophy and chronic kidney disease (eGFR 66 mL/min/1.73m2) with albuminuria (561 mg/24 h). Verapamil and clonidine were prescribed to search for secondary hypertension but he missed the following appointment. A few months later he was admitted to the Intensive Care Unit due to a hypertensive emergency, with acute kidney failure and a large peri-renal hematoma. A CT scan and an angiography showed bilateral renal scarring, intrarenal pseudoaneurysms and small irregularities in the renal arteries. The immunologic panel was negative. A PET scan showed a slight enhancement of the aorta walls and common carotid arteries and the diagnosis of large-vessel vasculitis was established. He was discharged with high-dose corticosteroids and lisinopril and returned to our Hypertension Clinic. His blood pressure remained uncontrolled despite full-dose amlodipine, chlorthalidone and nebivolol; lisinopril was stopped due to worsening kidney function. Due to doubts on the diagnosis, the CT scan was repeated, now showing also irregularities in the common hepatic artery and mesenteric artery, suggesting a medium-vessel vasculitis, namely polyarteritis nodosa, and cyclophosphamide was started. His blood pressure is now controlled with lisinopril 2.5 mg, amlodipine 10 mg bid, furosemide 40 mg bid, nebivolol 5 mg and clonidine 0,15 mg tid and his kidney function is stable.Conclusions:Renovascular hypertension is responsible for less than 1% of all cases of hypertension and, when present, it is usually caused by atherosclerotic disease or fibromuscular dysplasia. However, in more infrequent cases, an inflammatory systemic disease may be present and must be considered.