LVEF-based phenotyping in very old adults hospitalised for heart failure: cardiological discrimination, shared geriatric burden, and treatment gaps

Figures

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  Figure 1. Age-dependent guideline-directed therapeutic pillar coverage and ARNi uptake in patients with HFrEF. Left panel: prescription rates of individual therapeutic pillars and ARNi uptake by age strata in patients with HFrEF. The renin–angiotensin system inhibitor pillar was defined as any prescription of ACEi, ARB, or ARNi. ARNi is shown separately as a marker of advanced renin–angiotensin system optimisation. Right panel: proportion of patients receiving at least 3 of 4 therapeutic pillars by age strata (trend p = 0.005). P-values shown for individual drugs correspond to chi-squared tests for trend across ordered age categories. ARNi uptake p = 0.004; ACEi/ARB/ARNi pillar p = 0.011; MRA p < 0.001; SGLT2i p = 0.882; beta-blocker p = 0.590. ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor–neprilysin inhibitor; HFrEF, heart failure with reduced ejection fraction; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium-glucose cotransporter-2 inhibitor.

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  Figure 2. Variables independently associated with HFpEF versus HFrEF. Forest plot showing adjusted odds ratios and 95% confidence intervals from the multivariable logistic regression model comparing HFpEF with HFrEF. The model included age, sex, obesity, ischaemic cardiomyopathy, AF/flutter, hypertension, diabetes, malnutrition, Charlson CCI, MR ≥ moderate, and CKD stage. Age was analysed per standard deviation increase, and CKD stage was analysed as an ordinal variable. Adjusted odds ratios greater than 1 indicate higher odds of HFpEF compared with HFrEF, whereas adjusted odds ratios lower than 1 indicate lower odds of HFpEF compared with HFrEF. The vertical dashed line represents an adjusted odds ratio of 1. The model included 1,146 patients and had a Nagelkerke R² of 0.31. AF, atrial fibrillation; aOR, adjusted odds ratio; BMI, body mass index; CCI, Charlson Comorbidity Index; CI, confidence interval; CKD, chronic kidney disease; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; MR, mitral regurgitation; SD, standard deviation.

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  Figure 3. Central illustration: LVEF discriminates cardiological phenotype but not CGA-derived geriatric burden or shared geriatric characteristics. The left panel shows variables that differed markedly across LVEF categories, including ischaemic cardiomyopathy, MR ≥ moderate, pacemaker/ICD, obesity, female sex, and admission NT-proBNP. The right panel shows variables that were similarly distributed across LVEF categories or showed similar distributions across LVEF categories, including CGA-derived geriatric burden, iron deficiency, remote monitoring, SGLT2i prescription, and in-hospital mortality. The figure summarises variables showing marked differences or similar distributions across LVEF categories. P-values refer to comparisons across HFrEF, HFmrEF, and HFpEF groups. ESC, European Society of Cardiology; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; NT-proBNP, N-terminal pro-B-type natriuretic peptide; SGLT2i, sodium-glucose cotransporter-2 inhibitor.