Age old problem: heart failure treatment in elderly

Heart failure (HF) affects more than 26 million patients worldwide,1 and it is responsible for more than one million hospitalisations per year.2 Despite advances in treatment, the prognosis of HF is poor, with a 30-day readmission rate of 30%,3 one-year mortality rate of up to 45% and 5-year mortality above 50%.4 Despite the stable incidence of HF over the previous decades, its prevalence is growing, mostly because of the aging population and improved survival owing to progress in cardiovascular disease/HF management.5 Among elderly people, there is a notable increase in the prevalence of HF, which is twofold greater in men and threefold greater in women, with every decade after the age of 65 years.1 HF is also the leading cause of morbidity, hospitalisation and mortality in older people.6 In addition, elderly patients less frequently receive optimal treatment with angiotensin-converting enzyme inhibitors or beta-blockers (BBs), despite having higher morbidity and mortality than younger patients with HF.6 Aging confers greater morbidity and mortality due to the increased prevalence of comorbidities, different response to medical treatment and underutilisation of guideline-directed medical treatment (GDMT). In addition, discrepancies in the quality of care of the elderly, as well as patient preferences, intolerance and low compliance with GDMT may adversely impact HF treatment.7 Despite initiatives to improve HF management in the elderly, there is a paucity of ‘real-world’ data and a necessity for the contemporary analysis of medium to long-term management and outcomes of elderly patients with HF. This important issue is addressed by the analysis of the CHECK-HF registry (Chronisch Hartfalen ESC–richtlijn Cardiologische praktijk Kwaliteitsproject HartFalen) presented in the current issue of the journal by Veenis et al.7 This analysis compiled data on 8351 patients with chronic HF and reduced ejection fraction (HFrEF) older than 60 years from 34 Dutch outpatient clinics, treated between 2013 and 2016. The study showed that the aging of patients with chronic HFrEF was associated with more comorbidities, including a greater likelihood of worsening renal function and atrial fibrillation. In addition, the elderly had a greater prevalence of type 2 diabetes, hypertension, thyroid disorders and chronic obstructive pulmonary disease. Also, the elderly less frequently received GDMT (BBs, renin–angiotensin system inhibitors (RASis), mineralocorticoid receptor antagonists (MRAs) and ivabradine), but were significantly more often treated with diuretics compared with younger patients. The contraindication or intolerance rates were significantly higher for all GDMT among the elderly, but in approximately 60% of patients the reasons for underprescription remained unspecified. Furthermore, as patients got older, the uptitration of BBs, RASis and MRAs to target doses was less likely. Multivariable adjusted analysis showed that with each 10-year increase in the age the probability of receiving MRAs, BBs, RASis and ivabradine decreased by 10%, 12%, 29% and 21%, respectively. At the same time, the probability of receiving diuretics increased by 32% with every decade of age. As expected, the elderly were more likely to receive a pacemaker, but they were less likely to receive implantable cardioverter defibrillators (ICDs) or cardiac resynchronisation therapy (CRT), in comparison to younger patients (i.e. each 10-year increase in the age decreased the probability of ICDs or CRT implantation by 39% and 17%, respectively). The results of the CHECK-HF registry are in line with several other registries (i.e. EuroHeart Failure Survey II, IN-CHF, IMPROVE-HF and CHAMP-HF), which have consistently demonstrated a lower prescription rate of GDMT among elderly patients with HFrEF.8–11 Nevertheless, this registry adds important new data from a large contemporary population of real-world HFrEF patients. It provides information on contraindications and target doses of GDMT, as well as the rates of device implantation in the elderly. However, these data reflect the current status of HFrEF management in a country with a well-developed healthcare system, which limits translation into global HF treatment. In addition, registry-derived data may be limited by coding inconsistencies, hidden confounding and difficulties in verifying information (central validation and adjudication of diagnosis and left ventricular ejection fraction measurements). Although the elderly represent a significant proportion of the overall HF population, those above 75 years have been largely underrepresented in randomised clinical trials of HFrEF therapies (approximately 30% of the participants).12,13 Most frequently, elderly patients were excluded because of a higher burden of comorbidities, lower body mass index and a higher risk of adverse drug reactions/interactions due to polypharmacy. This resulted in uncertainty about the applicability of evidence-based HF therapies in the elderly, particularly concerning drug initiation and optimal dosing. However, subgroup analyses of HFrEF trials have suggested a similar improvement in outcomes with GDMT in older HFrEF patients compared with younger age groups.14 In addition to GDMT, there was an evident trend of less ICD or CRT implantation in the elderly.13 This may be related to a greater risk of non-arrhythmic mortality among the elderly that may attenuate risk reduction following ICD implantation.15 The 2016 European Society of Cardiology guidelines for the diagnosis and management of HF16 postulate that HF management is more challenging among the elderly because of multiple comorbidities, cognitive impairment, polypharmacy, frailty and limited social support. The oldest patients (above the age of 85 years) and patients discharged after HF hospitalisation, represent especially vulnerable groups.17 It is estimated that 75% of the elderly have more than two non-cardiac comorbidities and 25% have more than five non-cardiac comorbidities.18 Cognitive impairment, polypharmacy and limited social support decrease adherence to GDMT, and increase the propensity for adverse drug reactions. Also, frailty has been observed in more than 70% of patients with HF above 80 years of age,19 and is identified as an important contributor to increased mortality and readmission rates. It also represents a potential target for improvement in the management of HF patients.20 In treating HF in the elderly, several points deserve consideration. Dose adjustments of GDMT are frequently needed during the initiation or uptitration phases, or following changes in clinical status, to avoid intolerance and adverse reactions.21 In the elderly, a vasodilating BB (nebivolol) may be preferred instead of conventional BBs, and eplerenone may be better tolerated than spironolactone.22–25 In addition, CRT can improve survival and functional capacity and allow the uptitration of GDMT irrespective of age.26 Also, after consideration of patients’ preferences and life expectancy, ICDs may be recommended as an effective therapy for preventing sudden death in the elderly.27 A simplification of the treatment scheme is highly recommended. It is advisable to discontinue symptom-controlling drugs, which may cause adverse reactions or worsening of HF (e.g. non-steroidal anti-inflammatory drugs). Cognitive impairment and HF frequently coexist and a multidisciplinary team approach is recommended. The use of compliance aids and greater involvement of family members and caregivers could improve self-care and adherence to HF treatment. In the years to come, expansion of the aging population will challenge healthcare systems to provide optimal management of this subset of HF patients. Being multicomorbid, vulnerable and frail, they need special attention. A more comprehensive approach to this problem will include broader representation of elderly HF patients in clinical trials. For the time being, the CHECK-HF registry provides valuable data on the current status of HFrEF management. It also represents a solid ground to design future strategies aimed towards better implementation of GDMT and improvement in outcomes in older patients with HFrEF. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.