Management and Prognosis of Heart Failure in Octogenarians: Final Report from the KorAHF Registry

Abstract

Treatment of heart failure (HF) in the elderly face many difficulties due to lack of robust evidence. We analyzed the outcome of HF in octogenarians using a nationwide HF registry. Among 5625 patients from the Korean Acute Heart Failure (KorAHF) registry, prognosis of octogenarian HF and the association of guideline-directed medical therapy (GDMT) with mortality and readmissions were analyzed. Octogenarian patients (1185, 22.4%) showed a higher mortality, and males were especially at increased risk (HR (hazard ratio) 1.19, 95% CI 1.01–1.40). A J-curve association between blood pressure (BP) and mortality was observed regardless of age, but the nadir value was lower in octogenarians (123.8 vs. 127.9 mmHg for systolic blood pressure (SBP); 67.1 vs. 73.9 mmHg for diastolic blood pressure (DBP), p < 0.001). Use of GDMT in octogenarian patients with HF and reduced ejection fraction (EF) were inadequate (74.3%, 47.1%, and 46.1% in octogenarians vs. 78.4%, 59.8%, and 55.2% in non-elderly for renin-angiotensin system inhibitors, beta-blockers, and aldosterone antagonists, respectively; all p < 0.05). However, those on medications had a significant reduction in 6 month mortality. For octogenarians with HF and preserved EF, angiotensin receptor blocker use reduced hospitalizations for HF in men (HR 0.19, 95% CI 0.04–0.87), but not in women (p-interaction = 0.037). HF in octogenarians were found to have different characteristics compared with the non-elderly. However, adequate use of GDMT was still associated with improved survival, and more attention should be given to prescribing medications with clinical benefits.

Use of evidence‐based therapy in heart failure with reduced ejection fraction across age strata

“…Age has been shown to be one of the major determinants of low prescription rates 5–10 . However, current guidelines do not report age‐related differences in treatment strategies.…”

“…Age has been shown to be one of the major determinants of low prescription rates. [5][6][7][8][9][10] However, current guidelines do not report age-related differences in treatment strategies. The scarce enrolment of older patients in RCTs might be interpreted as limiting generalizability of the available evidence on tolerability and efficacy of GDMT to this patient group.…”

“…older age in comparison with other studies. [7][8][9][10] Age-based differences in use of treatments were more evident for ARNI and MRA. A combination of RASI, beta-blockers and MRA was less used in patients aged ≥80 years compared to <70 years (26% vs. 50%), perhaps due to the perceived/actual higher exposure of older patients to adverse events or tolerability issues while on treatment with multiple drugs.…”

“…Most RCTs in heart failure (HF) with reduced ejection fraction (HFrEF) do not explicitly exclude older patients, but these are often poorly represented, though HF is highly prevalent and incident in older populations 1 . Age per se is not a contraindication to guideline‐directed medical therapy (GDMT), 2–4 but lower use of GDMT has frequently been observed in older patients 5–10 . Potential explanations might be perceived contraindications and reduced tolerance, patient preferences, or clinical inertia.…”

Prevalence and Prognosis of HFimpEF Developed From Patients With Heart Failure With Reduced Ejection Fraction: Systematic Review and Meta-Analysis

“…Discontinuation was another critical predictor of recurrence of left ventricular systolic dysfunction in patients with HFrecEF ( 35 , 36 ). Therefore, individual up-titrated treatment, adherence to the guideline-directed management and therapy (GDMT), and the certification of optimal medical therapy (OMT), which included both medications and daily management of heart failure were essential for cardiac function improvement ( 37 ). However, there is still a lack of prospective data to guide the treatment of patients with improved LVEF or myocardial recovery, and there is little evidence for treatment strategy for patients with left ventricular ejection fraction in the borderline of 40–50% (HFmrEF) or complete recovery (left ventricular ejection fraction ≥ 50%) ( 38 ).…”