Elderly heart-failure patients often denied evidence-based therapies

Reuters Health - 06/07/2021 - Heart-failure patients in their 80s are less likely to receive recommended therapies compared to their younger counterparts, according to data from the Swiss Heart Failure Registry.

"Guidelines recommend the same treatments for all heart failure patients regardless of age. Our analysis adjusted for other conditions that might justify withholding therapy or reducing the dose - for example impaired kidney function - and age was independently associated with under treatment," study author Dr. Davide Stolfo, with Karolinska Institute, Stockholm, said in a statement.

Dr. Stolfo presented the study results at Heart Failure 2021, an online scientific congress of the European Society of Cardiology (ESC).

"There is still large room for improvement in the care of patients with HF in terms of adherence to treatment recommendations," Dr. Stolfo told Reuters Health by email.

Older patients "deserve more attention in the management of their condition as there are no solid evidences against the implementation of treatments in the elderly and in our study age, per se, appeared to negatively influence patients' care," he added.

The researchers assessed use of guideline-directed therapy in more than 27,000 patients with heart failure with reduced ejection fraction (HFrEF) according to three age categories: under 70, 70 to 79, and 80 years or older.

"Octogenarians are progressively becoming a predominant proportion of the whole heart-failure population. For this reason, we divided our patients into three age categories and in this way we provided exhaustive and punctual data for the three explored age subgroups," Dr. Stolfo told Reuters Health.

The results showed that use of evidence-based therapies for HFrEF progressively decreased with increasing age.

In terms of medications, renin-angiotensin-system inhibitor (RASI) / angiotensin-receptor neprilysin inhibitor (ARNI), beta-blockers, and mineralocorticoid-receptor antagonist (MRA), respectively, were prescribed in 95%, 95% and 54% of patients younger than age 70; in 90%, 93% and 47% of patients aged 70 to 79; and in 80%, 88% and 35% in those aged 80 and older.

Heart-failure patients aged 80 or older were also less likely to be given the recommended dose of medications or to receive all three recommended types of medications.

Among HFrEF patients eligible for device therapies, the use of implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT), respectively, was 22% and 50% in patients younger than age 70; 17% and 42% in those 70 to 79 years; and in 5% and 23% of those aged 80 or older.

"There are several potential explanations for the under-treatment of older patients with HFrEF including more perceived contraindications/lower tolerability by physicians, safety concerns due to the larger burden of comorbidities, patients' preference, less awareness of efficacy in older categories and of course clinical inertia," Dr. Stolfo told Reuters Health.

"In this study, we did not specifically collect the reasons of under-use/under-dosing, but we performed extensive adjustment for several surrogates including low blood pressure, heart rate, renal function, comorbidities etc. and age was still associated with under-implementation of treatment," he said.

"This is not actually justified by current guidelines for HF treatment and from evidences neither since, at least for the use of drugs, in randomized trials there was not influence of age on treatments effect," Dr. Stolfo said.

"The optimal dose instead is more largely debated as post hoc analyses and observational studies reported no additional benefit from high vs. intermediate doses of beta-blockers in older ages," he added.

Under-treatment of elderly heart failure patients has also been observed in the United States and Europe.

"In particular," said Dr. Stolfo, "in the CHAMP-HF registry, age was inversely associated with the likelihood of initiation or dose optimization for beta-blockers and ARNI, but not for RASI or MRA (https://bit.ly/3qJsW1n). Similar findings for RASI and beta-blockers were observed in the BIOSTAT-CHF study (https://bit.ly/369ZckE)."

Summing up, Dr. Stolfo said, "data from trials do not support a lack of efficacy of treatments with increasing age, although the poor representation of older (age) categories in trials advocates for stronger efforts from the scientific community in including older patients in randomized clinical trials."

The study was supported by Boehringer Ingelheim. Dr. Stolfo reports personal fees from Novartis, Merck, GlaxoSmithKline and Acceleron.

SOURCE: https://bit.ly/3qL3zvS Heart Failure 2021, held June 29 to July 1, 2021.

By Megan Brooks



Posted on 6 July 202120 July 2021