Medical treatment of octogenarians with chronic heart failure: data from CHECK-HF

Exercise as a Therapeutic Tool in Age-Related Frailty and Cardiovascular Disease: Challenges and Strategies

Understanding the link between heart disease and frailty in older adults is crucial. Although medical progress has extended life, it has not fully addressed the decline in function and quality of life in frail older people. Frailty is a state of vulnerability to health stressors that needs comprehensive solutions. Its assessment within health care, especially in cardiology, is important owing to its association with worse clinical outcomes. Recent evidence and guidelines suggest that the prescription of a comprehensive exercise regimen, tailored to progressively include strength, balance, mobility, and endurance training improves adherence, functionality, and health-related quality of life, in both acute and chronic cardiovascular diseases. In addition, exercise is a vital tool that improves function, targets frailty, and holistically affects the body's systems. Still, many frail people do not exercise enough, and when they do, they usually do not follow an appropriate plan tailored for better functional outcomes. Overcoming barriers and limitations in exercise enrollment and adherence through strategies such as automated cardiac rehabilitation referral, patient education, and eHealth tools can notably improve clinical outcomes.

Medication and Outcome in Older Heart Failure Patients: Results from a Prospective Cohort Study

Purpose: Acute heart failure (AHF) is associated with high morbidity and mortality, and the prognosis is particularly poor in older patients. Although the application of guideline-directed medical therapy (GDMT) has shown a positive impact on prognosis, the effects are less clear in older age groups. The aim of this study was to analyze real-world data regarding GDMT and outcomes in older HF patients. Methods: This is a prospective cohort study from a secondary care hospital in central Switzerland. A total of 97 consecutive patients aged ≥60 years were enrolled between January 2019 and 2022. The main outcome parameters were prescribed GDMT at discharge, and in case of rehospitalization, GDMT at readmission, and survival in terms of all-cause mortality and HF-related hospitalizations during a 3-year follow-up period. Results: Follow-up data were available for 93/97 patients. The mean age was 77.8 ± 9.8 years, 46% being female. The mean left ventricular ejection fraction (LVEF) was 35.3 ± 13.9%, with a mean BNP level of 2204.3 ± 239 ng/L. Upon discharge, 86% received beta-blockers and 76.3% received renin-angiotensin system (RAS) inhibitors. At rehospitalization for AHF, beta-blockers use was significantly lower and decreased to 52.8% (p = 0.003), whereas RAS inhibitor use increased slightly to 88.9% (p = 0.07), and SGLT-2 inhibitors showed a significant increase from 5.4% vs. 47.2% (p = 0.04). GDMT prescription was not dependent on LVEF. Overall, 73.1% of patients received two-stage or three-stage GDMT at discharge, whereas this percentage decreased to 61% at rehospitalization (p = 0.01). Kaplan-Meier analysis for the combined outcome rehospitalization and death stratified by LV function showed significant differences between LVEF groups (aHR: 0.6 [95% CI: 0.44 to 0.8]; p = 0.0023). Conclusions: Our results indicate that first, the majority of older AHF patients from a secondary care hospital in Switzerland were not on optimal GDMT at discharge and even fewer at readmission, and second, that prognosis of the population is still poor, with almost half of the patients having been rehospitalized or died during a 3-year follow-up period under real-world conditions, without significant difference between women and men. Our findings underline the need for further improvements in the medical treatment of AHF, in particular in older patients, to improve prognosis and to reduce the burden of disease.

Heart failure treatment in patients with and without obesity with an ejection fraction below 50

BACKGROUND

The aim of this study was to assess heart failure (HF) treatment in patients with and without obesity in a large contemporary real-world Western European cohort.

METHODS

Patients with a left ventricular ejection fraction (LVEF) <50% and available information on body mass index (BMI) were selected from the CHECK-HF registry. The CHECK-HF registry included chronic HF patients in the period between 2013 and 2016 in 34 Dutch outpatient clinics. Patients were divided into BMI categories. Differences in HF medical treatment were analysed, and multivariable logistic regression analysis (dichotomized as BMI <30 kg/m² and ≥30 kg/m² ) was performed.

RESULTS

Seven thousand six hundred seventy-one patients were included, 1284 (16.7%) had a BMI ≥30 kg/m² , and 618 (8.1%) had a BMI ≥35 kg/m² . Median BMI was 26.4 kg/m² . Patients with obesity were younger and had a higher rate of comorbidities such as diabetes mellitus, hypertension and obstructive sleep apnoea (OSAS). Prescription rates of guideline-directed medical therapy (GDMT) increased significantly with BMI. The differences were most pronounced for mineralocorticoid receptor antagonists (MRAs) and diuretics. Patients with obesity more often received the guideline-recommended target dose. In multivariable logistic regression, obesity was significantly associated with a higher likelihood of receiving ≥100% of the guideline-recommended target dose of beta-blockers (OR 1.34, 95% CI 1.10-1.62), renin-angiotensin system (RAS)-inhibitors (OR 1.34, 95% CI 1.15-1.57) and MRAs (OR 1.40, 95% CI 1.04-1.87).

CONCLUSIONS

Guideline-recommended HF drugs are more frequently prescribed and at a higher dose in patients with obesity as compared to HF patients without obesity.

Use of Guideline-Directed Medical Therapy in Patients Aged 80 Years or Older with Heart Failure with Reduced Ejection Fraction

Background

Guideline-directed medical therapy (GDMT) reduces morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). Use of GDMT is recommended in all adults with HFrEF, but it is potentially underutilized in patients with advanced age. This study sought to characterize use of GDMT in octogenarians and nonagenarians with HFrEF and identify barriers to initiation and uptitration.

Methods

This retrospective cohort study included patients aged 80-99 years at 3 heart failure clinics in the Lower Mainland region of British Columbia, Canada. Patients with a left ventricular ejection fraction ≤ 40% and heart failure hospitalization < 12 months were included. Data were collected between September 2019 and August 2021, for up to 24 months from the initial clinic visit.

Results

A total of 91 patients were included. The mean age was 85 years, and the mean left ventricular ejection fraction was 30%. About 50% of patients had New York Heart Association class II symptoms. Throughout the study follow-up period, approximately 91% of patients were on a beta-blocker, 72% were on a renin-angiotensin system (RAS) inhibitor, 31% were on a mineralocorticoid receptor antagonist (MRA), and 4% were on a sodium-glucose cotransporter 2 (SGLT2) inhibitor. The target dose was achieved in 19% of patients on a beta-blocker, 7% on an RAS inhibitor, 11% on an MRA, and 100% on an SGLT2 inhibitor. Frequent barriers to GDMT initiation and/or uptitration were renal dysfunction, hypotension, and hyperkalemia.

Conclusions

The levels of use of RAS inhibitors and beta-blockers in patients aged 80-99 years with HFrEF were reasonable, whereas the levels of use of MRAs and SGLT2 inhibitors were low. Achievement of target doses of GDMT was rare, owing to common adverse effects.

CardioMEMS™: a tool for remote hemodynamic monitoring of chronic heart failure patients

Remote monitoring is becoming increasingly important for management of chronic heart failure patients. Recently, hemodynamic monitoring by measuring intracardiac filling pressures has been gaining attention. It is believed that hemodynamic congestion precedes clinical congestion by several weeks and that remote hemodynamic monitoring therefore enables clinicians to intervene in an early stage and prevent heart failure hospitalizations. The CardioMEMS HF system (Abbott, CA, USA) is a sensor capable of measuring pulmonary artery pressures as a surrogate of left ventricular filling pressures. Clinical evidence for CardioMEMS has been convincing in terms of efficacy and safety. This article provides detailed information on the CardioMEMS HF system and summarizes all available evidence of this promising technique.

Epidemiology and treatment of heart failure in Spain: the HF-PATHWAYS study

INTRODUCTION AND OBJECTIVES

To describe the epidemiology and treatment of a large contemporary cohort of patients with heart failure (HF).

METHODS

Observational, retrospective, population-based study using the BIG-PAC database, which includes people aged ≥ 18 years seeking care for HF between 2017 and 2019. The main variables were the prevalence/annual incidence rate, comorbidities, clinical variables, and medication administered.

RESULTS

We identified 19 762 patients with HF from a total of 1 189 003 persons seeking medical attention from 2017 to 2019 (2019: mean age, 78.3 years; 53.0% men). Distribution by type of left ventricular ejection fraction (LVEF) was as follows: 51.7% reduced, 40.2% preserved, and 8.1% mid-range. In 2019, the prevalence was 1.89% (95%CI, 1.70-2.08), with an incidence rate of 2.78 new cases per 1000 persons/y. No statistically significant differences were observed in prevalence and/or incidence from 2017 to 2019. Among patients with HF with reduced ejection fraction (HFrEF), 64% received beta-blockers, 80.5% angiotensin-converting enzyme inhibitor/angiotensin receptor blockers or sacubitril-valsartan, and 29.8% an aldosterone antagonist. In addition, from the diagnosis (baseline) to 24 months of follow-up, there was discreet treatment optimization, which was notable in the first 3 to 6 months.

CONCLUSIONS

Epidemiological data on HF remained stable during the study period, with a lower prevalence than that reported in non-population-based studies. There is wide room for improvement in the optimization of medical treatment of HFrEF.

Six-minute walk test: prognostic value and effects of nebivolol versus placebo in elderly patients with heart failure from the SENIORS trial

BACKGROUND

There is limited information about the 6-min walk test (6MWT) in elderly patients with heart failure. We evaluated 6MWT and the effect of nebivolol on 6MWT from the SENIORS trial.

METHODS AND RESULTS

The SENIORS trial evaluated nebivolol versus placebo on death and hospitalisation in patients aged ≥ 70 years with heart failure. A total of 1982 patients undertook a 6MWT at baseline and 1716 patients at 6 months. Patients were divided into tertiles (≤ 200 m, 201 to ≤ 300 m and > 300 m) and to change in distance walked between baseline and 6 months (< 0 m, 0 to < 30 m and ≥ 30 m). The primary outcome was all-cause mortality and cardiovascular hospital admission. Secondary endpoint was all-cause mortality. Baseline walk distance of ≤ 200 m incurred a greater risk of the primary and secondary outcomes (HR 1.41, CI 95% 1.17-1.69, p < 0.001) and (HR 1.37, CI 95% 1.05-1.78, p = 0.019). A decline in walk distance over 6 months was associated with increased risk of clinical events. Nebivolol had no influence on change in walk distance over 6 months.

CONCLUSIONS

The 6MWT has prognostic utility in elderly patients. Those who walked less than 200 m were at highest risk. Nebivolol had no effect on 6MWT.

Kardiologische Therapie im Alter aus geriatrischer Sicht

Kardiovaskuläre Erkrankungen, wie Arteriosklerose, arterielle Hypertonie, Herzinsuffizienz oder Vorhofflimmern, haben die höchste Prävalenz im fortgeschrittenen Lebensalter. Als Grundlage für die pharmakologische Therapie dienen jeweils die aktuellen Leitlinien. Allerdings bedarf es aufgrund der Komplexizität und Vulnerabilität geriatrischer Patienten eines individuellen Behandlungsansatzes, welcher sich im Einzelfall von Leitlinien unterscheiden kann. Im folgenden Beitrag werden einige relevante kardiovaskuläre Erkrankungen aus der Perspektive eines geriatrischen Behandlungsansatzes beleuchtet sowie Empfehlungen ausgesprochen.

Protected risk stratification with the wearable cardioverter-defibrillator: results from the WEARIT-II-EUROPE registry

Background

The prospective WEARIT-II-EUROPE registry aimed to assess the value of the wearable cardioverter-defibrillator (WCD) prior to potential ICD implantation in patients with heart failure and reduced ejection fraction considered at risk of sudden arrhythmic death.

Methods and results

781 patients (77% men; mean age 59.3 ± 13.4 years) with heart failure and reduced left ventricular ejection fraction (LVEF) were consecutively enrolled. All patients received a WCD. Follow-up time for all patients was 12 months. Mean baseline LVEF was 26.9%. Mean WCD wearing time was 75 ± 47.7 days, mean daily WCD use 20.3 ± 4.6 h. WCD shocks terminated 13 VT/VF events in ten patients (1.3%). Two patients died during WCD prescription of non-arrhythmic cause. Mean LVEF increased from 26.9 to 36.3% at the end of WCD prescription (p < 0.01). After WCD use, ICDs were implanted in only 289 patients (37%). Forty patients (5.1%) died during follow-up. Five patients (1.7%) died with ICDs implanted, 33 patients (7%) had no ICD (no information on ICD in two patients). The majority of patients (75%) with the follow-up of 12 months after WCD prescription died from heart failure (15 patients) and non-cardiac death (15 patients). Only three patients (7%) died suddenly. In seven patients, the cause of death remained unknown.

Conclusions

Mortality after WCD prescription was mainly driven by heart failure and non-cardiovascular death. In patients with HFrEF and a potential risk of sudden arrhythmic death, WCD protected observation of LVEF progression and appraisal of competing risks of potential non-arrhythmic death may enable improved selection for beneficial ICD implantation.

Graphic abstract