Consensus of experts from the French Society of Geriatrics and Gerontology on the management of heart failure in very old subjects

Effects of different sodium-glucose cotransporter 2 inhibitors in heart failure with reduced or preserved ejection fraction: a network meta-analysis

Background

This systematic review and meta-analysis aimed to explore the effects of different sodium-glucose cotransporter-2 inhibitors (SGLT2i) on prognosis and cardiac structural remodeling in patients with heart failure (HF).

Methods

Relevant studies published up to 20 March 2024 were retrieved from PubMed, EMBASE, Web of Science, and Cochrane Library CNKI, China Biomedical Literature Service, VIP, and WanFang databases. We included randomized controlled trials of different SGLT2i and pooled the prognosis data of patients with HF. We compared the efficacy of different SGLT2i in patients with HF and conducted a sub-analysis based on left ventricular ejection fraction (LVEF).

Results

We identified 77 randomized controlled trials involving 43,561 patients. The results showed that SGLT2i significantly enhanced outcomes in HF, including a composite of hospitalizations for HF and cardiovascular death, individual hospitalizations for HF, Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, left atrial volume index (LAVi), and LVEF among all HF patients (P < 0.05) compared to a placebo. Sotagliflozin was superior to empagliflozin [RR = 0.88, CI (0.79-0.97)] and dapagliflozin [RR = 0.86, CI (0.77-0.96)] in reducing hospitalizations for HF and CV death. Dapagliflozin significantly reduced hospitalizations [RR = 0.51, CI (0.33-0.80)], CV death [RR = 0.73, CI (0.54-0.97)], and all-cause mortality [RR = 0.69, CI (0.48-0.99)] in patients with HF with reduced ejection fraction (HFrEF). SGLT2i also plays a significant role in improving cardiac remodeling and quality of life (LVMi, LVEDV, KCQQ) (P < 0.05). Among patients with HF with preserved ejection fraction (HFpEF), SGLT2i significantly improved cardiac function in HFpEF patients (P < 0.05). In addition, canagliflozin [RR = 0.09, CI (0.01-0.86)] demonstrated greater safety compared to sotagliflozin in a composite of urinary and reproductive infections of HFpEF patients.

Conclusion

Our systematic review showed that SGLT2i generally enhances the prognosis of patients with HF. Sotagliflozin demonstrated superiority over empagliflozin and dapagliflozin in a composite of hospitalization for HF and CV death in the overall HF patients. Canagliflozin exhibited greater safety compared to sotagliflozin in a composite of urinary and reproductive infections of HFpEF. Overall, the efficacy of SGLT2i was greater in HFrEF patients than in HFpEF patients.

Heart failure with mildly reduced and preserved ejection fraction: A review of disease burden and remaining unmet medical needs within a new treatment landscape

This review provides a comprehensive overview of heart failure with mildly reduced and preserved ejection fraction (HFmrEF/HFpEF), including its definition, diagnosis, and epidemiology; clinical, humanistic, and economic burdens; current pharmacologic landscape in key pharmaceutical markets; and unmet needs to identify key knowledge gaps. We conducted a targeted literature review in electronic databases and prioritized articles with valuable insights into HFmrEF/HFpEF. Overall, 27 randomized controlled trials (RCTs), 66 real-world evidence studies, 18 clinical practice guidelines, and 25 additional publications were included. Although recent heart failure (HF) guidelines set left ventricular ejection fraction thresholds to differentiate categories, characterization and diagnosis criteria vary because of the incomplete disease understanding. Recent epidemiological data are limited and diverse. Approximately 50% of symptomatic HF patients have HFpEF, more common than HFmrEF. Prevalence varies with country because of differing definitions and study characteristics, making prevalence interpretation challenging. HFmrEF/HFpEF has considerable mortality risk, and the mortality rate varies with study and patient characteristics and treatments. HFmrEF/HFpEF is associated with considerable morbidity, poor patient outcomes, and common comorbidities. Patients require frequent hospitalizations; therefore, early intervention is crucial to prevent disease burden. Recent RCTs show promising results like risk reduction of composite cardiovascular death or HF hospitalization. Costs data are scarce, but the economic burden is increasing. Despite new drugs, unmet medical needs requiring new treatments remain. Thus, HFmrEF/HFpEF is a growing global healthcare concern. With improving yet incomplete understanding of this disease and its promising treatments, further research is required for better patient outcomes.

Practical management of frailty in older patients with heart failure: Statement from a panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology

AIMS

The heart failure (HF) prognosis in older patients remains poor with a high 5-years mortality rate more frequently attributed to noncardiovascular causes. The complex interplay between frailty and heart failure contribute to poor health outcomes of older adults with HF independently of ejection fraction. The aim of this position paper is to propose a practical management of frailty in older patients with heart failure.

METHODS

A panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology conducted a systematic literature search on the interlink between frailty and HF, met to propose an early frailty screening by non-geriatricians and to propose ways to implement management plan of frailty. Statements were agreed by expert consensus.

RESULTS

Clinically relevant aspects of interlink between frailty and HF have been reported to identify the population eligible for screening and the most suitable screening test(s). The frailty screening program proposed focuses on frailty model defined by an accumulation of deficits including geriatric syndromes, comorbidities, for older patients with HF in different settings of care. The management plan of frailty includes optimization of HF pharmacological treatments and non-surgical device treatment as well as optimization of a global patient-centred biopsychosocial blended collaborative care pathway.

CONCLUSION

The current manuscript provides practical recommendations on how to screen and optimize frailty management in older patients with heart failure.

Frailty as a predictor of clinical problems and events that require elderly patients with heart failure to use health resources

BACKGROUND

The clinical management of elderly patients with heart failure (HF) is not firmly established. Decision-making should be individualized depending on the biological deterioration of each patient, from aggressive management to a palliative approach. Frailty can serve as the basis for this comprehensive individualized management. Our objective was to evaluate the importance of the main clinical problems, as well as the events that required the use of health resources, based the degree of frailty, in elderly patients with HF.

METHODS AND RESULTS

Retrospective observational cohort study. Frailty was defined according to the deficit accumulation construct. A total of 546 patients hospitalized for acute HF were included. The median age (Q1-Q3) was 82 (78-86) years. A total of 454 patients (83%) showed some degree of frailty: 221 (48.7%) mild, 207 (45.6%) moderate and 26 (5.7%) advanced. There was a significant tendency towards polypharmacy from no to severe frailty. Hospital events were recorded for 4 (1-6) patients with mild frailty, 4 (2-6) patients with moderate frailty and 2 ((1-4) patients with advanced frailty (p = 0.045). A total of 204 patients (37.4%) died during follow-up. The median time to death was 11.4 (4-16.8), 6.7 (3.3-11.6), 6.5 (3.4-12.2) and 4.1 (0.8-7.7) months for patients with no, mild, moderate, or advanced frailty, respectively (p = 0.006).

CONCLUSIONS

Frailty due to deficit accumulation is a good predictor of clinical problems and events that require the use of health resources; therefore, it can serve as a basis for the management of HF in the elderly.

Pharmacological treatment of type 2 diabetes in elderly patients with heart failure: randomized trials and beyond

Heart failure (HF) and type 2 diabetes mellitus (T2DM) represent two important public health problems, and despite improvements in the management of both diseases, they are responsible for high rates of hospitalizations and mortality. T2DM accelerates physiological cardiac aging through hyperglycemia and hyperinsulinemia. Thus, HF and T2DM are chronic diseases widely represented in elderly people who often are affected by numerous comorbidities with important functional limitations making it difficult to apply the current guidelines. Several antidiabetic drugs should be used with caution in elderly individuals with T2DM. For instance, sulfonylureas should be avoided due to the risk of hypoglycemia associated with its use. Insulin should be used with caution because it is associated with higher risk of hypoglycemia, and may determine fluid retention which can lead to worsening of HF. Thiazolindinediones should be avoided due to the increased risk of fluid retention and HF. Biguanides may lead to a slightly increased risk of lactic acidosis in particular in elderly individuals with impaired renal function. Dipeptidyl peptidase 4 (DPP-4) inhibitors are safe having few side effects, minimal risk of hypoglycemia, and a neutral effect on cardiovascular (CV) outcome, even if it has been reported that saxagliptin treatment is associated with increased risk of hospitalizations for HF (hHF). Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown a CV protection without a significant reduction in hHF. On the other hand, sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown a significant improvement in CV outcome, with a strong reduction of hHF and a positive impact on renal damage progression. However, it is necessary to consider the possible some side effects related to their use in elderly individuals including hypotension, bone fractures, and ketoacidosis.It is important to remark that elderly patients, in particular the very elderly, are not sufficiently represented in the trials; thus, the management and treatment of elderly diabetic patients with HF should be mainly based on the integration of scientific evidence with clinical judgment and patients' condition, with respect to the dignity and quality of life.

Prognostic impact of systolic blood pressure in acute heart failure with preserved ejection fraction in older patients

Aims

Recent guidelines recommend a systolic blood pressure (SBP) target below 130 mmHg in heart failure patients with preserved ejection fraction (HFpEF), whatever their age. We investigated whether this intensive SBP control was associated with better survival in very old adults hospitalized for acute HFpEF.

Methods and results

We conducted an observational study in an acute geriatric unit: all consecutive patients discharged from hospital for acute heart failure from 1 March 2019 to 29 February 2020 with a diagnosis of HFpEF were included. Re‐hospitalization and all‐cause mortality at 1 year were compared according to the mean SBP at discharge (patients with a mean SBP < 130 mmHg vs. those with SBP ≥ 130 mmHg). We included 81 patients with a mean age of 89 years. Among them, 47 (58%) were re‐hospitalized and 37 (46%) died at 1 year. All‐cause mortality (hazard ratio [HR] [95% confidence interval]: 1.50 [0.75–2.98], P = 0.2) and re‐hospitalization rate (HR: 1.04 [0.58–1.86], P = 0.90) at 1 year did not significantly differ between patients with SBP ≥ 130 mmHg and those with SBP < 130 mmHg at discharge. However, a prescription for antihypertensive drugs at discharge was associated with a better long‐term prognosis (all‐cause mortality: HR: 0.42 [0.20–0.88], P = 0.02; re‐hospitalization rate: HR: 0.56 [0.28–1.10], P = 0.09).

Conclusions

Although SBP < 130 mmHg at discharge was not associated with a better prognosis among very old patients hospitalized for acute HFpEF, the prescription of antihypertensive drugs was associated with mortality and re‐hospitalization rates that were reduced by half. Future prospective studies are needed to assess target blood pressure in very elderly patients with HFpEF.

Diagnosis and Management of Heart Failure in Elderly Patients from Hospital Admission to Discharge: Position Paper

Multidisciplinary management of worsening heart failure (HF) in the elderly improves survival. To ensure patients have access to adequate care, the current HF and French health authority guidelines advise establishing a clearly defined HF patient pathway. This pathway involves coordinating multiple disciplines to manage decompensating HF. Yet, recent registry data indicate that insufficient numbers of patients receive specialised cardiology care, which increases the risk of rehospitalisation and mortality. The patient pathway in France involves three key stages: presentation with decompensated HF, stabilisation within a hospital setting and transitional care back out into the community. In each of these three phases, HF diagnosis, severity and precipitating factors need to be promptly identified and managed. This is particularly pertinent in older, frail patients who may present with atypical symptoms or coexisting comorbidities and for whom geriatric evaluation may be needed or specific geriatric syndrome management implemented. In the transition phase, multi-professional post-discharge management must be coordinated with community health care professionals. When the patient is discharged, HF medication must be optimised, and patients educated about self-care and monitoring symptoms. This review provides practical guidance to clinicians managing worsening HF in the elderly.