Guideline-recommended medical therapy and outcomes in octogenarian patients with HFrEF

Background

Heart failure with reduced ejection fraction (HFrEF) is common in octogenarians, yet this population is underrepresented in clinical trials. Advanced age, comorbidities, and treatment intolerance may limit the use of guideline-recommended medical therapy (GRMT). Real-world data on GRMT utilization and clinical outcomes in octogenarian patients with HFrEF are limited.

Purpose

This study aimed to evaluate treatment patterns and outcomes in octogenarian patients with HFrEF.

Methods

All patients admitted to the outpatient clinic with HFrEF between January and June 2022 were retrospectively screened and octogenarian patients were included.

Results

A total of 64 patients (mean age 83.0 ± 2.6 years) were included; 40 (62.5%) were male. Ischemic heart disease was the underlying etiology of HFrEF in 41 patients (64.1%). Hypertension was present in 43 (67.2%), diabetes mellitus in 15 (23.4%), and chronic kidney disease in 15 (23.8%) patients. The mean left ventricular ejection fraction was 32.0 ± 6.9%, and the median NYHA functional class was 1 (IQR 1–3).

All patients were treated with beta-blockers; 58 (90.6%) received a renin–angiotensin system inhibitor or ARNI, and 37 (57.8%) were on mineralocorticoid receptor antagonists. None of the patients were treated with sodium–glucose cotransporter 2 inhibitors (SGLT2i). Triple therapy was used in 37 patients (57.8%), dual therapy in 21 (32.8%), and monotherapy in 6 (9.4%). The distribution of cases based on GRMT use was illustrated in Figure 1. The median NYHA class was 2 (IQR 1–3) in the monotherapy and dual-therapy groups and 1 (IQR 1–3) in the triple-therapy group.

Heart failure–related hospitalization within the preceding year occurred in all patients receiving monotherapy, compared with 52.4% of those on dual therapy and 40.5% of those on triple therapy. The most common reason for not receiving triple therapy was chronic kidney disease (CKD) (n = 11, 40.7%), followed by hypotension (n = 8, 29.6%).

Conclusions

GRMT was widely implemented and generally well tolerated in octogenarian patients with HFrEF, supporting its relevance even in very elderly populations. CKD and hypotension were the principal barriers to full treatment optimization. None of the patients in the cohort received SGLT2 inhibitors, primarily due to clinical inertia related to safety concerns in octogenarians and limitations in health insurance coverage. The lack of data on SGLT2i is an important limitation and underscores the need for prospective studies to further define the safety and efficacy of comprehensive GRMT in octogenarians.Figure 1For image description, please refer to the figure legend and surrounding text.