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Management of heart failure in the elderly: what I should know?. Muntwyler et al., Eur J Heart Fail 2004 Clinical Characteristics of HF Patients According... The pathophysiology is diffe

Management of heart failure in the elderly:

what I should know?

Professor Andrew Coats

Joint Academic Vice-President and Director, Monash-Warwick Alliance

The ageing world

www.un.org/esa/socdev/ageing/agewpop1.htm

• Population of 151,000 in

West London

• 82 GP’s

• Rapid access HF clinic

• Survey of all admissions to

local hospital

• 20 month study

The Hillingdon Study

Cowie, Wood, Coats, Poole-Wilson, Thompson, Suresh, Sutton

They have more co-morbidities

Elderly HF Patients are not like

younger HF patients

Co-Morbidity in Elderly Patients with Heart

Hypercholest

Ocular disorders

COPD Diabetes Hypertension

Braunstein et al., J Am Coll Cardiol 2003

% of patients

N=122,630

Muntwyler et al., Eur J Heart Fail 2004

Clinical Characteristics of HF Patients According

The pathophysiology is different

Elderly HF Patients are not like

younger HF patients

Clinical Characteristics of HF Patients According

Two Types of Heart Failure

Heart Failure with reduced left

ventricular systolic function

Heart Failure with preserved left ventricular systolic function

Euroheart Failure: Distribution of ejection

Cleland et al Euroheart Survey EHJ 2003

11,015 patients in 115 hospitals in 24 countries

HF with preserved Ejection Fraction

(HFPEF) According to Age!

0 10 20 30 40 50 60

Prevalence (%)

Zile, Brutsaert, Circulation 2002

<50 50-70 >70 yrs

The Treatment is Different

Elderly Patients are not treated like younger

patients

Muntwyler et al., Eur J Heart Fail 2004b

BRING UP

Reasons for Not Commencing ß-Blockade

On 

blockers (n = 771)

 blockers started (n = 865)

No  blockers (n = 1455)

The evidence isn’t there

Mean Age in Multicentre HF Trials

62

5 010 Val-HeFT

63

2 289 COPERNICUS

64 EPHESUS

71 ELITE-II

Mean Age Trial

61 RALES

61 CIBIS-II

64 MERIT-HF

63 DIG

61 SOLVD-T

71 CONSENSUS I

ACE inhibitors in heart failure

evaluated in placebo-controlled

clinical trials

function, symptoms and clinical

Effect of ACE Inhibitors on Outcomes in

HF Patients According to Age

>75 65-75 55-64

<55 Death/CHF/MI

>75 65-75 55-64

<55 Deaths

Risk ratio (95% CI)

878/3165 1534/4315 1761/4194 590/1066

No of events/No of patients

Flather M et al., Lancet 2000

 blockers in heart failure

placebo-controlled clinical trials

function, symptoms and clinical status

35% (p<0.0001)

hospitalisation by 25–30% (p<0.0001)

Trials of treatment in heart failure

recruiting an elderly cohort

Trial Intervention Primary EP Result ELITE (722, >65 yrs) Los vs Cap Renal Function Not Sig

ELITE-II (3152, >60 yrs) Los vs Cap Death Not Sig

SENIORS (2135, >70 yrs) Nebivolol Death or HF Hosp Reduced 14%,

p = 0.039 PEP-CHF (850, >70 yrs) Perindopril Death or HF Hosp Not Sig

I-PRESERVE (4128, >60 yrs) Irbesartan Death or CV Hosp Not Sig

The SENIORS Trial

b) HF hospital admission within 1 year

cardiovascular hospital admission (time to first event)

Treatment Doses Achieved

Nebivolol (n=1067)

Placebo (n=1061)

Mean treatment dose, mg 7.7 8.5

Maintenance dose level achieved:

≥ 5 mg 815 (80.4%) 881 (87.1%)

10 mg 688 (67.9%) 805 (79.5%) Patient-years of follow-up 1863 1839 Median follow-up months 20.4 19.9

Nebivolol

(n = 1067 )

Placebo (n = 1061)

Placebo: 375 events (35.3%)

Nebivolol: 332 events (31.1%)

0.55 0.6 0.7 0.8 0.9 1.0 1.1 1.2

0.6 0.7 0.8 0.9 1.0 1.1 1.2

Unknown, not classifiable Non-cardiovascular death

Sudden cardiac death Worsening of heart failure Acute MI

Stroke (including RIND) Other CV deaths

Cardiac arrhythmia

Months

Risk Reduction 27%

Post-Hoc Analyses

Months

Risk Reduction 38%

Post-Hoc Analyses

Favors Nebivolol

Favors Placebo

Post-Hoc analysis

Continuing Unsolved Problems in

the Treatment of Chronic Heart Failure

“ Heart failure in elderly patients is inadequately

recognized and treated” *

“ Uncertainties concerning risk/benefit are exacerbated

by the fact that very old individuals are poorly

represented in large-scale clinical trials” *

“ It is recommended that evidence-based therapy for

HF be used in the elderly patient” *

* ACC/AHA Guidelines, Circulation 2009;119;e391-e479; originally published online Mar 26, 2009