Use of evidence-based therapy in heart failure with reduced ejection fraction across age strata

Abstract

Aims: In older patients, guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (<40%; HFrEF) is not contraindicated, but adherence to guidelines is limited. We investigated the implementation of GDMT in HFrEF across different age strata in a large nationwide cohort.

Methods and results: Patients with HFrEF and HF duration ≥3 months registered in the Swedish HF Registry between 2000-2018 were analysed according to age. Multivariable logistic and multinomial regressions were fitted to investigate factors associated with underuse/underdosing. Of 27 430 patients, 31% were <70 years old, 34% 70-79 years old, and 35% ≥80 years old. Use of treatments progressively decreased with increasing age. Use of renin-angiotensin system/angiotensin receptor-neprilysin inhibitors, beta-blockers and mineralocorticoid receptor antagonists was 80%, 88% and 35% in age ≥80 years; 90%, 93% and 47% in age 70-79 years; and 95%, 95% and 54% in age <70 years, respectively. Among patients with an indication, use of implantable cardioverter defibrillator and cardiac resynchronization therapy (CRT) was 7% and 23% in age ≥ 80 years; 22% and 42% in age 70-79 years; and 29% and 50% in age <70 years, respectively. Older patients were less likely treated with target doses or combinations of HF medications. Except for CRT, after extensive adjustments, age was inversely associated with the likelihood of GDMT use and target dose achievement.

Conclusion: In HFrEF, gaps persist in the use of medications and devices. In disagreement with current recommendations, older patients remain undertreated. Improving strategies and a more individualized approach for implementing use of GDMT in HFrEF are required, particularly in older patients.

Keywords: Elderly; Guideline-directed medical therapy; Heart failure with reduced ejection fraction.

Figure 1

Target dose achievement of guideline‐directed medical therapies in the overall cohort and across age strata. Doses of mineralocorticoid receptor antagonists (MRA) were available from 2015. ARNI, angiotensin receptor–neprilysin inhibitor; RASI, renin–angiotensin system inhibitor.

Figure 2

Temporal trends in the adjusted probability of guideline‐directed medical therapy use in the overall cohort and across age strata. Trends in use of heart failure treatments start from 2003 when SwedeHF was implemented. ARNI, angiotensin receptor–neprilysin inhibitor; CI, confidence interval; MRA, mineralocorticoid receptor antagonist; RASI, renin–angiotensin system inhibitor.

Figure 3

Temporal trends in the adjusted probability of target dose achievement of heart failure medications in the overall cohort and across age strata. Trends in use of heart failure treatments start from 2003 when SwedeHF was implemented; doses of mineralocorticoid receptor antagonists (MRA) were available from 2015. ARNI, angiotensin receptor–neprilysin inhibitor; CI, confidence interval; RASI, renin–angiotensin system inhibitor.

Figure 4

Temporal trends in the adjusted probability of heart failure device use in the overall cohort and across age strata. Trends in use of heart failure treatments start from 2003 when SwedeHF was implemented. CI, confidence interval; CRT, cardiac resynchronization therapy; ICD, implantable cardioverter defibrillator.