Guideline-directed medical therapy in elderly patients with heart failure with reduced ejection fraction: a cohort study

Abstract

Objectives and design: Guideline-directed medical therapy (GDMT) with renin-angiotensin system (RAS) inhibitors and beta-blockers has improved survival in patients with heart failure with reduced ejection fraction (HFrEF). As clinical trials usually do not include very old patients, it is unknown whether the results from clinical trials are applicable to elderly patients with HF. This study was performed to investigate the clinical characteristics and treatment strategies for elderly patients with HFrEF in a large prospective cohort.

Setting: The Korean Acute Heart Failure (KorAHF) registry consecutively enrolled 5625 patients hospitalised for acute HF from 10 tertiary university hospitals in Korea.

Participants: In this study, 2045 patients with HFrEF who were aged 65 years or older were included from the KorAHF registry.

Primary outcome measurement: All-cause mortality data were obtained from medical records, national insurance data or national death records.

Results: Both beta-blockers and RAS inhibitors were used in 892 (43.8%) patients (GDMT group), beta-blockers only in 228 (11.1%) patients, RAS inhibitors only in 642 (31.5%) patients and neither beta-blockers nor RAS inhibitors in 283 (13.6%) patients (no GDMT group). With increasing age, the GDMT rate decreased, which was mainly attributed to the decreased prescription of beta-blockers. In multivariate analysis, GDMT was associated with a 53% reduced risk of all-cause mortality (HR 0.47, 95% CI 0.39 to 0.57) compared with no GDMT. Use of beta-blockers only (HR 0.57, 95% CI 0.45 to 0.73) and RAS inhibitors only (HR 0.58, 95% CI 0.48 to 0.71) was also associated with reduced risk. In a subgroup of very elderly patients (aged ≥80 years), the GDMT group had the lowest mortality.

Conclusions: GDMT was associated with reduced 3-year all-cause mortality in elderly and very elderly HFrEF patients.

Trial registration number: NCT01389843.

Keywords: adult cardiology; cardiac epidemiology; heart failure.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Study flow. EF, ejection fraction; HFrEF, heart failure with reduced ejection fraction; KorAHF, Korean Acute Heart Failure.

Figure 2

Discharge medication profiles. Prescription of beta-blockers, RAS inhibitors (A) and GDMT (B) in elderly patients with HFrEF according to age group. GDMT, guideline-directed medical therapy; HFrEF, heart failure with reduced ejection fraction; RAS, renin-angiotensin system.

Figure 3

Three-year cumulative survival according to the treatment groups. Patients receiving GDMT had lower mortality among all patients (A), patients aged between 65 years and 79 years (B) and patients aged 80 years or older (C). BB, beta-blocker; GDMT, guideline-directed medical therapy; RASi, renin–angiotensin system inhibitor.

Figure 4

Subgroup analysis. The HRs of medical therapy (ie, GDMT, beta-blockers only and RAS inhibitors only) compared with no GDMT for all-cause mortality in subgroups were calculated using multivariate Cox regression analysis. The forest plots demonstrate the HRs of GDMT versus no GDMT from the results. There was no significant interaction between the treatment strategy (no GDMT, beta-blockers only, RAS inhibitors only and GDMT) and diverse subgroups, and GDMT was associated with lower morality across subgroups. *The p for interaction indicates whether treatment strategy interacts with the subgrouping variable. It was calculated from multivariable Cox regression analysis that included the variables for treatment strategy, subgrouping variables, interaction term of the treatment strategy-by-subgrouping variable, sex, hypertension, diabetes, atrial fibrillation and prescription of mineralocorticoid receptor antagonists, digitalis and diuretics. CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; HF, heart failure; GDMT, guideline-directed medical therapy; RAS, renin–angiotensin system.