Clinical profile, management, and mortality in very-elderly patients hospitalized with acute decompensated heart failure: An analysis from the ATTEND registry

Highlights

• Frequency of preserved left ventricular function increased with advancing age.

• Coronary risk factors excluding hypertension were lowest in very-elderly patients.

• Diuretics and vasodilators were administered well in older patients.

• However, very-elderly patients had worst cardiac mortality.

• Further, very-elderly patients were at high risk for cardiac death even though it was their first episode.

Abstract

Background

Acute decompensated heart failure (ADHF) is a leading cause of hospitalization among the elderly. Discussion of optimal management of ADHF in older patients is a growing health care priority. The aim of this study was to examine the clinical profile, management, and mortality in patients admitted with ADHF according to age.

Methods

We analyzed 4824 patients enrolled in the Acute Decompensated Heart Failure Syndromes registry from April 2007 to December 2011. Patient characteristics, management, and in-hospital outcomes were compared among four age groups (< 65, 65–74, 75–84, and ≥ 85 years).

Results

The mean age of the overall population was 73 years; approximately 20% were aged ≥ 85 years. Older patients were more likely to be women and have preserved left ventricular ejection fraction (LVEF) and decreased renal function. Intravenous treatments were well administered in both young and elderly patients irrespective of LVEF. Invasive procedures were less frequently performed in the eldest group. The median length of hospital stay was 21 days, and in-hospital cardiac death in the eldest group was four-fold higher than that in the youngest group (2.2% vs. 8.9%, P < 0.001).

Conclusions

Clinical characteristics of ADHF differ considerably with age, and cardiac death increases linearly with age. Despite a higher rate of preserved systolic function in very-elderly individuals aged ≥ 85 years, in-hospital mortality was higher, suggesting that more suitable treatments for the elderly might be needed.

Introduction

Improvement in the treatment of cardiovascular diseases, including revascularization therapy for myocardial infarction and strict control of hypertension, has resulted in both reduced in-hospital mortality and length of hospital stay in the aging the population [1], [2]. However, better treatment and salvage of patients with these diseases have resulted in a steady increase in the prevalence of chronic heart failure in the elderly; heart failure (HF) is the leading cause of hospitalization in seniors [3], [4], [5], [6], [7], [8]. Cumulative morbidity, mortality, and associated costs will undoubtedly escalate as the elderly population increases; thus, optimal management of HF in older adults is a growing health care priority.

It is well known that evidence-based guidelines have the potential to improve health care. However, patients enrolled in most randomized clinical trials are relatively young males; thus, a clinical gap may exist between clinical trials and the real-world population [8], [9]. In fact, previous studies have suggested that elderly patients with HF differ from younger patients with HF in terms of several biologic characteristics; older patients are more often women and are more likely to present with preserved left ventricular (LV) systolic function [10], [11], [12], [13], [14], [15]. Furthermore, some studies have reported that evidence-based therapies are less frequently used, and underdosage of recommended medications is constantly observed in the elderly [16], [17]. Therefore, information from adequate population-based studies is required to elucidate real-world data.

Many studies have addressed the issue of chronic HF management, and a limited number of acute HF studies have dedicated data specifically to age. Because patient characteristics and clinical signs in elderly patients with acute HF may differ from those of younger populations, it might be inappropriate to contextualize data derived from younger patients with acute HF to older patients with acute HF. In addition, few studies have demonstrated age differences in intravenous treatment, in-hospital management, and in-hospital cardiac mortality.

Thus, the purpose of this study was to examine the clinical profile, management, and outcome, especially pertaining to cardiac death, in patients admitted with acute decompensated HF according to age.