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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


Detecting Heart Failure in The Population
The Hillingdon Study
Cowie, Wood, Coats, Poole-Wilson, Thompson, Suresh, Sutton

• Population of 151,000 in
West London
• 82 GP’s
• Rapid access HF clinic
• Survey of all admissions to
local hospital
• 20 month study


Elderly HF Patients are not like
younger HF patients
They have more co-morbidities


Co-Morbidity in Elderly Patients with Heart

Failure
Hypertension
Diabetes
COPD
Ocular disorders
Hypercholest.
Atherosclerosis

55
31
26
24
21
20
19

Arthritis
COPD
Thyroid disorders
Complicated HBP
Alzheimer's

14
14
11
9
8
7

Depression

Renal failure
0
N=122,630

10

20

30

% of patients

40

50

60

Braunstein et al., J Am Coll Cardiol 2003


Clinical Characteristics of HF Patients According
to Age

35
30
25
20
15
10

5
0

Renal dysfunction

Atrial Fibrillation

p<0.001

p<0.001

32
25
19
10

40
% patients

% patients

IMPROVEMENT Study

30
20

25

31

36

16

10
0

<65 65-74 75-84 >84

<65 65-74 75-84 >84

Years

Years
Muntwyler et al., Eur J Heart Fail 2004


Elderly HF Patients are not like
younger HF patients
The pathophysiology is different


Clinical Characteristics of HF Patients According
to Age

70
60
50
40
30

20
10
0

62

Male Sex

Concomitant CAD

p<0.001

p<0.001

54

50
43
31

% patients

% patients

IMPROVEMENT Study

40

46

43

37

30

23

20
10
0

<65 65-74 75-84 >84

<65 65-74 75-84 >84

Years

Years

n=8256

Muntwyler et al., Eur J Heart Fail 2004


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
fraction
11,015 patients in 115 hospitals in 24 countries
Percentage of patients
14

Women
Men

12
10
8

6
4
2
0
<10 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 7514 19 24 29 34 39 44 49 54 59 64 69 74 80

Left Ventricular Ejection Fraction (%)
Cleland et al Euroheart Survey EHJ 2003


HF with preserved Ejection Fraction
(HFPEF) According to Age!
Prevalence (%)
60

50
40
30
20
10
0

<50

50-70

>70 yrs

Zile, Brutsaert, Circulation 2002


The Treatment is Different
Elderly Patients are not treated like younger
patients


Beta-Blocker Prescribing in HF Patients
According to Age
IMPROVEMENT Study
Females

Males
p<0.001

80

60
40

44
31

23

20

p<0.001

100

14

0

% patients

% patients

100

80
60
40

35

31

23

20

12

0
<65 65-74 75-84 >84

<65 65-74 75-84 >84

Years

Years
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)

P value

Age  70 years
NYHA III-IV

24%

25%

43%

0.001

26%

29%

42%

0.001

Pulmonary rales

10%

20%

26%

0.001

Periph. oedema

12%

13%

21%

0.001

Atrial
fibrillation

14%

17%

21%

0.001

EF not available

5%

3%

6%

0.008

EF < 30%

30%

30%

35%

0.017

Maggioni A et al. Heart 2003


TEMISTOCLE
(hearT failurE epideMIological STudy FADOI-ANMCO in itaLian pEople)

69% pts (1468 /2127) aged >70 years
7.7% (114 /2127) on BB at discharge

Reasons why BB-Therapy was not started
PVD
Absence of indication
AVBlock >2° HR<50 bpm
Diabetes
Hypotension

Other
NYHA IV
COPD
Advanced age >75 yr

1.1%
1.5%
3.0%
3.5%
4.0%
10.4%
11.4%
37.2%
43.8%

Di Lenarda et al. Am Heart J. 2003

N=1354


The evidence isn’t there


Mean Age in Multicentre HF Trials
Trial
CONSENSUS I

# Patients

Mean Age

253

71

SOLVD-T

6 797

61

DIG

7 788

63

MERIT-HF

3 991

64

CIBIS-II

2 647

61

COPERNICUS

2 289

63

RALES

1 633

61

EPHESUS

6 642

64

ELITE-II

3 152

71

Val-HeFT

5 010

62

CHARM

7 601

66


ACE inhibitors in heart failure

n Approximately 7000 patients
evaluated in placebo-controlled
clinical trials
n Consistent improvement in cardiac
function, symptoms and clinical
status
n Decrease in all-cause mortality by
20–25% (p<0.001)

n Decrease in combined risk of death
and hospitalisation by 20–25%
(p<0.001)


Effect of ACE Inhibitors on Outcomes in
HF Patients According to Age
No of events/No of patients
495/3165

Deaths
<55
Age

(years)

55-64

994/4315

65-75

1227/4194

>75

454/1066

Death/CHF/MI
<55
Age
(years)

878/3165

55-64

1534/4315

65-75

1761/4194

>75

590/1066

0.4

0.6

0.8

1

Risk ratio (95% CI)

1.2

1.4

Flather M et al., Lancet 2000


 blockers in heart failure

n Over 13 000 patients evaluated in
placebo-controlled clinical trials
n Consistent improvement in cardiac
function, symptoms and clinical status
n Decrease in all-cause mortality by 30–
35% (p<0.0001)
n Decrease in combined risk of death and
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
• Randomised, Double blind, Placebo controlled trial of
Nebivolol
• Age  70 years with a clinical diagnosis of CHF and either
of:
a) documented LVEF  35% within 6/12
or
b) HF hospital admission within 1 year
• Primary end-point: Combined all-cause mortality and
cardiovascular hospital admission (time to first event)
• Placebo n=1061, Nebivolol n=1067


Treatment Doses Achieved

Nebivolol
Placebo
(n=1067)
7.7

(n=1061)
8.5

815 (80.4%)
688 (67.9%)

881 (87.1%)
805 (79.5%)

Patient-years of follow-up

1863

1839

Median follow-up months

20.4

19.9

Mean treatment dose, mg
Maintenance dose level achieved:
≥ 5 mg
10 mg

Nebivolol
(n = 1067)

Placebo
(n = 1061)


Nebivolol: 332 events (31.1%)

Placebo: 375 events (35.3%)