Caution Against Standard HF Meds Urged in Very Elderly With Preserved-EF Heart Failure

March 16, 2009

from Heartwire — a professional news service of WebMD

March 16, 2009 (Los Angeles, California) — Conventional heart-failure drugs don't prolong survival in patients 80 years or older who have HF with preserved ejection fraction (HFPEF), but they do saddle a group already likely to be on multiple medications with additional drug-drug-interaction risk, according to researchers based on their five-year observational study [1].

The observed lack of survival benefit from beta blockers, ACE inhibitors, angiotensin receptor blockers (ARBs), and calcium-channel blockers in their analysis is consistent with and complements larger prospective HFPEF trials that found no benefit or only questionable clinical gains from these agents in primarily younger patients.

"The risk of adverse drug effects is high in the geriatric population because of polypharmacy and altered pharmacokinetics, and judicious use of medications should be advocated," write Dr Faramarz Tehrani (Cedars-Sinai Medical Center, Los Angeles, CA) and associates in a report published in the March 15, 2009 issue of the American Journal of Cardiology. "In patients >80 years with HF and preserved LVEF, there appears to be no proven benefit for pharmacologic therapy, and yet there may be costs, both financial and physiologic."

The most important thing for clinicians is to look at these patients as a different entity.

Yet senior author Dr Ernst R Schwarz (Cedars-Sinai Medical Center) told heartwire , "We shouldn't give up on these medications in the very elderly. We may not be using them in the right way. I think we would probably need lower doses of these medications while keeping in mind that there might be comorbid conditions and concomitant medications that require further dosage adjustment."

Of the 142 octogenarians followed in the analysis, averaging 87 years in age and of whom two-thirds were women, 69% died within a five-year follow-up; that group didn't differ significantly at baseline from those who lived longer with respect to sex, renal function, comorbidities, echocardiographic LV pressures and cardiac structural dimensions, or medication use.

Five-year Kaplan-Meier survival curves showed no significant differences between patients on and not on individual heart-failure medications, including ACE inhibitors or ARBs (p=0.912), beta blockers (p=0.891), calcium-channel blockers (p=0.690), digoxin (p=0.223), diuretics (p=0.303), or statins (p=0.321).

Statins showed a consistent trend toward survival benefit throughout the five years. The trends were in the opposite direction for digoxin and diuretics; survival in patients receiving diuretics appeared to start falling off after about three years.

No medication appeared to reduce the composite of either all-cause hospitalization/mortality or cardiac hospitalization/mortality.

The authors acknowledge that any increase in mortality with digoxin or diuretics may have reflected that patients getting those drugs were simply sicker. "However, it was also possible that these medications may carry a greater risk in patients >80 years," and so they should be used with more caution in that age group, according to Tehrani et al.

Schwarz pointed out that the analysis looked primarily at survival, while symptom status and other quality-of-life issues are also important. "And for many patients, they are more important than anything else." Many conventional heart-failure medications may well provide significant symptomatic benefit in the >80 age group, he observed.

"The most important thing for clinicians is to look at these patients as a different entity. It's very difficult to simplify, to treat every patient with heart failure as if they're the same," Schwarz said, indicating the need for more clinical trials to explore the value of these drugs in the very elderly.

  1. Tehrani F, Phan A, Chien CV, et al. Value of medical therapy in patients >80 years of age with heart failure and preserved ejection fraction. Am J Cardiol 2009; 103:829-833. Abstract


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