The Year in Cardiology

Heart Failure: the Year in Cardiology 2019

John G.F. Cleland; Alexander R. Lyon; Theresa McDonagh; John J.V. McMurray


Eur Heart J. 2020;41(12):1232-1248. 

In This Article

Age and Prognosis

Analysis of a large primary care database suggested that the cardiovascular (CV) prognosis of new-onset heart failure improved substantially between 2002 and 2014 [hazard ratio (HR): 0.73; 95% CI 0.68–0.80] for patients above and below the age of 80 years.[5] However, in those aged >80 years, the fall in CV mortality was entirely offset by non-CV mortality. In other words, treatment changed the way that elderly patients died but not overall mortality (Figure 1). Unfortunately, information on LVEF was not available; many patients will have had HFpEF and, therefore, caution should be exercised in attributing the reduction in CV mortality to treatment of heart failure. A systematic review of survey and registry data also suggested that the prognosis of heart failure had improved; important determinants of outcome were age and cardiology input to management.[36] Frailty, which might be considered a biological rather than chronological measure of age, may be an even more powerful predictor of disability and death.[37]

Figure 1.

Changes in cause-specific mortality and hospitalizations for patients with incident heart failure in the UK between 2002 and 2013. Reproduced with permission from ref.5

Guideline-recommendations for the treatment of HFrEF do not discriminate by age. The Swedish Heart Failure Registry found that prescription of ACE inhibitors or beta-blockers to patients with HFrEF aged >80 years was associated with a lower mortality.[38,39] However, observational associations have many explanations other than a therapeutic effect.[40] An individual patient-data meta-analysis of three RCTs of MRA (RALES, EMPHASIS, and TOPCAT-Americas)[13] suggested that MRAs exerted a similar reductions in mortality (by about ~25%) for patients with HFrEF above and below age 75 years but benefit was less certain for HFpEF.