Epidemiology and clinical characteristics of hospitalized elderly patients for heart failure with reduced, mid-range and preserved ejection fraction
Introduction
Heart failure (HF) is a major cause of cardiovascular morbidity and mortality. The incidence and prevelance of HF progressively increases in parallel with the population's age.1 The incidence of HF reaches 10 per 1000 population after age of 65.2 Besides the higher incidence, elderly patients also have lower survival rates.3 In addition to this, HF is the leading cause of frequent hospitalizations among the elderly.4 Nearly 80% of patients hospitalized with HF are more than 65 years old.5 Despite the higher incidence, mortality and hospitalization rates, a large knowledge gap exists regarding epidemiology, clinical characteristics and treatment strategy of this special group.
HF is a complex clinical syndrome and the elder patients may have nonspecific clinical signs and sypmtoms that may cause difficulties in diagnosing. The diagnosis, management and classification of HF are based on mainly left ventricular ejection fraction (LVEF). In previous guidelines on the diagnosis and management of HF, LVEF ≥ 50% has been considered as HFpEF (heart failure with preserved ejection fraction) whereas, LVEF <40% has been considered as HFrEF (heart failure with reduced ejection fraction). Patients in the range of LVEF 40–49% have often been considered as a grey area or intermediate group and less thoroughly studied. In 2013 AHA guidelines have defined this group as borderline HFpEF for the first time.6 Latest and updated 2016 ESC Guidelines for the diagnosis and treatment of HF clearly classified HF in 3 distinct groups: HFpEF (LVEF ≥50%), HFmrEF (heart failure with mid range ejection fraction) (LVEF 40–49%) and HFrEF (LVEF <40%); where each have different clinical characteristics, prognostic factors and response to theraphy.7 This distinction is important in the management strategy of hospitalized elderly patients with HF. Despite the higher incidence and poor survival rates of this group, there are limited data describing the distinguishing clinical characteristics of hospitalized elderly patients for HFpEF, HFmrEF and HFrEF aged ≥80 years old and 65–79 years old. The presence of multiple co-morbidities and higher cardiovascular risk factors complicate the treatment strategy of elder patients. Morever, evidence-based treatment strategies are less frequently used in these patients.8 Acknowledging clinical characteristics, demographics, comorbidities and cardiovascular risk factors of patient ≥80 years old and comparison between 65–79 years old are important to report evidence based and updated treatment strategies in HF for this special group.9 This study assessed and compared comorbidities, cardiovascular risk factors, medication usages, in hospital outcomes and precipitating clinical factors for hospitalization in hospitalized HF patients 65–79 years old and ≥80 years old with reduced, mid range and preserved ejection fraction.
Section snippets
Materiel and method
Journey HF study was a cross-sectional, multicenter and observational study. It was conducted between September 2015 and September 2016 and included a total of 1606 patients from 37 centers. Patients in cardiac care units, intensive care units as well as cardiology wards were recruited. The methodology and primary results of the Journey HF study have been previously described (10). To be eligible for the study, patients had to be hospitalized with new-onset or worsening HF, >18 years old, and
Statical analysis
Statistical analysis Continuous variables were presented as mean ± standard deviation (mean±SD) and the categorical variables were expressed as number and percentage (%). The continuous variables were compared across the groups using the Student's t-test or the Mann–Whitney U test.
Normality of the data distribution was verified by the Kolmogorov–Smirnov test. Homogeneity of variance was assessed by the Levene's test. The categorical variables were compared using the chi-square or Fisher's exact
Baseline clinical characteristics
A total of 1034 elder patients hospitalized with a diagnosis of HF were recruited. Of all, 740 (71.6%) were 65–79 years old and 294 (28.4%) were ≥80 years old. Of those 740 patients 65–79 years old 499 (67.4%) had HFrEF, 120 (16.2%) had HFmrEF and 121 (16.3%) had HFpEF. Among the 294 patients ≥80 years old 181 (61.6%) had HFrEF, 46 (15.6%) had HFmrEF and 67 (22.8%) had HFpEF. The baseline clinical characteristics, comorbidities and laboratory values of the overall elderly patients are presented
Discussion
This study has shown statistically significant differences in the clinical characteristics, demographics, medication usage, precipitant factors and outcomes of hospitalized elder patients with HFrEF, HFmrEF and HFpEF between different age groups and has provided new insight into elder patients hospitalized with HF. Our data also provides demographics of patients ≥80 years old and further describes the clinical characteristics, medication usage and outcomes of this special group according to
Conclusion
Our results suggest a significant under-prescription of recommended theraphy in elderly patients for HF treatments and do raise concerns about the lack of effective treatment strategy especially in patients ≥80 years old with HFmrEF due to high mortality and in hospital stay. This registry also demonstrates an apportunity to improve care of elderly patients according to HF groups. We also increase awareness of avoidable or modifiable factors to improve optimizing HF management according to
Declaration of Competing Interest
All authors declare that they do not have conflict of interest.
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Collaboraters: Dogac Caglar Gurbuz, MD, Oguzhan Celik, MD, Huseyin Altug Cakmak, MD, Sinan Inci, MD, Mehmet Erturk, MD, Erkan Yildirim, MD, Duygu Kocyigit, MD, Ilgın Karaca, MD,Faruk Ertaş, MD, Ahmet Çelik, MD, Fatih Aksoy, MD, Hasan Ali Gumrukcuoglu, MD, Umit Yuksek, MD, Mahir Cengiz, MD, Emre Arugaslan, MD, Mustafa Kursun, MD, Ali Coner, MD, Ozlem Ozcan Celebi, MD, Cengiz Ozturk, MD, Onur Dalgic, MD, Nurullah Cetin, MD, Ebru Ipek Turkoglu, MD, Hatice Kemal, MD, Emine Gazi, MD, Cihan Altin, MD, Servet Altay, MD, Murat Meric, MD Ozgen Safak, MD, Murathan Kucuk, MD, Alper Kepez, MD, Ozcan Vuran, MD, Hakki Kaya, MD, Mehmet Serdar Kucukoglu, MD, Ahmet Ekmekci MD, Benay Ozbay MD, Filiz Akyildiz Akcay MD, Lutfu Bekar MD, Yavuzer Koza MD, Ismail Bolat MD, Umut Kocabas MD.