Article ID: CJ-23-0470
Background: Acute decompensated heart failure (ADHF) is the main cause of hospitalization and death of octogenarians, but no data on the 1-year post-discharge mortality rate. We evaluated the clinical status and predictors of 1-year mortality in octogenarians with ADHF.
Methods and Results: From the AURORA (Acute Heart Failure Registry in Osaka Rosai Hospital) study, we examined 1,246 hospitalized ADHF patients. We compared the in-hospital mortality rate and the proportion of heart failure (HF) with preserved ejection fraction (HFpEF) between octogenarians and non-octogenarians. After discharge we compared the 1-year mortality rate between these groups, and we also evaluated the predictors of death in both groups. The proportion of HFpEF among the in-hospital deaths of octogenarians was significantly higher than in non-octogenarians (46.2% vs. 15.0%, P=0.031). The 1-year mortality rate after discharge was significantly higher in the octogenarians than non-octogenarians (P=0.014). Multivariable Cox regression analysis revealed that albumin ≤3.0 g/dL and antiplatelet agents were useful predictors of 1-year death after discharge of octogenarians whereas chronic kidney disease was a predictor in the non-octogenarians.
Conclusions: The proportion of HFpEF among in-hospital deaths of octogenarians with ADHF was high as compared with non-octogenarians. When octogenarians with ADHF have severe hypoalbuminemia and antiplatelet agents, early nutritional and medical interventions after discharge may be important to improve the 1-year prognosis.
Aging of the population worldwide is accompanied by increasing numbers of elderly patients requiring treatment of heart failure (HF). The aging trend in Japan is more remarkable than in Europe and the USA. In Japan, the percentage of individuals aged ≥65 years was 28.9% in 2020, and is projected to exceed 35% in 2040.1 Additionally, the proportion of individuals aged ≥80 years (octogenarian) was 9.3% in 2020 in Japan. Consequently, Japan has the most aging society worldwide, and has already entered an ‘HF pandemic’.2 Therefore, it should be relatively easy to collect data regarding HF in octogenarians in Japan.
However, despite several reports regarding octogenarian HF, including our own,3 there are few that have focused on the 1-year mortality rate in octogenarians with HF.4 In addition, patients admitted for acute decompensated HF (ADHF) have high in-hospital morbidity and mortality rates, as well as frequent rehospitalizations and subsequent cardiovascular death, partly due to suboptimal medical management of ADHF at discharge.5 Accordingly, to improve the prognosis of ADHF, early intervention is important, but again, there have been few reports focusing on very elderly patients with ADHF. In an aging society, it is important to evaluate the clinical status and predictors of 1-year deaths of octogenarians with ADHF in order to better manage elderly patients with HF.
The Acute Heart Failure Registry in Osaka Rosai Hospital (AURORA) is a single-center study that collected the data of consecutive HF patients who were hospitalized for treatment at the Osaka Rosai Hospital (UMIN-CTR ID: UMIN000045096). From the AURORA study, we extracted the data for HF patients who were admitted between December 1, 2015 and April 30, 2021. The diagnosis of HF was defined using the Framingham criteria.6 Patients were excluded if they were lost to follow-up or did not have echocardiographic data. We divided our study patients into the octogenarian group (≥80 years old) and non-octogenarian group.
We compared the age, sex, history of HF admission, length of stay, past histories of hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease (CKD), coronary artery disease (CAD) and stroke, atrial fibrillation, laboratory data at discharge including the levels of sodium, potassium, chloride, hemoglobin, B-type natriuretic peptide (BNP), C-reactive protein (CRP), blood urea nitrogen (BUN), creatinine, albumin, and uric acid, echocardiographic parameters at discharge including the left ventricular ejection fraction (LVEF), left ventricular end-diastolic/end-systolic diameters (LVEDD/LVESD), left atrial dimension (LAD), E/e’ (mean of the septal and lateral E/e’ values), and moderate to severe mitral regurgitation (MR), aortic regurgitation (AR) and tricuspid regurgitation (TR), and prescribed medications at discharge including β-blockers, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), mineralocorticoid-receptor antagonists (MRA), diuretics, antiplatelet agents, and anticoagulants. Hypertension and dyslipidemia were defined as a history of a diagnosis or treatment for hypertension or dyslipidemia. Diabetes mellitus was defined as a clinical history of diabetes, the use of oral hypoglycemic or insulin or a fasting blood glucose ≥126 mg/dL or a random blood glucose >200 mg/dL.7 CKD was defined as a glomerular filtration rate <60 mL/min/1.73 m2, as determined by the Modification of Diet in Renal Disease formula. CAD was defined as ≥1 of the following histories: percutaneous coronary intervention, coronary artery bypass graft and myocardial infarction (MI).
Mortality RateWe compared the proportion of in-hospital deaths and the 1-year mortality rate between the octogenarian and non-octogenarian groups. In addition, we compared the proportion of HF with preserved ejection fraction (HFpEF) (LVEF ≥50%) of in-hospital deaths in each group.
Predictor of 1-Year Death of Octogenarians With ADHFWe investigated the predictors of the 1-year mortality rate in the octogenarians and non-octogenarians with ADHF to elucidate improvements in the management of elderly HF patients.
Statistical AnalysisWe used JMP 17 statistical software (SAS Institute Inc., Cary, NC, USA). Continuous variables are expressed as the median (interquartile range) and categorical variables as the count (percentage). Differences between groups were analyzed by a Mann-Whitney U test for continuous variables, and the categorical variables were compared using Fisher’s exact test or a chi-squared test. Kaplan-Meier analysis was used for the 1-year mortality rate, and the log-rank test was used for comparing the octogenarian and non-octogenarian groups. Multivariable Cox regression analysis to evaluate the predictors for 1-year death was performed using the factors with a P value <0.05 in the univariable analysis. Univariable Cox regression analysis was performed using clinically relevant factors including age, sex, body mass index (BMI) ≤22 kg/m2, previous HF hospitalization, hypertension, dyslipidemia, diabetes mellitus, current smoking, CKD, atrial fibrillation, systolic blood pressure <90 mmHg, heart rate <60 beats/min, sodium, hemoglobin, albumin, BNP, and CRP levels, LVEF ≥50% and medications according to previous reports.8–10 Receiver operating characteristics (ROC) analysis was used to determine the optimal cutoff value for the continuous variables other than BMI, LVEF, systolic blood pressure and heart rate. Statistical significance was defined as P<0.05.
There were 1,740 consecutive ADHF patients between December 1, 2015 and April 30, 2021 in the AURORA study. Of them 494 patients were excluded according to the criteria, and during their hospitalization, 46 patients died. The proportion of HFpEF among the in-hospital deaths of octogenarian patients was significantly higher than for non-octogenarians (12 patients [46.2%] vs. 3 patients [15.0%], P=0.031), but there was no significant difference in the proportion of in-hospital deaths between groups (26 patients [4.1%] vs. 20 patients [3.3%], P=0.457). In addition, the proportion of in-hospital deaths among the 1,740 ADHF patients in this study was 5.0%. The causes of in-hospital death were: 14 HF and 2 MI as cardiac deaths and 6 infection, 2 renal failures, 1 cerebrovascular disease (CVD) and 1 malignancy as non-cardiac deaths in the octogenarians, and 15 HF and 1 MI as cardiac deaths and 3 infection and 1 renal failure as non-cardiac deaths in the non-octogenarians. Accordingly, the study group comprised 1,200 ADHF patients who survived to discharge: 609 patients (50.8%) in the octogenarian group and 591 patients in the non-octogenarian group (Figure 1).
Flow chart of the study patients. ADHF, acute decompensated heart failure; AURORA, Acute Heart Failure Registry in Osaka Rosai Hospital.
The baseline characteristics and medications of the study patients are shown in Table 1. Patients were significantly older and the percentage of males and length of stay were significantly lower in the octogenarian group than in the non-octogenarian group. Regarding past history, the incidence of hypertension was significantly higher and that of diabetes mellitus significantly lower in the octogenarian group than in the non-octogenarian group, but the other parameters including CAD, stroke and atrial fibrillation were similar. For the laboratory data, the values of sodium, CRP, BUN, and creatinine were significantly higher in the octogenarian group than in the non-octogenarian group, but potassium and hemoglobin were significantly lower in the octogenarian group. Regarding the echocardiographic parameters, LVEF and incidence of moderate/severe AR were significantly higher in the octogenarian group than in the non-octogenarian group, and LVEDD, LVESD and LAD were significantly lower in the octogenarian group. Regarding the prescribed medications, β-blockers, ACEIs or ARBs, and MRAs were significantly less often prescribed in the octogenarian group. There were no significant differences in the other baseline characteristics between the 2 groups.
Baseline Characteristics of Study Patients
| Octogenarian group (n=609) |
Non-octogenarian group (n=591) |
P value | |
|---|---|---|---|
| Age (years) | 86 (82, 89) | 72 (65, 76) | 0.020 |
| Male, n (%) | 261 (42.9) | 367 (62.1) | <0.001 |
| History of HF admission | 304 (49.9) | 293 (49.6) | 0.908 |
| Length of stay | 14 (9, 21) | 15 (10, 23) | 0.044 |
| Past history | |||
| Hypertension, n (%) | 434 (71.3) | 389 (65.8) | 0.047 |
| Dyslipidemia, n (%) | 354 (58.3) | 357 (60.1) | 0.445 |
| Diabetes mellitus, n (%) | 175 (28.7) | 249 (42.1) | <0.001 |
| Chronic kidney disease, n (%) | 312 (51.2) | 334 (56.5) | 0.073 |
| Coronary artery disease, n (%) | 154 (25.3) | 157 (26.6) | 0.645 |
| Stroke, n (%) | 59 (9.7) | 56 (9.5) | 0.922 |
| Atrial fibrillation, n (%) | 239 (39.2) | 204 (34.5) | 0.106 |
| Laboratory data | |||
| Sodium (mEq/L) | 139 (137, 141) | 138 (136, 140) | <0.001 |
| Potassium (mEq/L) | 4.1 (3.8, 4.5) | 4.2 (3.9, 5.6) | 0.026 |
| Chloride (mEq/L) | 102 (99, 105) | 102 (99, 105) | 0.390 |
| Hemoglobin (g/dL) | 10.9 (9.6, 12.3) | 11.9 (10.2, 13.9) | <0.001 |
| BNP (pg/mL) | 174 (129, 349) | 189 (128, 440) | 0.473 |
| CRP (mg/dL) | 0.38 (0.16, 1.08) | 0.29 (0.12, 0.84) | 0.019 |
| BUN (mL/min/1.73 m2) | 32 (23, 46) | 26 (19, 39) | <0.001 |
| Creatinine (mg/dL) | 1.3 (1.0, 1.9) | 1.2 (0.92, 1.9) | 0.027 |
| Albumin (g/dL) | 3.4 (3.1, 3.7) | 3.6 (3.2, 3.9) | <0.001 |
| Uric acid (mg/dL) | 7.0 (5.9, 8.7) | 7.0 (5.8, 8.5) | 0.315 |
| Echocardiographic parameters | |||
| LVEF (%) | 54 (41, 64) | 42 (32, 54) | <0.001 |
| LVEF ≥50%, n (%) | 378 (62.1) | 350 (59.2) | 0.316 |
| LVEDD (mm) | 51 (47, 57) | 57 (51, 62) | <0.001 |
| LVESD (mm) | 34 (28, 44) | 40 (32, 50) | <0.001 |
| LAD (mm) | 48 (44, 52) | 50 (40, 55) | 0.009 |
| E/e’ | 15.8 (12.3, 19.7) | 15.5 (12.0, 20.9) | 0.901 |
| Moderate/severe MR (n, %) | 63 (10.3) | 67 (11.3) | 0.642 |
| Moderate/severe AR (n, %) | 32 (5.3) | 14 (2.4) | 0.010 |
| Moderate/severe TR (n, %) | 57 (9.4) | 55 (9.3) | 0.975 |
| Prescribed medications | |||
| β-blocker, n (%) | 380 (62.4) | 452 (76.4) | <0.001 |
| ACEI or ARB, n (%) | 308 (50.6) | 353 (59.7) | 0.002 |
| MRA, n (%) | 150 (24.6) | 231 (39.1) | >0.001 |
| Diuretics, n (%) | 406 (66.7) | 418 (70.7) | 0.135 |
| Antiplatelet, n (%) | 231 (37.9) | 252 (42.6) | 0.100 |
| Anticoagulant, n (%) | 313 (51.4) | 305 (51.6) | 0.954 |
ACEI, angiotensin-converting enzyme inhibitor; AR, aortic regurgitation; ARB, angiotensin II receptor blocker; BNP, B-type natriuretic peptide; CRP, C-reactive protein; HF, heart failure; LAD, left atrial dimension; LVEDD, left ventricular end-diastolic diameter; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; MR, mitral regurgitation; MRA, mineralocorticoid-receptor antagonist; TR, tricuspid regurgitation.
One-Year Mortality Rates for the Octogenarian and Non-Octogenarian Groups
Over the year after discharge, 182 patients (29.9%) died in the octogenarian group and 141 patients (23.9%) in the non-octogenarian group. The cause of the deaths were 99 HF and 9 MI as cardiac deaths and 41 infection, 16 malignancy, 13 renal failure and 4 CVD as non-cardiac deaths in the octogenarians, and 100 HF and 5 MI as cardiac deaths and 22 infection, 8 renal failure, 4 malignancy and 2 CVD as non-cardiac deaths in the non-octogenarians. Kaplan-Meier analysis demonstrated that the octogenarian group had a higher incidence of 1-year post-discharge death than the non-octogenarian group (P=0.014, Figure 2).
One-year mortality rates for the octogenarian and non-octogenarian groups. CI, confidence interval; HR, hazard ratio.
Predictors of 1-Year Death
According to the ROC analysis for cutoff values in octogenarians with ADHF, the values of age, sodium, hemoglobin, albumin, BNP and CRP to predict 1-year death were 86 years, 140 mEq/L, 11.4 g/dL, 3.0 g/dL, 184 pg/mL and 0.99 mg/L respectively. In the univariable Cox regression analysis, CKD, albumin, BNP, ACEI/ARB, diuretics, antiplatelet agents, and anticoagulants were significantly correlated with 1-year death in the octogenarian group, whereas age, sex, and previous HF hospitalization showed no correlation. Multivariable Cox regression analysis showed that an albumin level ≤3.0 g/dL and antiplatelet agents were independently associated with 1-year death in the octogenarian group (P=0.049, hazard ratio (HR): 1.59, 95% confidence interval (CI): 1.00–2.52 and P=0.006, HR: 2.13, 95% CI: 1.24–3.66, respectively) (Table 2). ROC analysis of suitable cutoff values for the same continuous variables in the non-octogenarian group revealed 76 years, 134 mEq/L, 11.4 g/dL, 3.3 g/dL, 179 pg/mL and 0.31 mg/L respectively. Univariable Cox regression analysis an association of CKD, dyslipidemia, ACEI/ARB, and anticoagulants with 1-year death. Age, sex, and previous HF hospitalization did not correlate with 1-year death in the non-octogenarian group. Multivariable Cox regression analysis showed that CKD significantly and independently correlated with 1-year death (P=0.005, HR): 7.68, 95% CI: 2.11–50.05) (Table 3).
Predictors of 1-Year Death of Octogenarians With ADHF
| Univariable | Multivariable | |||
|---|---|---|---|---|
| HR (95% CI) | P value | HR (95% CI) | P value | |
| Age >86 years | 1.22 (0.91–1.61) | 0.177 | ||
| Male | 0.75 (0.55–1.01) | 0.062 | ||
| BMI ≤22 kg/m2 | 1.37 (0.95–1.98) | 0.095 | ||
| Previous HF hospitalization | 1.19 (0.86–1.61) | 0.268 | ||
| Hypertension | 1.09 (0.74–1.56) | 0.675 | ||
| Diabetes mellitus | 0.83 (0.58–1.19) | 0.322 | ||
| Dyslipidemia | 1.16 (0.85–1.62) | 0.319 | ||
| Current smoker | 1.26 (0.81–1.95) | 0.300 | ||
| CKD | 3.35 (3.26–3.45) | 0.032 | 2.69 (0.34–21.2) | 0.348 |
| Atrial fibrillation | 1.27 (0.94–1.71) | 0.119 | ||
| Systolic blood pressure <90 mmHg | 0.94 (0.42–2.12) | 0.880 | ||
| Heart rate <60 beats/min | 0.97 (0.64–1.45) | 0.864 | ||
| EF ≥50% | 1.09 (0.75–1.58) | 0.666 | ||
| Sodium >140 mEq/L | 0.98 (0.72–1.32) | 0.884 | ||
| Hemoglobin ≤11.4 g/dL | 1.35 (0.98–1.87) | 0.066 | ||
| Albumin ≤3.0 g/dL | 1.21 (1.18–1.24) | 0.022 | 1.59 (1.00–2.52) | 0.049 |
| BNP >184 pg/mL | 0.94 (0.92–0.96) | 0.042 | 0.89 (0.46–1.72) | 0.731 |
| CRP >0.99 mg/L | 1.30 (0.95–1.77) | 0.100 | ||
| ACEI/ARB | 0.96 (0.94–0.99) | <0.001 | 0.92 (0.58–1.47) | 0.732 |
| β-blocker | 0.92 (0.61–1.40) | 0.70 | ||
| MRA | 0.77 (0.53–1.10) | 0.151 | ||
| Anticoagulant | 1.57 (1.10–2.23) | 0.016 | 1.44 (0.90–2.30) | 0.134 |
| Antiplatelet | 2.53 (1.80–3.55) | <0.001 | 2.13 (1.24–3.66) | 0.006 |
| Diuretic | 1.19 (1.16–1.21) | 0.003 | 1.49 (0.93–2.38) | 0.096 |
ACEI, angiotensin-converting enzyme inhibitor; ADHF, acute decompensated heart failure; ARB, angiotensin II receptor blocker; BMI, body mass index; BNP, B-type natriuretic peptide; CI, confidence interval; CKD, chronic kidney disease; CRP, C-reactive protein; EF, ejection fraction; HF, heart failure; HR, hazard ratio; MRA, mineralocorticoid-receptor antagonist.
Predictors of 1-Year Death of Non-Octogenarians With ADHF
| Univariable | Multivariable | |||
|---|---|---|---|---|
| HR (95% CI) | P value | HR (95% CI) | P value | |
| Age >76 years | 1.46 (0.87–1.861) | 0.218 | ||
| Male | 1.05 (0.74–1.49) | 0.071 | ||
| BMI ≤22 kg/m2 | 1.38 (0.88–2.19) | 0.160 | ||
| Previous HF hospitalization | 1.33 (0.94–1.861) | 0.105 | ||
| Hypertension | 1.02 (0.69–1.50) | 0.925 | ||
| Dyslipidemia | 2.72 (1.68–4.39) | <0.001 | 1.93 (0.72–5.18) | 0.167 |
| Diabetes mellitus | 1.19 (0.83–1.69) | 0.343 | ||
| Current smoker | 0.81 (0.52–1.27) | 0.354 | ||
| CKD | 4.16 (2.23–7.76) | <0.001 | 7.85 (1.82–33.88) | 0.005 |
| Atrial fibrillation | 1.20 (0.82–1.76) | 0.335 | ||
| Systolic blood pressure <90 mmHg | 0.66 (0.29–1.49) | 0.317 | ||
| Heart rate <60 beats/min | 0.85 (0.43–1.67) | 0.634 | ||
| EF ≥50% | 1.02 (0.735–1.43) | 0.916 | ||
| Sodium >134 mEq/L | 0.89 (0.58–1.35) | 0.572 | ||
| Hemoglobin ≤11.4 g/dL | 1.10 (0.78–1.55) | 0.595 | ||
| Albumin ≤3.3 g/dL | 1.08 (0.78–1.55) | 0.688 | ||
| BNP >179 pg/mL | 1.02 (0.62–1.51) | 0.927 | ||
| CRP >0.31 mg/L | 1.24 (0.89–1.75) | 0.212 | ||
| ACEI/ARB | 0.57 (0.35–0.93) | 0.023 | 0.98 (0.12–8.01) | 0.981 |
| β-blocker | 0.58 (0.29–1.14) | 0.112 | ||
| MRA | 0.74 (0.52–1.05) | 0.095 | ||
| Anticoagulant | 1.68 (1.07–2.64) | 0.026 | 2.45 (0.42–14.21) | 0.336 |
| Antiplatelet | 1.54 (0.98–1.14) | 0.061 | ||
| Diuretic | 1.02 (0.69–1.51) | 0.208 | ||
Abbreviations as in Table 2.
Our 3 major findings in the octogenarian group were as follows. (1) The proportion of HFpEF associated with death during hospitalization in octogenarians was significantly higher than in non-octogenarians (46.2% vs. 15.0%, P=0.031), however, the mortality rate during hospitalization was similar for octogenarians and non-octogenarians. (2) The 1-year mortality rate after discharge was significantly higher in octogenarians than in non-octogenarians (P=0.014). (3) Albumin ≤3.0 g/dL and antiplatelet agents were useful predictors of 1-year death after discharge of octogenarians with ADHF, whereas CKD was the predictor of 1-year death in non-octogenarians.
In-Hospital Deaths of Octogearians With ADHFADHERE, the most relevant ADHF multicenter registry, included 107,362 hospitalizations between October 1, 2001 and January 4, 2004 from 282 different hospitals in the USA, reported an in-hospital mortality rate of 4%,11 which is almost similar to our study result (4.1% in the octogenarian group and 3.3% in the non-octogenarian group). It has been reported that in ADHF patients, NYHA class IV, the serum creatinine level, and the LVEF are independent predictors of in-hospital death.12 We found that in octigenarians with ADHF, even if the LVEF was preserved (including HFpEF), the proportion of in-hospital deaths was significantly higher than in non-octogenarians, so HF in octogenarins even with preserved LVEF needs to be managed during the hospitalization.
One-Year Mortality Rate in Octogenarians With ADHFHF is a serious conditon with a high moratlity rate, reportedly 35% in octogenarians with HF,13 which is almost similar to the result from our study (29.9%). In addition, the 1-year mortality rate in the octogenarians was significantly higher than in non-octogenarians (P=0.014). Although it may seem natural that the 1-year mortality rate of older patients would be significantly higher than that of younger patients, when we adjusted for important comorbidities factors such as CKD, albumin and antiplatelet therapy, the difference was not significant (P=0.235, HR 1.16, 95% CI 0.86–1.83). However, because the median age of the non-octogenarians in this study was also high (72 years (Table 1)), it is very important to manage octogenarians with ADHF early after discharge because approximately 30% of them, in general, died within 1 year after discharge.
Predictors of One-Year Death in Octogenarians With ADHFIt has been reported that a low LVEF is an independent predictor of the 1-year death of ADHF patients,12 but it remains unknown whether a low LVEF is also a useful predictor of the 1-year death of octogenarians with ADHF because octogenarians tend to have many comobidities14,15 and tend to develop HFpEF.16,17 In fact, our study results showed that albumin ≤3.0 g/dL and antiplatelet agents, but not a low LVEF, were significant and independent predictors of 1-year post-discharge death in the octogenarians with ADHF. In addition, CKD was a significant and independent predictor for 1-year death in non-octogenarians with ADHF. Therefore, HF in the octogenarians had different characteristics than that in non-octogenarians.
Regarding the albumin level, many have reported that the serum albumin level, which represents the nutrition status,18 correlates with prognosis in eldely HF patients.19,20 We also reported that hypoalbuminemia is a good predicotor of long-stays and HF readmissions in eldely HFpEF patients.3,18 It has been reported that hypoalbuminemia (albumin ≤3.4–3.7 g/dL) correlates with poor prognosis including long-term death and readmission for HF. We found that albumin ≤3.0 g/dL, which is lower than in previous studies, was a key to predicting 1-year death in octogenarians with ADHF. Although our predicted albumin value was lower than the previously reported values, it has been reported that a serum albumin <3 g/dL is a powerful predictor of in-hospital deaths of older patients with severe HF,21 which supports our finding. Therefore, if octogenarians with ADHF have severe hypoalbuminemia (≤3.0 g/dL) at discharge, their nutritional status must be managed early after discharge.
In terms of therapies, our study demonstrated that antiplatelet agents were significantly and independently correlated with 1-year deaths of octogenarians with ADHF. Foebel et al also reported that the use of antiplatelet agents increased the risk of 1-year deaths and hospitalizations of elderly patients with HF.22 Current guideline-directed medical therapy (GDMT), the progressive use of multiple drugs and complex therapeutic regimens can lead to polypharmacy,23 complicated by the fact that older patients usually have more comorbidities that are being concurrently treated.24 Polypharmacy is associated with adverse outcomes.25 However, for GDMT of CAD, which is a major comorbidity of HF, the current guidelines recommend a shorter duration of triple or dual antithrombotic treatment including antiplatelet agents.26,27 Therefore, to manage elderly HF patients with a risk of bleeding, we should consider reducing or ceasing antiplatelet agents if they are not necessary. The European Society of Cardiology guidelines for HF also recommend that clinicians should aim to reduce polypharmacy when possible, including the complexity of regimens, and consider stopping any medications that will not affect prognosis, symptom relief, or quality of life.28 In particular, when elderly patients with HF are prescribed combination therapy with an oral anticoagulant plus antiplatelet agents, we should consider monotherapy with an oral anticoagulant and avoid antiplatelet agents.29
Predictors of One-Year Mortality in Non-Octogenarians With ADHFOur study revealed a correlation of CKD with 1-year death. There are reports showing CKD as an independent predictor of prognosis in the patients with HF,30,31 but few showing the difference of predictors of death between octogenarians and non-octogenarians. According to our results, addressing CKD may be more important to improve prognosis in non-octogenarians with ADHF.
Clinical ImplicationsOur study showed that the proportion of HFpEF among in-hospital deaths of octogenarians with ADHF was higher than for non-ocotgenarians. In addition, when they had severe hypoalbuminemia (≤3.0 g/dL) and/or antiplatelet agents at discharge, more attention to nutritional status and polypharmacy early after discharge should improve prognosis.
Study LimitationsThis was a single-center retrospective cohort study that only investigated the 1-year mortality rates, and did not examine longer-term data. We did not evaluate follow-up plans or medication changes that may have been associated with deaths. Despite these limitations, it should be emphasized that this work has provided important information for managing octogenarians with ADHF.
The proportion of HFpEF cases among the in-hospital deaths of octogenarians with ADHF was high as compared with non-octogenarians. Severe hypoalbuminemia (≤3.0 g/dL) and antiplatelet agents at discharge were predictors of 1-year death after discharge in octogenarians with ADHF.
The authors thank Mr. John Martin for assistance with this manuscript.
The authors declare no conflicts of interest.
The present study was approved by the Ethics Committee of Osaka Rosai Hospital (Reference no. 2021-63).
