Heart Failure in Older Adults: A Geriatrician Call for Action
Antithrombotic Therapy
The large multicenter, double-blind randomized trial WARCEF found no added benefit with warfarin vs aspirin for patients with HFrEF in sinus rhythm.22 There was no reduced time to first stroke or death, and the reduced ischemic stroke risk was offset by an increase in major hemorrhage. It is not clear whether subgroup analysis for the etiology of patients’ HF was performed in WARCEF.
The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial (N = 1,587) found that treatment with warfarin resulted in significantly fewer strokes in patients with ischemic cardiomyopathy.23 Randomization was not stratified by age group in both trials, and baseline characteristics included mostly white men, and no patients were older than aged > 75 years.
The risk of bleeding with prophylactic aspirin use for CV disease is dose dependent and increases with higher aspirin doses.24 The use of aspirin, 325 mg/d, in the WARCEF study might have contributed to the increased risk of hemorrhage.
Recently published results of COMMANDER HF found that the addition of rivaroxaban at a dose of 2.5 mg twice daily to standard care, including clinically selected antiplatelet therapies was not associated with a significantly lower rate of the composite primary outcome composite outcome of death, myocardial infarction (MI), or stroke among 5,022 patients with a recent episode of worsening heart failure compared with that of placebo.25
Several medical conditions are known to increase bleeding risk, including hypertension, cerebrovascular disease, ischemic stroke, serious heart disease, diabetes mellitus, renal insufficiency, alcoholism, liver disease, and falls.26 Many of these conditions are common among very old patients and should be considered when estimating risk–benefit ratio of oral anticoagulation therapy.
β-blockers
In several large studies, β-blockers have been shown to be effective in reducing mortality in patients with HFrEF. In the Cardiac Insufficiency Bisoprolol Study II, bisoprolol improved all-cause mortality and all-cause hospitalizations, and reduced sudden death in patients with NYHA III or IV HF.27 In the Carvedilol or Metoprolol European Trial (COMET), carvedilol was superior to metoprolol in reducing all-cause mortality for patients with NYHA II or IV HF.28 Both trials included mostly white men; patients with several comorbidities were excluded, and no patients were aged > 80 years.
COMET compared carvedilol with metoprolol tartrate, the short-acting form of metoprolol that has not shown a survival benefit for patients with HF. However, the Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure trial demonstrated survival benefits with metoprolol CR/XL and included patients aged > 80 years.29
In the SENIORS study, patients treated with nebivolol had a 4.2% absolute risk reduction in a composite of mortality or hospital admission at a mean follow-up of 21 months.30 It is reasonable to use nebivolol for managing HF in older patients. Careful monitoring of heart rate is necessary when prescribing β-blockers for older patients.
Cardiac Glycosides
Digoxin with diuretics was the first-line treatment for HF for many decades and the mainstay of HF therapy until the first large HF trials were performed in the 1980s. One trial initiated by the Digoxin Investigation Group (DIG) studied patients with HFrEF who were already receiving treatment for HF (including 94% taking ACE inhibitors and 82% on diuretics) and randomized them to either digoxin or placebo.31 The study found no significant difference in mortality between the groups at the 3-year follow-up; however, the digoxin group had significantly fewer hospitalizations compared with that of the placebo group.
