This very well attended session started with an overview by Professor Cowie of the demographic time bomb in Europe that will lead to a large increase in the number of elderly people with heart failure and all the implications that will have for health services and the cost of health care.
Professor Follath then went on to review the distinct characteristics of the very elderly with heart failure, referring to the Euro Heart Failure 1 Survey. He pointed out that, compared to the younger patients represented in current clinical trials, older patients are more often women and have a higher ejection fraction. Importantly, they have more cardiovascular and non-cardiovascular co-morbidity, including renal dysfunction, anaemia and atrial arrhythmias. A startling statistic from the Euro Heart Failure 1 Survey was that over a fifth of octogenarians with heart failure also had dementia or confusion.
Next Professor Hobbs discussed treatment, starting by asking the question “what are the goals of therapy” in the very elderly. He discussed the merits of symptom relief and improvement in quality of life compared to increasing survival. He then went on to review the evidence for currently recommended treatment in low ejection fraction heart failure. Professor Hobbs pointed out that most trials had enrolled relatively few elderly patients and that our understanding of the effect of treatment in such patients was entirely dependent on sub-group analysis, with the single exception of the SENIORS trial with the beta-blocker nebivolol. Accepting this limitation, he concluded that, as far as we can tell, the recommended treatments in this type of heart failure (ACE inhibitors, beta-blockers, aldosterone antagonists and angiotensin receptor blockers) are all beneficial in older as well as younger patients.
Lastly, Professor Komajda reviewed the actual treatments received by elderly patients, again using data from the Euro Heart Failure 1 Survey. The very elderly received significantly less evidence-based treatments than younger patients, even allowing for differences in systolic function and co-morbidity. He speculated that the physicians who look after these patients, who are often geriatricians, internists and primary care physicians, may not have received the latest guidelines and education about the modern, evidence-based, treatment of heart failure which have been targeted at cardiologists. He also concluded that more trials directly relevant to these patients should be considered.