Use of Guideline-Directed Medical Therapy in Patients Aged 80 Years or Older With Heart Failure With Reduced Ejection Fraction

Background: Guideline-directed medical therapy (GDMT) reduces morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). Use of GDMT is recommended in all adults with HFrEF, but it is potentially underutilized in patients with advanced age. This study sought to characterize use of GDMT in octogenarians and nonagenarians with HFrEF and identify barriers to initiation and uptitration. Methods: This retrospective cohort study included patients aged 80-99 years at 3 heart failure clinics in the Lower Mainland region of British Columbia, Canada. Patients with a left ventricular ejection fraction <= 40% and heart failure hospitalization < 12 months were included. Data were collected between September 2019 and August 2021, for up to 24 months from the initial clinic visit. Results: A total of 91 patients were included. The mean age was 85 years, and the mean left ventricular ejection fraction was 30%. About 50% of patients had New York Heart Association class II symptoms. Throughout the study follow-up period, approximately 91% of patients were on a beta-blocker, 72% were on a renin-angiotensin system (RAS) inhibitor, 31% were on a mineralocorticoid receptor antagonist (MRA), and 4% were on a sodium-glucose cotransporter 2 (SGLT2) inhibitor. The target dose was achieved in 19% of patients on a beta-blocker, 7% on an RAS inhibitor, 11% on an MRA, and 100% on an SGLT2 inhibitor. Frequent barriers to GDMT initiation and/or uptitration were renal dysfunction, hypotension, and hyperkalemia. Conclusions: The levels of use of RAS inhibitors and beta-blockers in patients aged 80-99 years with HFrEF were reasonable, whereas the levels of use of MRAs and SGLT2 inhibitors were low. Achievement of target doses of GDMT was rare, owing to common adverse effects.