Aspects on heart failure and drug treatment in geriatric patients

Abstract

Background: Patients with chronic heart failure (HF) are very common in geriatric care, but the prevalence of different types of HF and comorbidities, as well as the nature of investigations, treatment, planning and outcome in this patient group are less well known. The overall aim of this thesis was to assess central aspects of geriatric care such as strategies for drug changes and in particular, investigations and treatment strategies for geriatric patients with HF prior to and during geriatric care. Finally, treatment in a subgroup of patients with both HF and Alzheimer´s disease (AD) was studied.

Study I: Data were extracted during one geriatric care episode in 2005, 2010 and 2015 and prescription trends and factors contributing to drug changes were analyzed. Compared to 2005, patients in 2015 had more comorbidities and used more drugs but had shorter hospital stays and significantly fewer prescription changes. We found that high activity in prescribing correlated to higher quality of drug use and to longer care episodes.

Study II: Data on diagnostics and treatment of HF from a cohort of 134 patients prior to admission to geriatric care for worsening of HF were collected. We found that a majority had been investigated with echocardiography (ECHO) and NT-pro-BNP, but most of the investigations were old and not updated, particularly in patients with HF with preserved ejection fraction (HFpEF, 53%). Patients with HF with reduced ejection fraction (HFrEF) were treated according to guidelines, but only to half of target doses. Study III: The same cohort as in Study II was used.

In Study III, retrospective data on diagnostics and treatment of HF during an inpatient hospital stay in a clinic specialized in geriatric medicine was obtained. Few additional investigations on etiology and status of HF were performed. The geriatricians did not change the prescriptions of angiotensin converting enzyme inhibitors or angiotensin II receptor blockers (ACEI/ARB) or beta blocking agents (BB) but increased the treatment with furosemide to a large extent and mineralocorticoid receptor antagonists (MRA) to some extent. The information given from the previous caregiver to geriatric care was at discharge significantly washed-out in the referrals from geriatricians to primary care physicians.

Study IV: In a (propensity score) matched cohort of individuals with HF and AD where 455 were treated with cholinesterase inhibitors (ChEIs) and 455 were not, we wanted to investigate whether use of ChEI, known to affect cardiovascular function, affect the risk of hospitalization for HF and mortality. Indeed, it was found, that treatment with ChEIs was associated with a significantly lower mortality (21%) and a lower risk of hospitalization for HF (47%).

Conclusion: This thesis shows that many geriatric patients with chronic HF do not have up-dated information on type of HF and consequently do not receive adequate drug treatment nor adequate dosing according to guidelines. There is also a significant loss of information on HF etiology and treatment in referrals between caregivers. One reason may be short care episodes. The results of study I indicated that when geriatricians were given more time to treat patients, the result was a higher quality of drug prescribing.

It is urgent to increase adherence to HF guidelines regarding investigations and treatment for HF in older people. In addition, the collaboration between specialists in cardiology and geriatric medicine and primary care must be increased and encouraged.

Interestingly, we also found that individuals with HF and AD who were treated with ChEIs was associated with improved survival and a decreased risk of hospital care for HF. This may be explained by the anti-inflammatory properties and negative chronotropic effects of the ChEIs and warrants further study.