Use of evidence-based therapy in heart failure with reduced ejection fraction across age strata

Aims: In older patients guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF; EF<40%) is not contraindicated, but adherence to guidelines is limited. We investigated the implementation of GDMT in HFrEF across different age strata in a large nationwide cohort. Methods and results: Patients with HFrEF and HF duration ≥3 months registered in the Swedish HF Registry between 2000-2018 were analyzed according to age. Multivariable logistic and multinomial regressions were fitted to investigate factors associated with underuse/underdosing. Of 27,430 patients, 31% were <70, 34% 70-79 and 35% ≥80 years old. Use of treatments progressively decreased with increasing age. Use of renin-angiotensin-system/angiotensin receptor neprilysin inhibitors, beta-blockers and mineralocorticoid receptor antagonists was, respectively, 80%, 88% and 35% in age ≥80 years; 90%, 93% and 47% in age 70-79 years; and 95%, 95% and 54% in age <70 years. Among patients with an indication, use of implantable cardioverter defibrillator and cardiac resynchronization therapy (CRT) was, respectively, 7% and 23% in age ≥80; 22% and 42% in age 70-79; and 29% and 50% in age <70 years. Older patients were less likely treated with target doses of or combinations of HF medications. Except for CRT, after extensive adjustments, age was inversely associated with the likelihood of GDMT use and target dose achievement. Conclusion: In HFrEF, gaps persist in the use of medications and devices. In disagreement with current recommendations, older patients remain undertreated. Improving strategies and a more individualized approach for implementing use of GDMT in HFrEF are required, in particular in older patients.