Physicians' Academy for Cardiovascular Education

Underuse and underdosing of HF medication in elderly HF patients

Age differences in contemporary treatment of patients with chronic heart failure and reduced ejection fraction

Literature - Veenis JF, Brunner-La Rocca H-P, Linssen GCM et al. - Eur Heart J 2019: DOI: 10.1177/2047487319835042

Introduction and methods

The majority of heart failure (HF) populations consists of elderly patients, with ~80% >65 years and 40-50% ≥75 years [1,2]. Optimizing HF management remains more challenging in elderly HF patients because of the high prevalence of comorbidities in these patients [3]. To date, only small numbers of elderly patients have been included in randomized clinical trials (RCTs) investigating HF treatment [4], except for the SENIORS trial [5]. Although discussion is ongoing on optimal therapy in elderly HF patients, there are no European Society of Cardiology (ESC) recommended age-specific guidelines for HF therapy [1], and data in groups of patients with advanced age are limited.

This observational study (n=8351) therefore investigated age-related differences in HF treatment in HF patients with reduced (HFrEF) and mid-range ejection fraction (HFmrEF) in the CHECK-HF registry, reflecting actual practice-based HF care at outpatient clinics including large numbers of elderly patients. The CHECK-HF (Chronisch Hartfalen ESC – richtlijn Cardiologische praktijk Kwaliteitsproject HartFalen) registry was a large-scale cross-sectional registry of 34 Dutch HF clinics that enrolled 10.910 patients with chronic HF, diagnosed according to the 2012 ESC guidelines [1], based on symptoms and echo parameters, who were seen at the outpatient’s HF clinic (96%) or general cardiology outpatient clinic (4%) (enrollment 2013-2016). Participants in the CHECH-HF registry were classified as HFrEF (LVEF <50%, n=8360) or according to 2016 ESC HF guidelines [6] as HFmrEF (LVEF= 40-49%, n=1574). Further stratification was based on age (<60 years [13.9%], 60-74 years [36.0%], and ≥75 years [50.2%]). Mean age of HFrEF participants was 72.3±11.8 years and of HFmrEF patients 73.7±11.7 years.

Main results

Pharmacological therapy in HFrEF

Device implantation in HFrEF

General therapy in subgroups of HFmrEF

Underuse and underdosing of HF medication in elderly HF patients


This observational study of a large Dutch registry of a real-world outpatient HF population showed that elderly HFrEF and HFmrEF patients (aged ≥75 years) were treated less often with recommended types and dosages of HF medication, and received less often ICD and CRT device treatment. These data suggest that in elderly HF patients there is a need for optimization of medical treatment and further uptitration of dosages or reflection on policy and acceptation of lower age-adjusted target doses in elderly HF patients when they do not tolerate higher dosages.


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