INTRODUCTION

Heart failure (HF) patients older than 75 years have specific geriatric conditions.1-4 The treatment of these patients might vary depending on cardiologists' and geriatricians' awareness and perception of HF, comorbidities, and functional status.5 We address the differences in patients' profile, treatment, and prognosis according to the initial department of hospitalization for acute HF (AHF).

METHODS Population and design

This prospective multicenter study consecutively included all patients admitted for AHF to the acute geriatric units of three hospitals, and one cardiology unit, Paris, France, between April 4, 2019, and January 13, 2020. Patients were included if they were older than 75 years and presented with AHF.6 Each patient's medical record was reviewed in order to confirm the main diagnosis of AHF by an adjudication committee consisting of three expert cardiologists. Two groups were constituted, a “cardiology cohort” and a “geriatrics cohort” according to the patients' initial care unit. The study was conducted in compliance with the Declaration of Helsinki (1983) and was approved by the local ethics committee (#20181128163709). At admission, we recorded demographic, clinical, and biological characteristics. At discharge, patient destination as well as patient's medication were recorded. All patients were followed up for all-cause mortality and AHF rehospitalization at 1 month, 6 months, and 1 year, using electronic health records, telephone call, and death records from the French National Institute of Statistics and Economic Studies (INSEE). The 1-year survival aged-adjusted curves between the two departments were made using the Kaplan–Meier method, and the two groups were compared by a log-rank test. All analyses were two-sided and a p value of <0.05 was considered statistically significant.

RESULTS

A total of 180 patients were included between April 2019 and January 2020. Patients hospitalized in geriatric units were older (p = 0.002), more often had chronic kidney disease (p = 0.01), had a major neurocognitive disorder (p = 0.01), had undernutrition (p = 0.04), and more often lived in nursing homes (p = 0.0236). Geriatric department patients had lower albumin levels (p = 0.03). Regarding treatment at discharge, fewer geriatric department patients had prescriptions for renin–angiotensin–aldosterone system inhibitors, beta-blockers, or mineralocorticoid receptor antagonists. The 1-year all-cause mortality was higher among patients discharged from geriatric departments than among those discharged from cardiology departments (Figure 1A). However, rates of rehospitalization for AHF were identical at 1 year for patients initially managed in cardiology or geriatric departments (Figure 1B).

(A) Survival curve of all-cause death at 1 year according to cardiologic or geriatric unit (stratified by hospital). (B) Survival curve of rehospitalization for acute heart failure at 1 year according to cardiologic or geriatric departments (stratified by hospital)

DISCUSSION

This study found differences in AHF patient's presentation and management between units, with no significant difference in readmission for AHF at 1 month, 6 months, and 1 year. The 1-year mortality was higher in patients discharged from acute geriatric care units. We observed that patients in geriatric care units were more often frail and had more comorbidities.4, 7 The management of cardiac disease is closely related to frailty and multimorbidity associated with advanced age.8, 9 Numerous studies have highlighted the potential benefits of concomitant cardiology and geriatric management in the comprehensive care of the elderly patients.10, 11

The use of optimal medical therapy in HF was low on admission and discharge in both groups, particularly angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and beta-blockers, in accordance with prior studies.9, 11 A number of reasons may explain this reluctance to apply treatment guidelines in geriatric departments. First, the greater proportion of patients with AHF had a preserved ejection fraction (almost half of the patients had a left ventricular ejection fraction of >50%) and hence the absence of specific treatment recommended for this condition at the time of the study. In HF with reduced ejection fraction (HFrEF), the reasons for the low use of optimal medical treatment may be poor tolerance of recommended drug doses, fear of side effects, comorbidities, and difficulties in obtaining echocardiography.3 Optimal medical treatment of HFrEF has demonstrated benefits in terms of lower rates of rehospitalization and death in many previous studies. It is important to intensify medical therapy and train geriatricians in titration of HFrEF medications.5

We found no significant difference in readmission for AHF between the two departments. This finding is quite surprising in view of the differences observed in terms of patient profiles and treatment. One possible explanation is the comprehensive geriatric approach and its impact on the prognosis.

CONCLUSION

Our study showed that AHF patients managed in geriatric departments are more frail and present more comorbidities than those managed in cardiology departments.

Although the 1-year mortality was higher in patients discharged from geriatric departments, the rate of 1-year rehospitalization for AHF was identical in both populations.

CONFLICT OF INTEREST

The authors have no conflicts of interests to declare.

AUTHOR CONTRIBUTIONS

Abdelhakim Hacil collected the data and wrote the main manuscript. Emmanuelle Berthelot conceived the idea of the study, reviewed all the data, and wrote and edited the main manuscript. Bastien Genet performed the statistical analysis, was responsible for tables and figures, and reviewed and commented on the article. Olivier Hanon, Patrick Assayag, Justina Motiejunaite, Jean Philippe David, and Christiane Verny edited the main manuscript. Patrick Jourdain completed the idea of the study and edited the main manuscript.

SPONSOR'S ROLE

None.

REFERENCES

1Shah RU, Tsai V, Klein L, Heidenreich PA. Characteristics and outcomes of very elderly patients after first hospitalization for heart failure. Circ Heart Fail. 2011; 4: 301- 307. 2Chaudhry SI, Mc Avay G, Chen S, et al. Risk factors for hospital admission among older persons with newly diagnosed heart failure: findings from the Cardiovascular Health Study. J Am Coll Cardiol. 2013; 6: 635- 642. 3Komajda M, Hanon O, Hochadel M, et al. Contemporary management of octogenarians hospitalized for heart failure in Europe: Euro Heart Failure Survey II. Eur Heart J. 2009; 30(4): 478- 486. 4Remme WJ, McMurray JJ, Hobbs FD, et al. Public awareness of heart failure in Europe: first results from SHAPE. Eur Heart J. 2005; 26(22): 2413- 2421. 5Laveau F, Hammoudi N, Berthelot E, et al. Patient journey in decompensated heart failure: an analysis in departments of cardiology and geriatrics in the greater Paris University hospitals. Arch Cardiovasc Dis. 2017; 110: 42- 50. 6McDonagh TA, Metra M, Adamo M, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021; 36: 3599- 3726. 7Dewan P, Jackson A, Jhund PS, et al. The prevalence and importance of frailty in heart failure with reduced ejection fraction–an analysis of PARADIGM-HF and ATMOSPHERE. Eur J Heart Fail. 2020; 22(11): 2123- 2133. 8Vidán MT, Blaya-Novakova V, Sánchez E, Ortiz J, Serra-Rexach JA, Bueno H. Prevalence and prognostic impact of frailty and its components in non-dependent elderly patients with heart failure. Eur J Heart Fail. 2016; 18(7): 869- 875. 9Boully C, Vidal JS, Guibert E, et al. National survey on the management of heart failure in individuals over 80years of age in French geriatric care units. BMC Geriatr. 2019; 19(1): 1- 12. 10Berthelot E, Broussier A, Damy T, et al. Good performance in the management of acute heart failure in cardiogeriatric departments: the ICREX-94 experience. BMC Geriatr. 2021; 21(1): 1- 11. 11Deschodt M, Van Grootven B, Jeuris A, et al. Gériatric CO-management for Patients en cardiologie à l'hôpital (G-COACH): protocole d'étude d'une étude prospective avant-après efficacité-mise en œuvre. BMJ Open. 2018; 8(10):e023593.