Evaluating treatment burden associated with contemporary quadruple heart failure therapy in older adults - a systematic review
Abstract
Background: Heart failure is a predominant cause of hospital admissions, and this mainly affects adults over the age of 65. Extensive research has shown that four-pillar medical therapy increasingly improved clinical outcomes for this age group. Despite this, adherence is relatively poor, particularly in frail adults, to this guideline-directed medical therapy. Thus, it is vital to explore the reasons for non-adherence so that we can treat patients more holistically and continue to improve clinical outcomes in this population.
Aim: to evaluate other imperative outcomes of quadruple therapy for heart failure. This includes geriatric outcomes such as falls, orthostatic symptoms, adherence, deprescribing, cognition, and functional decline.
Method: a systematic search of Embase, MEDLINE, CENTRAL and Scopus identified cohort, case-controlled studies and randomized controlled trials that evaluated treatment burden associated with current guideline recommended heart failure therapy in adults aged 65 and over. Case reports, literature reviews and editorials were excluded
Results: Evidence was derived from major randomized controlled trials and observational cohort studies conducted in routine clinical practice. The cardiovascular evidence from current guideline directed medical therapy was associated with preserved cardiovascular outcomes across older individuals with varying degrees of frailty; yet implementation was suboptimal. Only 15%-18% of older adults received quadruple therapy for heart failure following hospital admission, with around one-third discontinuing treatment within 12 months. Polypharmacy was a key contributor to treatment burden affecting up to 84% of patients, of whom 42% experienced polypharmacy.
Conclusion: Guideline-directed medical therapy preserves cardiovascular health outcomes in patients with varying frailty with heart failure. However, its real-world impact is limited by poor implementation, low uptake of quadruple therapy treatment discontinuation, and the substantial burden of polypharmacy, highlighting the need for strategies to improve adherence and optimize prescribing in this population.
Comments
Polypharmacy and treatment burden
Really insightful into the tension between guideline-based HF therapy and treatment burden in older adults. I found the association between polypharmacy and treatment discontinuation very interesting, as it takes into account the patients' ability to manage complex medication regimes. I wonder whether improving patient understanding of medications could be one way of reducing the treatment burden and supporting continuation?
Thank you! I definitely…
Thank you! I definitely agree that improving patients’ understanding of their medications could help reduce some of the treatment burden and improve adherence. If patients understand why they’re taking each medication and the benefits, they may feel more confident continuing them. It could also reduce taking unnecessary medications, which can happen especially in patients who don’t understand why they’re taking certain medications. I also think regular medication reviews and simplifying regimens where possible could work alongside this, particularly in older and frailer patients.
Good insight in to this. How…
Good insight in to this. How many papers were included in your final analysis ?