Heart Failure-Related Mortality Increasing Among Older Adults in US

Muhammad Shahzeb Khan, MD

New research from an analysis of the CDC WONDER database details an apparent increase in heart failure-related mortality rate among older patients in the US since 2012.

Led by investigators from the Duke University School of Medicine, results of the study suggest the age-adjusted mortality rates for heart failure-related deaths among adults aged 75 years or older declined annually from 1999 until 2011 but increased from 2012 until 2019.

Spurred by data from previous studies indicating an increase in heart failure-related mortality among young adults beginning around 2012, a team led by Muhammad Shahzeb Khan, MD, of Department of Cardiology, Duke University Medical Center, designed the current study with the intent of assessing whether this apparent trend among older populations with heart failure. Using the CDC WONDER database, investigators obtained data related to 5,014,919 heart failure-related deaths occurring among patients aged 75 years or older from 1999-2019.

Initial analysis indicated the age-adjusted mortality rate (AAMR) per 10,000 persons declined from 141.0 in 1999 to 121.3 in 2019. Investigators pointed out the annual percentage change decreased by 2.1% (95% CI, -2.4 to -1.9) per year from 1999 to 2012, when rates reached their lowest at 108.3 per 10,000 persons. By 2019, the annual percent change reflected an increase of 1.7% (95% CI, 1.2 to 2.2) per year, with rates reaching 121.3 per 10,000 persons. Subgroup analysis pointed to significant disparities according to sex, race/ethnicity, and region.

With an interest in learning more about the study findings and their clinical implications, Practical Cardiology reached out to Khan for further insights and that conversation can be found in the Q&A below.

Trends in Heart Failure-Related Mortality Among Older Adults in the US

Practical Cardiology: Can you briefly describe the onus behind this study?

Khan: After the Hospital Readmissions Reduction Program (HRRP) was introduced by Medicare in 2012. After that, there have been a few studies have shown that there has been potential increase in heart failure-related mortality, but we did a recent study looking at trends of mortality among young patients with heart failure and we saw pretty concerning results with those as well, with mortality among young patients with heart failure drastically increasing. We also saw a pretty significant racial and geographic disparity among those results. So, that led to us doing the present study in older patients, because as know, that heart failure is mainly a disease of older patients. So, we wanted to see what are the trends of heart failure mortality among older patients. Is it following the same trend as the younger patients? And do we have similar disparities among the trends in mortality among older patients in heart failure as well? This drove us to conduct the study.

Practical Cardiology What do you think should be the main takeaways that you would want a practicing clinician to have from your study results?

Khan: I think the thing I would like people to take away from the study is from 1999-2011, heart failure-related mortality was decreasing, but from 2011/2012 until now, heart failure-related mortality is again increasing. So, I think that is one major result that we found, that heart failure-related mortality is increasing again, even among older patients. Now, when we see heart failure patients who are older, the general theme I've seen, among a lot of clinicians, is that they say "Don't rock the boat". I mean, the patients are very old, so why do we need to rock the boat? Why do we need to introduce guideline-guided medical therapy? Why do we need to be so aggressive in treating heart failure motivations?

So, I think, the main message I would like to give is that heart failure mortality among older patients is increasing. We have created these therapies for heart failure like SGLT2 inhibitors and RNAs and, of course, beta-blockers, which have been there for a very long time. However, instead of saying that, we say "These patients are old. These patients have other comorbidities. Let's not rock the boat". There's so much clinical inertia, including these older patients, because the team and others just don't rock the boat. The main message is that heart failure mortality among older patients is also increasing. Now, with rising comorbidities, I think it's very important for us to treat these patients aggressively with guideline-directed medical therapy, which we have already available.

Practical Cardiology: Thank you for that. Can you discuss the disparities observed related to region and location type?

Khan: Absolutely, I think that's a very good point. I think there have been multiple studies now which have shown that rural regions and nonmetropolitan regions have higher incidences of mortality from various diseases. I think there are multiple factors that drive this. First and foremost is access to care.

I think regions or some other regions might not have that much credit access to get, there might be some insurance problems as well. I've seen a lot of patients who just can't afford medical therapies, or they have insurance issues, and they can subsequently have worsening of their disease progression because just they can't afford the medications. It is simply about the social determinants of health, which are very important factors and can cause disease progression because if we can be on medication, obviously, the disease will progress.

I think access to care and access to medications are very important factors. Another factor is education and awareness. There might be some regions where there might not be enough awareness or education about cardiometabolic conditions like obesity, diabetes, or controlling their blood pressure, which can eventually lead to the progression of heart failure. So, I think a combination of all of these factors: access to care, access to medications, health policies in their region, access to PCPs, and education and awareness.

Practical Cardiology: How concerning is it to see that we're seeing this rise despite such marked advances in heart failure therapies?

Khan: I think that's a very good question. So, first of all, I don't think this has anything to do with this new knowledge or advances that we have made. I think there's a huge difference and the best therapy that we have and the best therapy that has being delivered. I think there have been multiple studies from our group, which have shown that the new medications, like SGLT2 inhibitors and ARNIs, their consumption in the wider population, where there is real-world impact, is actually very, very low. Multiple studies have shown less than 10%, the heart failure patients are on optimal doses of GDMT.

So, I think all of these results show us that we really need to target this clinical inertia. I think these results, again, put emphasis that the clinical uptake of the new medication, which we know work, are not being delivered in real-world clinical practice for a variety of reasons. We really need to use these medications and patients start taking these medications which will, hopefully, in the long run reduce heart failure-related mortality among older patients and younger patients as well.