Age-Specific Differences in Non-Cardiac Comorbidities Among HF Elderly Patients

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Age-Specific Differences in Non-Cardiac Comorbidities Among Elderly Patients Hospitalized with Heart Failure: A Special Focus on Young-Old, Old-Old, and Oldest-Old

Heart failure (HF) represents a critical public health challenge, particularly among aging populations. The prevalence of HF escalates dramatically with age, rising from 6% in individuals aged 60–79 years to approximately 14% in those ≥80 years. However, HF in older adults rarely exists in isolation. Instead, it is accompanied by complex interactions between cardiac and non-cardiac comorbidities, polypharmacy, and geriatric syndromes, all of which significantly influence clinical outcomes. This study provides a comprehensive analysis of age-specific differences in non-cardiac comorbidities and medication regimens among elderly patients hospitalized for HF, stratified into three groups: young-old (65–74 years), old-old (75–84 years), and oldest-old (≥85 years).

Study Design and Methodology

The retrospective analysis included 1,053 patients aged ≥65 years admitted to the Heart Failure Center of China-Japan Friendship Hospital between 2013 and 2017. HF diagnoses followed Chinese Society of Cardiology guidelines, incorporating symptoms (e.g., dyspnea, fatigue), signs (e.g., edema, rales), biomarker assessments (B-type natriuretic peptide or N-terminal pro-B type natriuretic peptide), and echocardiographic evidence of structural or functional abnormalities.

Patients were categorized into three age groups:

  1. Young-old: 65–74 years (n = 401, 38.1%)
  2. Old-old: 75–84 years (n = 518, 49.2%)
  3. Oldest-old: ≥85 years (n = 134, 12.7%)

Data collected included demographics, clinical presentations, comorbidities (cardiac and non-cardiac), medications, and hospitalization details. Non-cardiac comorbidities assessed were anemia, diabetes, chronic kidney disease (CKD), stroke, dyslipidemia, infection, chronic obstructive pulmonary disease (COPD)/asthma, cancer, osteoporosis, sleep apnea, thyroid disease, depression, and cognitive impairment. Polypharmacy was defined as the concurrent use of ≥5 medications.

Statistical analyses compared differences across groups using ANOVA, Kruskal-Wallis tests, and chi-square tests, with post-hoc adjustments for multiple comparisons.

Key Findings

Demographic and Clinical Characteristics

  • Mean age: 76.7 ± 6.6 years; 52.9% male.
  • Hospitalization trends: Emergency admissions increased with age (24.2% young-old vs. 41.0% oldest-old, P < 0.001). The oldest-old had the longest median hospital stay (18 days vs. 15 days in young-old, P = 0.004).
  • Biomarkers: Hemoglobin levels declined with age (121.2 g/L in young-old vs. 112.5 g/L in oldest-old, P < 0.001), while BNP and NT-proBNP levels rose significantly in the oldest-old.
  • Left ventricular ejection fraction (LVEF): Preserved LVEF (≥50%) was more common in the oldest-old (63.4% vs. 49.4% in young-old, P < 0.001).

Burden and Patterns of Comorbidities

  • Overall comorbidity burden: 97.1% of patients had ≥2 comorbidities, with non-cardiac comorbidities outweighing cardiac conditions across all groups. The median number of comorbidities increased progressively with age (Figure 1A).
  • Cardiac comorbidities: Coronary heart disease prevalence rose with age (60.8% young-old vs. 74.7% old-old), while cardiomyopathy decreased (11.2% young-old vs. 3.7% oldest-old, P < 0.001).
  • Non-cardiac comorbidities:
    • Young-old: Anemia (53.6%), dyslipidemia (45.9%), and diabetes (42.4%) dominated.
    • Oldest-old: Anemia (73.1%), infection (58.2%), and CKD (44.0%) were most prevalent (Figure 1C).
    • Notable age-related increases: Infection (29.2% to 58.2%, P < 0.001), CKD (31.4% to 44.0%, P = 0.002), stroke (19.0% to 35.1%, P < 0.001), and osteoporosis (4.2% to 11.9%, P = 0.004).

Medication Regimens and Appropriateness

  • Polypharmacy: 93.0% of patients received ≥5 medications; 43.0% used ≥10. Polypharmacy escalated with age (33.7% young-old vs. 65.7% oldest-old prescribed ≥10 medications, P < 0.001).
  • Inappropriate prescribing patterns:
    • Antibiotics: Overused across all groups, with 67.0% of patients receiving antibiotics despite only 40.3% having documented infections. Overuse peaked in the oldest-old (81.3% prescribed vs. 58.2% diagnosed, P < 0.001).
    • Iron repletion: Despite 60.4% of patients having anemia, only 8.9% received iron therapy. Rates were lowest in the oldest-old (16.4% treated vs. 73.1% anemic).
  • Guideline-directed HF therapies: Underutilization worsened with age. At admission, ACE inhibitors/ARBs were prescribed to 39.8% of oldest-old vs. 62.2% young-old (P < 0.001); β-blockers to 53.0% vs. 70.1% (P = 0.001). Discharge prescriptions further declined (Figure S2).

Significance of Non-Cardiac Comorbidities

  • Anemia: Prevalence increased with age (53.6% to 73.1%), yet <1% underwent serum ferritin testing for iron deficiency. This highlights a critical gap in anemia management, particularly given its association with worsened HF outcomes.
  • Infection: A leading precipitant of HF decompensation. The high antibiotic use without confirmed infections raises concerns about antimicrobial resistance and adverse drug events.
  • Stroke: Prevalence in the oldest-old (35.1%) far exceeded national averages for Chinese elderly (5.2%), underscoring shared vascular pathophysiology between HF and stroke.

Clinical Implications and Recommendations

  1. Tailored comorbidity management:
    • Young-old: Focus on traditional risk factors (diabetes, dyslipidemia).
    • Oldest-old: Prioritize infection prevention, renal function preservation, and anemia management.
  2. Optimizing pharmacotherapy:
    • Reduce polypharmacy: Regular medication reviews to deprescribe non-essential drugs.
    • Improve guideline adherence: Increase ACE inhibitor/ARB and β-blocker use in eligible older patients.
    • Targeted anemia care: Implement routine iron deficiency screening and supplementation.
  3. Infection stewardship: Utilize biomarkers (e.g., procalcitonin) to guide antibiotic use, minimizing empiric treatment.

Conclusion

This study delineates the evolving profile of non-cardiac comorbidities and pharmacotherapy challenges in elderly HF patients across age strata. Nearly universal non-cardiac comorbidities, escalating polypharmacy, and frequent inappropriate prescribing underscore the need for age-specific management strategies. Future research must explore how these differences impact long-term outcomes and refine interventions tailored to the unique needs of the oldest-old.

doi.org/10.1097/CM9.0000000000000560

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