AHF Management Among Elderly, Super-Elderly Needs Improvement in Japan

Rates of acute heart failure (AHF) have recently been rapidly increasing among elderly and super-elderly patients in Japan, and this study investigated rates of all-cause death and mode of death among this patient population.

Higher rates of death were seem among elderly (75-84 years) and super-elderly (85 years and older) patients with acute heart failure (AHF) in a recent study out of Japan, according to findings published in Clinical Cardiology.

“To our knowledge, this is the first prospective report to examine the association between super-elderly and prognosis,” the authors wrote.

Because AHF prevalence has recently been increasing among elderly and super-elderly patients in Japan, this study investigated the primary endpoints of all-cause death and mode of death among this patient population, with the authors saying they hope their findings will be “helpful for preventative approaches and management for patients following AHF.”

Of the 1253 patients recruited for the multicenter cohort study from the Kitakawachi Clinical Background and Outcome of Heart Failure Registry, follow-up data were available on 1117 patients alive at discharge from 13 hospitals in Osaka, Japan, and included in the final analysis. In addition to the elderly (n = 401) and super-elderly (n = 323) age groups, a third age group of nonelderly (younger than 75 years; n = 393) patients was studied.

Overall, there were similar rates of death among the 3 age groups. However, compared with the nonelderly group, the elderly and super-elderly individuals both had a greater risk of all-cause death:

  • Elderly: HR, 2.60 (95% CI, 1.93-3.54)
  • Super-elderly: HR, 5.04 (95% CI, 3.72-6.92)

The corresponding rates of all-cause death were 55.4% among the super-elderly group, 36.7% among the elderly group, and 16.0% among the nonelderly group.

Deaths due to infection (eg, noncardiovascular death) also were significantly increased in the older age groups:

  • Elderly: HR, 4.25 (95% CI, 1.75-10.33)
  • Super-elderly: HR, 10.10 (95% CI, 3.78-27.03)

The lowest proportion of cardiovascular-related deaths were seen in the super-elderly compared with the nonelderly and elderly groups: 43% vs 48% vs 47%, respectively.

“Information for detailed prognosis in elderly and super-elderly patients are limited,” the authors noted. “Previous large randomized clinical trials had a limitation of a direct adoption for all patients in real-world settings because of various exclusion criteria.” They point out that patients with AHF are typically older with many comorbidities, such as those they studied.

The median (interquartile range [IQR]) follow-up was 1078 (IQR, 430-1160) days, 51.1% of the patients were male, and the mean age was 77.3 years. Follow-up data gathered at 6 months and 1, 2, and 3 years after discharge were analyzed between April 2015 and August 2017, and Framingham risk criteria were used to give the AHF diagnosis. Cardiovascular death was classified as that from heart failure, sudden death, acute coronary syndrome, stroke or intracranial hemorrhage, and other cardiac death causes. Noncardiovascular death was classified as that from infection, cancer, renal or liver failure, and other causes.

Analysis also found:

  • The lowest proportion of coronary artery disease, cardiomyopathy, and diabetes among the super-elderly group.
  • The highest proportion of valvular disease, chronic kidney disease, and stroke among the super-elderly group.
  • Higher left-ventricular ejection fraction and lower body mass index and estimated glomerular filtration rate with the older age groups.

The authors point out that their findings reveal how noncardiovascular death, especially that resulting from infection, is more common among elderly and super-elderly persons, and that this association remained even after adjusting for comorbidities and prescriptions.

“These findings suggest that patients with AHF should have managements to prevent infections, to improve the outcomes after discharge,” the authors concluded, “not only following cardiovascular events but also infections using medical resources and their supporters. Further data and understanding about the detailed mode of death in patients with AHF are necessary.”


Takabayashi K, Kitaguchi S, Yamamoto T, et al. Mode of death in elderly and super-elderly patients with acute heart failure: insights from Japanese heart failure registry. Clin Cardiol. Published online May 8, 2021. doi:10.1002/clc.23619

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