Anatol J Cardiol. 2019 May; 21(4): 196–205.
Published online 2019 Mar 1. doi: 10.14744/AnatolJCardiol.2018.94556
PMCID: PMC6528498
PMID: 30930455
Demographics of patients with heart failure who were over 80 years old and were admitted to the cardiology clinics in Turkey
Gülay Gök, Mehdi Zoghi,1 Ümit Yaşar Sinan,2 Salih Kılıç,1 and Lale Tokgözoğlu3
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Abstract
Objective:
Heart failure (HF) has a high prevalence and mortality rate in elderly patients; however, there are few studies that have focused on patients older than 80 years. The aim of this study is to describe and compare the age-specific demographics and clinical features of Turkish elderly patients with HF who were admitted to cardiology clinics.
Methods:
The Epidemiology of Cardiovascular Disease in Elderly Turkish population (ELDER-TURK) study was conducted in 73 centers in Turkey, and it recruited a total of 5694 patients aged 65 years or older. In this study, the clinical profile of the patients who were aged 80 years or older and those between 65 and 79 years with HF were described and compared based on the ejection fraction (EF)-related classification: HFrEF and HFpEF (is considered as EF: ≥50%).
Results:
A total of 1098 patients (male, 47.5%; mean age, 83.5±3.1 years) aged ≥80 years and 4596 patients (male, 50.2 %; mean age, 71.1±4.31 years) aged 65-79 years were enrolled in this study. The prevalence of HF was 39.8% for patients who were ≥80 years and 27.1% for patients 65–79 years old. For patients aged ≥80 years with HF, the prevalence rate was 67% for hypertension (HT), 25.6% for diabetes mellitus (DM), 54.3% for coronary artery disease (CAD), and 42.3% for atrial fibrilation. Female proportion was lower in the HFrEF group (p=0.019). The prevalence of HT and DM was higher in the HFpEF group (pp>
Conclusion:
HF is common in elderly Turkish population, and its frequency increases significantly with age. Females, diabetics, and hypertensives are more likely to have HFpEF, whereas CAD patients are more likely to have HFrEF.
Keywords: epidemiology, heart failure, elder patients
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Introduction
Heart failure (HF) is a leading cause of cardiovascular mortality and morbidity, and it is associated with high costs that are burdening health deva systems (1). Approximately 6.5 million adults suffer from HF in the United States (2). According to veri from the Heart Failure Prevalence and Predictors in Turkey (HAPPY) study, the estimated prevalence of HF is 2.9% in Turkey, which means that 2.000.424 Turkish adults have HF (3). This huge population needs age-specific prudent deva to decrease the burden of the disease in Turkey.
The incidence and prevalence of HF gradually increase with advanced age. The number of elderly patients is also increasing in our population. Nearly 8.6% of total population is aged ≥85 years in Turkey (4). Furthermore, as the population gets older, the prevalence of HF continues to increase (5). This is due to progressive aging of the population, as well as the improvements in the HF survival over the years. In addition to its high prevalence, the disease also has a poor prognosis and high mortality rate in elderly patients. The 5-year mortality rate for 80-year-olds with HF is as high as 54.4% (2). Although HF has a markedly high mortality rate and prevalence in the elderly, few studies have focused on patients with HF who are older than 80 years. In large clinical trials, this growing population is underrepresented or excluded. However, patients aged ≥80 years show a different clinical profile when compared with younger patients. Patients aged ≥80 years with HF have a complex comorbidity and a high number of cardiovascular risk factors, which have a significant impact on the prognosis of the disease (6). Moreover, the effective treatment of chronic cardiovascular disorders, such as coronary artery disease (CAD), hypertension (HT), and diabetes mellitus (DM), may prevent the progression of HF.
Traditionally, HF has been defined as failure of the contractile function of the left ventricle. However, it is recognized that the HF symptoms can occur in the presence of olağan or near-normal EF, which is defined as HF with preserved ejection fraction (HFpEF). HFpEF and HFrEF have different clinical characteristics and prognostic factors. Patients with HFpEF are more often female and are more likely to have HT but less likely to have CAD. A recent meta-analysis suggests that patients with HFpEF may have a lower mortality rate than those with HFrEF (7). Altough all these differences are well known to affect the prognosis and the clinical outcome of elderly patients with HF, there is not much evidence, especially considering those issues related to specific characteristics of the elderly with HFrEF and HFpEF. Further studies are required to determine specific clinical characteristics of patients aged ≥80 years with HFrEF and HFpEF to produce a contemporary management strategy. The objective of this study is to determine clinical characteristics and major comorbidities of Turkish patients aged ≥80 years with HFrEF and HFpEF, and to compare them with patients aged 65-79 years.
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Methods
Study design
In this study, we used veri of 5694 patients aged ≥65 years who were recruited from the ELDER–TURK study, which was conducted in 73 volunteering hospital cardiology clinics participating in 12 EUROSTAT NUTS1 regions of Turkey (Fig. 1, Table 1). The design and details of this study have been reported before (8-10).
Figure 1
Twelve NUTS regions of Turkey
Table 1
List of participating centers and NUTS1 regions
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In this population-based study, patients aged ≥65 years who were admitted to outpatient cardiology clinics and inpatient wards of state, university, private, and training and research hospitals between March 2015 and December 2015 were included after signing the informed consent for veri sharing. In this study, elderly patients from the ELDER–TURK population with known HF (n=1681, 29.5%) were evaluated. As there is no specific classification cutoffs for elderly patients, in this study, participants aged ≥80 years were defined as being of an advanced age. The participants with HF were divided into two groups patients aged 65-79 years (n=1248) and patients aged ≥80 years (n=433). Cardiovascular diseases, risk factors, comorbidities, demographic characteristics, and the laboratory findings were analyzed and compared.
The study was approved by the Local Ethics Committee and was conducted according to the principles of the Declaration of Helsinki (as revised in Brasil, 2013).
The diagnosis of HF was established if the following HF symptoms were found: dyspnea, paroxysmal nocturnal dyspnea, and signs of pulmonary and/or peripheral congestion (11). Left ventricular (LV) function was determined by two-dimensional transthorasic echocardiography, which was performed by a physician in all subjects participating in the study. Patients with HF signs and symptoms and a olağan or mildly reduced LV systolic function (LVEF >50%) with relevant structural heart disease (left atrial enlargement, LV hypertrophy) and/or diastolic dysfunction were classified as having HFpEF. Patients with HF symptoms and a reduced LV systolic function (LVEF ≤50%) were classified as having HFrEF (12).
Cardiovascular diseases, risk factors, and comorbidities were recorded according to the self-reported history or hospital medical records.
The diagnosis of HF was established by the local investigators by combining information about history, clinical veri, medications, and echocardiography. To be eligible for inclusion in the studies, patients were required to have a history of shortness of breath on minimal exertion or at rest [New York Heart Association (NYHA) Class III or IV], within the last month and had to be in NYHA Class II–IV at the time of randomization. Patients were also required to have been treated with a diuretic. The diagnosis of HF was established by the local investigators by combining information about history, clinical veri, medications, and echocardiography. To be eligible for inclusion in the studies, patients were required to have a history of shortness of breath on minimal exertion or at rest (NYHA Class III or IV), within the last month and had to be in NYHA Class II–IV at the time of randomization. Patients were also required to have been treated with a diuretic.
The diagnosis of HF was established by the local investigators by combining information about history, clinical veri, medications, and echocardiography. To be eligible for inclusion in the studies, patients were required to have a history of shortness of breath on minimal exertion or at rest (NYHA Class III or IV), within the last month and had to be in NYHA Class II–IV at the time of randomization. Patients were also required to have been treated with a diuretic.
The diagnosis of HF was established by the local investigators by combining information about history, clinical veri, medications, and echocardiography. To be eligible for inclusion in the studies, patients were required to have a history of shortness of breath on minimal exertion or at rest (NYHA Class III or IV), within the last month and had to be in NYHA Class II–IV at the time of randomization. Patients were also required to have been treated with a diuretic.
Patients were defined as hypertensive if they were using antihypertensive medications or if they had high blood pressure on examination (systolic >140 mm Hg or diastolic >90 mm Hg) (13). Patients who were newly diagnosed as diabetic or who were already using an oral hypoglycemic agent or insulin were reported as diabetic. The glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease formula. Chronic renal failure (CRF) was defined as an estimated GFR min for at least 3 months (14). Smoking status was recorded as positive if the patients were an active smoker. Patients were considered as having CAD in the presence of previous myocardial infarction, stable or unstable CAD, a history of myocardial revascularization, and coronary artery by-pass graft operation (15).
Statistical analysis
All statistical analyses were performed using the SPSS program, version 21 (Chicago, VİLAYET, USA) for Windows XP. Veri summary was planned to be shared by tables. Continuous variables were expressed as the mean±standard deviation. The chi-square test was used for categorical variables and was expressed as the number of cases and percentages (%). Mean differences between groups were compared by Student’s t-test, whereas the Mann–Whitney U test was applied for comparisons of the not normally distributed veri. Values for pp>
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Results
Among 1089 patients aged ≥80 years (male, 47.5%; mean age, 83.5±3.1 years), 39.8% (433) had HF. The prevalence of CAD and peripheral artery disease (PAD), DM, and atrial fibrilation (AF) were higher in patients aged ≥80 years with HF when compared to those without HF (54.3% vs. 32.3%, 45.5% vs. 14.3%, 25.6% vs. 23%, 42.3% vs. 31.7%, respectively, all pp>
Table 2
Comparison of demographics and prevalence of comorbid conditions and cardiovascular risk factors between the patients aged ≥80 years, with and without HF
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AF – atrial fibrilation; CAD – coronary artery disease; COPD – chronic obstructive pulmonary disease; CRF – chronic renal failure; DBP – diastolic blood pressure; DM – diabetes mellitus; eGFR – estimated glomerular filtration rate; Hb – hemoglobin; HF – heart failure; HT – hypertension; LDL – low-density lipoprotein; PAD – peripheral artery disease; SBP – systolic blood pressure; TC – total cholesterol
Table 3
Demographics of patients aged ≥80 years, with HFrEF and HFpEF
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AF – atrial fibrilation; CAD – coronary artery disease; COPD – chronic obstructive pulmonary disease; CRF – chronic renal failure; DM – diabtes mellitus; HFrEF – HF with reduced ejection fraction; HFpEF – HF with preserved ejection fraction;
HT – hypertension; LDL – low-density lipoprotein; PAD – peripheral artery disease
Among 4596 of patients aged 65-79 years (male, 50.2%; mean age, 71.1±4.31 years), 27.1% (1248) had HF. In those patients, the prevalence of HFrEF and HFpEF were 56.1% (700) and 43.9% (548), respectively. In the HFrEF group, DM had a higher frequency in patients aged 65–79 years when compared with patients aged ≥80 years (5.3% vs. 24.1%, pp>
Table 4
Comparison of clinical characteristics of very elderly and the youngers with HFpEF and HFrEF
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AF – atrial fibrilation; CAD – coronary artery disease; COPD – chronic obstructive pulmonary disease; CRF – chronic renal failure; DM – diabtes mellitus; HFrEF – HF with reduced ejection fraction; HFpEF – HF with preserved ejection fraction; HT – hypertension
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Discussion
In this multi-centered, epidemiologic study, a large number of elderly patients with HF who were admitted to cardiology clinics were recruited. Significant epidemiologic veri on cardiovascular disease and risk factors among Turkish elderly patients with HF were obtained. We observed significant differences between patients with HF aged 65–79 years and ≥80 years.
The age-specific prevalence of HF among patients aged 75–84 years was 22% in the CARLA study (German), 13% in the ROTTERDAM study (The Netherlands), and 8.4% in the Olmsted county study (USA) (5, 16, 17). In patients aged ≥80 years, the prevalence of HF is 14.1% for males and 13.4% for females in the United States (2). In southwestern Europe, the prevalence of HF for patients aged ≥80 years is 16.14% (18). In those community-based epidemiological surveys, the prevalence of HF for the elderly population was lower than our finding in cardiology clinics in Turkey.
The prevalence of HFrEF progressively increases with advanced age and grows by 12%–14% in the population aged ≥80 years (19). We observed that nearly half of the very elderly patients with HF had HFrEF in cardiology clinics, which was similar to the other large studies, such as the Framingham and Olmsted county study. In accordance with those large studies, among very elderly patients with HF, CAD was the most contributing factor to HF and was followed by HT (5, 20, 21). CAD is also a strong predictor of all-cause mortality in the elderly (20, 21). In our study, CAD had a higher prevalence in patients aged ≥80 years with HF compared to those without HF.
In the TAKTIK study, the prevalence of CAD for patients hospitalized for acute HF in Turkey was 61% (22). However, our finding was close to results of the EFHS II study (23). In the EFHS II study, the prevalence of CAD in patients aged ≥80 years with HF was 51%, which is similar to our result. This observed difference between the studies might be due to the age distribution of study populations. The prevalence of cardiovascular comorbidities depends on age, but the relationship is not linear. All cardiovascular comorbidities gradually increase until the age of 80 years and then decrease (24, 25). In the EHFS II study, the mean age was similar to the one in our study; however, the mean age was lower in the TAKTIK study (62±13). As a consequence, the prevalence of CAD seems to be higher in the TAKTIK study. Nevertheless, the ELDER–TURK study includes both outpatient cardiology clinics and inpatient wards, which might have an impact on these reported different results.
As CAD is a predominantly caused by HF and has a higher prevalence in very elderly with HF, prevention of the onset of CAD is the key to reducing the burden of HF in cardiology clinics in Turkey. In our study, most of cardiovascular disease risk factors and comorbidities such as CAD, DM, PAD, AF, and anemia were higher in very elderly patients with HF, as shown in Table 3.
In contrast to EHFS II, the prevalence of HT in patients aged ≥80 years with HF was not statistically different than the patients aged 65–79 years with HF. In our study, the mean systolic blood pressure (SBP) was lower in very elderly patients with HF compared to those without HF, which means very elderly patients with HF were more hypotensive. This means those patients should be monitored more closely in cardiology clinics, and aggressive antihypersensive treatment should be avoided in those patients.
In very elderly with HFpEF, the proportion of females was higher, which was similar to large studies such as MAGGIC, HAPPY, PREFER, and CHARM (3, 7, 26, 27). In the CARLA study, single strongest determinant for HFpEF was HT, and this result was similar to our study; HT had a higher prevalence in very elderly patients with HFpEF compared to those with HFrEF. On the other hand, in accordance with the OPTIMIZE-HF, registry the frequency of DM was higher in patients with HFpEF compared to those with HFrEF (26). Very elder patients with HFpEF were found to be older than patients with HFrEF in some studies that do not consider patients aged ≥80 years. However, in our study, there was no age difference between very elderly patients with HFrEF and HFpEF (28, 29). The prevalence of DM in patients aged ≥80 years with HFrEF was lower than in patients aged 65–79 years with HFrEF. This result was consistent with the EHFS I and II studies. This may be related to reduced likelihood of surviving in older patients with DM compared to those without DM.
One of the predictors of all-cause mortality in patients aged ≥70 years with HF is PAD (21). In this study, PAD was significantly higher in very elderly with HF compared to those without HF.
AF has a great prognostic importance with regard to long-term mortality in very elderly with HF (30). In our study, the prevalence of AF was lower in very elderly with HF compared to those without HF. This may be a satisfactory result for a better long-term survival in very elderly with HF in Turkey. In the EFHS II study, the prevalence of AF was 48% in patients aged ≥80 years with HF, and this was also close to our result (23).
Smoking status should also be questioned and identified in cardiology clinics. The prevalence of smoking for very elderly with HF was as high as for those without HF in our study. The cardiologist should be focused more on smoking-cessation efforts for primary deva in those patients. Smokers need to be identified and offered pharmacological or behavioral smoking-cessation support. Moreover, guidelines should focus on smoking cessation for very elderly with HF.
In our study, the prevalence of COPD in very elderly with HF was higher than in the EHFS II study (23), whereas the prevalence of renal failure was similar with the HAPPY cohort (25). Renal failure is a strong predictor of both in-hospital mortality and follow-up mortality (31). In our study, the mean creatinine value was significantly higher in very elderly with HF, which may be associated with poor outcome.
Study limitations
This study included only patients who were admitted to outpatient cardiology clinics and inpatient wards. Hence, the prevalence of HF is higher than in the population-based studies. This is thought to be the cause of selection bias and is one of the study limitations.
Very elderly who were followed up at outpatient wards were less frail and were functioning better, and we believe that this led to underestimated prevalence of cardiovascular disease and risk factors. In addition, some comorbidities lead to a reduced survival rate. This could also have caused underestimated prevalence of CAD and risk factors, such as DM.
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Conclusion
In this study, we provide a national database about the prevalence of cardiovascular diseases, risk factors, and comorbidities of a large population of Turkish elderly patients with HF and compare it with other large studies. Despite the high prevalence of comorbidities and risk factors, there is no evidence-based therapy for the treatment of very elderly with HF. Consequently, there is a need to develop more effective and targeted management strategies for this population.
*Clinical Investigators
Mutlu Çağan Sümerkan, MD (Department of Cardiology, Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey), Volkan Emren, MD (Afyonkarahisar State Hospital, Cardiology Clinic, Afyon, Turkey), Lütfü Bekar, MD (Department of Cardiology, Hitit University Çorum Education and Research Hospital, Çorum, Turkey), Sinan Cerşit, MD (Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, İstanbul, Turkey), Elif Tunç, MD (İzmir Military Hospital, Cardiology Clinic, İzmir, Turkey), Gurur Ulucan, MD (Department of Cardiology, Mevlana University, Konya, Turkey), Emine Altuntaş, MD (Bingöl State Hospital, Cardiology Clinic, Bingöl, Turkey), Uğur Canpolat, MD (Department of Cardiology, Hacettepe University, Ankara, Turkey), Namık Özmen, MD (Department of Cardiology, GATA Haydarpaşa Training Hospital, İstanbul, Turkey), Gönül Açıksarı, MD, (İstinye State Hospital, Cardiology Clinic, İstanbul, Turkey), Nazile Alım Doğan, MD (Menemen State Hospital, Cardiology Clinic, İzmir, Turkey), Şeyda Günay, MD (Tarsus State Hospital, Cardiology Clinic, Mersin, Turkey), Meltem Didem Kemaloğlu, MD (Antalya Atatürk Education and Research Hospital, Cardiology Clinic, Antalya, Turkey), Alper Buğra Nacar, MD (Department of Cardiology, Mustafa Kemal University, Hatay, Turkey), Süleyman Karakoyun, MD (Department of Cardiology, Kafkas University, Kars, Turkey), Sinan İnci, MD (Department of Cardiology, Aksaray State Hospital, Aksaray, Turkey), Bülent Özlek, MD (Manisa State Hospital, Cardiology Clinic, Manisa, Turkey), Onur Aslan, MD (Tarsus Education and Research Hospital, Cardiology Clinic, Mersin, Turkey), Derya Baykız, MD (Tekirdağ State Hospital, Cardiology Clinic, Tekirdağ, Turkey), Sabahattin Gündüz, MD (Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, İstanbul, Turkey), Sedat Koroğlu, MD (Necip Fazıl City Hospital, Cardiology Clinic, Kahramanmaraş, Turkey), Ayşen Helvacı, MD (Okmeydanı Training and Research Hospital, Cardiology Clinic, İstanbul, Turkey), Raşit Coşkun, MD (Bayburt State Hospital, Cardiology Clinic, Bayburt, Turkey), İsa Öner Yüksel, MD (Antalya Education and Research Hospital, Cardiology Clinic, Antalya, Turkey), Şükrü Çetin, MD (Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey), Mahmut Yesin, MD (Koşuyolu Kartal Heart Training and Research Hospital, Department of Cardiology, İstanbul, Turkey), Mustafa Ozan Gürsoy, MD (Gaziemir State Hospital, Cardiology Clinic, İzmir, Turkey), Sibel Çatırlı Enar, MD (Department of Cardiology, Türkiye Hospital, İstanbul, Turkey), Müjgan Tek Öztürk, MD (Department of Cardiology, Ankara Keçiören Training and Research Hospital, Ankara, Turkey), Aykut Yılmaz, MD (Siirt State Hospital, Cardiology Unit, Siirt, Turkey), Özcan Başaran, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Kaan Okyay, MD (Department of Cardiology, Başşehir University Medical School Ankara Hospital, Ankara, Turkey), Cengiz Öztürk, MD (Department of Cardiology, Gülhane Medical School, Ankara, Turkey), Oğuzhan Çelik, MD (Department of Cardiology, Hitit University, Çorum, Turkey), Emre Yalçınkaya, MD (Aksaz Military Hospital, Cardiology Clinic, Muğla, Turkey), Vedat Aslan, MD (Defne Hospital, Cardiology Clinic, Hatay, Turkey), Utku Şenol, MD (Bolvadin State Hospital, Cardiology Clinic, Afyon, Turkey), Fatih Mehmet Uçar, MD (Denizli State Hospital, Cardiology Clinic, Denizli, Turkey), Volkan Kozluca, MD (Denizli Server Gazi State Hospital, Cardiology Clinic, Denizli, Turkey), Ebru İpek Turkoğlu, MD (Kemalpaşa State Hospital, Cardiology Clinic, İzmir, Turkey), Cevat Şekuri, MD (Department of Cardiology, Kent Hospital, İzmir, Turkey), Mehmet Ertürk, MD (İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey), İbrahim Altun, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Erdal Belen, MD (Okmeydanı Training and Research Hospital, Cardiology Clinic, İstanbul, Turkey), Gökhan Aksan, MD (Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey), Erkan Yıldırım, MD (Department of Cardiology, Erzurum Region Training and Research Hospital, Erzurum, Turkey), Ahmet Sayın, MD (İzmir Tepecik Training and Research Hospital, Cardiology Clinic, İzmir, Turkey), Dursun Çayan Akkoyun, MD (Department of Cardiology, Namık Kemal University, Tekirdağ, Turkey), Abdullah Tunçez, MD (Department of Cardiology, Selçuk University, Konya, Turkey), Volkan Doğan, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Yusuf Emre Gürel, MD (Pendik State Hospital, Cardiology Clinic, İstanbul, Turkey), Selami Demirelli, MD (Erzurum Training and Research Hospital, Cardiology Clinic, Erzurum, Turkey), Çiğdem Koca, MD (Manisa Demirci State Hospital, Cardiology Clinic, Manisa, Turkey), Murat Biteker, MD (Department of Cardiology, Muğla University, Muğla, Turkey), Hasan Aydın Baş, MD (Isparta State Hospital, Cardiology Clinic, Isparta, Turkey), Feza Güzet, MD (Department of Cardiology, Surp Pirgic Armenian Hospital, İstanbul, Turkey), Gülten Taçoy, MD (Department of Cardiology, Gazi University Faculty of Medicine, Ankara, Turkey), Erdem Alpsoy, MD (Department of Cardiology, Namık Kemal University, Tekirdağ, Turkey), Turhan Turan, MD (Ahi Cihan Training and Research Hospital, Cardiology Clinic, Trabzon, Turkey), Vedat Davutoğlu, MD (Department of Cardiology, Gaziantep University, Gaziantep, Turkey), Alparslan Birdane, MD (Department of Cardiology, Osmangazi University, Eskişehir, Turkey), Ersel Onrat, MD (Afyon Kocatepe University, Cardiology Clinic, Afyon, Turkey), Mehmet Reşat Baha, MD (Osmaniye State Hospital, Cardiology Clinic, Osmaniye, Turkey), Sabiye Yılmaz, MD (Sakarya Training and Research Hospital, Cardiology Clinic, Sakarya, Turkey), Servet Altay, MD (Department of Cardiology, Trakya University, Edirne, Turkey), Mehmet Hayri Alıcı, MD (Gaziantep 25 Aralık State Hospital, Cardiology Clinic, Gaziantep, Turkey), İsmail Turkay Özcan, MD (Department of Cardiology, University of Mersin, Turkey), Görkem Kuş, MD (Antalya Training and Research Hospital, Cardiology Clinic, Antalya, Turkey), Gültekin Günhan Demir, MD (Department of Cardiology, İstanbul Medipol University Esenler Hospital, İstanbul, Turkey), Kadriye Memiç Sancar, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Muhammed Bora Demirçelik, MD (Department of Cardiology, Turgut Ozal University, Malatya, Turkey), Ahmet Yanık, MD (Samsun State Hospital, Cardiology Clinic, Samsun, Turkey), Atike Nazlı Akciğer, MD (Sinop State Hospital, Cardiology Clinic, Sinop, Turkey), Yeşim Hoşcan, MD (Antalya OFM Private Hospital, Cardiology Clinic, Antalya, Turkey), Kurşat Arslan, MD (Erzurum Education and Research Hospital, Erzurum, Turkey), Yılmaz Omur Otlu, MD (Kars State Hospital, Cardiology Clinic, Kars, Turkey), İsmail Şahin, MD (Ereğli State Hospital, Cardiology Clinic, Konya, Turkey), İbrahim Ersoy, MD (Isparta State Hospital, Cardiology Clinic, Isparta, Turkey), Dilek Çiçek Yılmaz, MD (Department of Cardiology, Mersin University, Mersin, Turkey), Kadir Uğur Mert, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Perihan Varim, MD (Sakarya State Hospital, Cardiology Clinic, Sakarya, Turkey), Hatem Ari, MD (Department of Cardiology, Süleyman Demirel University, Isparta, Turkey).
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Acknowledgments
This study was supported by Turkish Society of Cardiology.
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Footnotes
Conflict of interest: None declared.
Peer-review: Externally peer-reviewed.
Authorship contributions: Concept – M.Z.; Design – M.Z.; Supervision – L.T.; Fundings – G.G.; Materials – S.K.; Veri collection &/or processing – Ü.Y.S.; Analysis &/or interpretation – Ü.Y.S.; Literature search – L.T.; Writing – G.G.; Critical review – S.K.
*On behalf of Elder-Turk study investigators
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Okumaya devam et...
Published online 2019 Mar 1. doi: 10.14744/AnatolJCardiol.2018.94556
PMCID: PMC6528498
PMID: 30930455
Demographics of patients with heart failure who were over 80 years old and were admitted to the cardiology clinics in Turkey
Gülay Gök, Mehdi Zoghi,1 Ümit Yaşar Sinan,2 Salih Kılıç,1 and Lale Tokgözoğlu3
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Abstract
Objective:
Heart failure (HF) has a high prevalence and mortality rate in elderly patients; however, there are few studies that have focused on patients older than 80 years. The aim of this study is to describe and compare the age-specific demographics and clinical features of Turkish elderly patients with HF who were admitted to cardiology clinics.
Methods:
The Epidemiology of Cardiovascular Disease in Elderly Turkish population (ELDER-TURK) study was conducted in 73 centers in Turkey, and it recruited a total of 5694 patients aged 65 years or older. In this study, the clinical profile of the patients who were aged 80 years or older and those between 65 and 79 years with HF were described and compared based on the ejection fraction (EF)-related classification: HFrEF and HFpEF (is considered as EF: ≥50%).
Results:
A total of 1098 patients (male, 47.5%; mean age, 83.5±3.1 years) aged ≥80 years and 4596 patients (male, 50.2 %; mean age, 71.1±4.31 years) aged 65-79 years were enrolled in this study. The prevalence of HF was 39.8% for patients who were ≥80 years and 27.1% for patients 65–79 years old. For patients aged ≥80 years with HF, the prevalence rate was 67% for hypertension (HT), 25.6% for diabetes mellitus (DM), 54.3% for coronary artery disease (CAD), and 42.3% for atrial fibrilation. Female proportion was lower in the HFrEF group (p=0.019). The prevalence of HT and DM was higher in the HFpEF group (pp>
Conclusion:
HF is common in elderly Turkish population, and its frequency increases significantly with age. Females, diabetics, and hypertensives are more likely to have HFpEF, whereas CAD patients are more likely to have HFrEF.
Keywords: epidemiology, heart failure, elder patients
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Introduction
Heart failure (HF) is a leading cause of cardiovascular mortality and morbidity, and it is associated with high costs that are burdening health deva systems (1). Approximately 6.5 million adults suffer from HF in the United States (2). According to veri from the Heart Failure Prevalence and Predictors in Turkey (HAPPY) study, the estimated prevalence of HF is 2.9% in Turkey, which means that 2.000.424 Turkish adults have HF (3). This huge population needs age-specific prudent deva to decrease the burden of the disease in Turkey.
The incidence and prevalence of HF gradually increase with advanced age. The number of elderly patients is also increasing in our population. Nearly 8.6% of total population is aged ≥85 years in Turkey (4). Furthermore, as the population gets older, the prevalence of HF continues to increase (5). This is due to progressive aging of the population, as well as the improvements in the HF survival over the years. In addition to its high prevalence, the disease also has a poor prognosis and high mortality rate in elderly patients. The 5-year mortality rate for 80-year-olds with HF is as high as 54.4% (2). Although HF has a markedly high mortality rate and prevalence in the elderly, few studies have focused on patients with HF who are older than 80 years. In large clinical trials, this growing population is underrepresented or excluded. However, patients aged ≥80 years show a different clinical profile when compared with younger patients. Patients aged ≥80 years with HF have a complex comorbidity and a high number of cardiovascular risk factors, which have a significant impact on the prognosis of the disease (6). Moreover, the effective treatment of chronic cardiovascular disorders, such as coronary artery disease (CAD), hypertension (HT), and diabetes mellitus (DM), may prevent the progression of HF.
Traditionally, HF has been defined as failure of the contractile function of the left ventricle. However, it is recognized that the HF symptoms can occur in the presence of olağan or near-normal EF, which is defined as HF with preserved ejection fraction (HFpEF). HFpEF and HFrEF have different clinical characteristics and prognostic factors. Patients with HFpEF are more often female and are more likely to have HT but less likely to have CAD. A recent meta-analysis suggests that patients with HFpEF may have a lower mortality rate than those with HFrEF (7). Altough all these differences are well known to affect the prognosis and the clinical outcome of elderly patients with HF, there is not much evidence, especially considering those issues related to specific characteristics of the elderly with HFrEF and HFpEF. Further studies are required to determine specific clinical characteristics of patients aged ≥80 years with HFrEF and HFpEF to produce a contemporary management strategy. The objective of this study is to determine clinical characteristics and major comorbidities of Turkish patients aged ≥80 years with HFrEF and HFpEF, and to compare them with patients aged 65-79 years.
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Methods
Study design
In this study, we used veri of 5694 patients aged ≥65 years who were recruited from the ELDER–TURK study, which was conducted in 73 volunteering hospital cardiology clinics participating in 12 EUROSTAT NUTS1 regions of Turkey (Fig. 1, Table 1). The design and details of this study have been reported before (8-10).
Figure 1
Twelve NUTS regions of Turkey
Table 1
List of participating centers and NUTS1 regions
| Percentage (%) of total patient population | Percentage (%) of total Turkish population | ||
|---|---|---|---|
| 1) İstanbul | Pendik State Hospital | 398 | |
| Şişli Etfal Training and Research Hospital | 231 | ||
| Kartal KoşuyoluYüksek İhtisas Training and Research Hospital | 208 | ||
| Okmeydanı Training and Research Hospital | 94 | ||
| İstanbul University, Cardiology Institute | 83 | ||
| GATA Haydarpaşa | 77 | ||
| İstinye State Hospital | 75 | ||
| Türkiye Hospital/Memorial Hospital | 43 | ||
| Surp Pirgiç Ermeni Training and Research Hospital | 17 | ||
| Medipol University Faculty of Medicine | 5 | ||
| Mehmet Akif Ersoy Training and Research Hospital | 40 | ||
| Total | 1271 | 22.32 | 16.5 |
| 2) West Anatolia | Mevlana University Faculty of Medicine | 104 | |
| Selçuk University Faculty of Medicine | 31 | ||
| Başkent University Faculty of Medicine | 41 | ||
| Gazi University Faculty of Medicine | 15 | ||
| GATA Ankara | 41 | ||
| TürkiyeYüksek İhtisas Training and Research Hospital | 428 | ||
| Hacettepe University Faculty of Medicine | 87 | ||
| Ankara University Faculty of Medicine | 40 | ||
| Keçiören Training and Research Hospital | 43 | ||
| Yenimahalle Training and Research Hospital | 234 | ||
| Ereğli State Hospital | 1 | ||
| Turgut Özal University Faculty of Medicine | 4 | ||
| Total | 1069 | 18.77 | 13.88 |
| 3) East Marmara | Sakarya Training and Research Hospital | 9 | |
| Total | 9 | 0.15 | 0.11 |
| 4) Eagean Region | Ege University Faculty of Medicine | 366 | |
| Muğla Sıtkı Koçman University Faculty of Medicine | 142 | ||
| Muğla Yücelen Private Hospital | 127 | ||
| Menemen State Hospital | 74 | ||
| Manisa State Hospital | 61 | ||
| Gazi Buyruk State Hospital | 44 | ||
| Aksaz Military Hospital | 40 | ||
| Denizli State Hospital | 40 | ||
| Denizli Server Gazi State Hospital | 40 | ||
| Kemalpaşa State Hospital | 40 | ||
| Kent Hospital | 40 | ||
| İzmir Tepecik Training and Research Hospital | 38 | ||
| Manisa Demirci State Hospital | 24 | ||
| İzmir Military Hospital | 120 | ||
| Afyon State Hospital | 114 | ||
| Bolvadin State Hospital | 40 | ||
| Afyon Kocatepe University Faculty of Medicine | 8 | ||
| Total | 1358 | 23.84 | 17.63 |
| 5) West Marmara | Edirne State Hospital | 7 | |
| Tekirdağ State Hospital | 60 | ||
| Namık Kemal University Faculty of Medicine | 46 | ||
| Total | 113 | 1.98 | 1.46 |
| 6) Mediterranean | Antalya Atatürk State Hospital | 137 | |
| Tarsus State Hospital | 126 | ||
| Akdeniz University Faculty of Medicine | 120 | ||
| Mustafa Kemal Univercity Training and Research Hospital | 65 | ||
| Necip Fazıl State Hospital | 57 | ||
| Antalya Training and Research Hospital | 55 | ||
| Antakya Defne Private Hospital | 40 | ||
| Isparta State Hospital | 19 | ||
| Süleyman Demirel University Faculty of Medicine | 1 | ||
| Antalya OFM Private Hospital | 2 | ||
| Mersin University Faculty of Medicine | 8 | ||
| Osmaniye State Hospital | 8 | ||
| Total | 638 | 11.2 | 8.28 |
| 7) West Black Sea | Samsun Training and Research Hospital | 15 | |
| Hitit University Faculty of Medicine | 153 | ||
| Sinop State Hospital | 3 | ||
| Osmangazi University Faculty of Medicine | 10 | ||
| Total | 181 | 3.17 | 2.35 |
| 8) Middle Anatolia | Ahi Cihan Thorasic and Cardiovascular | 12 | |
| Training and Research Hospital | |||
| Ahi Evran University Training and Research Hospital | 219 | ||
| Aksaray State Hospital | 62 | ||
| Total | 293 | 5.14 | 3.8 |
| 9) East Black Sea | Rize Kaçkar State Hospital | 340 | |
| Total | 340 | 5.97 | 4.41 |
| 10) Southeast Anatolia | Mardin State Hospital | 91 | |
| Siirt State Hospital | 43 | ||
| Gaziantep University Faculty of Medicine | 11 | ||
| Gaziantep 25 Aralık State Hospital | 7 | ||
| Total | 152 | 2.66 | 1.97 |
| 11) Middle East Anatolia | Bingöl State Hospital | 88 | |
| Total | 88 | 1.54 | 1.14 |
| 12) Northeast Anatolia | Kars State Hospital | 2 | |
| Bayburt State Hospital | 53 | ||
| Erzurum Training and Research Hospital | 64 | ||
| Kafkas University Faculty of Medicine | 63 | ||
| Total | 182 | 3.19 | 2.36 |
Open in a separate window
In this population-based study, patients aged ≥65 years who were admitted to outpatient cardiology clinics and inpatient wards of state, university, private, and training and research hospitals between March 2015 and December 2015 were included after signing the informed consent for veri sharing. In this study, elderly patients from the ELDER–TURK population with known HF (n=1681, 29.5%) were evaluated. As there is no specific classification cutoffs for elderly patients, in this study, participants aged ≥80 years were defined as being of an advanced age. The participants with HF were divided into two groups patients aged 65-79 years (n=1248) and patients aged ≥80 years (n=433). Cardiovascular diseases, risk factors, comorbidities, demographic characteristics, and the laboratory findings were analyzed and compared.
The study was approved by the Local Ethics Committee and was conducted according to the principles of the Declaration of Helsinki (as revised in Brasil, 2013).
The diagnosis of HF was established if the following HF symptoms were found: dyspnea, paroxysmal nocturnal dyspnea, and signs of pulmonary and/or peripheral congestion (11). Left ventricular (LV) function was determined by two-dimensional transthorasic echocardiography, which was performed by a physician in all subjects participating in the study. Patients with HF signs and symptoms and a olağan or mildly reduced LV systolic function (LVEF >50%) with relevant structural heart disease (left atrial enlargement, LV hypertrophy) and/or diastolic dysfunction were classified as having HFpEF. Patients with HF symptoms and a reduced LV systolic function (LVEF ≤50%) were classified as having HFrEF (12).
Cardiovascular diseases, risk factors, and comorbidities were recorded according to the self-reported history or hospital medical records.
The diagnosis of HF was established by the local investigators by combining information about history, clinical veri, medications, and echocardiography. To be eligible for inclusion in the studies, patients were required to have a history of shortness of breath on minimal exertion or at rest [New York Heart Association (NYHA) Class III or IV], within the last month and had to be in NYHA Class II–IV at the time of randomization. Patients were also required to have been treated with a diuretic. The diagnosis of HF was established by the local investigators by combining information about history, clinical veri, medications, and echocardiography. To be eligible for inclusion in the studies, patients were required to have a history of shortness of breath on minimal exertion or at rest (NYHA Class III or IV), within the last month and had to be in NYHA Class II–IV at the time of randomization. Patients were also required to have been treated with a diuretic.
The diagnosis of HF was established by the local investigators by combining information about history, clinical veri, medications, and echocardiography. To be eligible for inclusion in the studies, patients were required to have a history of shortness of breath on minimal exertion or at rest (NYHA Class III or IV), within the last month and had to be in NYHA Class II–IV at the time of randomization. Patients were also required to have been treated with a diuretic.
The diagnosis of HF was established by the local investigators by combining information about history, clinical veri, medications, and echocardiography. To be eligible for inclusion in the studies, patients were required to have a history of shortness of breath on minimal exertion or at rest (NYHA Class III or IV), within the last month and had to be in NYHA Class II–IV at the time of randomization. Patients were also required to have been treated with a diuretic.
Patients were defined as hypertensive if they were using antihypertensive medications or if they had high blood pressure on examination (systolic >140 mm Hg or diastolic >90 mm Hg) (13). Patients who were newly diagnosed as diabetic or who were already using an oral hypoglycemic agent or insulin were reported as diabetic. The glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease formula. Chronic renal failure (CRF) was defined as an estimated GFR min for at least 3 months (14). Smoking status was recorded as positive if the patients were an active smoker. Patients were considered as having CAD in the presence of previous myocardial infarction, stable or unstable CAD, a history of myocardial revascularization, and coronary artery by-pass graft operation (15).
Statistical analysis
All statistical analyses were performed using the SPSS program, version 21 (Chicago, VİLAYET, USA) for Windows XP. Veri summary was planned to be shared by tables. Continuous variables were expressed as the mean±standard deviation. The chi-square test was used for categorical variables and was expressed as the number of cases and percentages (%). Mean differences between groups were compared by Student’s t-test, whereas the Mann–Whitney U test was applied for comparisons of the not normally distributed veri. Values for pp>
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Results
Among 1089 patients aged ≥80 years (male, 47.5%; mean age, 83.5±3.1 years), 39.8% (433) had HF. The prevalence of CAD and peripheral artery disease (PAD), DM, and atrial fibrilation (AF) were higher in patients aged ≥80 years with HF when compared to those without HF (54.3% vs. 32.3%, 45.5% vs. 14.3%, 25.6% vs. 23%, 42.3% vs. 31.7%, respectively, all pp>
Table 2
Comparison of demographics and prevalence of comorbid conditions and cardiovascular risk factors between the patients aged ≥80 years, with and without HF
| Parameter | HF (−) (n=656) | HF (+) (n=433) | P value |
|---|---|---|---|
| Female | 357 (54.4%) | 214 (49.4%) | 0.106 |
| Male | 299 (45.6%) | 219(50.6%) | 0.120 |
| Smoking | 49 (13.4%) | 43 (9.9%) | 0.149 |
| HT | 487 (74.2%) | 290 (67%) | 0.009 |
| DM | 157 (23%) | 111 (25.6%) | td> |
| CAD | 212 (32.3%) | 235 (54.3%) | td> |
| PAD | 94 (14.3%) | 197 (45.5%) | td> |
| COPD | 116 (17.7%) | 110 (25.4%) | 0.581 |
| AF | 208 (31.7%) | 183 (42.3%) | 0.003 |
| Pacemaker | 21 (3.2%) | 30 (6.9%) | 0.005 |
| CRF | 83 (12.6%) | 86 (19.7%) | 0.457 |
| Anemia | 123 (18.7%) | 116 (26.8%) | 0.001 |
| Age | 83.4±3.0 | 83.7±3.3 | 0.111 |
| Heart rate (betas/min) | 76.4±14.3 | 80.5±18.5 | td> |
| SBP (mm Hg) | 131.1±17.0 | 127.4±18.5 | 0.043 |
| DBP (mm Hg) | 76.7±10.8 | 75.5±12.1 | 0.097 |
| Hb (g/dL) | 12.4±1.7 | 12.0±1.8 | 0.340 |
| TC (mg/dL) | 193 (164-220) | 180 (148-207) | 0.174 |
| LDL (mg/dL) | 118 (93-142) | 106 (84-135) | 0.245 |
| Kreatinin (mg/dL) | 0.9 (0.8-1.1) | 1 (0.8-1.3) | 0.001 |
| eGFR (mL/min) | 70 (55.4-83.4) | 63.6 (48.7-79.5) | 0.245 |
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AF – atrial fibrilation; CAD – coronary artery disease; COPD – chronic obstructive pulmonary disease; CRF – chronic renal failure; DBP – diastolic blood pressure; DM – diabetes mellitus; eGFR – estimated glomerular filtration rate; Hb – hemoglobin; HF – heart failure; HT – hypertension; LDL – low-density lipoprotein; PAD – peripheral artery disease; SBP – systolic blood pressure; TC – total cholesterol
Table 3
Demographics of patients aged ≥80 years, with HFrEF and HFpEF
| Parameter | HFrEF (n=217) | HFpEF (n=216) | P value |
|---|---|---|---|
| Female | 95 (43.8%) | 119 (55.1%) | 0.019 |
| Male | 122 (56.2%) | 97 (44.9%) | 0.024 |
| Smoking | 27 (12.4%) | 16 (7.4%) | 0.078 |
| HT | 126 (58.1%) | 164 (75.9%) | td> |
| DM | 48 (22.1%) | 63 (29.2%) | 0.003 |
| CAD | 136 (62.7%) | 99 (45.8%) | 0.002 |
| PAD | 96 (44.2%) | 101 (46.8%) | 0.350 |
| COPD | 52 (24%) | 58 (26.8%) | 0.247 |
| AF | 88 (40.5%) | 95 (44%) | 0.356 |
| Pacemaker | 21 (9.7%) | 9 (4.2%) | 0.025 |
| CRF | 48 (22.1%) | 38 (17.6%) | 0.350 |
| Anemia | 57 (26.3%) | 59 (27.3%) | 0.254 |
| Age | 83.8±3.2 | 83.7±3.3 | 0.457 |
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AF – atrial fibrilation; CAD – coronary artery disease; COPD – chronic obstructive pulmonary disease; CRF – chronic renal failure; DM – diabtes mellitus; HFrEF – HF with reduced ejection fraction; HFpEF – HF with preserved ejection fraction;
HT – hypertension; LDL – low-density lipoprotein; PAD – peripheral artery disease
Among 4596 of patients aged 65-79 years (male, 50.2%; mean age, 71.1±4.31 years), 27.1% (1248) had HF. In those patients, the prevalence of HFrEF and HFpEF were 56.1% (700) and 43.9% (548), respectively. In the HFrEF group, DM had a higher frequency in patients aged 65–79 years when compared with patients aged ≥80 years (5.3% vs. 24.1%, pp>
Table 4
Comparison of clinical characteristics of very elderly and the youngers with HFpEF and HFrEF
| Parameter | Group I: 65-79 years with HFpEF 548 (43.9%) | Group II: ≥80 years with HFpEF 216 (49.9%) | P value | Group I: 65-79 years with HFrEF 700 (56.1%) | Group II: ≥80 years with HFrEF 217 (50.1%) | P value |
|---|---|---|---|---|---|---|
| HT (%) | 426 (77.7%) | 164 (75.9%) | 0.591 | 455 (65%) | 126 (58.1%) | 0.064 |
| DM (%) | 180 (32.8%) | 63 (29.2%) | 0.321 | 220 (31.4%) | 48 (22.1%) | 0.009 |
| CAD (%) | 296 (54%) | 99 (45.8%) | 0.731 | 493 (70.4%) | 136 (62.7%) | 0.088 |
| CRF (%) | 75 (13.7%) | 38 (17.6%) | 0.156 | 155 (22.1%) | 48 (22.1%) | 0.979 |
| COPD (%) | 89 (16.2%) | 35 (16.2%) | 0.260 | 117 (16.7%) | 36 (16.6%) | 0.653 |
| AF (%) | 204 (37.2%) | 95 (44%) | 0.469 | 282 (40.3%) | 88 (40.5%) | 0.607 |
Open in a separate window
AF – atrial fibrilation; CAD – coronary artery disease; COPD – chronic obstructive pulmonary disease; CRF – chronic renal failure; DM – diabtes mellitus; HFrEF – HF with reduced ejection fraction; HFpEF – HF with preserved ejection fraction; HT – hypertension
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Discussion
In this multi-centered, epidemiologic study, a large number of elderly patients with HF who were admitted to cardiology clinics were recruited. Significant epidemiologic veri on cardiovascular disease and risk factors among Turkish elderly patients with HF were obtained. We observed significant differences between patients with HF aged 65–79 years and ≥80 years.
The age-specific prevalence of HF among patients aged 75–84 years was 22% in the CARLA study (German), 13% in the ROTTERDAM study (The Netherlands), and 8.4% in the Olmsted county study (USA) (5, 16, 17). In patients aged ≥80 years, the prevalence of HF is 14.1% for males and 13.4% for females in the United States (2). In southwestern Europe, the prevalence of HF for patients aged ≥80 years is 16.14% (18). In those community-based epidemiological surveys, the prevalence of HF for the elderly population was lower than our finding in cardiology clinics in Turkey.
The prevalence of HFrEF progressively increases with advanced age and grows by 12%–14% in the population aged ≥80 years (19). We observed that nearly half of the very elderly patients with HF had HFrEF in cardiology clinics, which was similar to the other large studies, such as the Framingham and Olmsted county study. In accordance with those large studies, among very elderly patients with HF, CAD was the most contributing factor to HF and was followed by HT (5, 20, 21). CAD is also a strong predictor of all-cause mortality in the elderly (20, 21). In our study, CAD had a higher prevalence in patients aged ≥80 years with HF compared to those without HF.
In the TAKTIK study, the prevalence of CAD for patients hospitalized for acute HF in Turkey was 61% (22). However, our finding was close to results of the EFHS II study (23). In the EFHS II study, the prevalence of CAD in patients aged ≥80 years with HF was 51%, which is similar to our result. This observed difference between the studies might be due to the age distribution of study populations. The prevalence of cardiovascular comorbidities depends on age, but the relationship is not linear. All cardiovascular comorbidities gradually increase until the age of 80 years and then decrease (24, 25). In the EHFS II study, the mean age was similar to the one in our study; however, the mean age was lower in the TAKTIK study (62±13). As a consequence, the prevalence of CAD seems to be higher in the TAKTIK study. Nevertheless, the ELDER–TURK study includes both outpatient cardiology clinics and inpatient wards, which might have an impact on these reported different results.
As CAD is a predominantly caused by HF and has a higher prevalence in very elderly with HF, prevention of the onset of CAD is the key to reducing the burden of HF in cardiology clinics in Turkey. In our study, most of cardiovascular disease risk factors and comorbidities such as CAD, DM, PAD, AF, and anemia were higher in very elderly patients with HF, as shown in Table 3.
In contrast to EHFS II, the prevalence of HT in patients aged ≥80 years with HF was not statistically different than the patients aged 65–79 years with HF. In our study, the mean systolic blood pressure (SBP) was lower in very elderly patients with HF compared to those without HF, which means very elderly patients with HF were more hypotensive. This means those patients should be monitored more closely in cardiology clinics, and aggressive antihypersensive treatment should be avoided in those patients.
In very elderly with HFpEF, the proportion of females was higher, which was similar to large studies such as MAGGIC, HAPPY, PREFER, and CHARM (3, 7, 26, 27). In the CARLA study, single strongest determinant for HFpEF was HT, and this result was similar to our study; HT had a higher prevalence in very elderly patients with HFpEF compared to those with HFrEF. On the other hand, in accordance with the OPTIMIZE-HF, registry the frequency of DM was higher in patients with HFpEF compared to those with HFrEF (26). Very elder patients with HFpEF were found to be older than patients with HFrEF in some studies that do not consider patients aged ≥80 years. However, in our study, there was no age difference between very elderly patients with HFrEF and HFpEF (28, 29). The prevalence of DM in patients aged ≥80 years with HFrEF was lower than in patients aged 65–79 years with HFrEF. This result was consistent with the EHFS I and II studies. This may be related to reduced likelihood of surviving in older patients with DM compared to those without DM.
One of the predictors of all-cause mortality in patients aged ≥70 years with HF is PAD (21). In this study, PAD was significantly higher in very elderly with HF compared to those without HF.
AF has a great prognostic importance with regard to long-term mortality in very elderly with HF (30). In our study, the prevalence of AF was lower in very elderly with HF compared to those without HF. This may be a satisfactory result for a better long-term survival in very elderly with HF in Turkey. In the EFHS II study, the prevalence of AF was 48% in patients aged ≥80 years with HF, and this was also close to our result (23).
Smoking status should also be questioned and identified in cardiology clinics. The prevalence of smoking for very elderly with HF was as high as for those without HF in our study. The cardiologist should be focused more on smoking-cessation efforts for primary deva in those patients. Smokers need to be identified and offered pharmacological or behavioral smoking-cessation support. Moreover, guidelines should focus on smoking cessation for very elderly with HF.
In our study, the prevalence of COPD in very elderly with HF was higher than in the EHFS II study (23), whereas the prevalence of renal failure was similar with the HAPPY cohort (25). Renal failure is a strong predictor of both in-hospital mortality and follow-up mortality (31). In our study, the mean creatinine value was significantly higher in very elderly with HF, which may be associated with poor outcome.
Study limitations
This study included only patients who were admitted to outpatient cardiology clinics and inpatient wards. Hence, the prevalence of HF is higher than in the population-based studies. This is thought to be the cause of selection bias and is one of the study limitations.
Very elderly who were followed up at outpatient wards were less frail and were functioning better, and we believe that this led to underestimated prevalence of cardiovascular disease and risk factors. In addition, some comorbidities lead to a reduced survival rate. This could also have caused underestimated prevalence of CAD and risk factors, such as DM.
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Conclusion
In this study, we provide a national database about the prevalence of cardiovascular diseases, risk factors, and comorbidities of a large population of Turkish elderly patients with HF and compare it with other large studies. Despite the high prevalence of comorbidities and risk factors, there is no evidence-based therapy for the treatment of very elderly with HF. Consequently, there is a need to develop more effective and targeted management strategies for this population.
*Clinical Investigators
Mutlu Çağan Sümerkan, MD (Department of Cardiology, Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey), Volkan Emren, MD (Afyonkarahisar State Hospital, Cardiology Clinic, Afyon, Turkey), Lütfü Bekar, MD (Department of Cardiology, Hitit University Çorum Education and Research Hospital, Çorum, Turkey), Sinan Cerşit, MD (Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, İstanbul, Turkey), Elif Tunç, MD (İzmir Military Hospital, Cardiology Clinic, İzmir, Turkey), Gurur Ulucan, MD (Department of Cardiology, Mevlana University, Konya, Turkey), Emine Altuntaş, MD (Bingöl State Hospital, Cardiology Clinic, Bingöl, Turkey), Uğur Canpolat, MD (Department of Cardiology, Hacettepe University, Ankara, Turkey), Namık Özmen, MD (Department of Cardiology, GATA Haydarpaşa Training Hospital, İstanbul, Turkey), Gönül Açıksarı, MD, (İstinye State Hospital, Cardiology Clinic, İstanbul, Turkey), Nazile Alım Doğan, MD (Menemen State Hospital, Cardiology Clinic, İzmir, Turkey), Şeyda Günay, MD (Tarsus State Hospital, Cardiology Clinic, Mersin, Turkey), Meltem Didem Kemaloğlu, MD (Antalya Atatürk Education and Research Hospital, Cardiology Clinic, Antalya, Turkey), Alper Buğra Nacar, MD (Department of Cardiology, Mustafa Kemal University, Hatay, Turkey), Süleyman Karakoyun, MD (Department of Cardiology, Kafkas University, Kars, Turkey), Sinan İnci, MD (Department of Cardiology, Aksaray State Hospital, Aksaray, Turkey), Bülent Özlek, MD (Manisa State Hospital, Cardiology Clinic, Manisa, Turkey), Onur Aslan, MD (Tarsus Education and Research Hospital, Cardiology Clinic, Mersin, Turkey), Derya Baykız, MD (Tekirdağ State Hospital, Cardiology Clinic, Tekirdağ, Turkey), Sabahattin Gündüz, MD (Department of Cardiology, Koşuyolu Kartal Heart Training and Research Hospital, İstanbul, Turkey), Sedat Koroğlu, MD (Necip Fazıl City Hospital, Cardiology Clinic, Kahramanmaraş, Turkey), Ayşen Helvacı, MD (Okmeydanı Training and Research Hospital, Cardiology Clinic, İstanbul, Turkey), Raşit Coşkun, MD (Bayburt State Hospital, Cardiology Clinic, Bayburt, Turkey), İsa Öner Yüksel, MD (Antalya Education and Research Hospital, Cardiology Clinic, Antalya, Turkey), Şükrü Çetin, MD (Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey), Mahmut Yesin, MD (Koşuyolu Kartal Heart Training and Research Hospital, Department of Cardiology, İstanbul, Turkey), Mustafa Ozan Gürsoy, MD (Gaziemir State Hospital, Cardiology Clinic, İzmir, Turkey), Sibel Çatırlı Enar, MD (Department of Cardiology, Türkiye Hospital, İstanbul, Turkey), Müjgan Tek Öztürk, MD (Department of Cardiology, Ankara Keçiören Training and Research Hospital, Ankara, Turkey), Aykut Yılmaz, MD (Siirt State Hospital, Cardiology Unit, Siirt, Turkey), Özcan Başaran, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Kaan Okyay, MD (Department of Cardiology, Başşehir University Medical School Ankara Hospital, Ankara, Turkey), Cengiz Öztürk, MD (Department of Cardiology, Gülhane Medical School, Ankara, Turkey), Oğuzhan Çelik, MD (Department of Cardiology, Hitit University, Çorum, Turkey), Emre Yalçınkaya, MD (Aksaz Military Hospital, Cardiology Clinic, Muğla, Turkey), Vedat Aslan, MD (Defne Hospital, Cardiology Clinic, Hatay, Turkey), Utku Şenol, MD (Bolvadin State Hospital, Cardiology Clinic, Afyon, Turkey), Fatih Mehmet Uçar, MD (Denizli State Hospital, Cardiology Clinic, Denizli, Turkey), Volkan Kozluca, MD (Denizli Server Gazi State Hospital, Cardiology Clinic, Denizli, Turkey), Ebru İpek Turkoğlu, MD (Kemalpaşa State Hospital, Cardiology Clinic, İzmir, Turkey), Cevat Şekuri, MD (Department of Cardiology, Kent Hospital, İzmir, Turkey), Mehmet Ertürk, MD (İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey), İbrahim Altun, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Erdal Belen, MD (Okmeydanı Training and Research Hospital, Cardiology Clinic, İstanbul, Turkey), Gökhan Aksan, MD (Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey), Erkan Yıldırım, MD (Department of Cardiology, Erzurum Region Training and Research Hospital, Erzurum, Turkey), Ahmet Sayın, MD (İzmir Tepecik Training and Research Hospital, Cardiology Clinic, İzmir, Turkey), Dursun Çayan Akkoyun, MD (Department of Cardiology, Namık Kemal University, Tekirdağ, Turkey), Abdullah Tunçez, MD (Department of Cardiology, Selçuk University, Konya, Turkey), Volkan Doğan, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Yusuf Emre Gürel, MD (Pendik State Hospital, Cardiology Clinic, İstanbul, Turkey), Selami Demirelli, MD (Erzurum Training and Research Hospital, Cardiology Clinic, Erzurum, Turkey), Çiğdem Koca, MD (Manisa Demirci State Hospital, Cardiology Clinic, Manisa, Turkey), Murat Biteker, MD (Department of Cardiology, Muğla University, Muğla, Turkey), Hasan Aydın Baş, MD (Isparta State Hospital, Cardiology Clinic, Isparta, Turkey), Feza Güzet, MD (Department of Cardiology, Surp Pirgic Armenian Hospital, İstanbul, Turkey), Gülten Taçoy, MD (Department of Cardiology, Gazi University Faculty of Medicine, Ankara, Turkey), Erdem Alpsoy, MD (Department of Cardiology, Namık Kemal University, Tekirdağ, Turkey), Turhan Turan, MD (Ahi Cihan Training and Research Hospital, Cardiology Clinic, Trabzon, Turkey), Vedat Davutoğlu, MD (Department of Cardiology, Gaziantep University, Gaziantep, Turkey), Alparslan Birdane, MD (Department of Cardiology, Osmangazi University, Eskişehir, Turkey), Ersel Onrat, MD (Afyon Kocatepe University, Cardiology Clinic, Afyon, Turkey), Mehmet Reşat Baha, MD (Osmaniye State Hospital, Cardiology Clinic, Osmaniye, Turkey), Sabiye Yılmaz, MD (Sakarya Training and Research Hospital, Cardiology Clinic, Sakarya, Turkey), Servet Altay, MD (Department of Cardiology, Trakya University, Edirne, Turkey), Mehmet Hayri Alıcı, MD (Gaziantep 25 Aralık State Hospital, Cardiology Clinic, Gaziantep, Turkey), İsmail Turkay Özcan, MD (Department of Cardiology, University of Mersin, Turkey), Görkem Kuş, MD (Antalya Training and Research Hospital, Cardiology Clinic, Antalya, Turkey), Gültekin Günhan Demir, MD (Department of Cardiology, İstanbul Medipol University Esenler Hospital, İstanbul, Turkey), Kadriye Memiç Sancar, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Muhammed Bora Demirçelik, MD (Department of Cardiology, Turgut Ozal University, Malatya, Turkey), Ahmet Yanık, MD (Samsun State Hospital, Cardiology Clinic, Samsun, Turkey), Atike Nazlı Akciğer, MD (Sinop State Hospital, Cardiology Clinic, Sinop, Turkey), Yeşim Hoşcan, MD (Antalya OFM Private Hospital, Cardiology Clinic, Antalya, Turkey), Kurşat Arslan, MD (Erzurum Education and Research Hospital, Erzurum, Turkey), Yılmaz Omur Otlu, MD (Kars State Hospital, Cardiology Clinic, Kars, Turkey), İsmail Şahin, MD (Ereğli State Hospital, Cardiology Clinic, Konya, Turkey), İbrahim Ersoy, MD (Isparta State Hospital, Cardiology Clinic, Isparta, Turkey), Dilek Çiçek Yılmaz, MD (Department of Cardiology, Mersin University, Mersin, Turkey), Kadir Uğur Mert, MD (Department of Cardiology, Muğla Sıtkı Koçman University, Muğla, Turkey), Perihan Varim, MD (Sakarya State Hospital, Cardiology Clinic, Sakarya, Turkey), Hatem Ari, MD (Department of Cardiology, Süleyman Demirel University, Isparta, Turkey).
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Acknowledgments
This study was supported by Turkish Society of Cardiology.
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Footnotes
Conflict of interest: None declared.
Peer-review: Externally peer-reviewed.
Authorship contributions: Concept – M.Z.; Design – M.Z.; Supervision – L.T.; Fundings – G.G.; Materials – S.K.; Veri collection &/or processing – Ü.Y.S.; Analysis &/or interpretation – Ü.Y.S.; Literature search – L.T.; Writing – G.G.; Critical review – S.K.
*On behalf of Elder-Turk study investigators
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