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Polypharmacy in Older Heart Failure Patients: a Multidisciplinary Approach

  • Comorbidities (J. Tromp, Section Editor)
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Abstract

Purpose of Review

We provide a review of considerations when applying principles of optimal pharmacotherapy to older adults with heart failure (HF), an analysis on the pivotal clinical trials focusing on applicability to older adults, and multi-disciplinary strategies to optimize the health of HF patients with polypharmacy.

Recent Findings

Polypharmacy is very common among patients with HF, due to medications for both HF and non-HF comorbidities. Definitions of polypharmacy were not developed specifically for older adults with HF and may need to be modified in order to meaningfully describe medication burden and promote appropriate medical therapy. This is because clinical practice guidelines for multi-drug HF regimens have unique considerations, given that they improve outcomes and symptoms of HF.

Summary

Adults older than 65 years are well represented in contemporary clinical trials for HF with preserved ejection fraction (HFpEF) and guideline directed medical therapy (GDMT) for HF with reduced ejection fraction (HFrEF). While these trials did not have significant heterogeneity in safety or efficacy across a broad age spectrum, some may have limited representation of adults ≥ 80 years old, the sickest older adults, or those with decreased functional status. There is also a lack of data on the safety and efficacy of deprescribing HF medications, and deprescription in otherwise stable patients may lead to clinical destabilization or disease progression. There is therefore innate tension between the well-studied benefits of optimized HF therapy for older adults that must be weighed against the risks of polypharmacy and many unknowns that still exist. Given the strong evidence that optimized HF therapies confer symptomatic and mortality benefits for older adults, it is clear that polypharmacy in this context can be appropriate. A shift in paradigm is therefore needed when evaluating polypharmacy in patients with HF. Instead of assuming all polypharmacy is “good” or “bad,” we propose a concerted move, using a multidisciplinary approach, to focus on the “appropriateness” of specific medications, in order to optimize HF medical therapy. Clinicians of all specialties caring for complex older adults with HF must consider goals of care, functional status, and new evidence-based therapies, in order to optimize this polypharmacy for older adults.

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Authors and Affiliations

  1. Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Smrithi Sukumar & James L. Januzzi

  2. Department of Medicine, VA Boston Healthcare System, Boston, MA, USA

    Ariela R. Orkaby & Haider J. Warraich

  3. New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA

    Ariela R. Orkaby

  4. Division of Aging, Brigham & Women’s Hospital, Boston, MA, USA

    Ariela R. Orkaby

  5. Department of Medicine, UC San Francisco, San Francisco, CA, USA

    Janice B. Schwartz

  6. UW School of Pharmacy, University of Washington, Seattle, WA, USA

    Zachary Marcum

  7. Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Muthiah Vaduganathan & Haider J. Warraich

  8. Boston, MA, USA

    Haider J. Warraich

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Conflict of Interest

AO is supported by VA CSR&D CDA-2 award IK2-CX001800 and NIA GEMSSTAR award R03-AG060169. HW is an advisor for Embrace Prevention Care. MV is supported by the KL2/Catalyst Medical Research Investigator Training award from Harvard Catalyst (National Institutes of Health [NIH] National Center for Advancing Translational Sciences Award UL 1TR002541); serves on advisory boards for Amgen, AstraZeneca, Baxter Healthcare, Bayer AG, Boehringer Ingelheim, Cytokinetics, and Relypsa; and has participated on clinical end point committees for studies sponsored by Novartis (including the PARAGON-HF trial) and the NIH. JJ is supported by the Hutter Family Professorship; is a trustee of the American College of Cardiology; is a board member of Imbria Pharmaceuticals; has received grant support from Abbott Diagnostics, Applied Therapeutics, Innolife, and Novartis; has received consulting income from Abbott Diagnostics, Boehringer Ingelheim, Janssen, Novartis, and Roche Diagnostics; and participates in clinical end point committees/data safety monitoring boards for AbbVie, Siemens, Takeda, and Vifor.

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Sukumar, S., Orkaby, A.R., Schwartz, J.B. et al. Polypharmacy in Older Heart Failure Patients: a Multidisciplinary Approach. Curr Heart Fail Rep 19, 290–302 (2022). https://doi.org/10.1007/s11897-022-00559-w

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