Dr. David T. Kelly, University of Sydney, Australia, discussed the demographics and management of heart failure, focusing the medical challenges of treating the aging population. The prevalence of heart failure is increasing globally due to population aging and its successful treatment leading to increased numbers of patients with heart failure living longer and needing continuing management.

Figure 1. Estimated Resident Population of Japan 【Click to enlarge】

Global population projections estimate that the numbers of people over 65 years will dramatically increase from 1990 to 2020. The elderly population in Asia is rapidly increasing, with a huge increase in the population aged ≥80 years that is expected to continue increasing (Figure 1). By the year 2030 the number of Japanese females ≥ 80 years is expected to be double that of males in the same age group. The number of people in Japan ≥80 years increased from about 500,000 in 1950 to more than 6,000,000 in 2010 and is expected to increase to about 12,000,000 in 2050. Compared to the US, Australia, and China, the percentage of the population over 65 is increasing much more rapidly in Japan.

Figures from the World Bank show that annual deaths due to circulatory diseases in developing countries are rapidly increasing, while deaths in developed countries are only slightly increasing. In addition to population aging, other factors leading to increased prevalence of heart failure are the lifestyle changes associated with urbanization, the decrease in other causes of death, and better medical management.

In 1970 about one-quarter of India’s population lived in urban settings; this is expected to increase to about one-half of the population by 2030. Lifestyle changes altered by urbanization include increased physical inactivity, diet changes, and increased smoking, leading to increased obesity, hypertension, and diabetes, all risk factors for heart failure.

Figure 2. CHD Mortality, Australia 1970, 2000 & Projected to 2030 【Click to enlarge】

An epidemiological transition has occurred from 1970 to the present—the mortality of acute myocardial infarction (AMI) has declined faster than that of overall coronary disease. Possible reasons for this include the advent of coronary care units, therapeutic and interventional management of CVD, and prevention. For example, in Australia the mortality rate from MI in people under 65 years decreased from about 35% in 1970 to less than 20% in 2000. In people over 65, mortality due to MI increased from more than 70% in 1970 to almost 90%. This trend is expected to continue for the next 30 years (Figure 2).

All of these data indicate that the number of patients who will need to be treated for heart failure is increasing rapidly worldwide. In this epidemiological transition, increasing age and better treatment of coronary disease and hypertension is leading to more heart failure in the elderly than in younger people. In Asia there is less coronary disease and more hypertension, while in the rest of the developed world there is a balance between the two.

Data from the Framingham study illustrate that heart failure is basically a disease of old age, rising from 1% prevalence in people in their 50s to 10% in people in their 80s. Prior to the availability of ACE inhibitor therapy, 50% of people with heart failure died in one year. In the carvedilol heart failure trial, even the placebo arm had 90% survival, while the carvedilol arm had about 95% survival. Many other trials reported similar results, indicating that medical treatment for heart failure has vastly improved.

According to Dr. Kelly, a big problem is the difference between patients in heart failure trials and those seen in everyday practice. Heart failure trials enroll mostly men who are about 60 years old, while the patients who present with heart failure are mostly women over the age of 75. The clinical status of patients in clinical trials is stable, while it is unstable in practice. Patients in clinical trials have few comorbidities, while those in practice have more comorbidities because of their advanced age. In clinical trials treatment is controlled, optimal, and better defined; in practice it is variable and generally sub-optimal. The etiology of heart failure in clinical trial patients generally is ischemia versus hypertension in practice. Heart failure in clinical trial patients usually is systolic, while in practice it more often is diastolic. All of the treatment recommendations are based on the clinical trial data. The issue is whether the trial data are relevant when the patient population is so different. Further, heart failure in the very old is a completely different disease than it is in middle aged people.

In a 2000 survey of heart failure in 1,058 patients in 120 French hospitals, the median age was 76 and 45% of the patients were women. The ejection fraction was >40% in 53% of the patients, suggesting diastolic heart failure. Framingham study data showed that community mortality from heart failure is quite different from that in trials, at 17% at 1 year, 30% at 2 years, and 78% at 10 years.

Thus, in clinical practice, the patient population with heart failure is quite different. The clinical diagnosis of heart failure is not accurate and often is difficult. Investigation of heart failure in the elderly is minimal. Adequate therapy usually is not given and the dosages are low due to comorbidities in the elderly.

Figure 3. Baseline Projections of GDP Per Capita by Region, 1990-2020 【Click to enlarge】

The management of heart failure in the very elderly population is much different than in younger patients. It is broad in scope and multi-disciplinary in nature because of comorbidities. The focus is on quality of life and the patient’s independence, rather than hospitalization. Optimal therapy has not been identified and the prognosis is poor, with a 2-year survival of 50%. Additionally, management is very expensive. The period of time that the elderly need medical treatment is increasing, causing greater expense for heart failure management. World Bank baseline projections of GDP per capita in world regions (1990-2020) indicates much higher and more rapidly rising GDP in the established market economies compared with other regions (Figure 3). According to Dr. Kelly, much of the world will not have the resources needed to manage heart failure in the elderly. 

The most important future challenge in managing heart failure is the aging of the population, which is increasing the prevalence. Management favorably alters prognosis and paradoxically increases the number of patients who need treatment and the length of time they need to be treated. Trial data needs to be reconciled with the realities of actual practice. Finally, therapy in the aged needs to be evaluated, especially for those with diastolic heart failure.