Older Adults See Rebound in Rates of HF-Related Death: CDC Data

Deaths related to heart failure (HF), having decreased from 1999 to 2012, are again on the rise among US adults ages 75 and older, according to an analysis of Centers for Disease Control and Prevention (CDC) data spanning two decades.

Mortality was higher in men than women and highest among non-Hispanic white adults versus other racial/ethnic groups overall between 1999 and 2019.

Researcher Muhammad Shahzeb Khan, MD (Duke University School of Medicine, Durham, NC), pointed out to TCTMD that the results stand in contrast to earlier findings in adult patients under age 45. In the younger group, Khan and colleagues found Black patients had not only the highest HF mortality but also the sharpest increase in risk over the years.

“Among the younger patients with HF, the proportion of Black individuals that I see in my clinical practice is very high compared to the older populations,” where prevalence is much more spread out among various racial/ethnic groups, said Khan.

It may be that many Black patients susceptible to dying of HF are doing so before they reach the age of 75, which would translate into a higher prevalence of white patients above that cutoff, he explained. “I think [the pattern] might be due to survival bias that we’re seeing.”

For him, the biggest takeaway from the mortality trends in the over-75 group is that “it’s imperative that we start them on updated [guideline-directed medical therapy] to the maximal possible dose and all the foundational therapies for heart failure,” Khan said. He cautioned against “clinical inertia” and urged against taking the perspective of: “Don’t rock the boat . . . because they’re older patients, they’re frail patients, they have a lot of comorbidities.”

Led by Tariq Jamal Siddiqi, MD (University of Mississippi Medical Center, Jackson), the paper was published this week in JACC: Heart Failure.

CDC WONDER: 1999-2019

Using the CDC’s Wide-Ranging Online Data for Epidemiologic Research (WONDER) platform, the researchers analyzed 5,014,919 HF-related deaths that occurred among adults 75 and up between 1999 and 2019.

Age-adjusted mortality per 10,000 persons decreased overall from 141.0 in 1999 to 108.3 in 2012, for an annual percent change of -2.1%. Mortality then rose, by 1.7% annually, to 121.3 per 10,000 persons in 2019.

Across the 20-year study period, men and non-Hispanic white individuals stood out as having higher age-adjusted mortality.

HF-Related Deaths in Adults ≥ 75

There also were regional differences in age-adjusted mortality, which was highest in the Midwest (133.9 per 10,000 persons), followed by the South (119.2), West (116.3), and Northeast (113.5). The riskiest states were Mississippi, Oklahoma, West Virginia, Oregon, and Indiana, which had twice as many HF-related deaths as those in the lowest-risk states. Moreover, nonmetropolitan areas had higher death rates than did cities (147.0 vs 115.2).

“These data should be used as impetus to redouble efforts to prevent and treat HF among older adults. Such older populations with HF are particularly vulnerable to underuse of evidence-informed therapies, and sensitivities over polypharmacy, frailty, or perceived risks of intolerance or side effects may curtail use,” the investigators write.

“However,” they continue, “any such concerns should be balanced with data from randomized clinical trials highlighting that contemporary disease-modifying therapies show consistent efficacy and safety across the spectrum of age, with greater absolute risk reductions among older adults.”

Khan acknowledged that the WONDER database derives its information from death certificates and can’t provide details that would give additional clues on what’s driving HF mortality. Possibilities might include differences related to preserved or reduced ejection fraction, lab abnormalities, access to primary care, and comorbidities like hypertension and diabetes, he suggested. “Population-based studies that look into multiple other factors would be very valuable to give us precise reasons we are finding these trends.”