Reducing heart failure deaths by 25% in 25 years: the ‘25in25’ heart failure summit

Heart failure (HF) is a major cause of morbidity and mortality in older people, and 80% of people with HF are aged over 60 years. HF is the end point for almost all common cardiovascular diseases, as well as many non-cardiovascular diseases. Despite this, HF remains underdetected and undertreated. Detection and treatment of HF has improved significantly in recent years, with several novel treatments developed in the last decade improving outcomes for patients. Therefore, earlier detection and improved treatment of HF has the potential to reduce morbidity and mortality for older people, particularly given the shift in ageing demographics anticipated over the coming decades. The British Geriatrics Society Cardiovascular Specialist Interest Group recently participated in the British Society for Heart Failure (BSH) ‘25in25’ Heart Failure Summit, which aims to reduce deaths due to HF by 25% in the next 25 years. The 2023 summit comprised experts from over 45 top health organisations across Europe, Canada and the US. The summit brought together cross-disciplinary expertise to support the implementation of strategies to improve outcomes for people living with HF, and, in this commentary, we reflect upon the priorities identified. We discuss the current barriers to the early detection and management of HF, and the particular challenges and complexity of managing HF in older people. Finally, we discuss the role of patient empowerment and how this can lead to improved care for older people living with HF.

Introduction

Despite notable advances in care, cardiovascular disease remains a leading cause of morbidity and mortality in the UK.¹ Currently, about one million people in the UK are living with heart failure (HF), and the prevalence increases significantly with age.¹ There is a strong relationship between HF and increasing age, with 80% of all cases occurring in those aged over 60 years.¹ Although mortality from HF has declined, the number of people living with disability has increased, particularly among older people.² Moreover, about 385,000 people are living with undiagnosed and untreated HF, and people can wait up to three years for a diagnosis.^1,2 There have been several advancements in the detection and management of HF in the last decade, but many people are not afforded these due to a lack of early detection and diagnosis.³ This leads to a significant burden of untreated disease, with important health, economic and social consequences for the individuals, their carers and society as a whole. Given the number of people aged over 80 years is set to double in the next 25 years,¹ this problem will only become more acute. This emerging heart failure crisis led to the ‘25in25’ summit, led by the British Society for Heart Failure (BSH) and hosting over 45 organisations internationally, which aims to reduce deaths in HF by 25% in the next 25 years. Below, we consider the main challenges associated with detection and management of HF in older people, and how this can be tackled.

Challenges in detection and management

Diagnosis

People living with HF commonly experience multiple long-term conditions and frailty.^3,4 This can often make a diagnosis of HF challenging, as patients have comorbid conditions, such as chronic obstructive pulmonary disease, anaemia, atrial fibrillation and chronic kidney disease, which may mask the symptoms of heart failure.⁴ This is compounded by cognitive impairment, commonly associated with HF, making clinical history challenging to elicit the symptoms of HF.⁵ Many older people experience significant polypharmacy as a result of multi-morbidity, with drug interactions and side effects both contributing to, and masking, HF symptoms.⁵

Almost all patients (98%) living with HF have at least one associated chronic or long-term condition, such as type two diabetes or hypertension.¹ However, older people living with HF, chronic multi-morbidity and frailty may have different treatment priorities, and a balance between disease management, risk reduction and quality of life must be sought through holistic and patient-centred care.⁶

Currently, about 80% receive a diagnosis of HF during an acute hospital admission,⁷ however, approximately 40% of these patients are seen prior to admission in primary care with symptoms consistent with HF.⁷ This represents a significant missed opportunity for earlier diagnosis and treatment, before decompensation occurs. Patients who are admitted for HF also have a high mortality risk, with 30% dying within one year of admission.⁸ This clearly has significant financial implications, and earlier diagnosis and management in the community has the potential to reduce economic burden associated with hospitalisation through improved disease management.³

Frailty

Frailty is a state of increased vulnerability to poorer health outcomes for people of the same chronological age.⁹ Frailty is common in people living with HF, with studies estimating the prevalence to be as high as 79%.¹⁰ Pooled data from clinical trials have estimated a prevalence of about 60%,¹¹ but this is likely to be greater among community dwelling individuals.¹² Data from trials and epidemiological studies suggest poorer health outcomes for those with greater frailty, such as higher rates of mortality and hospitalisation.^12,13 Despite this, evidence suggests that frail patients still benefit from active treatment, and may have greater gains than non-frail patients. In a pre-specified subgroup analysis of the DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure) trial, participants with preserved ejection fraction and high frailty had less favourable outcomes (worsening of heart failure or cardiovascular death).¹³ However, benefits from treatment with dapagliflozin remained consistent across levels of frailty, and improvements in quality of life were greater and occurred earlier in those with higher frailty.¹³ Similarly, in a study of supervised aerobic exercise training in patients with stable heart failure with reduced ejection fraction, hospitalisation was lower among frailer patients receiving the intervention.¹⁴ This relationship is more ambiguous for invasive cardiac procedures. In patients who underwent left ventricular assist device implantation or heart transplantation, frailty was associated with greater morbidity and mortality.¹⁵ However, in a subgroup who survived, frailty was either partially or wholly reversible, suggesting that certain patients with frailty may selectively benefit from more intensive intervention and management.¹⁵

BGS Cardiovascular Specialist Interest Group recommendations to the ‘25in25’ summit

Integrated care

HF rarely occurs in isolation, particularly among older people, and many patients experience several chronic, long-term conditions.¹ The majority of readmissions for HF are due to comorbidities, rather than HF itself.¹⁶ Therefore, people living with HF need joined-up care, using an integrated approach to assessment and treatment, rather than treating individual conditions in silos. Treatment should follow a multi-disciplinary approach involving HF clinical nurse specialists, dietitians, pharmacists, geriatricians/cardiogeriatricians, cardiologists, palliative care, community urgent care response, reablement and rehabilitation teams. In particular, geriatricians should be involved earlier in the patient journey to facilitate advanced care planning, optimising comorbidities, rationalising medications, healthy living advice, functional support and psychological assessment and wellbeing.

Recognising frailty

Levels of frailty are high among people living with HF,¹⁰ and can modulate treatment outcomes, although the relationship is not always straightforward.¹⁵ Frailty has a predictive power beyond its comorbidity components.⁷ We advocate for recognition and grading of frailty using standardised tools, such as the Clinical Frailty Scale,¹⁷ in all patients with HF. This will allow healthcare professionals to appreciate the complexity of the patient and consider individualised care needs and planning using a holistic, patient-centred approach.

Patient empowerment

We need to empower patients with HF by listening to them and prioritising their needs as an individual. Preferably, we would advocate for the use of comprehensive geriatric assessment (CGA) or holistic care for older people living with HF. Given the complexity associated with frailty, HF, and multi-morbidity, these patients need more time for clinical assessments to fully appreciate their needs and treatment goals. Patients should be included at all stages of the decision-making process to promote patient-centred care, and allow their voices to be heard. Empowering patients should promote independence and self-management at home. Critically, treatments and their potential impacts need to be discussed in more detail, with consideration of all the available options to allow patients to make informed decisions about their care.

Population level, services and interventions

We proposed that population-based, proactive, anticipatory care is used for older people living with HF, and appointment of a specific person to sit on each commissioning board to advocate for the health and social care of older people and their carers. New systems should use co-design approaches, with patients and carers as equal partners, to monitor the impact. In particular, access to healthcare should be facilitated using integrated and multi-disciplinary ‘one-stop’ clinics in the community to reduce appointment fatigue and avoid duplications in care. Patient-initiated follow-up can be used to reduce unnecessary visits to hospital and support patient’s autonomy.

Clinics should focus on the use of tailored interventions, such as exercise (particularly strength and balance training), adequate nutrition, and structured medication reviews to optimise appropriate polypharmacy; promote independence and recovery at times of transition from hospital and after illness; and conduct advanced care planning. Services should provide opportunities for shared decision-making based on priorities for their care, increased opportunities for carers to ‘dial in’ and participate, and for multi-professional input in a single appointment. Given the emergence of remote technology since the COVID-19 pandemic, a hybrid model that utilises the benefits of remote telehealth, while embracing face-to-face one-stop clinic models, will allow improved access to care, particularly in remote or rural communities. Figure 1 summarises these proposals.

Discussion

In summary, HF remains underdiagnosed and undertreated, with significant personal, societal, and economic consequences. Older people living with frailty and multiple long-term conditions have complex care needs that are best addressed through a holistic and multi-disciplinary approach. We have outlined a series of proposals that advocate the use of integrated care and shared decision-making. To build on these proposals, we suggest a listening exercise coordinated by the British Geriatrics Society and British Society for Heart Failure should be conducted to ask older people how they could be better empowered to manage their care and be involved in care decisions. Services should be designed to improve access to care, using ‘one-stop-shop clinics’ and community-based care. Services should follow the guiding principles of CGA in their approach to older people living with HF and take a patient-centred approach that takes into account the patient’s values and priorities.

Key messages

• Older people living with heart failure have high rates of comorbidity and polypharmacy
• Assessment of older people living with heart failure should be holistic and encompass patient priorities
• All patients should be assessed for frailty using a validated measure to guide treatment decisions and advanced care planning
• A multi-disciplinary team approach that is patient centred, promotes independence, and self-management should be advocated
• Community-based initiatives that reduce appointment burden and use remote consultations require further investigation

Conflicts of interest

CB receives honoraria for advisory boards, educational events, presentations at meetings, and congresses from the following pharmaceutical companies: AstraZeneca, Pharmacosmos, Medtronic, Novartis, Alnylam. LB, RJ, SR-Z: none declared.

Funding

LB is an Academic Clinical Lecturer funded by the National Institute for Health Research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.

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