Background Advancing age is associated with a greater prevalence of coronary artery disease in heart failure (HF) with reduced ejection fraction and with a higher risk of complications following coronary artery bypass grafting (CABG). Whether the efficacy of CABG compared with medical therapy (MED) in patients with HF due to ischemic cardiomyopathy is the same in patients of different age is unknown. Methods 1212 patients (median follow up 9.8 years) with ejection fraction ≤35% and coronary disease amenable to CABG were randomized to CABG or MED in the STICH trial. Results Mean age at trial entry was 60 years; 12% women; 36% non-white; baseline EF 28%. For the present analyses, patients were categorized by age quartiles: Q1 ≤54 years, Q2 >54 and ≤60 years, Q3 >60 and ≤67 years, Q4 >67 years. Older vs. younger patients had more comorbidities. All-cause mortality was higher in older compared with younger patients assigned to MED (79 vs. 60% for Q4 and Q1, respectively; log-rank p=0.005) and CABG (68 vs. 48% for Q4 and Q1, respectively; log-rank p<0.001). In contrast, CV mortality was not statistically significantly different across the spectrum of age in the MED group (53 vs. 49% for Q4 and Q1, respectively; log-rank p=0.388) or CABG group (39 vs 35% for Q4 and Q1, respectively; log-rank p=0.103). CV deaths accounted for a greater proportion of deaths in the youngest vs oldest quartile (79% vs 62%). The effect of CABG vs MED on all-cause mortality tended to diminish with increasing age (pinteraction=0.062), while the benefit of CABG on CV mortality was consistent over all ages (pinteraction =0.307). There was a greater reduction in all-cause mortality or CV hospitalization with CABG versus MED in younger compared with older patients (pinteraction = 0.004). In the CABG group, cardiopulmonary bypass time or days in intensive care did not differ for older vs. younger patients. Conclusions CABG added to MED has a more substantial benefit on all-cause mortality and all-cause mortality and CV hospitalization in younger compared to older patients. CABG added to MED has a consistent beneficial effect on CV mortality regardless of age.

Aims Limited data on the uptake of guideline-directed medical therapies (GDMTs) and the mortality of acute decompensated HF (ADHF) patients are available from India. The National Heart Failure Registry (NHFR) aimed to assess clinical presentation, practice patterns, and the mortality of ADHF patients in India. Methods and resultsThe NHFR is a facility-based, multi-centre clinical registry of consecutive ADHF patients with prospective follow-up. Fifty three tertiary care hospitals in 21 states in India participated in the NHFR. All consecutive ADHF patients who satisfied the European Society of Cardiology criteria were enrolled in the registry. All-cause mortality at 90 days was the main outcome measure. In total, 10 851 consecutive patients were recruited (mean age: 59.9 years, 31% women). Ischaemic heart disease was the predominant aetiology for HF (72%), followed by dilated cardiomyopathy (18%). Isolated right HF was noted in 62 (0.6%) participants. In eligible HF patients, 47.5% received GDMT. The 90 day mortality was 14.2% (14.9% and 13.9% in women and men, respectively) with a re-admission rate of 8.4%. An inverse relationship between educational class based on years of education and 90 day mortality (high mortality in the lowest educational class) was observed in the study population. Patients with HF with reduced ejection fraction and HF with mildly reduced ejection fraction who did not receive GDMT experienced higher mortality (log-rank P < 0.001) than those who received GDMT. Baseline educational class, body mass index, New York Heart Association functional class, ejection fraction, dependent oedema, serum creatinine, QRS > 120 ms, atrial fibrillation, mitral regurgitation, haemoglobin levels, serum sodium, and GDMT independently predicted 90 day mortality. Conclusion One of seven ADHF patients in the NHFR died during the first 90 days of follow-up. One of two patients received GDMT. Adherence to GDMT improved survival in HF patients with reduced and mildly reduced ejection fractions. Our findings call for innovative quality improvement initiatives to improve the uptake of GDMT among HF patients in India.