Heart Failure in Older Adults: Medical Management and Advanced Therapies
Round 1
Reviewer 1 Report
Overall, this is well-written review adressing an important issue.
Unfortunately, the review does not (and, based on the data, cannot) offer a real solution to the problem that older people are underrepresented in the studies and therefore the guideline does not fit older people. Nevertheless, it is important to draw attention to this problem.
It would be beneficial to include more strongly for which subgroups (fail vs non-frail etc) there is evidence for or against specific HF therapy.
In addition, the procedure for the preparation of the review should be specified (database, selection of paper, MESH, etc.) to avoid bias in the selection of literature.
Minor:
110 f- "Studies have shown that benefit from the addition of a defibrillator
chemic cardiomyopathy". Please detail the reasons and the reference study.
119: "Patients often do not completely understand the benefits" Please provide reference for this
So what is your conclusion in terms of ICD in older adults?
Author Response
Manuscript ID: geriatrics-1624714
Type of manuscript: Review
Title: Heart Failure in Older Adults: Medical Management and Advanced Therapies
Authors: Ellen Liu, Brent C Lampert *
Reviewer #1:
Overall, this is well-written review addressing an important issue.
Response: Thank you for the kind feedback.
Unfortunately, the review does not (and, based on the data, cannot) offer a real solution to the problem that older people are underrepresented in the studies and therefore the guideline does not fit older people. Nevertheless, it is important to draw attention to this problem.
It would be beneficial to include more strongly for which subgroups (fail vs non-frail etc) there is evidence for or against specific HF therapy.
Response: Thank you for this comment. We agree this is an important topic with limited evidence to guide decision making. In light of the limited evidence we are not able to provide generalizable prescriptive strategies, but added the following to draw more attention and serve as a guide for this problem (lines 313-319) “Frail patients in particular may benefit from the aforementioned deprescribing strategy described above. This should especially be considered if medical therapy contributes to orthostatic symptoms or fatigue that limits physical rehabilitation or pill burden limits oral intake contributing to malnutrition. Unfortunately, no evidence currently exists to guide which medications to prioritize for deprescribing. Individual patient priorities and comorbidities should therefore influence medication changes.”
In addition, the procedure for the preparation of the review should be specified (database, selection of paper, MESH, etc.) to avoid bias in the selection of literature.
Response: Thank you for this comment. To clarify this we have added the following to our introduction section (lines 50-53) “This review was developed through extensive PubMed search and review of pivotal trials of guideline directed medical and device therapy for heart failure with specific focus on those addressing the geriatric population, polypharmacy, cognitive decline, and frailty.”
Minor:
110 f- "Studies have shown that benefit from the addition of a defibrillator
chemic cardiomyopathy". Please detail the reasons and the reference study.
Response: Thank you for this comment. We have modified this section to state (line 112-118): “From a mortality standpoint, the etiology of cardiomyopathy likely drives the benefit older patients receive from the addition of a defibrillator to resynchronization therapy. A study by Wang et al. found no difference in survival benefit in patients ≥75 years old with non-ischemic cardiomyopathy. Gras et al. evaluated patients with ischemic and non-ischemic cardiomyopathy and found improved all cause death in patients >75 years old with ischemic cardiomyopathy whereas no benefit was seen in those with non-ischemic cardiomyopathy”
119: "Patients often do not completely understand the benefits" Please provide reference for this
Response: Thank you for this comment. To our knowledge, there is not research to validate this assumption. We removed the sentence to not cause any confusion.
So what is your conclusion in terms of ICD in older adults?
Response: Thank you for this comment. We have added the following statement (lines 131-133): “It would be reasonable to pursue placement of an ICD in an older patient with a life ex-pectancy greater than one year and meaningful quality of life.”
Reviewer 2 Report
Excellent review on Heart Failure in Older Adults: Medical Management and Advanced Therapies
Well written and well structured
Needs not further changes in my opinion
Author Response
Reviewer #2:
Excellent review on Heart Failure in Older Adults: Medical Management and Advanced Therapies
Well written and well structured
Needs not further changes in my opinion
Response: Thank you for your review and kind feedback.
