Chief Investigator: Dr Eloise Radcliffe, Senior Research Fellow School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton

Team:

Dr Kinda Ibrahim, Associate Professor, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton

Dr Sara Mckelvie, Clinical lecturer, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton.

Dr Stephen Lim, Principal Clinical Research Fellow, Consultant Geriatrician, Medicine for Older People, University Hospital Southampton, Southampton General Hospital.

Dr Chris Young, Consultant Geriatrician, Medicine for Older People, University Hospital Southampton, Southampton General Hospital.

Dr Nina Fudge, Lecturer, Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London.

Dr James Sheppard, Associate Professor, Nuffield Dept of Primary Care Health Sciences, Medical Sciences Division, University of Oxford.

Mrs Clare Howard, Clinical Lead for Medicines Optimisation, Health Innovation Wessex.

Prof Simon Fraser, Professor of Public Health, School of Primary Care, Population Sciences and Medical Education,Faculty of Medicine, University of Southampton.

Dr Peter Cowburn, Consultant Cardiologist, University Hospital Southampton, Southampton, General Hospital.

Ms Rajneesh Kaur, Patient and carer representative .

Partners: University Hospital Southampton NHS Foundation Trust, University of Southampton, Health Innovation Wessex, Queen Mary University of London, University of Oxford.

Start: 1 October 2024

End: 31 March 2026

Background

Heart failure (HF) is a long-term disease with symptoms including breathlessness, tiredness and leg swelling. HF is more likely to affect older people and is the leading cause for hospital admission in the UK for those aged over 65 years. Most people with HF have other health conditions therefore taking multiple medication is common. Guidelines for doctors to treat HF recommending multiple medications to help improve symptoms and help people live longer, have led to concerns about further increases in numbers of medication for patients. The application of these guidelines in older adults has had the unintended problem of more complex medication regimes, and possible impacts on physical ability and quality of life. More generally, taking multiple medication can increase risk of side-effects, hospital admission and death for older people.

The research studies used to decide guidelines for doctors to treat HF, may underestimate the risks of taking multiple medicines as they do not include populations most vulnerable to potential harms such as older adults and those with  frailty. This leads to uncertainty about the long-term benefits and risks of HF medications in the very old and frail populations who are, nonetheless, still treated based on the guidelines.

Prescribing should ideally be tailored to each patient’s health condition and their preferences. These factors will change over time, supporting the need for regular medication reviews, and where appropriate, the need for reducing, stopping, or switching drugs in order to improve outcomes. However, this may be challenging due to the lack of research studies, as patients and multiple health care professionals involved in caring for older patients with HF, may experience uncertainty and have differing approaches to the application of the guidelines.

Aim

To examine research studies on prescribing and deprescribing of HF medication in older people, including those living with frailty. This will inform current guidelines for doctors to treat HF. It will also identify gaps in the research on this vulnerable group commonly prescribed HF medication, but at the greatest risk of experiencing harms linked with taking multiple medications.

Design and methods

Two literature searches will be carried out, guided by an information specialist librarian, following the established guidelines.

Patient, public and community involvement

This study has patient and public involvement (PPI) throughout. We will have PPI group of older people and carers living with HF, chaired by our PPI lead who is also a research team member and has contributed to study development. The group will contribute to the interpretation andcommunication of findings on a wider scale.

What did we find out?

•We found that there is very little research on prescribing for older people with heart failure, especially those aged over 75. No studies looked at frailty, which is important for understanding how well treatments work in this group. Very few studies reported on ethnicity, and none considered people’s socio-economic background. Only a small number included information about quality of life, and none were carried out in primary care settings.

•Overall, this means there is not enough good evidence to clearly understand the benefits of heart failure treatments for older people.

•Some medications may help, particularly a group called SGLT-2 inhibitors (also known as “gliflozins,” such as dapagliflozin), but it is difficult to say how much benefit they provide. In addition, side effects may make these treatments harder to tolerate and could increase the risk of harm for some patients.

•We found that for research on stopping or reducing (deprescribing) heart failure medications for older people is also limited. Stopping medicines during a sudden worsening of symptoms may be harmful. However, the available evidence is limited and varies in quality, and it does not properly consider people living with frailty. This highlights an important gap in research and a need for better evidence to guide safe treatment decisions.

What have we done with this new knowledge?

We have presented findings at the South West Society for Academic Primary Care conference in Oxford, and later in the year at the European Geriatric Medicine Society in France, and are publishing the results of the two systematic reviews in two peer-review widely read journals. We also plan to share the findings with We will share findings with the National Clinical Director for Prescribing in England, Prof. Tony Avery, and the British Geriatric Society (BGS) and present the findings to the South West BGS group. This will ensure the findings reach decision-makers who design and fund future clinical trials.

The impact of this research is in contributing to the evidence base and identifying critical gaps in knowledge about how heart failure medications are used in frail older populations. It highlights the underrepresentation of these groups in clinical trials and the limited evidence available to guide deprescribing. This will inform priorities for future research, while also supporting greater awareness among clinicians of the need for personalised, context-specific prescribing and shared decision-making. In the long-term this will contribute to safer prescribing, reduced medication-related harm, improved quality of life, and fewer avoidable hospital admissions.

What will we do next?

•This is a complex and challenging area of research. Our work has highlighted variation in approaches to prescribing, as well as differences in the challenges faced by healthcare professionals across disciplines and care settings.

•It is clear that further high-quality clinical trials are needed to address the important gaps we have identified—particularly the lack of robust evidence on prescribing and deprescribing for older people with heart failure who are living with frailty and multiple long-term conditions.

•We will share findings with the National Clinical Director for Prescribing in England, Prof. Tony Avery, and the British Geriatric Society (BGS) and present the findings to the South West BGS group.

•We hope our findings will contribute to the recent ongoing public debate on medicines optimisation in frail older people, and will shape and inform future research, supporting the development of clearer, more relevant evidence to guide care for this population.