Tafamidis treatment in octogenarians diagnosed with wild-type transthyretin cardiomyopathy (ATTRwt-CM) improves survival without age affecting treatment efficacy, although mortality remains considerable, according to an international cohort study published Feb. 26 in the European Heart Journal.

In light of the scare data on the impact of tafamidis among octogenarians diagnosed with ATTRwt-CM, Philippe Debonnaire, MD, et al., conducted the international, multicenter cohort study in a real-world population to evaluate its effect on the primary endpoint of all-cause mortality. They also examined the natural disease course and determinants of the response to tafamidis.

Of the 710 consecutive study patients with ATTRwt-CM, 58.5% were octogenarians (85±4 years, 74.2% male). Among those older than 80 years, the natural disease course was poor before tafamidis was available, with mortality at one year of 16% and 71% at 5 years, compared with 8% and 47%, respectively, among those younger than 80 years (p<0.001). The researchers found that after the drug became available, it was initiated in 70.1% of the octogenarians and 83.7% of the non-octogenarians (p<0.001). Moreover, discontinuation of the drug was similar between the two groups at 10.3 and 7.4%, respectively.

Results showed that unadjusted survival was higher in octogenarians treated vs. those not treated with tafamidis: 5% at one year and 24% at three years (p<0.001) over the mean 2.2 years of follow-up. In matched octogenarians, including for age, NYHA class and National Amyloidosis Centre (NAC) stage, tafamidis treatment was associated with a lower mortality (hazard ratio, 0.57; 95% CI, 0.33-1.01; p=0.053).

No interaction was observed between age at diagnosis and age at treatment initiation for the mortality benefit. Of note, survival was poorer when tafamidis was initiated in patients ≥90 years or with NAC stage ≥3.

The authors write that octogenarians "represent the vast majority of ATTRwt-CM patients" in real-world clinical practice, and that based on these findings tafamidis may be considered to improve survival in this population. Furthermore, work is needed to identify predictors of mortality to "rationalize the selection of optimal octogenarian treatment candidates."

In an accompanying editorial comment, Marianna Fontana, MD; Carlo Fumagalli, MS; and Francesco Capelli, discuss the growing need for a comprehensive geriatric assessment beyond age. "Validation of geriatric assessment tools and integration of a comprehensive assessment of geriatric syndromes into clinical practice will be essential for optimizing care in elderly patients with ATTRwt-CM."