Challenges of Managing Heart Failure in the Elderly

Prof. Dr. Magdy Abdel Hamid , MD , FSCAI

Professor of Cardiology

Faculty of Medicine, Cairo University

Heart failure (HF)

is the commonest reason for hospitalisation among older adults and a usual cause of readmission to hospital presenting a significant financial burden worldwide. The population over 65 years of age is exponentially increasing, and particularly very old people (over 85 years of age), so that all adult medicine will be more and more involved in the care of elderly people. Nevertheless elderly people with HF have not been well studied, and are generally not included in clinical trials. Age is an important predictor of 30-day and 1-year mortality in HF, and in elderly patientsthe management of the disease is complicated by comorbid diseases .

Ageing and Heart Failure

Ageing is associated with increased ventricular and arterial stiffness, diastolic dysfunction, increased blood pressure lability, reduced maximal heart rate and ability to increase cardiac output in response to increased demand. Blood pressure is more and more sensitive to filling pressure and load, while orthostatic hypotension (a fall in systolic blood pressure of 20 mmHg or more from lying to standing) is present in one-third of patients over the age of 65 years. The combination of ventricular and arterial stiffening contributes to pulmonary congestion in response to increased volume or pressure load. Additional relevant changes associated with advanced age

include decrease of glomerular filtration rate, reduced tubular transport, leading to reduced renal function and impaired capability to dilute urine and renal retention. Renal dysfunction correlates with the presence of HF and may limit the use of appropriate medications increasing the risk for toxic effects

Comorbid Diseases

One of the hallmarks of elderly patients is the increasing prevalence of multiple coexisting chronic conditions and geriatric syndromes, such as dementia, incontinence, falls and frailty. It has been estimated than more than two-thirds of patients with HF have two or more non-cardiac comorbidities, and more than 25% may have six or more concomitant diseases .

Common comorbidities include renal dysfunction, anaemia, chronic lung diseases, depression, arthritis, sensory and nutritional disorders.Renal dysfunction may be worsened by diuretics, angiotensin converting enzyme (ACE) inhibitors and may contribute to volume overload in persons prone to HF. Renal failure is associated with adverse outcomes, particularly in patients with HF.

Anaemia may be related to chronic diseases, such as renal diseases, malignancies or may be the consequence of treatments [aspirin, non-steroidal anti-inflammatory drugs (NSAID), warfarin] or inadequate intake (iron, folate, vitamin B12). It may increase symptoms and confers poor prognosis.

Chronic lung diseases may contribute to increased dyspnoea and exercise intolerance in elderly patients with HF. Plasma brain natriuretic peptide (BNP) may provide a reliable diagnostic tool to distinguish primary pulmonary symptoms.

Depression and social isolation (primarily because of the death of the spouse) may impair drug compliance and are associated with poor prognosis and increased hospitalisation rates.

Arthritis is a leading cause of disability in elderly people and is mainly treated with NSAID that may enhance renal sodium and water retention, antagonise the effects of diuretic and ACE inhibitors, and be responsible for gastrointestinal bleeding

Diagnostic Issues

Although the diagnosis of HF may be challenging in elderly patients, because atypical symptoms and presentations may be common in this age group, and comorbid conditions may mimic or complicate the clinical picture, diagnostic criteria do not change in elderly people.The definition of HF requires the presence of symptoms at rest or during exercise plus the objective evidence of cardiac dysfunction either systolic and/or diastolic, preferably by echocardiography. When the diagnosis is in doubt, the clinician should consider the response to treatments directed towards HF that may be confirmatory.Recently plasma BNP levels have acquired an increasing value in the diagnostic assessment of patients with unexplained shortness of breath.Although BNP levels may increase with age, especially in women, being less reliable than in younger patients, a BNP level < 100 pg/ml makes the diagnosis of HF unlikely, while a value > 400 pg/ml strongly suggest the diagnosis. On the contrary values between 100 and 400 g/ml may be not diagnostic.

Drug Therapy

Optimal management of HF includes control of risk factors, patient education, self-management and drug therapy. The goals of treatment are to relieve symptoms, improve the quality of life, reducing

hospitalisations and, when possible, prolonging survival.

General measures include the treatment of hypertension, diabetes and dyslipidaemia. Use of tobacco should be discontinued .Patients with a treatable, symptomatic coronary artery disease should undergo coronary revascularisation. Precipitating factors, such as anaemia, thyroid diseases, renal failure, infections and drugs (for instance NSAID) should be prevented and treated. Patients should restrict sodium intake (no more than 2000 mg daily) and total fluid intake. Monitoring of weights should be done, generally in the morning .Self-adjust of drugs, such as diuretics, should be recommended together with regular low-intensity aerobic exercise (e.g. walking, stationary cycling) three to five times per week. Patients should be given clear instructions about how and when to contact the physician to treat aggressively warning signs to prevent hospitalisations.

Drug therapy is not significantly different from that recommended in younger patients including (diuretics, ACEI or ARBs ,B blockers and mineralocorticoid receptor antagonists ) .Although clinical trials have generally excluded elderly people and patients with comorbid conditions , management still remains mainly empirical. On the contrary, the SENIORS study is a rare example of trial specifically

devoted to the study of elderly patients with HF. The trial was performed to assess the effects of the beta-blocker, nebivolol, in patients ≥ 70 years with HF regardless of ejection fraction. After a mean follow-up of 21 months, treatment with nebivolol decreased all-cause mortality or cardiovascular hospitalisation (HR 0.86, 95% CI 0.74-0.99; p = 0.039). Previous studies using beta-blockers (bisoprolol, carvedilol or metroprolol) demonstrated a decreased relative risk of death in HF in younger patients (excluding patients > 80 years) and focussed on those with low left ventricular ejection fraction (LVEF). The results of the SENIORS study reinforce current recommendations that beta-blockers should be given to all patients with HF regardless of age .

Diastolic Heart Failure in Elderly People

Diastolic HF is a clinical syndrome in which patients have symptoms and signs of HF with a normal or near normal left ventricular systolic function, and evidence of diastolic dysfunction (abnormal left ventricular filling and elevated filling pressures). Among patients with HF, 40-60% of cases may have a normal or near normal LVEF. The prevalence of diastolic HF increases with age. The prevalence of diastolic HF among patients with HF has been estimated 15%, 33% and 50% at ages < 50, 50-70 and > 70 years respectively .

Compared with those with systolic dysfunction, patients with diastolic HF are more likely to be older, female and hypertensive, less likely to have had a prior myocardial infarction or to be treated with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers.

The major causes of diastolic HF include hypertension with left ventricular hypertrophy (particularly in elderly people), hypertrophic cardiomyopathy, aortic stenosis with a normal LVEF, ischaemic heart disease, and restrictive cardiomyopathy, which can be idiopathic or caused by infiltrative heart diseases.

Asymptomatic diastolic dysfunction is more prevalent than symptomatic disease. Symptoms of diastolic HF do not differ significantly from those of systolic HF. Patients with diastolic HF had similar, although generally less severe, manifestations, such as reduced exercise capacity and impaired quality of life. The exercise intolerance is largely because of the impairment in left ventricular filling, which leads to elevations in left atrial and pulmonary venous pressures and pulmonary congestion. In addition, inadequate cardiac output during exercise is responsible for skeletal muscles fatigue.

The diagnosis of diastolic HF is generally made, or often presumed, in patients who have symptoms of HF and a normal LVEF by echocardiography. The electrocardiogram may be abnormal, showing left ventricular hypertrophy or a prior myocardial infarction, but is not diagnostic.

Among patients with normal left ventricular systolic function, symptoms suggestive of HF (such as shortness of breath, ankle oedema, or paroxysmal nocturnal dyspnoea) may be caused by disorders, such as obesity, lung disease, poorly controlled atrial fibrillation (AF), coronary ischaemia, volume overload (for instance renal failure) and increased afterload (for instance hypertensive crisis). These conditions should be considered in the differential diagnosis.

The treatment of diastolic HF is empiric, because trial data are lacking. Guidelines for treatment of patients with diastolic HF have been published in 2005 by the ACC/AHA task force on chronic HF, and the Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Management principles for patients with diastolic HF include the control of systolic and diastolic hypertension, as well as ventricular rate in patients with AF, maintenance of atrial contraction as much as possible, prevention of tachycardia, reduction of pulmonary congestion and peripheral oedema with diuretics, and treatment and prevention of myocardial ischaemia.

Control of blood pressure is the mainstay of therapy in patients with left ventricular hypertrophy caused by hypertension. Regression of hypertrophy

is an important therapeutic goal, because it may improve diastolic function. Although there is no definite evidence that more rapid regression of left ventricular hypertrophy is associated with improved long-term outcomes, angiotensin receptor blockers, calcium channel blockers, and ACE inhibitors have been shown to produce significantly more regression than beta-blockers.

The prognosis of patients with symptomatic diastolic HF is less well defined than in those with systolic HF. Similar data are available from the Framingham Heart Study, the V-HeFT trials and the Cardiovascular Health Study: diastolic HF is associated with a better prognosis than HF due to systolic HF but a worse outcome than matched controls (annual mortality 8-9% vs. 15-19% in systolic HF vs. 1-4% in matched controls). Older age, male gender, NYHA class, lower LVEF, the extent of coronary artery disease, peripheral vascular disease, diabetes, and impaired renal function are independent predictors of mortality.

Patients should be given clear instructions about how and when to contact the physician to treat aggressively warning signs to prevent hospitalizations.

Control of blood pressure is the mainstay of therapy in patients with left ventricular hypertrophy caused by hypertension.

Summary :

Ageing may predispose elderly people to heart failure, which is the commonest reason for hospitalisation and readmission among older adults. Diagnosis may be challenging, because atypical symptoms and presentations are common, and comorbid conditions may mimic or complicate the clinical picture. Clinical trials have systematically excluded elderly patients and those with comorbidities, thus drug treatment largely remains empiric, and is not significantly different from that recommended in younger patients.