Heart surgery in the elderly

Heart surgery has been performed in an increasing number of elderly patients in the recent years. Currently about 20 % of all patients in cardiac surgery are older than 75 years, however their number is increasing constantly. Valve replacement (mainly aortic valve replacement, AVR), coronary artery bypass grafting (CABG) or combined procedures (AVR and CABG) are the most common procedures in the elderly. However, surgical therapy of heart failure, implantation of assist devices or cardiac transplantation have been performed only in a limited number of elderly patients. Surgical pathways in the therapy of coronary artery disease or valve disease are described. Furthermore, age related morbidity and mortality and related surgical options to improve the outcome are discussed.     

Mitral valve surgery in elderly patients]

The increase in life expectancy results in a larger number of elderly patients with mitral valve pathology requiring surgical correction. Generally speaking, the indications for surgery are identical to those which apply to other age groups, but the greater incidence of mortality and, especially, of morbility make a degree of selectivity advisable. More than with any group, it is important to consider the risk: benefit ratio. However, in the majority of cases, it is possible to optimise the clinical condition of the patients with a significant decrease in risk. One of the most controversial aspects is that of the advantages or disadvantages of mitral valvuloplasty vs. prosthetic replacement. Although the eventual lower durability of the valvuloplasty might be considered a contraindication, because of the risk of reintervention at a later age, I believe that valvuloplasty is also preferable in elderly patients. This is confirmed by the well known fact that mitral valvuloplasty for myxomatous mitral regurgitation, prevailing in this age group, has the most durable results among all types of pathology. In the last 10 years, 433 patients above 70 years of age (11.6% of the total) were subjected to valvular surgery in Coimbra. Valvuloplasty was possible in more than 90% of the cases of mitral valve surgery. The mortality was only 2.6%, but significantly higher than that observed in younger patients (0.8%). In conclusion, mitral valve surgery in elderly patients is feasible with acceptable mortality and morbidity, but pre-operative optimization of the patients is essential.     

Heart surgery and human immunodeficiency virus]

The authors report their experience of cardiac surgery in 9 carriers of the human immunodeficiency virus (HIV). Eight HIV seropositive patients underwent surgery under cardiopulmonary bypass for valve repair or replacement. Eight patients were asymptomatic with respect to their viral infection: one patient had generalised lymphadenopathy. The hospital mortality was 1/9 (11.1%). There was no infectious morbidity. Five patients are alive with an average follow-up of 29.6 months and in NYHA Stages I or II. One patient deteriorated and presented symptoms of an AIDS-related complex. These results suggest that if the operative indications are justified, cardiac surgery under cardiopulmonary bypass may be performed in asymptomatic HIV seropositive patients.     

Heart failure in the elderly

Heart failure (HF) is a major disease of the elderly. Since their symptoms of HF are generally light, on admission of the hospitals HF is sometimes in an advanced stage. Therefore, preventive medicine for those with the risk factors of HF is needed as a future strategy of cardiac gerontology. The routine assessment of the HF severity may be performed noninvasively by Nohria's profiles rather than other invasive methods. HF is worsened by the interaction with the co-morbidity factors, such as renal dysfunction and anemia. The interaction between HF and kidney disease (and anemia) is called 'cardiorenal (anemia) syndrome.' Recurrent hospitalization due to HF is common, and the period of hospitalization tends to be long in this syndrome. One of the hopeful therapeutic agents is carperitide, a recombinant human atrial natriuretic peptide. In cardiorenal syndrome, much lower initial doses of carperitide, such as 0.0125 microg/kg/min is recommended for treatment of HF in order to avoid possible worsening of renal dysfunction. In cardiorenal anemia syndrome, supplement of iron, careful blood transfusion in severe cases, administration of recombinant human erythropoietin, should be performed if indicated. However, the possibility of anemia unrelated to HF, such as due to gastrointestinal carcinoma, is also considered in the elderly. In such cases, finding a decrease of serum ferritin preceding that of hemoglobin may contribute to a differential diagnosis of anemia in elderly HF patients. Thus, the therapies considering several features of HF in elderly will contribute to improving quality of life and outcome.     

老年人心力衰竭

心力衰竭（心衰）是老年人常见和主要的疾病。老年人心血管系统及其他脏器结构与功能均呈老龄性变化。心脏储备能力下降,易患高血压、冠心病等多种心血管疾病;同时常又合并多器官疾病。在感染、心肌缺血等多种诱发因素作用下,极易发生心力衰竭。但临床症状较为复杂、多变,且有时又不典型,因此极易误诊或漏诊,故必须及时做出准确的诊断与治疗。老年人心衰必须采用综合治疗措施,并遵循个体化的治疗原则;加强对治疗的指导与管理,缓解症状、提高生活质量、改善预后。     

Heart insufficiency in the elderly

Congestive heart failure in the elderly differs from the one in the younger. The ageing of the cardiovascular system makes the organism weaker. When a myocardial infarction or an other cardiovascular disease happens, the occurrence of congestive heart failure is precipitated. The symptoms which are often misleading and the polypathologies make the assumption of relationship difficult between a symptom like dyspnea and congestive heart failure. Further examinations are limited because of the reduced physical performances in the elderly (stress test) or because of an increased risk of side-effects (coronary angiogram). The echocardiography has a central role in the exploration of congestive heart failure. The medical treatment has the same principles than in the younger but with cautions especially regarding the renal insufficiency and the multiple treatments that an elderly patient has.     

Heart failure in the elderly

The acute and chronic compensatory mechanisms underlying the clinical syndrome of heart failure are summarised. Problems of diagnosing heart failure and causes of heart failure, particularly in the elderly, are noted, against a framework of reference of the determinants of cardiac output. The main approaches to treating heart failure are reviewed against the same framework of reference.     

Heart disease in the elderly

As the number of individuals over age 65 years continues to increase, the elderly will comprise an ever-growing portion of each physician's practice. While heart disease in the elderly may be similar in many respects to that in younger patients, major age-related differences do exist with regard to etiology, pathogenesis, natural history, clinical presentation, and management. Optimal management of the older cardiac patient requires that these differences be taken into account. In prescribing a medical regimen, it is important to keep in mind that age-related decreases in renal function, hepatic perfusion, and drug metabolism may result in higher drug levels and that the elderly are also often more prone to adverse drug effects, especially central nervous system changes. One should remember that chronology is not necessarily synonymous with physiology, and much depends on the individual patient in terms of the lifestyle he/she led and that which he/she wishes to have. Advanced age may be associated with greater interventional morbidity and mortality, but age alone should not be a contraindication to aggressive medical or surgical therapy.     

Heart failure in the elderly

Incidence and prevalence of heart failure are particularly common with advancing age, with notoriously grim prognoses. The absolute number of heart failure patients will undoubtedly surge as the population of older adults continues to escalate. This review emphasizes the importance of factors inherent in aging itself and the resulting predisposition to disease. Physiologic changes associated with cardiovascular aging fundamentally increase susceptibility to heart failure and to complexity of heart failure management. Likewise, typical age-associated diet and lifestyle changes compound risks of heart failure through mechanisms connected to the substrate of disease. In this review, the authors first summarize the demographics of heart failure and the intrinsic aspects of aging and lifestyle that predispose to heart failure. They then expand on related intricacies of diagnosis and therapy. Orientation to heart failure, particularly as a disease of aging, can help critically refine management of acute and chronic disease, as well as foster preventive strategies to reduce incidence of this common malady.     

Heart failure in the elderly

Heart failure is common in the elderly population. Approximately 6 to 10 percent of the population 65 years or older have heart failure. Heart failure is the most common reason for hospitalization in elderly patients. Etiology of heart failure is often multifactorial in the elderly. The common causes of heart failure include ischemic heart disease, valvular heart disease, hypertensive heart disease, and cardiomyopathy. Exacerbation of heart failure in the elderly is often accompanied by precipitating factors which include arrhythmia, renal failure, anemia, infection, adverse effect of drugs and non-compliance with medication and/or diet. Diagnosis of heart failure may be difficult in the elderly because symptoms of heart failure are often atypical or even absent. Heart failure with preserved systolic function is common in the elderly because aging has a greater impact on diastolic function. It is important to recognize that very old patients with heart failure are underrepresented in clinical trials.     

Heart failure in the elderly

Invited Editorial     

Heart failure in the elderly

The aging of the population is, currently, a major phenomenon, drawing the attention of a number of investigators. The significant increase of life expectancies over the past few decades, in addition to social and economic consequences, has lead to a major change in the morbidity and mortality profile of elders. Heart failure (HF) is a condition in which the heart can not pump enough blood to meet the body's needs. HF is predominantly a disorder of the elderly with rates increasing exponentially. The prevalence of HF approximately doubles with each decade of life. As people live longer, the occurrence of HF rises, as well as other conditions that complicate its treatment. Impaired heart function implies a reduced duration of survival. Fortunately, many factors that can prevent HF and improve outcome are known and can be applied at any stage. This review emphasizes the importance of factors inherent in aging itself. Focusing on heart disease, particularly as a disease of aging, can help critically refine management of this acute and chronic disease, as well as foster preventive strategies to reduce the incidence of this common malady.     

Heart failure in the elderly

Heart failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output and/or elevated intracardiac filling pressures at rest or during stress. HF is a major public health problem with high prevalence and incidence, involving both high morbidity and mortality, but also high economic costs. The incidence of HF progressively increases with age, reaching around 20% among people over 75 years old. Indeed, HF represents the leading cause of hospitalization in patients older than 65 years in Western countries. Hence, some authors even consider HF a geriatric syndrome, entailing worse prognosis and high residual disability, and often associating some complex comorbidities, common in older population, that may further complicate the course of the disease. On the other hand, however, clinical course and prognosis may be often difficult to predict. In this article, main pathophysiological issues related to the aging heart are addressed, together with key aspects related to both diagnosis and prognosis in elderly patients with HF. Besides, main geriatric conditions, common in the elderly population, are reviewed, highlighting the importance of a comprehensive and multidisciplinary approach.

Heart failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output and/or elevated intracardiac filling pressures at rest or during stress.^[1] HF is a major public health problem with high prevalence and incidence, involving both high morbidity and mortality, but also high economic costs. The incidence of HF progressively increases with age,^[2] reaching around 20% among people over 75 years old.^[3] Indeed, HF represents the leading cause of hospitalization in patients older than 65 years in Western countries.^[4,5]Hence, some authors even consider HF a geriatric syndrome, entailing worse prognosis and high residual disability, often associating some complex comorbidities, common in older population, that may further complicate the course of the disease.^[3,6] However, clinical course and prognosis may be often difficult to predict.^[7,8]In this article, main pathophysiological issues related to the aging heart are addressed, together with key aspects related to both diagnosis and prognosis in elderly patients with HF. Besides, main geriatric conditions, common in the elderly population, are reviewed, highlighting the importance of a comprehensive and multidisciplinary approach.