Interventional therapies for heart failure in the elderly

The aging of a population replete with risk factors for heart failure(HF) (coronary heart disease, diabetes, and hypertension) coupled with a declining age-adjusted mortality rate for coronary artery and hypertensive heart diseases has created, and will continue to create, a literal explosion in the prevalence of HF in the United States. Despite advances in maximal medical therapy, however, most patients who have symptomatic HF can expect functional impairment, interludes of worsening symptomatology, and a shortened lifespan. This article updates the use of interventional therapies for the treatment of elderly patients who have HF caused by coronary artery disease, valvular heart disease, congenital heart disease, myocardial disease, and renal vascular disease.     

Utilization of evidence-based therapies for heart failure in the institutionalized elderly

OBJECTIVES: Heart failure (HF) is a major source of morbidity and mortality in elderly populations. A significant proportion of the elderly with HF are living in long-term care facilities. Little is known about their management. The aim of this study was to evaluate the use of evidence-based therapies in institutionalized elderly patients with HF. DESIGN, SETTING AND PARTICIPANTS: Retrospective chart review conducted at 15 long-term care facilities in the Capital Health Region (Edmonton, Alberta). Residents > or =65 years of age with HF were identified using a pharmacy database. RESULTS: Overall prevalence of HF was 15% (313/2062 residents). Mean age was 87 years, median duration of residence was 1.8 years. Utilization of ACE-inhibitors, beta-blockers and spironolactone was 51%, 16% and 10%, respectively. Use of these medications was not significantly different between subgroups of those with and without contraindications to the therapies, different advance directive levels, gender or age. Sodium and fluid restricted diets were prescribed in only 11.0% and 3.8% of residents. Weight was not regularly monitored. Influenza and pneumococcal vaccination were administered to 60.4% and 81.2% of the residents. CONCLUSION: The use of evidence-based therapies in institutionalized elderly patients with HF is low, and unexplained by contraindications or advance directives. Efforts to increase the utilization of evidence-based therapies and improve monitoring are warranted.     

Interventional electrophysiology and cardiac resynchronization therapy: delivering electrical therapies for heart failure

Implantable devices have become a readily available option for patients with heart failure. Not only do these patients develop bradycardia and ventricular tachycardia, but their ventricular dysfunction can often improve with cardiac resynchronization therapy. However, this is a complex and rapidly developing clinical science for which the physician chooses techniques and selects patients on the basis of the results of clinical trials, clinical experience, and rapidly evolving tools. The results depend on the interplay of these complex variables. Placement of the left ventricular lead has forced the device physician to develop new skills and/or interdisciplinary relationships with physicians with vascular intervention, imaging, and surgical skills. Familiarity with the cardiac venous anatomy, occlusive venography, venoplasty, guide wire tools, guiding catheters, stenting, and new intracardiac visualization and magnetic intracardiac lead positioning tools are examples of just a few of the novel skills that are useful in the delivery of cardiac resynchronization therapy. Beyond implantation, these patients and devices require specialized follow-up with continued medical therapy and echo-guided adjustments of device programming. Finally, there are ongoing controversies and many as yet unanswered questions that are the subject of ongoing and planned clinical trials.     

Surgical therapies for heart failure

Heart transplantation remains the best hope for patients with end-stage heart failure unresponsive to conventional therapy, but the number of transplant candidates continues to exceed the number of available donor hearts. Despite major advances in the medical management of heart failure, researchers continue to explore alternative surgical therapies designed to augment cardiac function. Many of these surgical therapies are still in the experimental or clinical trial phases. Surgical approaches include coronary revascularization, mitral valve repair or replacement, cardiomyoplasty, left ventricular volume reduction surgery, and bridging to recovery with the use of ventricular assist devices. Although cardiac surgeons have gained considerable experience in the treatment of patients with heart failure, many improvements and innovations lie ahead.     

New surgical therapies for heart failure

A growing number of patients present with heart failure. Some of them may qualify for surgical correction of their cardiac condition. Since heart transplantation will always be available to only a small number of patients, several new surgical techniques have been developed for approval in heart failure patients. Classic interventions such as revascularization, valve repair, or valve replacement have been improved and modified to meet the need of heart failure patients. Several of these techniques are currently under investigation in large clinical trials. These trials will definitely have an impact on the development of surgical treatment of patients with heart failure.     

Interventional therapy in heart failure management

The incidence and prevalence of congestive heart failure are rapidly increasing because of the progressive decrease in age-adjusted mortality rates for coronary artery disease and hypertensive heart disease, together with the progressive aging of the US population. Despite great advances in maximal medical therapy, most patients with symptomatic congestive heart failure can expect functional impairment, interludes of worsening symptomatology, and a shortened life span. Thus, it is appropriate to ask whether the interventional revolution that is under way for the management of ischemic cardiovascular disease can be applied with benefit to the management of congestive heart failure. The use of interventional therapies for the treatment of elderly patients with congestive heart failure caused by coronary artery disease, valvular heart disease, or renal vascular disease is addressed.     

Evolving cell-based therapies for heart failure patients

Heart failure (HF) represents the only cardiovascular disease (CVD) whose incidence continues to rise in the developed world. With recent advances in device and drug therapies, the prognosis is improving. Nevertheless, the mortality associated with HF remains high, with more than 50% of patients dying within 5 years after initial diagnosis. The loss of cardiac cells is a major contributor to the development and progression of HF, thus therapeutic interventions to repair or regenerate lost cardiac cells hold tremendous promise. During the past several years, cell-based therapy for CVD has moved at a rapid pace from animal studies to clinical trials. To date, populations enrolled in cell-based therapy trials have comprised patients with coronary artery disease and myocardial infarction, with a limited number of trials conducted in patients with congestive HF. Also, most trials have used autologous skeletal myoblasts or bone marrow cells (whole bone marrow or subpopulations). The outcomes from these studies have been largely mixed, ranging from clear beneficial effects of cell therapy to no observed improvement, although all trials demonstrated a reasonable degree of safety, at least within the study period. Several critical issues, such as the type of cells, number of cells, timing, delivery methods, and the mechanisms of action involved, remain to be elucidated. This article reviews the current status of the emerging field of cell-based therapies for CVD, with particular focus on HF treatment.     

New therapies for the management of acute heart failure

The standard treatment for acute heart failure (synonymous with pulmonary edema) is an upright posture, oxygen, morphine (often accompanied by an antiemetic), and intravenous diuretics. This treatment has remained unchanged for many years, and the precise mechanism by which each of these methods alleviates symptoms in patients is unclear. Nitrates, oral or intravenous, are also used with benefit, and have some hemodynamic advantages over intravenous diuretics. Recently, three new forms of treatment have been investigated. The use of milrinone, a phosphodiesterase inhibitor, for exacerbation of heart failure in patients with a background of chronic heart failure was not advantageous. The trials of levosimendan, a calcium sensitizer, in patients with pulmonary edema hinted at benefit. Nesiritide, a formulation of brain natriuretic peptide, does bring about hemodynamic improvement in acute heart failure, and is at least as effective as nitroglycerin, easier to prescribe, but prone to cause hypotension. These are small but important advances that increase our knowledge of the pathophysiology of acute heart failure, and also provide an indication of which drugs are preferable for the treatment of this distressing condition.     

老年人心力衰竭的治疗原则

老年心力衰竭患者的治疗应遵循下列基本原则：综合治疗,即对所有心力衰竭的病因、诱因、临床症状、血流动力学异常、内环境改变和各种临床合并症的全面治疗;个体化治疗,即要根据每名患者的具体病情特点,采取个体化的治疗方案;同时重视用药指导和日常生活管理。     

Congestive heart failure in the elderly

Several aspects of congestive heart failure are discussed in the light of international literature and of recent findings of our group. The annual incidence of heart failure in elderly subjects, aged >or=75y, is 13 to 50/1000, while it is 1.6/1000 in people aged 45-54 y. The prevalence of heart failure is about 3% in subjects aged 45-64% in subjects aged more than 65 y and 10% in subjects aged more than 75 y. These data are confirmed by our population based study in elderly subjects. The etiology of congestive heart failure is similar in elderly and middle-aged patients. However, several anatomo-functional, hormonal and autonomic nervous system changes, typical of congestive heart failure, occur during physiologic ageing processes also. These findings may explain the dramatic evolution of congestive heart failure in elderly patients. Moreover, some features of the elderly - e.g. comorbidity, atypical clinical presentations, loss of autonomy, increased iatrogen risk should be considered. No specific drugs exist for the pharmacologic treatment of heart failure in the elderly, so that the geriatric specificity in the treatment of heart failure can be recognized in the art of drug choice and dosage, to obtain the best results with the least side effects. The multiple etiology of congestive heart failure, the comorbidity, the loss of autonomy and the deterioration of cognitive functions suggest the need for multidimensional approach and continuative intervention in elderly patients with heart disease, and in particular with congestive heart failure. Further studies on disease- and age-related changes are necessary to develop new and more potent strategies to secure 'successful ageing'.     

Diastolic heart failure in the elderly

Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.     

老年人舒张性心力衰竭

随着人口老龄化的增加,舒张性心力衰竭（DHF）的患病率逐步上升,严重威胁老年人的生命,现有的诊断方法对DHF的诊断有一定局限性,不同国家的心衰指南对于DHF的诊断标准也不完全相同,现有的治疗方案对DHF患者的自然病程和预后改善欠佳,因此成为目前的研究热点。现对老年性DHF最新的发病机制及诊断治疗进展进行阐述。     

Diastolic heart failure in the elderly

Heart failure with preserved left ventricular function is a common problem among elderly patients.Given that diastolic heart failure(DHF)occurs in up to 50% of all heart failure admissions,and that incidence increases with age,knowledge of current recommendations for its diagnosis and treatment are extremely important for the elderly population.Causes of DHF include the aging process itself,hypertension,left ventricular hypertrophy,aortic stenosis,and hypertrophic obstructive cardiomyopathy.The patient with DHF may present with signs and symptoms similar to those observed in systolic heart failure.Treatment goals for the patient with DHF include achieving normal volume status,improving relaxation of the left ventricle,regression of hypertrophy if possible,and management of any co-morbidities that may aggravate the clinical status of patients with DHF.Hopefully,in the future,further data from randomized clinical trials will allow a more defined approach to care in these patients.     

Diastolic heart failure in the elderly

Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.     

Systolic heart failure in the elderly

Aging is associated with changes in cardiac and vascular structure, promoting the development of heart failure. An increase in vascular stiffness leads to an increase of systolic arterial pressure and pulse wave velocity. This augments the afterload of the heart, which contributes to cardiac hypertrophy and neuroendocrine activation in the elderly. On the molecular level the age-associated changes in the sympathetic nervous system are similar to alterations that can be found in congestive heart failure. Therapy of systolic heart failure does not differ between the elderly and younger patients. All drugs which have shown to improve the prognosis of younger patients are indicated in the elderly as well. This holds true for ACE-inhibitors or angiotensin receptor antagonists, betablockers and aldosterone antagonists. However, comorbidities as well as changes in the pharmacokinetics and pharmacodynamics might require a cautious initiation of the therapy, an individual adjustment of the dosage and a thoroughly monitoring of the elderly patients.