Epidemiology and risk factors for heart failure in the elderly

Heart failure is a common problem in the elderly population, affecting 10% or more of persons more than 80 years of age. Heart failure is most likely to develop in the elderly population, with an annual incidence of 20 to 30 cases per 1000 persons aged more than 80 years. Heart failure is not only common in the elderly population but also commonly fatal, with fewer than 30% of elderly persons surviving 6 years after their first hospitalization for heart failure. Common risk factors leading to heart failure include coronary heart disease, systolic hypertension, and diabetes mellitus. The global aging of the population will perpetuate the epidemic of heart failure into the next century.     

Clinical manifestations, diagnostic assessment, and etiology of heart failure in elderly patients

Heart failure in elderly patients may be difficult to diagnose because of a lack of typical symptoms and physical findings that are common in younger patients with this disorder. When present, the symptoms and signs are often nonspecific and mistakenly may be thought to be caused by other disorders that are commonly present in elderly patients. In older elderly patients, the symptoms and signs may be obscured by the presence of aging changes or other diseases. As a result of these problems, physicians must be highly suspicious of heart failure in all elderly patients who have underlying heart disease or who present with nonspecific symptoms that may represent heart failure. After the diagnosis of heart failure is established, the cause must be determined and systolic and diastolic ventricular dysfunction must be differentiated.     

Diastolic heart failure: a difficult problem in the elderly

Heart failure with normal systolic function has been equated to diastolic heart failure (DHF). DHF appears to be quite common in the elderly, especially in elderly women with hypertension. Recent epidemiologic studies suggest that 30%–50% of patients with heart failure may have DHF. Morbidity for DHF is considerable and comparable to that of heart failure with left ventricular systolic dysfunction. Both groups of patients have similar rates of recurrent hospitalization and cost of care. Long-term mortality also appears to be similar in the two groups of patients. With the aging of the population, the numbers of patients with DHF will continue to rise and are likely to contribute significantly to the burden of disease caused by heart failure. Unfortunately, as yet, no reliable definition has been found for DHF. Currently the diagnosis of DHF is often made by exclusion, and treatment is empirical and unsatisfactory because of the lack of large-scale, randomized, controlled trials in this area; however, several large and other smaller trials are currently in progress that will hopefully provide some answers.     

Heart failure with preserved ejection fraction in the elderly: scope of the problem

Heart failure is an epidemic in the elderly and has become a leading cause for hospitalization and death. Heart failure with preserved ejection fraction (HFPEF) is more common than heart failure with reduced ejection fraction (HFREF) but disease identification remains challenging. Current criteria rely on symptoms of poor exercise tolerance, preserved ejection fraction and laboratory evidence for elevated filling pressures. Each of these clinical parameters is difficult to evaluate in the elderly and reduce the certainty of diagnosis. Aging is associated with changes in the peripheral vasculature, pulmonary function, oxygen transport and skeletal muscle function, all key determinants of exercise capacity. Furthermore, co-morbid conditions such as chronic obstructive pulmonary disease are common in the elderly and cloud the interpretation of symptoms. The choice of ejection fraction (EF) 45-50% as preserved appears arbitrary as there is evidence that the lower limit for EF in elderly women is much higher. B-type natriuretic peptide has emerged as a popular blood biomarker of heart failure and increased filling pressures but appears to have trouble discriminating HFPEF from normal elderly controls. Regardless of the difficulties in diagnosis, several population studies show that HFPEF incidence and prevalence are on the rise especially in those >70?years of age. Co-morbid diseases are common in HFPEF, and these patients often die from non-cardiac causes. Future studies need to emphasize a holistic approach to HFPEF and identify whether there are diagnostic or therapeutic targets outside of the heart.     

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.     

Surgical treatment of heart failure in the elderly

Heart failure (HF) in elderly patients who may benefit from surgical therapy is usually secondary to ischemic or valvular heart disease. When referring such patients for surgery, life expectancy, along with the expectations of the patient and family with regard to the surgical treatment, must be considered. The goals of cardiac surgery in this patient population are to maintain or improve cardiac function, decrease HF episodes, reduce hospital admissions, and improve functional class. Safer surgical techniques developed during the last two decades have allowed high-risk patients well into their 80s to undergo complex cardiac operations with decreasing morbidity and mortality. Successful surgical intervention often leads to a more productive and independent life for elderly patients who have HF.     

Surgical treatment of heart failure in the elderly

Heart failure (HF) in elderly patients who may benefit from surgical therapy is usually secondary to ischemic or valvular heart disease. When referring such patients for surgery, life expectancy, along with the expectations of the patient and family with regard to the surgical treatment, must be considered. The goals of cardiac surgery in this patient population are to maintain or improve cardiac function, decrease HF episodes, reduce hospital admissions,and improve functional class. Safer surgical techniques developed during the last two decades have allowed high-risk patients well into their 80s to undergo complex cardiac operations with decreasing morbidity and mortality. Successful surgical intervention often leads to a more productive and independent life for elderly patients who have HF.     

Heart failure in very elderly population - a profile of heart failure in patients over the age of eighty

Objective Heart failure is an epidemic in the elderly, but there is a striking lack of data in this clinically important patient population. We investigated the demographics, cardiac performance, and medication management of a segment of the hospital popula- tion in at least their eighth decade of life. Methods We retrospectively reviewed 75 records of heart failure patients who were 80 years of age or older. Records were reviewed for demographic information, presence or absence of diastolic dysfunction, evaluation of ejection fraction, and medication usage including angiotensin-concerting enzyme (ACE) inhibitors, angiotensin receptor antagonists (ARBs), beta-adrenergic blockers, digoxin, and aldosterone antagonists. Assessment for contra-indications to ACE inhibitor or ARBs use was also performed to assess co-morbidities that limit treatment of heart failure. Results The population of very elderly with heart failure is heterogeneous. We found a higher proportion of females as well as higher rates of diastolic dysfunction in patients aged ≥ 90 years compared to patients between the ages of 80-89 years. Usage of ACE inhibitors, ARBs and beta-adrenergic blockers was strikingly low throughout the very elderly population. While co-morbid conditions limited use of agents in many cases, there was a lack of explicit contra-indication in most patients not on an ACE inhibitor or an ARB. Conclusions Heart failure is not a single disease processes, but a continuum of disease processes that vary with age. The elderly with heart failure are an undertreated population, in part due to the multitude of co-morbidities that affect them. Further prospective studies are needed to better understand the physiology and ideal treatment regiment in this growing population.     

Heart failure

Heart failure is predominantly a disorder of older adults, and to a large extent the epidemiology of heart failure reflects the convergence of age-related changes in the cardiovascular system and the rising prevalence of age-related cardiovascular diseases. The diagnosis of heart failure in the elderly is often difficult because of the presence of atypical symptomatology and comorbid conditions. Similarly, optimal treatment frequently poses a therapeutic challenge because of the high prevalence of confounding medical, behavioral, psychosocial, and economic factors. In addition, there is a paucity of data on the pharmacotherapy of heart failure in the very elderly (over age 80), and in the large proportion of older patients with heart failure and preserved left ventricular systolic function. Despite these difficulties, a number of therapeutic options, including ACE inhibitors, digoxin, and possibly beta blockers and angiotensin receptor antagonists, have been shown to favorably affect the clinical course of heart failure in elderly patients. In addition, several studies have documented the efficacy of multidisciplinary heart failure disease management programs for reducing hospital admission rates, improving quality of life, and decreasing cost of care. At present, the three greatest challenges in managing older heart failure patients are: (1) to more effectively implement proven treatments, such as ACE inhibitors, disease management systems, and antihypertensive therapy; (2) to develop effective therapies for the treatment of diastolic heart failure; and (3) to develop more effective means for heart failure prevention. It is hoped that future studies will address each of these critically important issues.     

Management of Noncardiac Comorbidities in Chronic Heart Failure

Prevalence of heart failure is increasing, especially in the elderly population. Noncardiac comorbidities complicate heart failure care and are increasingly common in elderly patients with reduced or preserved ejection fraction heart failure, owing to prolongation of patient's lives by advances in chronic heart failure (CHF) management. Common comorbidities include respiratory disease, renal dysfunction, anemia, arthritis, obesity, diabetes mellitus, cognitive dysfunction, and depression. These conditions contribute to the progression of the disease and may alter the response to treatment, partly as polypharmacy is inevitable in these patients. Cardiologists and other physicians caring for patients with CHF need to be vigilant to comorbid conditions that complicate the care of these patients. There is now more guidance on management of noncardiac comorbidities in heart failure, and this article contains a comprehensive review of the most recent updates on management of noncardiac comorbidities in CHF.     

Office management of heart failure in the elderly

Heart failure is one of the most common conditions affecting older patients seen by clinicians in routine office practice. This article reviews the clinical features, diagnosis, and management of heart failure in elderly patients evaluated in the ambulatory care setting, and provides concise, practical information relevant to all major aspects of care. Specific topics include the role of diagnostic testing, such as echocardiography and B-type natriuretic peptide; principles of nonpharmacological management, including patient education, diet, exercise, and daily weights; drug therapy for systolic heart failure as well as heart failure with preserved left ventricular systolic function; end-of-life issues; and when to refer the patient to a specialist. Although heart failure in the elderly differs in many important respects from heart failure occurring in middle-aged patients, the general approach to diagnosis and management is similar in younger and older patients.     

Aortic valve surgery in the elderly

As the population ages, aortic valve replacement, particularly for aortic stenosis, has become more common. Although many patients have considerable coexisting morbidity, almost all symptomatic patients are candidates for surgery. Once symptoms develop, surgery should not be unduly delayed, because the operative mortality clearly increases in the presence of poor left ventricular function, heart failure, and New York Heart Association Class III or IV symptoms. Operative difficulties often are related to fragile tissues, a small aortic annulus, and extensive calcification of the aortic annulus and root. In the author's experience, approximately 10% of these patients undergo aortic annulus and root enlargement using pericardium. A tissue valve is the preferred prosthesis. Operative mortality for elective surgery in patients older than 80 years of age is 4-10%, depending on whether associated procedures are required (eg, coronary artery bypass grafting) or whether the patient has had previous surgery. Postoperative neurologic events are important complications that are more common in the elderly. Outcome after successful surgery is excellent, with a 5-year survival of approximately 60%. The vast majority of patients have an improved symptomatic status.     

Device Therapy to Modulate the Autonomic Nervous System to Treat Heart Failure

Heart failure is the final common pathway in many forms of heart disease, and is associated with excessive morbidity and mortality. Pathophysiologic alterations in the interaction between the heart and the autonomic nervous system in advanced heart failure have been noted for decades. Over the last decade, great advances have been made in the medical and surgical treatment of heart failure - and some of these modalities target the neuro-cardiac axis. Despite these advances, many patients progress to end-stage heart failure and death. Recently, device-based therapy targeting the neuro-cardiac axis with various forms of neuromodulatory stimuli has been shown to improve heart function in experimental heart failure models. These include spinal cord stimulation, vagal nerve stimulation, and baroreflex modulation. Human trials are now underway to evaluate the safety and efficacy of these device-based neuromodulatory modalities in the heart failure population.     

Comorbidity in heart failure in the elderly

Heart failure occurs principally in the geriatric population and often is associated with severe comorbidity. Comorbid conditions that occur in the geriatric population at a prevalence equal to or greater than that of heart failure itself include the brain failure syndromes (i.e., delirium and dementia), depression, falls, postural hypotension, urinary incontinence, undernutrition, frailty, sensory deprivation, polypharmacy, and lack of social support. The effect of major geriatric comorbidities on the management of patients with heart failure is reviewed.     

Is heart failure different on the two continents (North America and Europe)?

Heart failure is increasing in both North America and Europe. Although many similarities in the disease are apparent between the two continents, differences do exist. Heart failure with preserved systolic function appears to be increasingly important on both continents, and is associated more frequently with hypertension, aging, and female sex. Treatment guidelines from the two continents show more similarities than differences, though different treatment patterns emerge. Because more patients with heart failure will be older in the future, clinical trials that include greater numbers of these patients are needed to demonstrate that therapies are as effective and safe in this population.     

The role of hospitalists in the management of acute decompensated heart failure

Heart failure and episodes of acute decompensated heart failure have an important effect on the US health care system, especially the elderly Medicare population. Efforts to improve the quality of care for patients hospitalized with acute decompensated heart failure have focused on creating standardized treatment guidelines based on substantial clinical evidence, but inadequate implementation of these guidelines continues to result in excess morbidity and mortality from heart failure. Hospitalists specializing in inpatient treatment strategies may play an important role in implementing clinical guidelines because their main commitment is to overall clinical treatment of inpatients. This review focuses on current recommended guidelines for diagnosis, treatment, and long-term management of patients with acute decompensated heart failure and the hospitalist's role in providing the oversight needed to adhere to these guidelines and manage this complex disease state.     

Opportunities for training to advance the care for adults with congenital heart disease with advanced circulatory failure

Heart failure is an emerging issue with important implications in adult patients with congenital heart disease. Practitioners with expertise in both adult congenital heart disease and heart failure are needed to manage this growing and often complex population. In the United States, the optimal training pathway to enable practitioners to best care for these patients is ill‐defined. This article explores possibilities and issues that interested trainees may encounter during their training experience.     

Congestive heart failure in the elderly diabetic

The elderly diabetic is a potential congestive heart failure patient. Cardiac involvement is multifactorial, particularly ischemic conditions because of the accumulation at that age of vascular risk factors and therefore the frequency of coronary damages. The elderly diabetic very often has high blood pressure, with the risk of developing a hypertensive heart disease. Beyond these issues, the effects of chronic hyperglycaemia and insulin resistance on the heart specifically alter left ventricle compliance and therefore diastolic function, thus accelerating the effects proper to aging. No specific recommendation has been published on the management of the elderly diabetic with congestive heart failure. Even at an advanced age, with a clinical diagnosis of congestive heart failure that is sometimes difficult to make, the cardiological evaluation should be conducted rigorously within a global evaluation, and treatment should follow the same rules as in younger patients, with great caution given to the iatrogenic risks inherent to this population.     

Age-related hemodynamic, renal, and hormonal differences among patients with congestive heart failure

The purpose of this study was to determine if there were characteristics that distinguish elderly patients with heart failure (greater than 65 years of age) from younger patients with heart failure. We studied 128 consecutively admitted patients with chronic congestive heart failure (CHF) under uniform conditions, with measurement of systemic hemodynamics, vasoactive hormones and sodium status, and renal function. Additional characterization included the hemodynamic response to gravitational stress (head-up tilt; n = 65), and renal blood flow and function by steady-state clearance techniques (n = 46). Compared with younger patients with CHF, there was a greater frequency of ischemic heart disease in the elderly patients with CHF. Within the CHF population there was an increase of systemic vascular resistance and a trend of decreased heart rate with aging. Heart rate responsiveness was attenuated during tilt according to age. Circulating norepinephrine increased with aging, but a clear-cut age-related effect was not observed for renin system activity or sodium status. Both serum urea nitrogen and serum creatinine increased with age. More detailed renal studies confirmed an age-related decrease of glomerular filtration rate and a noncompensatory filtration fraction, despite increasing renal vascular resistance. We conclude that elderly patients with CHF have relatively greater vasoconstriction (or decreased compliance) and blunted heart rate responsiveness associated with increased circulating norepinephrine. Furthermore, renal function in the elderly patient with CHF is markedly compromised. These findings are consistent with superimposition of an aging effect on the CHF process, which must be considered in evaluating the response to drug therapy and the outcome of multicenter CHF trials.     

Mitral valve repair in the treatment of heart failure

Opinion statement Heart failure continues to be one of the leading causes of hospitalizations and mortality in the United States. Mitral valve regurgitation in patients with heart failure is most often a functional abnormality and as such represents a different disease entity from other more common causes of regurgitation. In general, in patients with heart failure the mitral valve structure is normal; however, regurgitation is secondary to changes in left ventricular (LV) structure and function, including mitral annular dilatation and changes in LV geometry. Mitral regurgitation affects almost all patients with heart failure as a preterminal or terminal event, and carries a high morbidity and mortality. Medical management is limited to treatment with diuretics and afterload reduction. Unfortunately, once significant amounts of mitral regurgitation are manifest, medical treatment alone is generally associated with poor long-term survival and outcome. Surgical treatment by means of undersized annuloplasty type repairs has shown great promise, for preventing worsening heart failure and improving overall LV function.