Epidemiology, pathophysiology, and prognosis of heart failure in the elderly

Heart failure (HF) represents the quintessential disorder of cardiovascular aging, reflecting the convergence of age-related changes in the cardiovascular system and other organ systems and the increasing prevalence of cardiovascular diseases at older age. The prevalence and incidence of HF increase progressively with advancing age, and HF imposes an enormous burden on society in mortality, morbidity, and associated health care costs. Despite major advances in treatment of HF over the last 25 years, the prognosis remains poor, with median survival rates of less than 5 years in older adults. As the population ages, it is anticipated that the number of older people with HF will increase dramatically over the next several decades.     

Epidemiology, pathophysiology, and prognosis of heart failure in the elderly

Heart failure (HF) represents the quintessential disorder of cardio-vascular aging, reflecting the convergence of age-related changes in the cardiovascular system and other organ systems and the increasing prevalence of cardiovascular diseases at older age. The prevalence and incidence of HF increase progressively with advancing age, and HF imposes an enormous burden on society in mortality,morbidity, and associated health care costs. Despite major advances in treatment of HF over the last 25 years, the prognosis re-mains poor, with median survival rates of less than 5 years in older adults. As the population ages, it is anticipated that the number of older people with HF will increase dramatically over the next several decades.     

Hypertension in black people: pathophysiology and therapeutic aspects

Salt sensitivity is regarded as an important contributor to the higher risk of hypertension in black people as compared with whites. This finding is in agreement with a better response to diuretics than to monotherapy with angiotensin-converting enzyme (ACE) inhibitor in black subjects. It is important to remember that the hypotensive effect of ACE inhibitor is augmented in patients on a thiazide diuretic. Moreover, the antihypertensive response to a specific drug varies among black patients. Thus, ACE inhibitors should also be viewed as important options to treat hypertensive black subjects. Results from clinical trials support an emphasis on lifestyle modification and a more intensive blood pressure lowering by pharmacological interventions to reduce the large black-white gap in cardiovascular events and end-stage renal disease (ESRD) attributed to hypertension.     

Hypertension in the elderly: treatment

Hypertension in the elderly is a common problem confronting the practitioner today. The rationale for treating hypertensive elderly patients is presented in this article. Guidelines for the use of specific agents for the treatment of older patients are also discussed.     

Epidemiology of Hypertension in the Elderly

In Western populations, mean systolic and diastolic blood pressures rise with advancing age up to the sixth decade of life, whereupon systolic blood pressure continues to increase and diastolic pressure starts to decline. The ensuing widening of pulse pressure is mainly ascribed to stiffening of the arterial vasculature. When hypertension is defined as systolic blood pressure of at least 140 mm Hg and/or diastolic pressure of at least 90 mm Hg, its prevalence amounts to 60%–70% of the population above 60 years of age. About 60% of these hypertensives have isolated systolic hypertension—that is, elevated systolic pressure and normal diastolic pressure. It should be realized, however, that approximately 25% of those labeled hypertensive on the basis of conventional blood pressure measurements have normal blood pressure on ambulatory blood pressure monitoring, or so-called white-coat, isolated clinic, or nonsustained hypertension. There is little doubt that elevated blood pressure leads to a number of cardiovascular complications. Whereas diastolic blood pressure has been emphasized for many years, the paradigm has shifted toward systolic blood pressure. In addition, pulse pressure has been shown to be an important predictor of cardiovascular events and death, above and beyond the predictive power of mean blood pressure.     

Hypertension in the elderly

Current data indicate that most patients over age 60 with systolic blood pressure greater than 160 mm Hg and diastolic blood pressure greater than 90 mm Hg should be treated. The current data support the use of a thiazide and potassium-sparing diuretic with the addition of a centrally acting antiadrenergic drug as needed to reduce the blood pressure to less than 160/90 mm Hg. This will reduce the morbidity and mortality, especially cerebrovascular events, severe congestive heart failure, development of severe or accelerated hypertension, nonfatal myocardial infarction, and sudden death. Those unable to take these medications or who do not have satisfactory reduction in blood pressure should have other antihypertensive drugs added or substituted to lower blood pressure to less than 160/90 mm Hg.     

Hypertension in the elderly

The decade of the 1990s has clarified the perspective on treating hypertension in the elderly and provided a wealth of evidence to assist in the treatment of elevated blood pressure in older persons. Despite this wealth of information, important questions remain about treatment of hypertension in the elderly.     

Hypertension in the elderly

The elderly are the most rapidly growing population group in the world.Data collected over a 30-year period have demonstrated the increasing prevalence of hypertension with age.The risk of coronary artery disease,stroke,congestive heart disease,chronic kidney insufficiency and dementia is also increased in this subgroup of hypertensives.Hypertension in the elderly patients represents a management dilemma to cardiovascular specialists and other practioners.During the last years and before the findings of the Systolic Hypertension in Europe Trial were published,the general medical opinion considered not to decrease blood pressure values similarly to other younger patients,in order to avoid possible ischemic events and poor oxygenation of the organs(brain,heart,kidney).The aim of this review article is to highlight the importance of treating hypertension in aged population in order to improve their quality of life and lower the incidence of the cardiovascular complications.     

Epidemiology,pathophysiology, prognosis,and treatment of systolic and diastolic heart failure in elderly patients

American College of Cardiology/American Heart Association class I recommendations for treating patients with heart failure (HF) and abnormal left ventricular ejection fraction are diuretics in patients with fluid retention, an angiotensin-converting enzyme (ACE) inhibitor unless contraindicated, a beta-blocker unless contraindicated, digoxin for the treatment of symptoms of HF, and withdrawal of drugs known to precipitate or aggravate HF such as nonsteroidal anti-inflammatory drugs, calcium channel blockers, and most antiarrhythmic drugs. Class II(a) recommendations for treating HF with abnormal left ventricular ejection fraction are spironolactone in patients with class IV symptoms, preserved renal function, and normal serum potassium; exercise training as an adjunctive approach to improve clinical status in ambulatory patients; an angiotensin receptor blocker in patients who cannot be given an ACE inhibitor because of cough, rash, altered taste sensation, or angioedema; and hydralazine plus nitrates in patients being treated with diuretics, a beta-blocker, and digoxin who cannot be given an ACE inhibitor or an angiotensin receptor blocker because of hypotension or renal insufficiency. Patients with diastolic HF should be treated with cautious use of diuretics and with a beta-blocker. An ACE inhibitor should be added if HF persists or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioedema, rash, or altered taste sensation. Isosorbide dinitrate plus hydralazine should be added if HF persists. A calcium channel blocker should be added if HF persists. Digoxin should be avoided in diastolic HF if sinus rhythm is present.     

Hypertension in the elderly

Hypertension in the older population has a serious prognosis and this is true even for isolated systolic hypertension. There is a markedly increased risk of stroke, cardiovascular disease and central nervous system in such patients. The hemodynamics in hypertension of the elderly differs in a number of parameters from hypertension in the younger patient. In addition, drug metabolism is markedly altered by the aging process. This combination of factors requires a selective choice of agents for the management of hypertension in the elderly. The role of various drug modalities and their efficacy is reviewed in this presentation.     

Hypertension in the elderly

High blood pressure, once believed to represent a normal and progressive component of the aging process, is now recognized as a manifestation of structural and physiologic abnormalities of aortic function. Elevated systolic blood pressure and increased pulse pressure unquestionably increase the risk of both fatal and nonfatal cardiovascular events, including stroke, myocardial infarction, and heart failure. Isolated systolic hypertension, defined as a systolic blood pressure ≥ 140 mm Hg with a diastolic blood pressure < 90 mm Hg, affects most individuals aged 60 years and older. Several clinical trials have clearly demonstrated that treatment of hypertension significantly reduces the cardiovascular event rate. However, controversy continues as to the choice of antihypertensive agents and combinations of agents. It is both appropriate and necessary to treat elderly hypertensives aggressively to the same target blood pressures identified for younger patients. It is also appropriate to initiate treatment with lower doses of antihypertensive agents and to bring the pressure down more slowly, monitoring for orthostatic hypotension, impaired cognition, and electrolyte abnormalities.