Acute heart failure in elderly patients: a review of invasive and non-invasive management

Acute heart failure (AHF) is a major cause of unplanned hospitalisations in the elderly and is associated with high mortality. Its prevalence has grown in the last years due to population aging and longer life expectancy of chronic heart failure patients. Although international societies have provided guidelines for the management of AHF in the general population, scientific evidence for geriatric patients is often lacking, as these are underrepresented in clinical trials. Elderly have a different risk profile with more comorbidities, disability, and frailty, leading to increased morbidity, longer recovery time, higher readmission rates, and higher mortality. Furthermore, therapeutic options are often limited, due to unfeasibility of invasive strategies, mechanical circulatory support and cardiac transplantation. Thus, the in-hospital management of AHF should be tailored to each patient’s clinical situation, cardiopulmonary condition and geriatric assessment. Palliative care should be considered in some cases, in order to avoid unnecessary diagnostics and/or treatments. After discharge, a strict follow-up through outpatient clinic or telemedicine is can improve quality of life and reduce rehospitalisation rates. The aim of this review is to offer an insight on current literature and provide a clinically oriented, patient-tailored approach regarding assessment, treatment and follow-up of elderly patients admitted for AHF.

Heart failure (HF) is a growing health issue affecting around 2% of the adult population in developed countries.^[1] HF predominantly concerns elderly patients, since its incidence doubles in men and triples in women with each decade after the age of 65 years.^[2] HF is a common cause of hospitalisation, accounting for an estimated annual expense of at least 108 billion dollars in direct and indirect costs for health economies worldwide.^[3] This disease may develop insidiously or presenting in an emergent fashion with rapidly progressive signs and symptoms, in the constellation of acute HF (AHF). Depending on the clinical profile, patients hospitalised with AHF may require loop diuretics to treat congestion, vasodilators, inotropic or vasopressor therapy, and non-invasive ventilation. Advanced interventions such as mechanical ventilation or mechanical circulatory support necessitate admission to an intensive care unit.^[4,5] Since elderly patients with HF commonly differ from younger patients in terms of comorbidities, disability and drug therapy, they are often excluded from invasive and complex interventions, requiring tailored therapeutic pathways based on their clinical status and life expectancy. Furthermore, hospitalisation for AHF in the aged population is associated with higher rates of mortality, rehospitalisation, and decline in physical activity.^[6–8] Earlier data suggested a 1-year all-cause mortality of 56% in patients aged > 75 years. ^[9] Finally, these patients have a greater symptom burden and a worse quality of life (QoL) than age-matched individuals with stable HF.^[10]Several attempts to improve the outcomes of geriatric patients have been done in the last years, although they are often excluded from HF clinical trials and underrepresented in clinical registries.^[7,11] Thus, the information about the clinical profile and prognosis of patients hospitalised for AHF at extreme ranges of age is scarce. The purpose of this review is to offer an insight on current literature and provide a clinically oriented, patient-tailored approach regarding assessment, treatment and follow-up of elderly patients admitted for AHF.