Management of Heart Failure in Special Populations
Heart failure (HF) is a prevalent condition in women, African Americans, and the elderly of both sexes and any race. In the absence of contradictory data, the clinical recommendations based on trial data derived from predominately younger white male study populations have generally been applied equally to these groups. However, there are etiologic and pathophysiologic considerations specific to these groups that warrant attention if care and outcomes are to be optimized. Discussion in this section is based primarily on available data from subgroup analyses of randomized HF trials and the results of cohort studies. A substantial amount of the data on drug efficacy comes from studies of patients treated after a recent acute myocardial infarction (MI).
Although a significant number of women and elderly patients with HF have preserved left ventricular ejection fraction (LVEF) there are few evidence-based data to guide therapy in this group. Other special populations, ethnic groups such as Hispanics, Asians, American Indians, or Pacific Islanders, are important special populations but there are inadequate data currently available about HF management to discuss these groups individually. Asian, particularly Chinese, patients have been reported to have a high incidence of cough with angiotensin converting enzyme (ACE) inhibitors, although this finding was not confirmed in a larger study of perindopril.1-3 Mitochondrial aldehyde dehydrogenase-2 is responsible for the bioactivation of nitroglycerin as well as the clearance of acetaldehyde.4 A polymorphism of this enzyme is present in 30-50% of Asians, and it is associated with decreased efficacy of the anti-anginal effects of nitroglycerin and an inability to clear acetaldehyde resulting in flushing after alcohol ingestion. Thus, it is possible, though not tested, that the combination of hydralazine and isosorbide dinitrate may not be effective in a significant number of Asians with HF. No HF treatment data is currently available in Hispanics, although epidemiologic factors such as diabetes may be particularly important in this subgroup.
The recommendations that follow are specific for the elderly, African-Americans, and women with HF and abnormal systolic function, as there are substantial data concerning HF management in these subgroups.