Management of Heart Failure in Special Populations
Elderly Patients with HF
Clinical Characteristics and Prognosis. HF represents a significant and growing public health problem for the elderly. The progressive aging of the US population is well established5 and has profound implications for the prevalence of cardiovascular disease-particularly HF. A number of studies have documented the substantial increase in the prevalence of this syndrome as age increases.6 As with most illnesses in the elderly, HF is associated with higher rates of morbidity and mortality than in younger patients.7,8 Among elderly patients hospitalized with HF, median survival is approximately 2.5 years, with 25% of patients dying within 1 year.9
Pathophysiology of HF in the Elderly. There are a number of well described changes in cardiovascular physiology which occur with aging. Resting systolic left ventricular (LV) function appears to be preserved, but perhaps at the expense of some LV enlargement.10 A diminution of diastolic function has been documented in otherwise normal elderly individuals.11 Exercise capacity declines with age, most likely from a combination of changes in cardiac and peripheral vascular factors, ventricular-vascular coupling and aortic distensibility.12,13 With age, diastolic filling of the ventricle becomes more dependent on atrial contraction and ventricular volume changes with increasing cardiac output are significantly different than those seen in younger subjects.14 Though these diverse cardiovascular changes tend to reduce exercise capacity, their impact on health and quality of life remains modest in most individuals compared to the detrimental effects of HF.
The presentation of HF may differ in elderly patients with HF. Although they commonly present with the classic symptoms of dyspnea and fatigue, the elderly are more likely than younger patients to present with atypical symptoms such as poor executive functioning, altered mental status, or depression.15,16
Recommendations
As with younger patients, it is recommended that elderly patients, particularly those age >80 years, be evaluated for HF when presenting with symptoms of dyspnea and fatigue. (Strength of Evidence = C)
Beta blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction. (Strength of Evidence = B) In the absence of contraindications, these agents are also recommended in the very elderly (age >80 years). (Strength of Evidence = C)
As in all patients, but especially in the elderly, careful attention to volume status, the possibility of symptomatic cerebrovascular disease, and the presence of postural hypotension is recommended during therapy with ACE inhibitors, beta blockers and diuretics. (Strength of Evidence = C)
Background
Beta Blockers. Diminished response to catecholamine stimulation in elderly individuals has been shown by several investigators17 and appears related to diminished number and activity of both beta1 and beta2 receptors.18 However, the changes in response to the sympathetic nervous system do not mitigate the need for beta receptor antagonism in the elderly. The striking risk in the elderly of major morbidity and early mortality, combined with the substantial benefit derived from beta blockade, strongly supports the use of these agents as tolerated in elderly patients with symptomatic LV systolic dysfunction.
Conclusions from randomized placebo-controlled trials are limited concerning the efficacy of beta blockade in the elderly. However, a retrospective analysis of a study of metoprolol CR/XL, which enrolled patients up to age 80 and included a substantial subgroup of elderly patients, found a similar degree of morbidity and mortality reduction in patients 69 or older versus those younger than 69.19,20 Observational studies of the outcome of elderly patients after MI have consistently shown substantial reductions in mortality when beta blockers are prescribed at discharge.21-23 These studies have included octogenarians. The one randomized trial of beta blockers in an elderly population with HF (mean age 76) demonstrated a reduction of 14% in the combined endpoint of all-cause mortality or primary cardiovascular admission for the group on nebivolol.24
ACE Inhibitors. No randomized controlled trial has been conducted specifically to investigate the benefit of ACE inhibition in elderly patients. However, convincing evidence of the effectiveness of ACE inhibition in elderly patients is provided by the results of a trial in which the mean age was 70 and the reduction in mortality was 31% at 2 year and 27% at the end of the study for patients with LV dysfunction following MI treated with ACE inhibition.23 Observational studies and a meta-analysis of post-MI patients with HF reinforce these findings,25-27 though caution is necessary in extrapolating the results of post-MI studies to chronic HF.
Other Medications. In the absence of data to the contrary, other HF medications, including angiotensin receptor blockers (ARBs), aldosterone antagonists, and the combination of hydralazine/isosorbide dinitrate, should be considered as options for elderly patients with HF, keeping in mind the complications of polypharmacy in a population characterized by multiple comorbidities. In particular, older age is an independent risk factor for hyperkalemia when inhibitors of the renin-angiotensin aldosterone system (RAAS) are used alone or in combination.28