Heart failure in the elderly.

Heart failure (HF) is a major public health problem worldwide entailing high morbidity and mortality as well as high costs.[1] This chronic syndrome associates with a low functional status and quality of life. Most patients with HF are elderly, constituting up to 80% of patients suffering from this disease with both incidence and prevalence of the condition increasing with age.[2] This is due to the progressive aging of the population as well as improved and better survival after cardiac insults, such as myocardial infarction, especially in developed countries. Notably, acute HF is the leading cause of hospitalization in patients over 65 years. Accordingly, early diagnosis and proper treatment are critical as they both influence prognosis in these patients.[3] Major therapeutic advancements, including drug development and some technological improvements related to HF therapies, have occurred in the last decade.[4] However, there is concern about whether patients treated every day in our clinical practice are similar to those included in clinical trials where these therapeutic strategies clearly demonstrated clinical efficacy. This is especially so for elderly patients, often under-represented or excluded in such large clinical trials.[5] Of note, the term “elder” has been applied until recently to patients with more than 65 years of age. Nevertheless, given the aging population, the age group that includes “elderly patients” has shifted to over 70–80 years, with all the implications that this change implies. These patients are even more underrepresented in large controlled clinical trials. Therefore most experts consider further evidence is required, especially regarding issues related to specific characteristics of the elderly population. In addition, the importance of proper diagnosis and adequate and optimized therapy, which also refers to treatment of comorbidities, should be highlighted. Likewise, issues regarding the end-of-life care ought to be addressed with major attention in the subset of very old patients with HF.

In patients with HF, age is associated with an increased risk of cardiovascular events and mortality during short and long term follow-up.[6],[7] Elderly patients show a different clinical profile when compared with younger patients. In particular, elderly patients with HF often present with complex comorbidities (hypertension, atrial fibrillation, peripheral vascular disease and coronary artery disease, valvular disease and kidney failure or anemia) and polypharmacy.[6],[7] Moreover, some clinical features common in older population may further complicate the course of the disease. Although all these factors are well known to impact the prognosis of elderly patients with HF they are often overlooked or simply not considered in the comprehensive diagnostic approach that is required in these patients. First, related to co-morbidities, particularly respiratory disease and obesity should be carefully analyzed. On the other hand, elder patients often have a low functional status. This may complicate the interpretation of symptoms related to any effort as a result of the low level of daily physical activity. In this regard, lower exercise performance and loss of body weight involve higher risk and worse outcomes.[8]–[10] Importantly, physical activity has demonstrated a protective effect on HF risk.[11] Frailty (which means a decreased physiologic reserve and resistance to stressors), also very common in elderly patients with HF, is an independent predictor of adverse outcomes.[12] Notably, frailty is associated with poorer prognosis in terms of quality of life, hospitalization and mortality.[12]–[14] Finally, depression and anxiety, as well as the often unrecognized cognitive impairment and dementia, are also frequently found in these patients and are related to worse clinical outcomes.[15]–[17] Consequently, continuous efforts should be made to readily detect and adequately diagnose and treat these associated conditions. Eventually, the clinical decision-making process required in these patients may be very challenging but is facilitated when a multidisciplinary approach is organized to address all these problems.

A correct diagnosis requires the presence of symptoms suggestive of HF, as well as a detailed echocardiographic assessment in order to confirm the diagnosis.[4] However, clinical characteristics, and specifically the other aspects previously discussed inherently related to elderly patients may complicate the diagnosis. Orthopnea and paroxysmal nocturnal dyspnea constitute the most useful clinical symptoms.[18] Levels of natriuretic peptides may increase with age and with some of the related comorbidities.[19] And normal values of these peptides may be used to precisely exclude that symptoms are indeed due to HF.[4] Of relevance, natriuretic peptides have also demonstrated to be useful to guide medical HF therapy.[20]

Concerning therapy, some special issues should be taken into account. Elderly patients receive less frequently angiotensin converting enzyme inhibitors, beta-blockers and spironolactone. This may represent a management bias in elderly patients with HF. Potential explanations include that such patients often show greater comorbidity but also that they are less frequently referred to a cardiologist which, in turn, may result in a lower adherence to current clinical guidelines.[21],[22] Moreover, and despite some differences in medication tolerance, drugs recommended for HF are frequently underused in the elderly whereas optimal doses are frequently not achieved in these patients in spite of their positive impact on prognosis.[23],[24] Consequently, elderly patients with HF often do not benefit from an optimized medical regimen.[25],[26] It is also important to keep in mind that a correct therapeutic approach includes the treatment of predisposing causes and precipitating factors.[3] Patients with worse baseline characteristics have less tolerance to therapeutic strategies with proven prognostic benefit.[10] It is, therefore, essential to properly identify patients in whom an optimized medical therapy may be implemented to further improve clinical outcome.

Adherence to medical treatment is another relevant issue. In a recent review of the literature that included 17 studies and more than 160,000 patients, older age was associated with adequate adherence to medical therapy in patients with HF.[27] In this regard, efforts in order to strength compliance and improve results are essential, especially in elderly patients with polypharmacy or cognitive problems.[27] Although clinical guidelines recommend against the use of devices such as implantable cardioverter-defibrillators or cardiac resynchronization therapy in patients with life expectancy < 1 year, the elderly or treatment-refractory patients may benefit from these advanced therapies.[4],[28] Finally, it should be noted that, irrespective of age, disease progress for individual patients with HF is difficult to anticipate, as there is no ‘typical’ dying trajectory.[29] Loss of functional capacity or autonomy may occur gradually or abruptly and sudden death is a frequent event. Honest and based on evidence discussions should consider the risk and benefits of any therapy in patients with HF. Importantly, patients themselves should be involved in the clinical decision-making process involved in their management throughout the entire course of the disease.[30]–[32] Eventually, in very elderly patients with advanced HF, or reaching the end-of-life, the aim of the care is to achieve the maximum quality of life.[33]

In conclusion, elderly patients with HF constitute the majority of patients with HF, and their number is increasing. However, they remain underrepresented in large clinical trials. The clinical profiles of these patients differ from those of younger patients entailing a significantly worse prognosis. Elderly patients often receive less specialized care. Consequently, it seems reasonable to provide a holistic approach, including a multidisciplinary and comprehensive clinical evaluation, to ensure adequate and proportionate care. Finally, continuous efforts to advance in knowledge and to better understand this challenging clinical entity are still necessary and to improve the care and the prognosis of elderly patients with HF.