With increasing age, both the incidence of heart failure and the importance of diastolic dysfunction increase. Symptoms are often nonspecific in old age. Diagnosis is no different from that in younger patients. Studies with multimorbid geriatric patients are currently lacking for evidence-based therapy. There is an urgent need to catch up here. Nevertheless, ACE inhibitors, AT-II antagonists, β-blockers, aldosterone antagonists, diuretics, and digitalis glycosides should be used even in the elderly. Interventional and surgical procedures should no longer be excluded in patients over 75 years of age. The risk-benefit assessment must be made on an individual basis.
The incidence of heart failure increases with age. At 70-year-olds, the prevalence is 2-3%. For 70- to 80-year-olds, it rises to 10-20%. At younger ages, men are more likely to be affected; at older ages, women are more likely to be affected. The median age of patients with heart failure in the Würzburg registry “Interdisciplinary Heart Failure Network” was approximately 72 years. About 50% of patients had seven or more comorbidities or risk factors, such as hyperuricemia, arterial hypertension, inflammation, chronic renal insufficiency, or coronary artery disease (CAD).
Heart failure is one of the most common diagnoses in hospitals: in 2007, it was the most common diagnosis among women and the third most common among men. For those over 65 years of age, heart failure is the most common cause of hospitalization overall.
As a cause of death, heart failure ranks second in women and fourth in men. Due to the aging population, the disease pattern will become increasingly important in the future. In the future, there will also be an increasing focus on the group of 95-year-old and older patients.
Guidelines
Geriatric patients remain underrepresented in clinical trials and resulting guidelines. There is a great need to catch up here, since cardiovascular diseases, including heart failure, increase sharply with age. The mortality of these diseases is also high. However, because of the lack of data, it is unclear whether elderly patients with heart failure benefit equally from guideline-based therapy as younger patients.
Guideline recommendations are followed less by internists, geriatricians, and general practitioners than by cardiologists, according to a study. In geriatric patients, however, the usefulness of disease-specific guidelines is generally questionable.
In one analysis, a hypothetical but typical geriatric case was addressed using several guidelines. It was found that adherence to the guidelines resulted in complex and costly therapy. In addition, the risk of side effects was increased by the multimedication. Overall, the complex and complicated handling is more likely to reduce guideline adherence. This supposition is supported by a survey of U.S. physicians. They fundamentally doubt the applicability of disease-specific guidelines to their geriatric patients.
The previous guidelines on heart failure only provide general guidance for geriatric patients. This is true for both the 2008 European guideline and the 2005 and 2009 US guidelines.
Classification
The stages of heart failure can be classified by the AHA classification and/or the NYHA classification.
The American Heart Association (AHA) classification consists of stages A through D (Table 1).
The New York Heart Association (NYHA) classification is more widely used in clinical practice. Depending on the level of exertion at which symptoms of heart failure occur, the patient is classified into stages I to IV. In stage I, there are no symptoms during everyday physical exertion. In stage II, discomfort occurs with greater physical exertion. In stage III, symptoms appear even with low physical exertion. In stage IV, these already exist at rest (Table 2).
Causes
Chronic heart failure is divided into left heart failure, right heart failure and global heart failure. Left heart failure, in turn, is differentiated into systolic heart failure and diastolic heart failure. In systolic heart failure, systolic left ventricular function is reduced, and the ejection fraction (EF) is <35-40%. It is also referred to as “heart failure with reduced ejection fraction” (HFREF).
Diastolic heart failure, on the other hand, is also referred to as heart failure with preserved left ventricular function or heart failure with preserved ejection fraction (HFPEF).
With age, the stiffness of the ventricle and atrium increases. At the same time, diastolic dysfunction is increased, blood pressure fluctuations increase, maximum heart rate decreases, and the ability to increase cardiac output is reduced.
The prevalence of diastolic dysfunction increases with age. In those under 50 years of age, it causes about 15% of heart failure cases; in those 50 to 70 years of age, 33%; and in those over 70 years of age, 50%.
In another 15% of elderly patients with only mildly impaired ejection fraction, diastolic dysfunction exacerbates symptoms. Women are affected more often than men. Dysfunction is often associated with diabetes mellitus, arterial hypertension, obesity, chronic renal insufficiency, and aortic valve stenosis.
By far the most common causes of heart failure are arterial hypertension, coronary artery disease, or a combination of both.
Together, they account for about 70-90% of heart failure cases. Less common causes are non-ischemic cardiomyopathies, i.e. dilated, hypertrophic (obstructive) and restrictive cardiomyopathies. Arrhythmias, valvular defects, pericardial disease, and “high output failure,” e.g., in anemia or hyperthyroidism, can also cause symptoms of heart failure.
Diagnostics
Heart failure is predominantly diagnosed clinically. The leading symptoms are dyspnea or exertional dyspnea, peripheral edema, and rapid physical fatigability. With age, some of the symptoms become more atypical. Patients often complain mainly of fatigue and exhaustion. This is then dismissed as a mere symptom of old age.
Medical history and physical examination
If heart failure is suspected, a thorough history and physical examination are performed.
Laboratory
Basic laboratory diagnostics initially include blood count, sodium, potassium, creatinine, blood glucose, liver enzymes, and urine status.
The determination of BNP (“brain natriuretic peptide”) is useful for differential diagnosis. At levels <100 pg/ml, heart failure can be fairly safely excluded. At levels >400 pg/ml, heart failure is highly likely. There is a gray area in between, as NBP levels physiologically increase with age.
The National Institute for Health and Clinical Excellence (NICE) recommends specialist evaluation within six weeks for values in the gray zone, regardless of the patient’s age [2]. However, no benefit has been shown for this in age-adjusted cohorts [36].
ECG, echocardiography, coronary angiography
A 12-lead ECG is followed by echocardiography. It is the core element of diagnostics. It can be used to distinguish between systolic and diastolic heart failure. Often, echocardiography can also clarify the cause of the disease.
Examination is difficult in poorly transducible patients, and sometimes in low-gradient aortic valve stenosis with poor systolic left ventricular function. In addition to good technical equipment, the training and experience of the examiner plays a crucial role in diagnosing the various stages of diastolic dysfunction.
Coronary angiography may also be indicated at an older age: when symptomatic CAD is suspected as the cause of heart failure or before planned valve surgery. The severity of high-grade aortic valve stenosis can be assessed sufficiently well by echocardiography. However, significant CHD must always be expected with age. This should be treated surgically at the same time.
Further investigations
Long-term ECG and stress echocardiography are not part of routine diagnostics. However, they are used to verify the causes of heart failure such as arrhythmias or to detect ischemia. The importance of stress testing should be seen primarily in therapy planning and progress monitoring.
X-ray
In NYHA stage III-IV heart failure, pulmonary congestion is often visible on chest radiograph.
Therapy Principles The therapy goals are:
- Reduction of symptoms,
- Improvement of stress tolerance,
- Reducing hospitalization rates and mortality,
- Inhibition of disease progression,
- favorable influence of co-morbidities and
- Improving the quality of life.
Even in old age, moderate physical activity and regular exercise are recommended for patients with NYHA stage I-III heart failure. Particularly suitable are brisk walking, cycling and targeted endurance training, e.g. as part of a cardiac group.
It is important to have a controlled intake of 1.5-2 l of fluid per day. Patients should ideally weigh themselves daily. In case of short-term weight gain of >1 kg per night, >2 kg in three days or >2.5 kg in one week, the physician should be notified.
Above all, the prognostically relevant comorbidities must be adequately treated, i.e., CHD, diabetes mellitus, chronic renal insufficiency, and depression. In old age, weight reduction in obesity no longer has any discernible advantage up to a body mass index of 35. Therefore, it does not have to be recommended. Treatable causes of heart failure should be treated appropriately, such as symptomatic coronary stenosis, valvular defects, or arrhythmias. In any case, the risk of the procedure must be weighed very carefully against the benefit. The patient’s wish is a deciding factor.
Up to 25% of patients with heart failure also suffer from depression. It is an independent factor for poorer prognosis and should be targeted.
Drug therapy
Many studies of heart failure drug efficacy have excluded elderly and especially multimorbid geriatric patients.
This was not the case in the SENIORS study (Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with Heart Failure). More than 2100 heart failure patients >70 years were included. The intervention group received the β-blocker nebivolol, and the control group received placebo.
However, the study is still an exception. In the large randomized clinical trials of heart failure, the mean age was 60 years, and the study population was predominantly men. Patients with an ejection fraction >40% were excluded. One-year mortality was approximately <15%. Therefore, in some cases, there are only expert recommendations for the use of these drugs in old age.
In geriatric patients, interactions with other medications must always be considered. However, there is consensus that the elderly should not be deprived of medications that have been shown to be beneficial in younger patients with heart failure.
Such drugs include ACE inhibitors, AT-II antagonists, β-blockers, aldosterone antagonists, and, somewhat less effectively, diuretics and digitalis (Table 3). A combination of ACE inhibitors and AT-II antagonists is not recommended. Each patient with chronic heart failure should be evaluated to determine if he or she is being adequately treated with the recommended medications or if contraindications exist. The target dose should also be as high as possible in old age. However, it often cannot be achieved due to poorer tolerance. It is important to start with the lowest possible dose and increase slowly (Table 4).
Therapy for diastolic dysfunction is predominantly empirical because of the paucity of data. Essentially, it consists of controlling systolic and diastolic hypertension, maintaining sinus rhythm as long as possible, controlling heart rate in atrial fibrillation, and reducing pulmonary congestion with diuretics.
Digitalis
Digitalis is indicated in atrial fibrillation for rate control. The target digoxin blood level should preferably be in the lower therapeutic range of 0.5-0.8 ng/ml. In renal insufficiency, which is common in the elderly, the dose should be reduced to 0.0625 and 0.125 mg/24 h, respectively.
Digitoxin is also excreted to some extent by the kidneys. Due to the very long half-life, it takes an extremely long time for the effect to wear off when a toxic level is reached. In individual cases of sinus rhythm, the use of digitalis is warranted in NYHA stage III-IV. Digitalis does not reduce mortality, but it does reduce the rate of rehospitalization for heart failure. One advantage of digitalis is that it does not lower blood pressure.
Anticoagulation
Heart failure by itself does not warrant therapeutic anticoagulation. It is indicated only in the setting of atrial fibrillation according to the appropriate criteria. However, this complex issue, especially the use of the new substances (dabigatran, rivaroxaban), is currently the subject of much controversy in the elderly patient.
Calcium antagonists
Only amlodipine and felodipine should be used as calcium antagonists in refractory arterial hypertension or angina pectoris. The other drugs in this group worsen the prognosis in heart failure.
Diuretics
Diuretics are often less effective in elderly patients with renal insufficiency. Often, use also worsens preexisting incontinence. This in turn worsens compliance.
Ivabradine (Procoralan®)
Recently, based on data from the SHIFT trial, ivabradine was also approved for the treatment of systolic symptomatic heart failure at heart rates of 75/min and higher [6]. This frequency cut-off has been shown not only to reduce hospitalization for heart failure but also to reduce mortality.
Unfavorably acting drugs
In patients with chronic heart failure, there are a number of drugs that have an unfavorable effect. They should be strictly avoided, e.g., nonsteroidal anti-inflammatory drugs, selective COX-2 inhibitors, negatively inotropic calcium channel blockers such as verapamil and diltiazem, class I and III antiarrhythmic drugs except amiodarone, tricyclic antidepressants, minoxidil, metformin, glitazones, and ergotamine preparations.
Therapy with pacemaker, cardioverter/defibrillator
In patients with NYHA stage III and IV heart failure, a biventricular pacemaker may be indicated. The guideline recommendations are sinus rhythm, ejection fraction <35%, QRS complex >120 ms. The goal is cardiac resynchronization. However, only some of the patients benefit from the therapy. Efficacy in geriatric patients has not been specifically studied.
In patients with survived sudden cardiac death and symptomatic recurrent or sustained ventricular tachycardia, a cardioverter/defibrillator (ICD) is indicated. The benefit for patients older than 75 years was shown in a subgroup analysis of the MADIT-II trial (Multicenter Automatic Defibrillator Implantation Trial). Mortality decreased by 46% with ICD implantation.
Surgical and interventional therapy Cardiac surgery
The number of cardiac surgery patients >75 years is increasing. Already 36% of cardiac surgery patients are older than 70, and the proportion of 80-year-olds is about 6%.
In surgical risk assessment scores, age is a strong predictor of outcome. Reduced left ventricular function is considered a predictor of poor outcome. In the elderly, morbidity and mortality are increased after cardiac surgery. However, the right patient selection plays a decisive role. In selected patients >80 years of age without significant comorbidity, the course is comparable to that in younger patients. However, many elderly patients do not present for surgery at all.
Aortic valve surgery
In one study, patients >75 years of age with severe symptomatic aortic valve stenosis were followed up. One third of the patients did not undergo surgery. Reasons cited were advanced age, impaired left ventricular function, but not comorbidity. However, because the prognosis of untreated symptomatic aortic stenosis is very poor, therapy should also be considered in the elderly. One study was able to show that the risk of aortic valve surgery in people over 80 years of age is acceptable. This is especially true with regard to quality of life and long-term survival. Of the patients, 77% were able to return home and 38% were able to continue living without assistance. In another study, 86% of patients felt better than before surgery, 66% had achieved NYHA class I, and 24% had achieved NYHA class II.
Non-coronary interventional procedures
In recent years, alternative aortic valve replacement procedures have been developed for patients at high surgical risk. The PARTNER (Placement of Aortic Transcatheter Valve Trial) trial compared transfemoral aortic valve replacement (TAVI) with conservative therapy in patients deemed inoperable. The median age was 83 years, and 30-day mortality was 30% vs. 26%. Mortality decreased from 50.7% to 30.7% in the intervention group after one year (p<0.001). The rehospitalization rate was almost halved. Symptoms also improved significantly. However, the specific complications must also be taken into account. The large arterial access significantly increased the number of vascular complications and strokes in the intervention group. It is important to select patients on an individual basis. It should be done in close consultation between cardiologists and cardiac surgeons.
Coronary revascularization
Coronary revascularization should also not be withheld from elderly patients with acute myocardial infarction.
A Canadian registry included nearly 30 000 patients >80 years of age with acute myocardial infarction from 1996 to 2007. Overall, the rate of percutaneous therapy procedures increased from 2.2% to 24.9% during this time. The rate of patients treated with evidence-based medications increased significantly. As a result, the one-year mortality of patients treated with interventions decreased significantly, while that of patients treated conservatively remained the same. The rehospitalization rate for heart failure decreased, whereas that for reinfarction remained constant.
Age should not be the sole reason to decline percutaneous intervention after infarction. The risk-benefit assessment must be carried out on an individual basis.
Training
In general, physical activity and exercise is recommended for the healthiest aging possible. This recommendation can be found in all secondary prevention or rehabilitative programs of the German, European and American professional societies for cardiovascular diseases. It is currently uncertain whether or not exercise training has a real positive impact on morbidity and mortality.
In a study of over 2000 patients, there was no positive result on this. However, resilience improved and so did quality of life. Specific intervention outcomes are not available in very old patients. Nevertheless, the results of general geriatric rehabilitation suggest that targeted training interventions have a positive effect.
Indications for geriatric (early) rehabilitation in heart failure or cardiovascular disease are:
– Age ≥70 years and geriatric-typical multimorbidity or
– Age ≥ 80 years with the objective:
- Optimization of drug therapy
- Treatment and management of comorbidity and geriatric syndromes.
- Initiation and continuation of physical mobilization and training therapy.
- Training on (self-)management and lifestyle intervention
- Support in coping with illness and stabilization of psychological symptoms
- Achievement of greater mobility and autonomy in self-care and thus improved or enabled social participation.
- Relative counseling and support.
Forecast
Elderly patients with advanced heart failure have a median life expectancy of less than three years, and one-year mortality is 25-50%. Older patients are less likely than younger patients to survive hospitalization for heart failure. In contrast, the probability of being readmitted as an inpatient in the following six months is higher. Adequate palliative care must be available for these patients.
Bibliography with the author
Dieter Fischer, MD
Initial publication appeared in CME 2012; 6: 7-14.
