Heart Failure in the Elderly

This is the seventh and final article in the series on cardiovascular issues in the older adult. The sixth article in the series, “Understanding Hypertension and its Treatment in Elders,” was published in the November 2011 issue of  Clinical Geriatrics and can be accessed online at www.clinicalgeriatrics.com/articles/Understanding-Hypertension-and-its-Treatment-Elders.
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It is estimated that more than 5.7 million adults in the United States are living with heart failure (HF).¹ HF is a syndrome that primarily affects the elderly, with nearly 75% of HF cases diagnosed in individuals older than 65 years,² the most rapidly expanding population cohort in the United States.³

Data published in 1993 from the Framingham Heart Study demonstrated a positive correlation between age and HF prevalence, ranging from 8 cases per 1000 persons for both men and women aged 50 to 59 years to 66 cases per 1000 persons for men and 79 cases per 1000 persons for women among individuals in their eighth decade of life.⁴ These rates may be even higher today, with Curtis and associates⁵ reporting in 2008 that the overall prevalence of HF in Medicare beneficiaries 65 years and older increased from approximately 90 cases per 1000 persons in 1994 to 120 cases per 1000 persons in 2003. The annual incidence of HF in those 65 years and older is said to approach 10 cases per 1000 persons, but data are conflicting as to whether the true incidence of HF is also on the rise.⁶ Curtis and colleagues⁵ found the incidence of HF in this demographic actually declined slightly between 1994 and 2003, largely due to decreased rates among adults 75 years and older.

Although data regarding the incidence and prevalence of HF among elders may be inconsistent, the condition clearly remains a significant concern. Given that an estimated 20% of the US population will be 65 years and older by 2050,⁷ the societal impact of HF cannot be understated. This review highlights clinically relevant aspects in the comprehensive management of the elderly patient with HF.

Risk Factors for Heart Failure

Modifiable and nonmodifiable factors increase an individual’s risk of developing HF (Table 1), the end stage on a pathway that is similar among various cardiovascular ailments, including valvular heart disease, arrhythmias, ischemic heart disease, and systemic hypertension (HTN). Age is the strongest predictor of one’s risk of HF. This nonmodifiable risk factor is associated with many pathophysiological changes, such as arterial stiffening and myocardial fibrosis, known to contribute to the development of the HF phenotype.

Advancing age is associated with higher rates of HTN and coronary artery disease, the two most potent modifiable risk factors for the development of HF.⁸ The critical importance of HTN in the pathogenesis of HF cannot be underestimated. A patient whose blood pressure is ≥160/100 mm Hg has nearly double the lifetime risk of developing HF than one whose blood pressure is <140/90 mm Hg.⁶

The elderly are less capable of favorable arterial remodeling and less able to tolerate cardiovascular disease. As a result, they are significantly more likely than younger adults to develop HF following myocardial infarction.⁹

The Spectrum of Heart Failure

The clinical spectrum of HF is heterogeneous, and signs and symptoms vary greatly between patients. Symptoms such as fatigue, dyspnea, and exercise intolerance may be misattributed to natural aging, deconditioning, a pulmonary process, or another disease entity. It is critical for physicians to maintain a high index of suspicion for HF and to know the signs and symptoms of venous congestion and impaired tissue perfusion.

Systolic HF (SHF; or systolic cardiac dysfunction) and HF with preserved ejection fraction (HFpEF) present similarly and occur with similar frequency, although the prevalence of HFpEF overtakes that of SHF in the 70 years and older demographic.¹⁰ SHF occurs when the heart muscle contracts with too little force, causing less oxygen-rich blood to be pumped throughout the body. Patients who have HFpEF suffer from underlying venous congestion and dyspnea with exertion due to impaired left ventricular (LV) relaxation, which renders them unable to accommodate increased blood flow upon activity. Differentiating between SHF and HFpEF requires cardiac imaging.

Establishing a diagnosis of HFpEF is challenging, and multiple definitions of this syndrome have been proposed. Most simply, HFpEF is defined as a signs and symptoms of HF in a patient who has a normal left ventricular ejection fraction (LVEF) on echocardiography.¹¹ The European Society of Cardiology favors a more rigorous definition that includes signs and symptoms of HF; LVEF ≥50%; and invasive hemodynamic, echocardiographic, or natriuretic peptide evidence of elevated filling pressures.¹² Patients 75 years and older have the highest prevalence of HFpEF, and their overall prognosis is similar to that for same-age patients with SHF.¹⁰ When HFpEF occurs in octogenarians, the prognosis is quite poor, as demonstrated by a study that found more than two-thirds of patients in this age group died within 5 years of diagnosis.¹³ 

HTN is common in patients with HFpEF, affecting about 50% of this population.¹⁴ The outcomes of patients with concomitant HTN and HFpEF are no better than outcomes for patients with HFpEF stemming from other etiologies, such as valvular heart disease.¹⁵ Cognitive impairment and renal insufficiency are poor prognostic findings in HFpEF.

The modes of death differ in HFpEF compared with SHF and are often related to noncardiac etiologies, including cancer, renal failure, and infections.¹⁶ Although survival for SHF has improved, mortality curves associated with HFpEF remain unchanged. Irrespective of the type of HF, a multidisciplinary approach to the care of HF patients is critical to their overall survival.

Managing Heart Failure in Elderly Patients

Managing HF in elderly adults presents many challenges, the first of which is deciding whom to consider elderly. Our definition of elderly is deeply rooted in cultural and societal beliefs and has been influenced by the design of clinical trials, which typically use an arbitrary cutoff of 65 years. Because of changes in how Americans age and today’s longer life expectancies, it is uncertain whether this cutoff should be increased to 75 years or even 80 years.

In general, there are meaningful differences between how clinicians treat disease in older versus younger adults, especially when caring for the very elderly (aged >80 years), whose overall prognosis often differs markedly from that of their younger counterparts. The EHFS II (European Heart Failure Survey II)¹⁷ studied 12-month outcomes for 741 octogenarians (mean age, 83.7 years) versus 2836 younger adults (mean age, 68.4 years). The authors found the rate of inpatient mortality for the octogenarians was nearly double that of the younger patients (10.7% vs 5.6%, respectively; P<.001), and the octogenarians also had significantly higher mortality rates in the first year after discharge (28.4% vs 18.5%, respectively; P<.001).

All patients diagnosed with HF should be educated on the importance of dietary salt restriction, symptoms of congestion, and counseled on symptom changes (eg, worsening orthopnea, lower extremity edema) that should prompt consultation with their physician. Patients require counseling on the importance of weighing themselves daily and potential interventions to address sudden undesirable changes in weight. Patients should be screened for common comorbid conditions, especially depression and sleep-disordered breathing in those with prominent fatigue or nonrefreshing sleep. They should also be encouraged to avoid a sedentary lifestyle. Exercise training in the elderly HF patient has been shown to improve oxygen uptake, gas exchange, and physical quality of life.¹⁸

The goals of HF pharmacotherapy are to reduce symptoms, enhance quality of life, and improve survival. Pharmacotherapy for older adults with HF is often suboptimal, however, with many physicians reluctant to prescribe established therapies or target dosing to levels proven in pivotal trials to provide maximal benefit.¹⁷ EHFS II found that medications were frequently underdosed and underprescribed for the older patient group; for example, only 53% of octogenarians who survived to discharge (349/660) were placed on a beta blocker. More successful management of HF in older adults will require eliminating arbitrary age barriers, which have become obstacles to prescribing evidence-based therapies.

A major concern when treating elderly patients with HF is the risk of adverse drug-drug interactions. This risk rises dramatically in accordance with the number of prescriptions, approaching 90% in patients taking 10 or more medications.¹⁹ Prescription drug use is ubiquitous in older adults. A recent survey found that 81% of respondents aged 57 to 85 years used at least one prescription drug and 29% used five or more prescription drugs; almost half used an over-the-counter-medication.²⁰ One study concluded that the average HF patient takes 10±3 prescription medications.²¹

Age-related changes in how the body absorbs, distributes, metabolizes, and eliminates nearly all drugs must also be taken into account when prescribing medications to older adults. For example, the glomerular filtration rate (GFR) declines by 5 to 10 cc/min/decade,²² and renal failure becomes increasingly prevalent with age. (Because of age-related declines in lean body mass, estimated GFR should be used to assess renal function, rather than the serum creatinine level.) Elderly patients who clinically demonstrate perturbations in renal function often require higher doses of diuretics and more frequent laboratory studies. Nonsteroidal anti-inflammatory drugs can lead to greater impairment of renal function and worsening HF in the elderly, and their use is generally discouraged.²³

The concomitant administration of a diuretic and an angiotensin-converting enzyme (ACE) inhibitor places elderly patients at increased risk of hyperkalemia and worsening renal function, and heightened surveillance is advised. Although the goal of HF pharmacotherapy is to titrate medications to achieve the doses proven most effective in clinical trials, published data suggest that even low doses of ACE inhibitors and beta blockers improve outcomes in patients who experience problematic side effects with higher doses.²⁴

Postural hypotension (orthostasis) may be particularly problematic in older adults, given their high prevalence of diuretic and vasodilator use. Supine and standing blood pressure should be recorded in all patients before initiating blood pressure agents. Educating patients on the need to move slowly when rising from a seated or supine position, monitoring patients for signs and symptoms of hypovolemia, and the use of compressive stockings may be necessary.²⁵

Successful treatment requires meticulous patient compliance, and active participation from the treating physician in uptitrating medications to target doses. Frailty and cognitive impairment often reduce compliance among older adults. Steps should be taken to minimize the likelihood of adverse drug-drug interactions, promote patient compliance, and enhance safety. Pillbox use should be encouraged. Medication lists (including over-the-counter preparations) must be periodically reviewed, and doses should be adjusted as necessary with each clinic visit. If a dedicated pharmacist is available, depending on patient volume and case complexity, it might be beneficial to have the pharmacist review the prescription list. Despite the barriers to successful HF pharmacotherapy in older adults, careful medication titration and use of a multidisciplinary approach focusing on patient and caregiver education is successful in most cases.

Weighing Applicability of Clinical Trial Outcomes for Elderly Patients

Studies on the effectiveness of various therapeutic drugs and devices often exclude the geriatric population. Trials that include older adults often restrict enrollment to “healthy” elderly patients, who are not representative of the population as a whole, to minimize the risk of adverse effects or complications contributing to negative outcomes.

Despite HF being most prevalent among elders, randomized clinical trials, which form the foundation for guidelines on HF therapy and provide the highest level of evidence for clinical practice, typically only capture a small slice of this population. A meta-analysis of more than 50 pivotal randomized clinical trials conducted between 1985 and 1999 revealed that the mean age of patients enrolled was 61 years; only three studies included patients older than 75 years.²⁶ Not surprisingly, most patients were white men despite the high prevalence of HF among women and the increased risk of HF in some minority populations.

These findings were confirmed by a more recent meta-analysis that found less age bias in randomized controlled trials for HF, yet concluded that 25% of included clinical trials had an arbitrary age limit for participation.²⁷ Despite the limitations inherent in the literature, we strongly believe that evidence-based HF pharmacotherapy is equally applicable to the elderly and very elderly populations. Subgroup analyses from various trials have rarely identified age as a predictor of nonresponse to therapy.

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Pharmacotherapy for Systolic Heart Failure

In the pharmacologic management of SHF, the neurohormonal and renin-angiotensin-aldosterone axes serve as the treatment target for those therapies found to have the greatest impact on mortality. ACE inhibitors improve symptoms and survival in SHF across a broad range of patient subgroups. The pivotal trials demonstrating effectiveness of ACE inhibitors included some elderly patients, and this finding was supported in several community-based observational studies.²⁸ It is generally safe to titrate ACE inhibitors every 2 weeks, but laboratory studies should be monitored closely. Development of symptomatic hypotension often limits dose escalation.

In patients who develop cough or angioedema with ACE inhibitor use and must therefore discontinue these drugs, angiotensin-II receptor blockers (ARBs) can be substituted. The Losartan Heart Failure Survival Study (Elite II)²⁹ randomized a population of elderly patients aged 60 years or older to receive the ACE inhibitor captopril or the ARB losartan. The researchers observed no differences in clinical outcomes, but found that losartan was better tolerated. Concomitant use of ARBs in patients taking beta blockers and ACE inhibitors may worsen survival due to excessive neurohormonal blockade and is therefore discouraged.³⁰

Of all agents studied in the treatment of SHF, beta blockers have had the greatest impact on mortality rates. The elderly have been well-represented in pivotal trials of beta blockers in HF. The MERIT-HF (Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure) study randomized patients to receive metoprolol succinate or placebo.³¹ Slightly more than one-third of patients were older than 70 years, and this subgroup received a level of benefit from metoprolol use similar to that observed in the overall study population. Subgroup analyses calculated a 37% reduction in relative risk in all-cause mortality in patients 65 years and older and a 29% reduction in relative risk for patients older than 75 years.³¹ In another randomized trial, Flather and colleagues³² studied nebivolol, a beta blocker with novel beta-3 receptor agonist properties, in patients 70 years and older who had recently been admitted to the hospital for HF. The drug was well-tolerated and associated with a significant reduction in the primary end point of all-cause mortality and cardiovascular hospital admission, and demonstrated a trend towards reduced all-cause mortality. The benefits of beta blocker therapy are thought to extend even to those patients typically excluded from clinical trials, such as octogenarians.³³

In patients with chronic obstructive pulmonary disease (COPD), selective beta-1 receptor blockers are considered safe when carefully prescribed and do not lead to clinical worsening or exacerbations of either disease.³⁴ Nonselective beta blockers should be avoided due to their potential to induce systemic side effects.

Aldosterone antagonists are recommended for patients who remain symptomatic with moderate to severe HF despite therapy with ACE inhibitors and beta blockers. In the RALES (Randomized Aldactone Evaluation Study), elderly patients with HF who received low-dose spironolactone (25 mg) experienced a 30% reduction in mortality risk.³⁵ RALES excluded patients with a baseline serum creatinine level >2.5 mg/dL or a serum potassium level >5.0 mmol/L. Despite the reported benefits of spironolactone in the RALES study, extreme caution is advised when treating older patients with this agent; “real world” experience indicates high rates of hyperkalemia and renal insufficiency with aldosterone blockade, approaching 11% and 38%, respectively, in patients older than 75 years.³⁶ Laboratory studies should be conducted 1 week after initiating therapy with aldosterone blockade. Gynecomastia is an adverse effect of spironolactone use, particularly among older adults, and the selective aldosterone blocker eplerenone is recommended for patients who experience this side effect.

The vasodilator combination of oral nitrates and hydralazine can be considered for patients unable to tolerate ACE inhibitors or ARB therapy due to renal insufficiency, or for patients who remain hypertensive despite receiving maximal doses of a neurohormonal blockade. Caution is advised when using concomitant nitrates and hydralazine in elderly patients because of the potential for dizziness and the combination’s cumbersome thrice-daily dosing schedule.

Adjunct therapy with diuretics is often required in patients treated with neurohormonal blockade to maintain euvolemia and relieve dyspnea. Loop diuretics are typically preferred, and the lowest effective dose should be prescribed. In some cases diuretic therapy can be discontinued, but this hinges on the patient complying with a low-sodium diet. Patients who have increasing diuretic requirements should be counseled on sodium intake and monitored for disease progression or worsening renal function.

Digoxin is a cardiac glycoside used to treat chronic HF; it has mild positive inotropic effects and affects parasympathetic vagal tone. Digoxin improves HF symptoms and reduces hospitalizations, but it does not improve survival³⁷ and its role today is limited to patients who remain symptomatic despite therapy with beta blockers, aldosterone antagonists, and ACE inhibitors. Aging affects the volume of distribution and clearance of digoxin, leading to higher serum concentrations in the elderly. Careful monitoring can minimize the potential for digoxin-related toxicity.³⁸ It should be started at a low dose, and levels should be checked after 2 to 3 weeks of use to ensure that they are not too high. Additional dose increases are not typically prescribed for subtherapeutic levels.

Pharmacotherapy for HFpEF

Pharmacologic treatments for HFpEF are limited; however, recommended treatment targets include optimization of volume status with diuretics, assessment and treatment of myocardial ischemia, optimization of blood pressure, and rate control of atrial fibrillation.³⁹ A rhythm control strategy for atrial fibrillation may be attempted for patients who remain symptomatic despite adequate rate control or are unable to be adequately rate controlled. HFpEF patients are often sensitive to subtle changes in fluid status, making diuretic dosing challenging. Pharmacotherapy trials in HFpEF have been disappointing. Studies of ACE inhibitors and ARBs have not yielded positive results.⁴⁰ The ongoing TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial is investigating the role of the antifibrotic agent spironolactone in HFpEF.

Device Therapy in the Elderly

All patients with SHF should be considered for an implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT), technologies that have dramatically altered the landscape of HF care over the past decade. Patients with HF and a reduced LVEF are at increased risk of potentially fatal ventricular arrhythmias. ICDs detect and treat these arrhythmias with synchronized rapid pacing (antitachycardia pacing) or shock. ICD guidelines (Table 2) exist for patients at risk of sudden cardiac death (primary prevention) and for those who have survived ventricular arrhythmias or cardiac arrest (secondary prevention).⁴¹ 

Elderly patients often have multiple noncardiovascular comorbidities, and some question whether they stand to derive similar benefit from ICD placement. Few pivotal ICD trials included patients older than 75 years. A study of octogenarians who underwent ICD placement found that their average survival after implantation exceeded 4 years.⁴² Renal function was identified as a strong predictor of mortality, highlighting the importance of considering noncardiovascular medical comorbidities when using ICDs in elderly patients.

There is no evidence to suggest that ICD placement should be withheld based solely on age. A meta-analysis of the large secondary prevention studies reported a high percentage of nonarrhythmic deaths among the very elderly (aged ≥75 years), suggesting a reduced benefit from ICD placement and underscoring the importance of identifying and treating comorbidities and personalizing treatment decisions.⁴³ A recent single-center, retrospective review of patients older than 80 years who underwent ICD placement as primary prevention from January 1995 to April 2010 reported a low rate of serious complications and estimated the rate of 5-year survival at 60%.⁴⁴

Despite receiving optimal therapy, some patients with HF remain symptomatic. CRT should be considered in symptomatic patients who have an LVEF ≤35% despite optimal medical therapy, a wide QRS complex (>120 ms), and NYHA class III-IV heart failure. Approximately one-third of HF patients will have intraventricular conduction delays associated with dyssynchronous LV contraction that may impair LV function. CRT involves placing a third pacing lead within the coronary sinus to simultaneously activate the LV free wall and the interventricular septum, with a goal of synchronizing interventricular and intraventricular contractions.

The two most recent pivotal CRT clinical trials—COMPANION (Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure)⁴⁵ and CARE-HF (Cardiac Resynchronization-Heart Failure)⁴⁶—found that CRT improved survival in ischemic and nonischemic older patients (mean age, 67 years) compared with standard medical therapy alone. Studies that have analyzed outcomes in subgroups of elderly patients have found no age-related differences in response to CRT or procedure-related complications.^47,48

Managing Atrial Fibrillation in HF Patients

An estimated 15% to 30% of patients with HF will develop atrial fibrillation (AF) at some point, including approximately one-third of patients with HFpEF.⁴⁹ The prevalence of AF increases dramatically with age, ranging from 4% in patients older than 60 years to 9% among octogenarians.⁵⁰ AF poses several unique challenges in the setting of HF. The loss of atrial contraction from AF can decrease ventricular filling and impair cardiac output; AF with rapid ventricular response can increase myocardial demand and impair cardiac contraction and relaxation.

AF is typically associated with increased mortality.⁵¹ However, an adjusted analysis of mortality for patients with baseline AF at the time of HFpEF concluded that AF was not an independent predictor of long-term survival.⁴⁹ Management of AF is concerned primarily with identifying and treating any precipitating factors, reducing the risk of thromboembolism, and mitigating symptoms, either with a rate or rhythm control strategy.

Stroke is the most disabling and devastating complication of AF. Multiple risk prediction models have been developed to estimate stroke risk. Although all have some limitations, we prefer the CHADS(2) scoring system, which emphasizes the importance of advanced age and concomitant HF in assessing stroke risk.⁵² (CHADS is an acronym for the major risk criteria for stroke: congestive heart failure/hypertension/age ≥75 years/diabetes/prior stroke.) Each one-point increase in the CHADS(2) score raises the stroke rate per 100 patient-years without antithrombotic therapy by a factor of 1.5.⁵³

Interventions to reduce the risk of falls and control blood pressure help reduce stroke risk. Anticoagulation should not be withheld based upon age alone. The BAFTA (Birmingham Atrial Fibrillation Treatment of the Aged) study⁵⁴ confirmed the benefit of warfarin anticoagulation over aspirin at reducing stroke in patients aged 75 years, and both therapies had similar rates of intracranial hemorrhage. A more recent report investigating warfarin anticoagulation for either AF or venous thromboembolism in octogenarians confirmed a low risk of major bleeding, with 1.87 events observed per 100 patient years.⁵⁵ These large studies^54,55 confirm the safety of warfarin anticoagulation in the very elderly when prescribed to compliant patients as part of a structured disease-monitoring program.The novel oral antithrombin inhibitor dabigatran also appears safe and efficacious in the elderly and does not require outpatient monitoring.⁵⁶

Current data do not support using an initial rhythm control strategy over a rate control strategy for HF patients who have AF. The AF-CHF (Atrial Fibrillation and Congestive Heart Failure) trial⁵⁷ examined patients with advanced symptomatic SHF and AF and found no mortality benefit with an initial rhythm control strategy versus a rate control strategy. For patients who remain highly symptomatic despite adequate rate control, rhythm control may be considered. Available agents are associated with multiple drug-drug interactions and toxicities, and expert consultation is advised. Patients with HF who continue to be symptomatic from AF and who have failed at least one antiarrhythmic drug can be considered for an AF ablation at an experienced center. In patients for whom medications for rate control are contraindicated due to sinus node dysfunction or tachy-brady syndrome, the atrioventricular node can be ablated with placement of a permanent pacemaker (typically a biventricular [CRT] device).

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Inpatient Management of Heart Failure

Hospitalizations for HF are on the rise, especially of older adults. A large proportion of the overall cost associated with managing HF is derived from the expense of inpatient care. Consequently, in addition to improving survival and quality of life, the goals of therapeutic strategies should also include reducing rates of hospital readmission and HF decompensation.

Older patients hospitalized for HF have a higher rate of mortality than their younger counterparts, with an estimated mortality rate of 18% annually.⁸ It is critical for practitioners to recognize that cardiovascular and noncardiovascular factors increase an HF patient’s risk of hospitalization. In addition to advanced age, the TIME-CHF (Trial of Intensified Versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure)⁵⁸ identified depression, elevated creatinine level, and edema as risk factors for hospitalization of HF patients. In a retrospective study of data for Medicare beneficiaries, researchers found that hospital readmission rates remained high and identified several noncardiac contributing factors, including renal failure, exacerbation of COPD, and pneumonia.⁵⁹ Thus, treatment strategies that focus only on managing HF and fail to address comorbid conditions appear inadequate for reducing the burden of HF readmissions.

Shah and colleagues⁶⁰ reviewed records for very elderly veterans (aged >80 years) in the Veteran Affairs database and found that mortality following admission for HF improved between 1998 and 2008. The 30-day mortality rate dropped from 14% in 1998 to 7% in 2008 and the 1-year mortality rate declined from 49% to 27%. Although HF readmissions decreased, no real change in all-cause readmissions was observed, emphasizing the importance of treating noncardiac chronic medical conditions in this patient population. Additionally, 90-day readmission rates remained high, at 24%. Not surprisingly, mortality was highest for the subgroup of patients 90 years and older.⁶⁰ In summary, although HF mortality has improved, hospital readmission rates remain unacceptably high and have stagnated over time. This high HF readmission rate is particularly relevant in light of planned changes to Medicare reimbursement authorized by the Patient Protection and Affordable Care Act. These changes are scheduled to be implemented in 2013 and may penalize hospitals that have unacceptably high HF readmission rates.⁶¹

Risk assessment is a critical component of an HF admission. Patients and caregivers need to be aware of the severity of the patient’s illness and his or her risk of death or rehospitalization. One study reported that the median survival for patients older than 85 years with four or more hospitalizations was only 6 months.¹⁷ The recently developed multidimensional prognostic index (MPI) appears to facilitate effective risk stratification of hospitalized patients with HF decompensation. The MPI model was derived from a comprehensive geriatric assessment and was used in a study of patients with a mean age of 80 years, where it was determined to be a powerful predictor of 30-day mortality risk in patients hospitalized for HF.⁶² The MPI assessment incorporates cognitive skills, motor tasks, memory, and nutrition, which do not figure into traditional inpatient HF risk schemes. Pilotto and colleagues⁶² reported that the rate of 30-day mortality for patients with MPI scores in the highest tertile was 47% compared with 2.8% for patients whose scores were in the lowest tertile. An important lesson from the MPI, which must not be underestimated, is that frailty and declining cognitive skills are tremendously important factors in assessing short-term survival in older adults and far more important than traditional cardiovascular parameters such as LVEF.⁶³ The MPI must be administered by a geriatrician and takes an average of 25 minutes to complete, making it a labor-intensive assessment tool.

Several goals should be achieved during hospitalization for inpatients with HF (Table 3). Prior to discharge, optimal blood pressure levels should be reached and euvolemia should be achieved. Routine use of intravenous inotropic medications or invasive pulmonary artery catheters is discouraged. These therapies should be reserved for patients who manifest hemodynamic instability or poor tissue perfusion with subsequent end-organ dysfunction.

Advanced Heart Failure Therapies

Heart transplantation (HT) is well-established as a therapy for patients with refractory HF. While an age older than 65 years has traditionally been viewed as a contraindication to HT, an increasing number of centers are now offering surgery to older patients who are otherwise healthy. Properly selected older patients often have outcomes comparable to those of younger patients.⁶⁴ Early referral to experienced centers—prior to the development of end-organ dysfunction and malnutrition—is critical for successful transplantation.

Left ventricular assist devices (LVADs) are surgically placed heart pumps, which are increasingly being used to manage advanced HF. Pumps can be used as destination therapy in patients for whom HT is contraindicated or as a bridge, stabilizing ill patients waiting for HT.⁶⁵ Newer continue-flow pumps are easier to implant and offer better outcomes than earlier generations of pulsatile systems.⁶⁶ Elderly patients typically have better outcomes when pumps are placed on an elective, rather than an emergent, basis. A discussion with the patient and his or her family and caregivers regarding the goals and expectations of LVAD therapy, what it is like to live with an LVAD, and the need for a preparedness plan should a catastrophic complication occur is critical. Similar to HT, early referral for LVAD placement often enhances the likelihood of improved outcomes.

Palliation for Heart Failure

HF remains a progressive, incurable syndrome despite tremendous advances in devices and pharmacotherapy over the past 20 years. Medication intolerances, weight loss, and poor appetite often signal inexorable disease progression. For patients who are not candidates for advanced HF options, consultation with a palliative care specialist may help with establishing realistic goals, optimizing quality of life, and facilitating referrals to a hospice.⁶⁷ With palliative care, the focus of care shifts toward symptom management, HF medications may be titrated downward, and discussions are held regarding turning off ICDs.

Conclusion

Physicians of all specialties and disciplines are increasingly exposed to elderly patients with HF, and providers are expected be knowledgeable regarding the unique challenges in this population. Traditional SHF pharmacotherapy is beneficial in the elderly and should not be withheld, but dose adjustments and more frequent monitoring may be needed. Device therapy is safe and beneficial in older adults who meet eligibility criteria as specified in published guidelines. Comorbid conditions, including AF and chronic kidney disease, require therapeutic modulation and careful monitoring; often, a multidisciplinary approach is warranted. Whenever possible, early referral should be made for robust elderly HF patients who are likely candidates for advanced HF treatment.

The authors report no relevant financial relationships.

Dr. Baker is with Saint Joseph’s Cardiovascular Associates, Towson, MD. Dr. Ramani is Assistant Professor of Medicine, University of Maryland School of Medicine, Baltimore.

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