Transcript Slide 1
Heart
Failure in
elderly
Farveh
Vakilian.M.D.Cardiologist
Fellowship in HF
Mashhad University of Medical
Sciences
Case 1
• An 80-year-old man with prior history of hypertension and myocardial
infarction presented with progressive dyspnea on exertion and leg swelling
for the past 6 months.
• He denied dyspnea at rest, orthopnea, PND, cough, wheezing, or chest
pain.
• A physical examination revealed only mild pitting lower extremity edema.
• He had neither jugular venous pressure elevation nor hepatojugular
reflux.
• On cardiac auscultation, his first and second heart sounds were regular; a
third or fourth heart sound could not be appreciated.
• On pulmonary examination, there were no râles or wheezing.
• He had normal sinus rhythm on his electrocardiogram.
• A chest x-ray revealed no cardiomegaly or pulmonary venous congestion.
• He had a left ventricular ejection fraction of 35% by an echocardiogram
done a week later.
Case 2
• An 84-year-old woman with known heart failure presented
with dyspnea for 4 weeks during which time she developed
dyspnea and fatigue on minimal exertion and even at rest.
• She also complained of orthopnea and reported that most
of the past week she slept sitting
• Her past medical history was remarkable for hypertension.
• She also reported right upper quadrant pain associated
with nausea and loss of appetite but no vomiting.
• She had chronic leg swelling which has gotten so severe
over the past several weeks that she could not wear her
shoes.
• She responded to her worsening symptoms by restricting her
activities and did not see her physician.
• her jugular venous pressure was elevated at 15 cm of water.
• She had no pulmonary râles or wheezing.
• She had severe bilateral pitting edema in both of her legs up
to mid-thigh areas with multiple blisters over lower legs.
• She also had evidence of venous insufficiency with brown
pigmentation and induration of skin.
• She had normal sinus rhythm by an electrocardiogram.
• Her chest radiograph was remarkable for marked
cardiomegaly and pulmonary venous congestion.
• a subsequent echocardiogram revealed a left ventricular
ejection fraction of >55%.
DEFINITION
Heart failure is a complex clinical syndrome
that can result from any structural or
functional cardiac disorder that impairs the
ability of the ventricle to fill with or ejec
blood.
Dyspnea and fatigue, with or without some
degree of leg swelling, are the cardinal
symptoms of heart failure
Hypertension and coronary artery disease are
the two most common causes of heart failure
in all ages, including older adults.
DIAGNOSIS
• Systolic and Diastolic heart failure
• is based on left ventricular ejection fraction.
An echocardiogram is the most commonly
used test to determine left ventricular ejection
fraction.
With age, there is a decrease both in number
and in function of myocytes, even without
cardiovascular disease
ENHANCED NECROSIS AND APOPTOSIS
Impaired calcium metabolism and regulation,
reflects an alteration of processes of
contraction and relaxation
Other changes,,,
contractile proteins change with age
ATP utilization
detrimental increase in myocardial collagen
content and development of fibrosis
arterial vascular wall fibrosis, thickening, and
stiffening
Pulse pressure is an easily hemodynamic
dependent marker can be a predictor of CHF
in 4 years follow up in eldery
• These mechanisms may cause HFpEF.
Exercise capacity is primarily affected due to
the lower heart rate increase during exercise
and higher end-diastolic pressure
stroke volume that is more preload dependent
due to impaired relaxation
• Elderly patients hospitalized for acute HF ar
more likely to be female
• have higher EF and a higher prevalence o
HFpEF
• CAD and diabetes are less common in the
very elderly
• They have an increased prevalence of
comorbidities, including:
AF, hypertension, cerebrovascular
disease, anaemia, malignancy, and
chronic kidney disease ,osteoarthritis,
and depression, and polypharmacy
Elevated IL-6, was associated with increased
risk of CHF in people without prior
myocardial infarction.
Symptoms and signs
• Less than 50% of systolic dysfunction patients
recognizaed in clinic
• Reliance cannot be placed on classic
symptoms of heart failure, and weight should
be measured daily
• Shortness of breath, orthopnea or nocturnal
cough and paroxysmal nocturnal dyspnea
• nonspecificity of complaints of fatigue,
ascribing of symptoms to aging or comorbid
conditions,
• reduction in activities to avoid symptoms
• memory impairment leading to poor
historical information.
• Physical examination may not be as definitive
as in younger individuals.
• Rales and third sounds are usualy heard in
decompensations
• jugular venous pressure and is likely to
underestimate jugular venous pressure. In one
study
• only 14% had elevated jugular venous
pressure.
• NT-proBNP can help in diagnosis but
• cutoffs for heart failure diagnosis are age
specific,
• almost fourfold higher cutoff value for
patients older than 75 years
Management
o Elderly patients with heart failure have the highest
rehospitalization rate of all adult patient groups.
o Education and involvement of the patient, family
members, and caregivers are key to the management
of older patients
o understanding of medication regimens, diet
adjustments, and regular moderate physical activity
should be emphasized.
A change in mental status is common in
elderly people with heart failure, especially
those with vascular dementia with extensive
cerebrovascular atherosclerosis or those who
have latent Alzheimer disease.
Multidisciplinary team,nurse directed
approaches with patient contacts between
office visits and more frequent contact during
the transitional period after hospital discharge
can be highly beneficial and reduce
rehospitalization rates
it is critical for clinicians to discuss end-of-life
issues with patients and their families as soon
as possible.
Age-associated changes in pharmacokinetics
must be taken into account when prescribing
drugs for heart failure.
NSAID related CHF risk is more than GI track
damage so NSAID should be given with
caution in eldery
• Dietary sodium restriction(less than 3g/day)
and moderate physical activity should be
encouraged
• Supervised exercise training programs based
on cardiac rehabilitation algorithms have
shown modest benefit
• Fluid restriction depends on the patient’s
clinical status
• While it is not necessary to limit fluid intake in
the absence of retention, a limit of 2 L/day is
recommended if edema is detected.
• If volume overload is severe, the limit should
be 1 L/day.
• Calories and fat intake are both important to
watch,
• particularly in patients with obesity,
hyperlipidemia, hypertension, or coronary
artery disease.
Treatment
• more recent usual therapy is an ACEinhibitor
or ARB
• beta blocker plus a diuretic, with lower rates
of digoxin use
• DIG trial analyses suggest that a morbidity and
hospitalization benefit can accompany digoxin
concentrations between 0.5 and 0.9 ng/ml
• spironolactone has been accompanied by
increased incidence of hyperkalemia in older
patients with heart failure, and close
monitoring is necessary.
• carefully controlled and monitored setting,
dose titration resulted in lower daily doses in
older patients, especially those older than 80
years.
• Vasodilating beta blockers are usually
considered and should be instituted at low
doses during periods of clinical stability.
• Nebivolol, a beta-blocker with vasodilating
properties, is an effective and well-tolerated
treatment for heart failure in the elderly.
Direct vasodilators such as hydralazine and
nitrates have a limited role in older patients
because of the increased likelihood of
orthostatic hypotension
As the plasma albumin level diminishes with
age, the free-drug concentration of salicylates
and warfarin,which are extensively albuminbound, may increase.
Revascularization therapies are considered in
the setting of ischemia
Cardiac resynchronization therapy can
decrease hospitalizations and reduce mortality
in selected patients with symptomatic systolic
heart failure despite optimal medical therapy.
The few highly selected patients older than 65
years who have received cardiac
transplantation appear to have survival times
similar to those of younger patients,
• with slightly more morbidity and mortality
due to the surgical procedure but lower rates
of rejection compared with younger patients
Approach to the ELDERY patients with HF
• Symptoms may be nonspecific in the older patientsuspect heart failure.
• Consider heart failure diagnosis in patients with
fatigue, dyspnea, exercise intolerance, or low activity.
• Diagnosis may be facilitated by use of
echocardiography or serum markers of heart failure.
• Heart failure may be present in the older patient with
preserved systolic function especially in older women.
• Aggressive treatment of hypertension or diabetes,
when present, may improve heart failure outcomes.
• Treat symptoms with a goal of improving quality of life and
morbidity.
• Control blood pressure-systolic and diastolic.
• Treat ischemia.
• Control atrial fibrillation rate.
• Promote physical activity.
• Adjust medications for age- and disease-related changes in
kinetics and dynamics.
• Educate and involve patients, family members, or caregivers
in management of heart failure.
• Monitor weight.
• Consider use of multidisiplinary team approaches