Heart Failure Pharmacotherapy and Supports in the Elderly - A Short Review

Abstract

Heart failure is predominantly a disease of the elderly with an increasing prevalence with increasing age. Increasing age is also associated with increased multi-morbidity such that elderly heart failure patients typically have five to six comorbidities in addition to heart failure. Elderly patients are also more likely to have heart failure with preserved ejection fraction (HFpEF), and there are fewer evidence-based treatments with proven efficacy in HFpEF. Hence the management of heart failure in these patients is largely about managing the symptoms of heart failure, along with the other cardiovascular and non-cardiovascular comorbidities. Any proposed treatments need to be considered for the potential for reduced benefit due to the competing risk of morbidity and mortality from the patient’s other conditions. In patients with heart failure, health related quality of life is impacted by both comorbidities and frailty, and frailty is associated with an increased risk of emergency department visits and hospitalisation. Frailty may also be associated with increased adverse reactions to medications. Although newer guidelines have more information on the management of these comorbidities there are still many areas of uncertainty and potential treatment conflicts. Further research is required on the interactions between different comorbidities, their treatments and heart failure and its management.

New Insights in Cardiac β-Adrenergic Signaling During Heart Failure and Aging

“…Particularly, HF prevalence has increased to 6.5 million in Americans ≥20 years of age ( Benjamin et al, 2017 ). Over the last several years, there has been an increase in the incidence and prevalence of HF in the elderly, drastically impacting their survival rate and quality of life ( Shakib and Clark, 2016 ; Ziaeian and Fonarow, 2016 ). HF represents the final common clinical event of numerous cardiovascular diseases (CVDs); coronary artery disease (CAD) followed by myocardial ischemia is the most common cause worldwide.…”

Mid-Term Prognosis After Landiolol Treatment in Atrial Fibrillation/Atrial Flutter Patients With Chronic Heart Failure ― A Prospective Observational Survey (AF-CHF Landiolol Survey) ―

“…The present mid-term analysis indicated that slightly more than half the patients had been switched to an oral β-blocker, most commonly bisoprolol/ bisoprolol fumarate (84%), although the mean initial dose of 1.66 mg was at the low end of the bisoprolol dose range risk of mortality has also been reported for HF patients. [25][26][27] This was observed in CHART-2, 28 as well as in JCARE-CARD, which reported an adjusted HR for all-cause mortality of 2.15 (95% CI 1.62-2.86) for age ≥80 vs. <80 years. 29 Mid-term findings of the AF-CHF Landiolol Survey appear to be consistent with these reports.…”

Heart failure with preserved ejection fraction: strategies for disease management and emerging therapeutic approaches

“…Patients who are diagnosed with HFpEF are generally older compared with patients with HFrEF [15], and frailty is a common issue experienced by elderly patients with HF [72,73]. Frailty is defined as having low grip strength, low energy, slow walking speed, and low physical activity [72] and has been associated with a 92% and 65% increased likelihood of emergency department visits and hospitalizations [73], respectively, in frail patients with HF compared with those who were not frail. Frailty may be negatively impacted by comorbidities, which can impair patients' ability to care for themselves [72].…”

“…Frailty is defined as having low grip strength, low energy, slow walking speed, and low physical activity [72] and has been associated with a 92% and 65% increased likelihood of emergency department visits and hospitalizations [73], respectively, in frail patients with HF compared with those who were not frail. Frailty may be negatively impacted by comorbidities, which can impair patients' ability to care for themselves [72]. As such, greater collaboration among PCPs, patients, and their caregivers may facilitate assessment of their quality-of-life (QoL) issues, end-of-life values, preferences in decision-making, management of comorbidities, and provide educational support [71,74].…”