Management of Heart Failure With Preserved Ejection Fraction in Elderly Patients: Effectiveness and Safety

Abstract

The proportion of the elderly population continues to increase due to the global increase in longevity. Heart failure with preserved ejection fraction (HFpEF) is common in the elderly due to cellular aging, myocardial stiffness, and multiple comorbidities. This age group is often under-represented in clinical trials. In this narrative review, we looked into the latest evidence-based lines of management of HFpEF in this vulnerable cohort. In this narrative review, we brought the latest evidence on the treatment of HFpEf in the elderly. We searched the largest three scientific databases (Pubmed, Google Scholar, and EMBASE) using the search words (elderly, HFpEF, heart failure with preserved ejection fraction, guidelines, treatment, and management) in different combinations. To date, screening for and treatment of the causes of HFpEF (such as hypertension, coronary artery disease [CAD], valvular heart disease, and cardiac amyloidosis) and associated comorbidities (such as diabetes mellitus [DM], iron deficiency, obesity, and thyroid dysfunction) are the main line of management of HFpEF. A multidisciplinary team, including an HF specialist cardiologist, an HF nurse, a geriatrician, a dietician, a psychologist, a physiotherapist, and an occupational therapist, should manage HFpEF elderly patients. Other specialist input may be needed according to the patient's requirements. The evidence on the effective management of HFpEF in the elderly age group is scarce and controversial. Some studied non-pharmacological approaches include supervised exercise training, pulmonary artery pressure monitoring, and the interatrial shunt device (an emerging modality that includes a small percutaneously inserted interatrial left to right valve aiming to reduce the left atrial and pulmonary wedge pressures). These modalities can only improve the symptoms and HF hospitalizations without robustly impacting cardiovascular (CV) death. Among the pharmacological approaches to treat HFpEF, only the sodium-glucose cotransporter 2 (SGLT-2) inhibitors proved efficacy in reducing the hard outcomes of CV death, HF hospitalizations, and urgent visits for HF when used in elderly HFpEF patients, irrespective of the presence of diabetes mellitus. Diuretics are only beneficial to alleviate the symptoms of fluid overload, with a risk of renal impairment in volume-depleted patients. The evidence on the effectiveness of other HF-specific disease-modifying agents in elderly HFpEF patients is controversial. Elderly patients have a higher risk of having side effects from HF medications due to the higher prevalence of polypharmacy, cognitive decline, and impairment of kidney and liver functions. Therefore, cautious initiation of HF treatment with a close follow-up of the blood pressure, liver functions, kidney functions, and electrolytes are of utmost importance.

Comprehensive effects of traditional Chinese medicine treatment on heart failure and changes in B-type natriuretic peptide levels: A meta-analysis

“…Comprehensive clinical outcomes: Comprehensive clinical outcomes were analyzed in all 16 trials[ 15 - 17 ], and the heterogeneity test showed no significant heterogeneity among trials ( P = 0.17, I 2 = 25%). Therefore, the fixed-effects model was chosen for analysis[ 18 ]. The results unveiled a marked difference between the two groups (RR = 3.20; 95%CI = 2.40, 4.26; P < 0.00001), indicating that TCM combined with CWM treatment could improve the comprehensive clinical outcomes of patients (Figure 3 ).…”

Relationship between serum uric acid levels and uric acid lowering therapy with the prognosis of patients with heart failure with preserved ejection fraction: a meta-analysis

“…Age-related mechanisms play an important role in the pathophysiology of HFpEF ( 49 ). Older patients are at higher risk of side effects from HF medications ( 50 ). The proportion of men and women in the studies we included was fairly evenly distributed.…”

Identification and therapy for patients with heart failure with preserved ejection fraction: An expert opinion of the Heart Failure Association of the Polish Cardiac Society

“…The aging process and the above comorbidities may induce chronic systemic inflammation, leading to myocardial remodeling and HFpEF [16]. Owing to the specific characteristics of the elderly age group and the presence of various comorbidities with overlapping symptoms, HF is often underdiagnosed in these patients [17].…”