A review of heart failure management in the elderly population.Am J Geriatr Pharmacother 2009; 7(5):233-49AJ
In the United States, the incidence of heart failure (HF) in the elderly population (age, > or =65 years) approached 10 per 1000 population in 2006, and HF was a common reason for hospitalization. Many clinical features and the management of HF differ in elderly patients compared with their younger counterparts due to changes in physiology and the presence of comorbidities.
The aim of this review was to explore the risks and benefits of different classes of HF pharmacotherapy for chronic HF management in the elderly population.
Peer-reviewed articles were identified from MEDLINE and Current Contents database (both, 1966-May 21, 2009) using the search terms HF, elderly, geriatrics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, aldosterone antagonists, diuretics, digoxin, and vasodilators. Citations from available articles were also reviewed for additional references. Randomized, double-blind, controlled studies that assessed the effects of HF pharmacotherapy on morbidity and mortality outcomes were included. The American College of Cardiology/American Heart Association (ACC/AHA) Clinical Guidelines on Management of Chronic HF and associated studies are discussed.
A total of 40 clinical studies were included in the present review. The ACC/AHA recommended that evidence-based therapy for HF be used in elderly patients, with individualized consideration of the elderly patient's altered ability to metabolize or tolerate standard medications. HF pharmacotherapies that have been associated with mortality benefits in elderly patients with left ventricular systolic dysfunction include ACE inhibitors or ARBs; beta-blockers; aldosterone antagonists; and, in patients who cannot tolerate ACE inhibitors or ARBs or who are black, a combination of hydralazine and nitrates. For symptom control and morbidity benefit, therapies include diuretics and digoxin. For HF with preserved ejection fraction (HF-PEF), no particular pharmacotherapeutic agent has been found to have mortality benefits. Managing the underlying cause for the HF symptoms is the key approach to treatment of HF-PEF. There was a lack of clinical trials that assessed the effects of HF treatment exclusively in elderly patients. Most clinical trials of HF pharmacotherapy have not specified the number of elderly patients included, or they included 30% to 50% elderly patients. This lack of data in the elderly leads to the necessity of applying clinical judgment to individual patient cases, together with consideration of their altered ability to metabolize or tolerate standard medications. Elderly patients also have variable responses to HF pharmacotherapy and might be susceptible to adverse events, such as orthostatic hypotension, renal dysfunction, electrolyte disturbances, and interactions with medications being received for the treatment of comorbidities. Elderly patients undergoing HF therapy should be closely monitored. The HF-related mortality rate is high in elderly patients. Discussing end-of-life issues and providing palliative care in patients with advanced disease are parts of an optimal care plan.
HF therapy that has published mortality and morbidity benefits in nonelderly patient populations has been associated with benefits in elderly patients. Elderly patients may have variable pharmacologic responses to these agents and may be susceptible to adverse events and drug-drug interactions due to concurrent treatments for comorbidities. Close monitoring of elderly patients undergoing HF treatment is essential to ensure optimal outcomes.