Journal of Geriatric Cardiology (2016) 13: 115117

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Editorial 
Open Access 

Heart failure in the elderly

Pablo Díez-Villanueva, Fernando Alfonso*

Department of Cardiology, Hospital Universitario de la Princesa, Madrid, Spain

J Geriatr Cardiol 2016; 13: 115117. doi: 10.11909/j.issn.1671-5411.2016.02.009

Keywords: Elderly; Heart failure; Prognosis

Heart failure (HF) is a major public health problem risk of cardiovascular events and mortality during short and
worldwide entailing high morbidity and mortality as well as long term follow-up.[6,7] Elderly patients show a different
high costs.[1] This chronic syndrome associates with a low clinical profile when compared with younger patients. In
functional status and quality of life. Most patients with HF particular, elderly patients with HF often present with com-
are elderly, constituting up to 80% of patients suffering plex comorbidities (hypertension, atrial fibrillation, periph-
from this disease with both incidence and prevalence of the eral vascular disease and coronary artery disease, valvular
condition increasing with age.[2] This is due to the progres- disease and kidney failure or anemia) and polypharmacy.[6,7]
sive aging of the population as well as improved and better Moreover, some clinical features common in older popula-
survival after cardiac insults, such as myocardial infarction, tion may further complicate the course of the disease. Al-
especially in developed countries. Notably, acute HF is the though all these factors are well known to impact the prog-
leading cause of hospitalization in patients over 65 years. nosis of elderly patients with HF they are often overlooked
Accordingly, early diagnosis and proper treatment are criti- or simply not considered in the comprehensive diagnostic
cal as they both influence prognosis in these patients.[3] Ma- approach that is required in these patients. First, related to
jor therapeutic advancements, including drug development co-morbidities, particularly respiratory disease and obesity
and some technological improvements related to HF thera- should be carefully analyzed. On the other hand, elder pa-
pies, have occurred in the last decade.[4] However, there is tients often have a low functional status. This may compli-
concern about whether patients treated every day in our cate the interpretation of symptoms related to any effort as a
clinical practice are similar to those included in clinical tri- result of the low level of daily physical activity. In this re-
als where these therapeutic strategies clearly demonstrated gard, lower exercise performance and loss of body weight
clinical efficacy. This is especially so for elderly patients, involve higher risk and worse outcomes.[8–10] Importantly,
often under-represented or excluded in such large clinical physical activity has demonstrated a protective effect on HF
trials.[5] Of note, the term “elder” has been applied until re- risk.[11] Frailty (which means a decreased physiologic re-
cently to patients with more than 65 years of age. Neverthe- serve and resistance to stressors), also very common in eld-
less, given the aging population, the age group that includes erly patients with HF, is an independent predictor of adverse
“elderly patients” has shifted to over 70–80 years, with all outcomes.[12] Notably, frailty is associated with poorer
the implications that this change implies. These patients are prognosis in terms of quality of life, hospitalization and
even more underrepresented in large controlled clinical tri- mortality.[12–14] Finally, depression and anxiety, as well as
als. Therefore most experts consider further evidence is the often unrecognized cognitive impairment and dementia,
required, especially regarding issues related to specific are also frequently found in these patients and are related to
characteristics of the elderly population. In addition, the worse clinical outcomes.[15–17] Consequently, continuous
importance of proper diagnosis and adequate and optimized efforts should be made to readily detect and adequately di-
therapy, which also refers to treatment of comorbidities, agnose and treat these associated conditions. Eventually, the
should be highlighted. Likewise, issues regarding the clinical decision-making process required in these patients
end-of-life care ought to be addressed with major attention may be very challenging but is facilitated when a multidis-
in the subset of very old patients with HF.  ciplinary approach is organized to address all these prob-
In patients with HF, age is associated with an increased lems.
A correct diagnosis requires the presence of symptoms
*Correspondence to: E-mails: falf@hotmail.com suggestive of HF, as well as a detailed echocardiographic

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116 Díez-Villanueva P & Alfonso F. HF in the elderly

assessment in order to confirm the diagnosis.[4] However, based on evidence discussions should consider the risk and
clinical characteristics, and specifically the other aspects benefits of any therapy in patients with HF. Importantly, pa-
previously discussed inherently related to elderly patients tients themselves should be involved in the clinical decision-
may complicate the diagnosis. Orthopnea and paroxysmal making process involved in their management throughout
nocturnal dyspnea constitute the most useful clinical symp- the entire course of the disease.[30–32] Eventually, in very eld-
toms.[18] Levels of natriuretic peptides may increase with erly patients with advanced HF, or reaching the end-of-life,
age and with some of the related comorbidities.[19] And the aim of the care is to achieve the maximum quality of life.[33]
normal values of these peptides may be used to precisely In conclusion, elderly patients with HF constitute the
exclude that symptoms are indeed due to HF.[4] Of relevance, majority of patients with HF, and their number is increasing.
natriuretic peptides have also demonstrated to be useful to However, they remain underrepresented in large clinical
guide medical HF therapy.[20] trials. The clinical profiles of these patients differ from those
Concerning therapy, some special issues should be taken of younger patients entailing a significantly worse prognosis.
into account. Elderly patients receive less frequently angio- Elderly patients often receive less specialized care. Conse-
tensin converting enzyme inhibitors, beta-blockers and spi- quently, it seems reasonable to provide a holistic approach,
ronolactone. This may represent a management bias in eld- including a multidisciplinary and comprehensive clinical
erly patients with HF. Potential explanations include that evaluation, to ensure adequate and proportionate care. Fi-
such patients often show greater comorbidity but also that nally, continuous efforts to advance in knowledge and to
they are less frequently referred to a cardiologist which, in better understand this challenging clinical entity are still
turn, may result in a lower adherence to current clinical necessary and to improve the care and the prognosis of eld-
guidelines.[21,22] Moreover, and despite some differences in erly patients with HF.
medication tolerance, drugs recommended for HF are fre-
quently underused in the elderly whereas optimal doses are References
frequently not achieved in these patients in spite of their
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