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Edisi 03_2009-utama

Management of Heart Failure in Elderly Patients
Idrus Alwi
Department of Internal Medicine, Faculty of Medicine, University of Indonesia-dr. Cipto Mangunkusumo Hospital. Jl. Diponegoro no. 71, Jakarta Pusat 10430. Correspondence mail to: idrus@hotmail.com.
ABSTRACT
INTRODUCTION
Heart failure is a clinical syndrome, associated with high Heart failure is a clinical syndrome, associated with mortality and frequent as well as long hospitalization high mortality and frequent as well as long hospitalization duration. Several cohort studies in elderly patients with >80 duration.1 The prevalence of heart failure is increasing years of age for 1 year duration demonstrate a very high with age.2 Several surveys, e.g. the Euro Heart Failure mortality rate for 3 months and 12 months hospitalization. Survey I (EHFS I),3 reported poor outcome, especially Major Cardiovascular Events (MACE) observed during in elderly patients4 since the management is frequently follow up is also increased significantly. These findings complicated due to multiple co-morbidity factors.4-7 support the idea that age is a strong predictor and Moreover, evidence-based therapies are still infrequently independent concerning mortality in patients with heartfailure. There are different factors associated with mortality applied and under-prescribing, i.e. giving drug less than during hospitalization and follow-up. the recommended dose, is commonly found in elderly Poor ejection fraction, a strong mortality predictor in young people, is not an independent factor in octogenarian Several cohort studies in elderly patients with >80 population. This owes to the high prevalence of heart years of age for 1 year duration demonstrate a very high failure with normal ejection fraction (preserved ejection mortality rate for 3 months and 12 months hospitalization.
fraction), and only one fifth of echocardiography results Major Cardiovascular Events (MACE) observed during demonstrate ejection fraction < 30%. The use of ACE-I or follow up is also increased significantly. These findings ARBs is associated with better one-year-outcome. support the idea that age is a strong predictor andindependent concerning mortality in patients with heart Key words: heart failure, cardiovascular, elderly patients.
There are different factors associated with mortality during hospitalization and follow-up. Hospital-ization mortality is primarily correlated to acute clinicalconditions; while long-term mortality is associated withdisability14 and the presence of other co-morbidities, suchas diabetes and kidney dysfunction. Previous studyshowed that kidney function is a strong predictor formortality during hospitalization and follow up.15 Poor ejection fraction, a strong mortality predictor in young people,16 is not an independent factor inoctogenarian population. This owes to the highprevalence of heart failure with normal ejection fraction(preserved ejection fraction), and only one fifth ofechocardiography results demonstrate ejection fraction< 30%. The use of ACE-I or ARBs is associated withbetter one-year-outcome.17-20 AGE AS PREDISPOSITION FOR HEART FAILURE
is a presumption of the existence of other disease, based Age is one of predisposing factors for the on the anamnesis and physical examination.
development of heart failure through various mechanisms.
First, heart failure is a common outcome for every THE MANAGEMENT OF HEART FAILURE IN ELDERLY
cardiovascular disease. Thus, patients with PATIENTS
cardiovascular diseases (such as hypertension, acute ACC-AHA has recently announced the guideline of coronary syndrome, heart surgery, etc) tend to develop heart failure in general23 (not exclusively for elderly and experience ventricular remodeling and heart failure patients). The management of heart failure based on the in their older age. Second, in spite of cardiovascular diseases, elderly itself is associated with decreasing aortaland left ventricle compliance, and increasing aortal EXERCISE AND LIFE STYLE MODIFICATION
impedance as well as abnormal left ventricle diastolicfunctions. These conditions lower the threshold of heart The benefit of exercise on heart failure includes failure progression when the heart is exposed to decreasing neuro-hormonal activity, improving precipitating factors, such as hypertension and/or endothelial and physiological function of skeletal muscle tachyarrhythmia (mainly, atrial fibrillation). The last and the sensation of improved quality of life. Patients mechanism explains why the clinical manifestation of shall have education in regard of dietary modification heart failure in elderly patients is basically different from syndromes described and studied on randomized clinical Recommendations
Exercise training is beneficial as an adjunctive Heart failure is more frequently found in female approach to improve clinical status in ambulatory patients because of their longer life expectation age; patients with current or prior symptoms of heart failure hence, they tend to suffer more risk of having and reduced left ventricular systolic function. (Class I, hypertension, normal left ventricular ejection fraction and a great number of co-morbidities.21 Compared to youngpeople, elderly patients are more frequently experienc- PHARMACOLOGICAL TREATMENT FOR HEART
ing inadequate assessment during hospitalization, and FAILURE IN ELDERLY PATIENTS
more often received under-prescribing or having Data regarding optimal pharmacological therapy for treatment less than the recommended dose for life heart failure in extremely elderly patients (age >80 years) saving therapies. Age is also a predictor of higher is very limited. Small studies and sub-group analysis on large scale clinical trial demonstrates the safety andefficacy of treatment, especially adjusted for elderly HEART FAILURE DIAGNOSIS IN ELDERLY PATIENTS
patients with congestive heart failure.
Symptoms of heart failure, such as tiredness and breathing difficulty, may be mistaken as aging process.
DIURETICS
Delirium, the presence of decreasing functional status, Diuretics are prescribed to all patients who have recent peripheral edema, or nocturnal symptoms (cough, evidence of symptoms or signs of pulmonary or systemic dyspnea) calls for further evaluation in regard of heart congestion. Once daily dose is more preferred.
Moreover, renal function and electrolyte balance should The basic examination for heart failure in elderly be monitored during treatment Patients who have patients is not significantly different, i.e.: complete blood hypo-perfusion symptoms or exaggerated kidney count, routine biochemistry, including liver and kidney insufficiency during the titration of neuro-hormonal function test, NT-proBNP test, chest x-ray and electro- blockade treatment should reduce their diuretics dose.
cardiography (ECG). Just as in young patients, objective For long-term treatment, diuretics dose can be altered assessment of left ventricle function should be performed several times to allow other drugs titration, and to obtain by means of echocardiography. Patients who seem to the lowest dose that can stabilize body weight and be having acute pulmonary edema must undergo examination and evaluation to find out the etiology thattriggers the development of disease (infection, ischemia, Recommendation
arrhythmia, change of drug regimens or non-compliance Diuretics and salt restriction are indicated in patients to therapy). Other examination depends on whether there with current or prior symptoms of heart failure and Management of Heart Failure in Elderly Patients Figure 1. Algorithm of heart failure management
reduced left ventricular systolic function who have pressure should be measure in standing, sitting and lying evidence of fluid retention. (Class I, Level of Evidence: position. The renal function and potassium serum level should be evaluated after altering ACE inhibitors anddiuretics dose or if there is any change in clinical ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR
Angiotensin converting enzyme (ACE) inhibitor ACE inhibitor study in elderly patients is reported on PEP-HF study28 (Perindopril in Elderly People with should be considered for all elderly patients with chronic Chronic Heart Failure). The incidence of primary heart failure, although the data regarding the effective- endpoint all-cause death or heart failure hospitalization ness of this drug in elderly patients is still limited.
tend to be reduced with perindopril than with placebo in CONSENSUS study24 (enalapril) excludes patients who one year time [hazard ratio (HR) 0.69, 95% confidence are over 75 years, and SOLVD study25 (enalapril) and interval (CI) 0.47 – 1.01; P=0.055]. However, such SAVE study26 (captopril) exclude patients who are over tendency was not found at the end of this study [HR 80 years. AIRE study27 (ramipril) does not exclude patients based on age alone, and there is a tendencytoward better end-result in population of over 65 years, Recommendation
however, the sample size is not large enough to achieve Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior When performing ACE inhibitors dose titration in symptoms of heart failure and reduced left ventricular elderly patients, it is important to start with low dose and systolic function, unless contraindicated. (Class I, Level increase gradually in accordance with the target dose in clinical trial or maximal lower dose that can still betolerated. Diuretics dose can be reduce if there is no ANGIOTENSIN II RECEPTOR BLOCKERS
water retention, to maintain stable blood pressure.In VAL-HEFT study29 (Valsartan Heart Failure Trial), several elderly patients, it would be more helpful if the with mean age of 63±11 years old (47% patients were consumption time of ACE inhibitor and diuretics are > 65 years), and CHARM study30 (Candesartan in Heart separated, to prevent peak hemodynamic effect. Blood Failure Assessment of Reduction in Mortality and Morbidity), with mean age of 66±11 years old (23% SPIRONOLACTONE
patients were >75 years), demonstrate the benefit of Study on the role of aldosterone antagonist in elderly ARB on similar outcome in patients <65 years of >65 patients is still lacking. Low- dose spironolactone (mean 26 mg/day) has been researched on RALES study36(Randomized Aldactone Evaluation Study). Subjects of Recommendation
Angiotensin II receptor blockers are recommended RALES study were population with mean age of 65 in all patients with current or prior symptoms of heart years with severe heart failure (NYHA III-IV, LVEF failure and reduced left ventricular systolic function, who < 35%), who had been receiving ACE inhibitors and loop are ACE inhibitor-intolerant. (Class I, Level of Evidence: diuretics treatment. However, patients with renal dysfunction (creatinine level > 220 μmol/L) or with othersignificant co-morbidities were excluded. Spironolactonedecreases mortality about 30%, as well as hospitalization BETA BLOCKERS
due to heart failure as much as 35% and significantly Beta blockers are also beneficial for elderly patients, improves NYHA functional class. Thus, low dose since there is greater role of activation of sympathetic spironolactone is recommended for patients with severe nervous system compared to the renin-angiotensin heart failure, albeit having received optimal medical system. CIBIS II study31, MERIT HF study32, and management. Gynecomastia occurs in 10% male patients.
COPERNICUS study33 demonstrate that beta blockers Also have to bear in mind that potassium and renal can increase survival as much as 30-35% and also function were routinely monitored in this study, i.e. on increase left ventricle systolic function. The mean age the 1st, 2nd, 3rd, 6th, 9th and 12th month and then 6 months of the patients in randomized clinical trial meta-analysis later. With strict monitoring, we expect that range from 60 to 65 years, and < 30% patients were hyperkalemia and renal dysfunction will not occur. Oral > 70 years and there were very few patients who were potassium supplement is not required, unless there is >80 years. Sub-group analysis shows that there is no significant interaction between age and the effect of beta Sub-group analysis on RALES study demonstrates blockers effect on the outcome.34 Beta blockers should effect on similar outcome of patients with <67 years and be started with the lowest dose, increase gradually in >67 years of age. Moreover, age is associated with weeks up to months duration. Monitoring shall be increased side effects, particularly hyperkalemia.22 performed on heart rate, blood pressure and patients’ Spironolactone study in patients who have heart failure and ejection fraction > 45% is currently being conducted The role of beta blockers nebivolol in elderly patients and it will evaluate whether spironolactone is effective who have heart failure (> 70 years) with normal left for heart failure with normal ejection fraction.
ventricle systolic function (diastolic heart failure) wasreported in the SENIORS study.35 There was a decline Recommendation
Addition of aldosterone antagonist is recommended of primary outcome (all-cause mortality or cardiovascu- in selected patients with moderately severe to severe lar hospitalization) of lower rate compared to other symptoms of heart failure and reduced left ventricular previous beta blockers studies [HR 0.86; 95% CI 0.74 – systolic function, who can be carefully monitored for 0.99; P=0.039]; and it was also different from previous preserved renal function and normal potassium level.
studies which had young patients as study subjects, since Creatinine level should be < 2.5 mg/dL for male and <2.0 it did not affect the mortality [HR 0.88; 95% CI 0.71 – mg/dL for female and potassium should be < 5 mEq/L.
1.08; P=0.21]. In sub-group analysis, nebivolol effect on primary outcome was significant in patients <75 years(median value), but it was not significant in patients >75years.
Study of digitalis on heart failure, which is called DIG Recommendation
(Digitalis Investigation Group) reported the advantages Beta blockers (using 1 from 3 proven to reduce of digoxin for stable heart failure, particularly in patients mortality, i.e. bisoprolol, carvedilol and sustained release with left ventricle systolic dysfunction (LVEF < 45%).
metoprolol succinate) are recommended for stable In addition, the other several small adjunct studies are patients with current or prior symptoms of heart failure also evaluating patients with LVEF > 45%. Twenty seven and reduced left ventricular systolic function, unless percent subjects were > 70 years. The benefit of treat- contraindicated. (Class I, Level of Evidence: A)23 ment in decreasing hospitalization was demonstrated in Management of Heart Failure in Elderly Patients all age groups.37 However, increased age was associ- Cardiologists and the French Geriatrics Society. Eur Heart J.
ated with higher rate of hospitalization due to assumed 12. Lee DS, Austin PC, Rouleau JL,et al. Predicting mortality among patients hospitalized for heart failure: derivation and mortality rate. In DIG study, digoxin dose was managed validation of a clinical model. JAMA. 2003;290:2581–7.
by using an algorithm in accordance with age, sex, weight 13. Pocock SJ, Wang D, Pfeffer MA, et al. Predictors of mortality and renal function.38 Digoxin should be used cautiously and morbidity in patients with chronic heart failure. Eur Heart (particularly for those with renal dysfunction). It may 14. Cacciatore F, Abete P, Mazzella F, et al. Frailty predicts longterm alleviate patients’ complains and decrease hospitalization mortality in elderly subjects with chronic heart failure. Eur J for patients with severe heart failure symptoms and very 15. Smith GL, Lichtman JH, Bracken MB, et al. Renal impairment In the sub-study, which was conducted in parallel and outcomes in heart failure: systematic review and meta- with the main study, there were almost 1000 patients analysis. J Am Coll Cardiol. 2006;47:1987–96.
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