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HEART FAILURE
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OBJECTIVES
Know and understand:
• The epidemiology, etiology, and pathophysiology
of heart failure (HF)
• The clinical signs and symptoms of HF as they
manifest in older adults
• Appropriate management strategies
• How to provide end-of-life care with
consideration of individual patient prognosis
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TO P I C S C O V E R E D
• Epidemiology
• Etiology and Pathophysiology
• Clinical Features
• Diagnosis
• Management
• Recurrent Hospitalization
• Prognosis
• End-of-Life Care
EPIDEMIOLOGY OF
H E A R T FA I L U R E ( H F )
• Incidence and prevalence increase with age
 Leading cause of hospitalization and
rehospitalization in older adults
 Median age of patients hospitalized with HF is
75 years, and approximately two thirds of
deaths attributable to HF are in patients age 75
years or older
• HF is a major cause of chronic disability and
impaired quality of life in older adults
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ETIOLOGY OF HF
• HF in older adults is often multifactorial in origin
• Hypertension is the most common antecedent
cardiovascular condition in both men and women
 60%–70% of women, 30%–40% of men
• In men, 30%–40% of HF cases are attributable to
coronary artery disease (CAD)
• Other common causes include valvular heart disease and
nonischemic dilated cardiomyopathy
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DEFINITIONS
• Systolic HF — HF with reduced left ventricular
ejection fraction (LVEF)
 Up to 90% of HF patients < 65 years old have
this form of the disease
• HF with preserved ejection fraction (HFPEF) —
HF with LVEF  50%
 Affects 40% of men and two thirds of women
> 65 years old with HF
S Y M P TO M S & S I G N S O F H F
I N O L D E R PAT I E N T S
• Often atypical and nonspecific
• Most common: exertional shortness of breath, fatigue,
orthopnea, and leg edema
 Exertional symptoms may be less prominent in older
adults because of a more sedentary lifestyle
 Prevalence of atypical symptoms increases with age
• Decreased mental acuity, confusion, lethargy,
irritability, anorexia, abdominal discomfort, or
altered bowel function
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DIAGNOSIS OF HF
• Standard chest radiograph remains the most useful
initial test for detecting pulmonary congestion and
pleural effusions
 Also excludes pneumonia as a cause of shortness
of breath
• B-type natriuretic peptide (BNP) and its precursor Nterminal pro-BNP (nt-proBNP) are valuable in
establishing the presence of HF and, in particular, in
distinguishing shortness of breath due to HF from that
attributable to noncardiac causes
 But specificity decreases with age
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O V E RV I E W O F H F M A N A G E M E N T
• Goals are to decrease symptoms and improve
quality of life, reduce acute exacerbations requiring
hospitalization, and increase survival
• Hypertension, hyperlipidemia, and diabetes should
be treated in accordance with current guidelines
• Smoking cessation should be strongly encouraged
and supported if indicated, and alcohol intake
should be limited to no more than 2 drinks/day in
men and 1 drink/day in women
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NONPHARMACOLOGIC THERAPY
• Restrict dietary sodium intake to ≤ 2 g/day
• Most patients with HF should also engage in regular
exercise such as walking, stationary cycling, swimming,
or water aerobics
 Exercise duration and intensity should be adjusted to
the individual patient’s level of conditioning, severity
of HF, and comorbidities
• Patients should keep an ongoing record of their daily
weight
PHARMACOTHERAPY OF
S Y S TO L I C H F
• Optimal treatment usually requires 3 medications and,
in some cases, up to 7
• Almost all patients take 1 additional medications for
coexisting illnesses
• Problems: adherence, high potential for drug
interactions and adverse events, cost
• Therapy must be individualized: consider the multiple
factors that influence QOL and other desirable clinical
outcomes in older adults who have multiple chronic
illnesses and limited life expectancy
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A C E I N H I B I TO R S F O R
S Y S TO L I C H F
• In general, start treatment at the lowest dosage and
gradually titrate to the maintenance dosage as tolerated
• Contraindications include known intolerance to these agents,
hyperkalemia, and severe renal insufficiency in patients not
currently undergoing dialysis
• Common adverse events include cough in 5%–10% of
patients during long-term treatment, mild worsening of renal
function (often transient), hyperkalemia, hypotension, and
GI distress
• ARBs are an option for HF patients unable to tolerate ACE
inhibitors because of cough, allergic reactions, or GI
disturbances
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β - B L O C K E R S F O R S Y S TO L I C H F
• As with ACE inhibitors and ARBs, treatment
should be started at the lowest available dosage
and gradually titrated to the maintenance
dosage over several weeks
• Contraindications include severe
decompensated HF, active bronchospastic lung
disease, marked bradycardia, relative
hypotension, significant atrioventricular nodal
block, and known intolerance to β-blockers
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D I U R E T I C S F O R S Y S TO L I C H F
• An essential component of HF therapy in most
patients
 Most effective agents for relieving congestion, edema
• In general, the diuretic dosage should be
adjusted to maintain euvolemia
 Manifested by the absence of pulmonary rales,
an S3 gallop, increased jugular venous pressure,
hepatojugular reflux, and peripheral edema
M I N E R A L O C O R T I C O I D A N TA G O N I S T S
FOR SYSTOLIC HF
• The mineralocorticoid antagonist spironolactone
has been shown to reduce mortality and
hospitalizations in patients with NYHA class III–
IV HF and LVEF ≤ 30%
• The selective mineralocorticoid antagonist
eplerenone has been associated with improved
outcomes in patients with recent MI complicated
by HF or LVEF < 40%, and in patients with
NYHA class II HF and LVEF ≤ 30%
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OTHER THERAPIES FOR
S Y S TO L I C H F
• Digoxin improves symptoms and reduces HF
hospitalizations in patients with chronic systolic HF
but has no effect on mortality
 Adverse events include nausea, visual
disturbances, and cardiac arrhythmias
• The combination of hydralazinenitrates is
recommended for patients with contraindications to
ACE inhibitors and ARBs and in black patients with
advanced HF as an adjunct to ACE-inhibitor and βblocker therapy
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PHARMACOTHERAPY FOR
H F W I T H P R E S E RV E D E F
• Optimal therapy remains undefined
• Current recommendations:
 Aggressively treat hypertension, other risk factors
 Manage comorbid CAD
 Maintain sinus rhythm or effective rate control in
patients with AF
 Judiciously use diuretics to maintain euvolemia
while avoiding overdiuresis (many of these patients
are “volume-sensitive”)
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I M P L A N TA B L E C A R D I A C
D E F I B R I L L ATO R
• Reduces mortality from sudden cardiac death in
patients with systolic HF and LVEF  35%, regardless
of ischemic or non-ischemic etiology
• Prophylactic placement is advised for patients with
NYHA class II or III HF, LVEF  35%, and life
expectancy  1 year
• Defer ICD implantation for 40 days after acute MI and
90 days after a new diagnosis of dilated
cardiomyopathy, in the latter case because LV function
often improves after initiation of β-blocker and ACE
inhibitor therapy
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C A R D I A C R E S Y N C R O N I Z AT I O N
• A biventricular pacemaker with one lead in the right
ventricle and a second lead inserted retrograde into
the coronary sinus to stimulate the left ventricle
• Indicated in patients with dyssynchronous LV
contraction, most commonly related to left bundle
branch block, present in up to 30% of patients with
systolic HF
• Improves symptoms, exercise tolerance, quality of life,
and survival in selected patients with advanced
systolic HF and persistent severe symptoms (NYHA
class III or IV) despite conventional medical therapy
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R E C U R R E N T H O S P I TA L I Z AT I O N
• Up to 50% of patients with HF are readmitted within
3–6 months after the initial hospitalization
• Patients who experience recurrent HF
hospitalization within 3–6 months after an index
admission should be questioned carefully
 Adherence to medication regimen; use of OTC
medications
 Recent changes in weight
 Recent dietary choices
 Daily fluid intake
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PROGNOSIS
• Median survival rates of 2–3 years
 25%–30% of patients die within 1 year after
initial diagnosis
 50% survive 1–5 years
 20%–25% survive >5 years
• Women and patients with HFPEF have
somewhat better survival rates than men and
patients with systolic HF
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END-OF-LIFE CARE
• Counsel regarding an advance directive, durable power
of attorney for health care, and explicit instructions
about what interventions they would or would not wish
to undergo if death appeared imminent
• Ask patients with ICDs to indicate under what conditions
they would want the ICD turned off to avoid repetitive
painful shocks at the end of life
• In patients with particularly poor prognosis and
remaining life expectancy < 6 months, undertake frank
but empathetic discussions with the patient and family
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S U M M A RY
• HF is the leading cause of hospitalization in older adults
and a major source of chronic disability
 Older patients with HF are more likely to be women and more
likely to have preserved LV systolic function
• ACE inhibitors, ARBs, β-blockers, and mineralocorticoid
antagonists reduce morbidity and mortality from HF with
reduced ejection fraction (systolic HF)
 Optimal medical therapy for HF with preserved ejection fraction
is undefined
• Optimal management of HF in older patients often
requires a multidisciplinary approach
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CASE 1 (1 of 4)
• A 70-year-old man comes to the office for follow-up
after hospitalization for exacerbation of HF.
• History includes HF with preserved systolic function,
hypertension, and atrial fibrillation.
• Longstanding medications include extended-release
metoprolol 100 mg/day, enalapril 10 mg q12h, and
hydrochlorothiazide 25 mg/day. In addition, he was
given both torsemide 40 mg q12h and digoxin 0.125
mg every other day during hospitalization and at
discharge.
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CASE 1 (2 of 4)
• Today he reports new symptoms of fatigue and lightheadedness when he initially stands. He has no
chest pain, and there has been no change in SOB.
• BP is 92/50 mmHg, pulse is 84 bpm, and O2
saturation is 97% on room air. Jugular venous
pressure is 5 cm2 HO; neck veins are flat, even when
he is supine. Chest is clear bilaterally. Heart sounds
are irregularly irregular with no murmur. The
abdomen is soft and nontender, with normal bowel
sounds and no distension. Extremities are mildly
cool; there is no edema, and dorsalis pedis pulses
are 1+ bilaterally.
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CASE 1 (3 of 4)
Which of the following is the best next step?
A. Administer furosemide 80 mg by IV.
B. Discontinue enalapril and metoprolol.
C. Hold torsemide and hydrochlorothiazide and
prescribe fluids.
D. Obtain serum digoxin levels and discontinue
digoxin.
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CASE 1 (4 of 4)
Which of the following is the best next step?
A. Administer furosemide 80 mg by IV.
B. Discontinue enalapril and metoprolol.
C. Hold torsemide and hydrochlorothiazide and
prescribe fluids.
D. Obtain serum digoxin levels and discontinue
digoxin.
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CASE 2 (1 of 4)
• A 78-year-old woman is brought to the emergency
department because she has had shortness of breath
for 2 weeks; it has become more severe over the
past 2 days.
• She has difficulty sleeping and now requires 2 or 3
pillows to elevate her head at night.
• History includes hypertension, osteoarthritis, and
COPD secondary to 50 pack-years of smoking.
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Medications include amlodipine, hydrochlorothiazide,
and montelukast.
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CASE 2 (2 of 4)
• Blood pressure is 160/90 mmHg, pulse is 84 bpm,
and respirations are 18 breaths per minute.
• There are jugular venous pulsations 5 cm above the
sternal notch. Bibasilar crackles are heard, and
cardiovascular examination reveals normal S1 and
S2 without S3. The abdomen is soft and nontender.
There is pitting pedal edema.
• ECG is unchanged from a year ago; it shows normal
sinus rhythm at 84 beats per minute and left
ventricular hypertrophy with repolarization
abnormalities.
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CASE 2 (3 of 4)
Which of the following tests would be most helpful in
differentiating COPD from heart failure?
A. B-type natriuretic peptide level
B. Troponin level
C. Electrolyte panel
D. Coronary calcium score
E. Chest radiography
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CASE 2 (4 of 4)
Which of the following tests would be most helpful in
differentiating COPD from heart failure?
A. B-type natriuretic peptide level
B. Troponin level
C. Electrolyte panel
D. Coronary calcium score
E. Chest radiography
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CASE 3 (1 of 3)
• A 75-year-old man comes to the office to establish care
because he has difficulty breathing. The breathing difficulty
limits his ability to walk 2 blocks to the corner store, and he
often has to sleep upright in his recliner.
• He takes no medication except chewable calcium carbonate
tablets for chronic indigestion.
• BP is 154/88 mmHg, pulse is 80 bpm, and respirations are
16 breaths per minute. There are bibasilar fine crackles.
Cardiac examination is notable for normal rhythm with
ectopy and a II/VI holosystolic murmur at the apex. There is
no peripheral edema. ECG, electrolyte panel, and CBC are
ordered. The presumptive diagnosis is heart failure.
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CASE 3 (2 of 3)
Which of the following tests should be ordered
next to help establish diagnosis and treatment?
A. Cardiac catheterization
B. Echocardiography
C. Radionuclide ventriculography
D. MRI
E. Chest radiography
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CASE 3 (3 of 3)
Which of the following tests should be ordered
next to help establish diagnosis and treatment?
A. Cardiac catheterization
B. Echocardiography
C. Radionuclide ventriculography
D. MRI
E. Chest radiography
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GRS8 Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author:
Michael W. Rich, MD, AGSF
GRS8 Question Author:
Mary Ann McLoughlin, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society