Download DIAGNOSIS Systolic and Diastolic heart failure

Heart
Failure in
elderly
Farveh
Vakilian.M.D.Cardiologist
Fellowship in HF
Mashhad University of Medical
Sciences
Case 1
• An 80-year-old man with prior history of hypertension and myocardial
infarction presented with progressive dyspnea on exertion and leg swelling
for the past 6 months.
• He denied dyspnea at rest, orthopnea, PND, cough, wheezing, or chest
pain.
• A physical examination revealed only mild pitting lower extremity edema.
• He had neither jugular venous pressure elevation nor hepatojugular
reflux.
• On cardiac auscultation, his first and second heart sounds were regular; a
third or fourth heart sound could not be appreciated.
• On pulmonary examination, there were no râles or wheezing.
• He had normal sinus rhythm on his electrocardiogram.
• A chest x-ray revealed no cardiomegaly or pulmonary venous congestion.
• He had a left ventricular ejection fraction of 35% by an echocardiogram
done a week later.
Case 2
• An 84-year-old woman with known heart failure presented
with dyspnea for 4 weeks during which time she developed
dyspnea and fatigue on minimal exertion and even at rest.
• She also complained of orthopnea and reported that most
of the past week she slept sitting
• Her past medical history was remarkable for hypertension.
• She also reported right upper quadrant pain associated
with nausea and loss of appetite but no vomiting.
• She had chronic leg swelling which has gotten so severe
over the past several weeks that she could not wear her
shoes.
• She responded to her worsening symptoms by restricting her
activities and did not see her physician.
• her jugular venous pressure was elevated at 15 cm of water.
• She had no pulmonary râles or wheezing.
• She had severe bilateral pitting edema in both of her legs up
to mid-thigh areas with multiple blisters over lower legs.
• She also had evidence of venous insufficiency with brown
pigmentation and induration of skin.
• She had normal sinus rhythm by an electrocardiogram.
• Her chest radiograph was remarkable for marked
cardiomegaly and pulmonary venous congestion.
• a subsequent echocardiogram revealed a left ventricular
ejection fraction of >55%.
DEFINITION
Heart failure is a complex clinical syndrome
that can result from any structural or
functional cardiac disorder that impairs the
ability of the ventricle to fill with or ejec
blood.
 Dyspnea and fatigue, with or without some
degree of leg swelling, are the cardinal
symptoms of heart failure
Hypertension and coronary artery disease are
the two most common causes of heart failure
in all ages, including older adults.
DIAGNOSIS
• Systolic and Diastolic heart failure
• is based on left ventricular ejection fraction.
An echocardiogram is the most commonly
used test to determine left ventricular ejection
fraction.
With age, there is a decrease both in number
and in function of myocytes, even without
cardiovascular disease
ENHANCED NECROSIS AND APOPTOSIS
Impaired calcium metabolism and regulation,
reflects an alteration of processes of
contraction and relaxation
Other changes,,,
contractile proteins change with age
ATP utilization
detrimental increase in myocardial collagen
content and development of fibrosis
arterial vascular wall fibrosis, thickening, and
stiffening
Pulse pressure is an easily hemodynamic
dependent marker can be a predictor of CHF
in 4 years follow up in eldery
• These mechanisms may cause HFpEF.
 Exercise capacity is primarily affected due to
the lower heart rate increase during exercise
and higher end-diastolic pressure
 stroke volume that is more preload dependent
due to impaired relaxation
• Elderly patients hospitalized for acute HF ar
more likely to be female
• have higher EF and a higher prevalence o
HFpEF
• CAD and diabetes are less common in the
very elderly
• They have an increased prevalence of
comorbidities, including:
 AF, hypertension, cerebrovascular
disease, anaemia, malignancy, and
chronic kidney disease ,osteoarthritis,
and depression, and polypharmacy
Elevated IL-6, was associated with increased
risk of CHF in people without prior
myocardial infarction.
Symptoms and signs
• Less than 50% of systolic dysfunction patients
recognizaed in clinic
• Reliance cannot be placed on classic
symptoms of heart failure, and weight should
be measured daily
• Shortness of breath, orthopnea or nocturnal
cough and paroxysmal nocturnal dyspnea
• nonspecificity of complaints of fatigue,
ascribing of symptoms to aging or comorbid
conditions,
• reduction in activities to avoid symptoms
• memory impairment leading to poor
historical information.
• Physical examination may not be as definitive
as in younger individuals.
• Rales and third sounds are usualy heard in
decompensations
• jugular venous pressure and is likely to
underestimate jugular venous pressure. In one
study
• only 14% had elevated jugular venous
pressure.
• NT-proBNP can help in diagnosis but
• cutoffs for heart failure diagnosis are age
specific,
• almost fourfold higher cutoff value for
patients older than 75 years
Management
o Elderly patients with heart failure have the highest
rehospitalization rate of all adult patient groups.
o Education and involvement of the patient, family
members, and caregivers are key to the management
of older patients
o understanding of medication regimens, diet
adjustments, and regular moderate physical activity
should be emphasized.
A change in mental status is common in
elderly people with heart failure, especially
those with vascular dementia with extensive
cerebrovascular atherosclerosis or those who
have latent Alzheimer disease.
Multidisciplinary team,nurse directed
approaches with patient contacts between
office visits and more frequent contact during
the transitional period after hospital discharge
can be highly beneficial and reduce
rehospitalization rates
it is critical for clinicians to discuss end-of-life
issues with patients and their families as soon
as possible.
Age-associated changes in pharmacokinetics
must be taken into account when prescribing
drugs for heart failure.
NSAID related CHF risk is more than GI track
damage so NSAID should be given with
caution in eldery
• Dietary sodium restriction(less than 3g/day)
and moderate physical activity should be
encouraged
• Supervised exercise training programs based
on cardiac rehabilitation algorithms have
shown modest benefit
• Fluid restriction depends on the patient’s
clinical status
• While it is not necessary to limit fluid intake in
the absence of retention, a limit of 2 L/day is
recommended if edema is detected.
• If volume overload is severe, the limit should
be 1 L/day.
• Calories and fat intake are both important to
watch,
• particularly in patients with obesity,
hyperlipidemia, hypertension, or coronary
artery disease.
Treatment
• more recent usual therapy is an ACEinhibitor
or ARB
• beta blocker plus a diuretic, with lower rates
of digoxin use
• DIG trial analyses suggest that a morbidity and
hospitalization benefit can accompany digoxin
concentrations between 0.5 and 0.9 ng/ml
• spironolactone has been accompanied by
increased incidence of hyperkalemia in older
patients with heart failure, and close
monitoring is necessary.
• carefully controlled and monitored setting,
dose titration resulted in lower daily doses in
older patients, especially those older than 80
years.
• Vasodilating beta blockers are usually
considered and should be instituted at low
doses during periods of clinical stability.
• Nebivolol, a beta-blocker with vasodilating
properties, is an effective and well-tolerated
treatment for heart failure in the elderly.
Direct vasodilators such as hydralazine and
nitrates have a limited role in older patients
because of the increased likelihood of
orthostatic hypotension
As the plasma albumin level diminishes with
age, the free-drug concentration of salicylates
and warfarin,which are extensively albuminbound, may increase.
Revascularization therapies are considered in
the setting of ischemia
Cardiac resynchronization therapy can
decrease hospitalizations and reduce mortality
in selected patients with symptomatic systolic
heart failure despite optimal medical therapy.
The few highly selected patients older than 65
years who have received cardiac
transplantation appear to have survival times
similar to those of younger patients,
• with slightly more morbidity and mortality
due to the surgical procedure but lower rates
of rejection compared with younger patients
Approach to the ELDERY patients with HF
• Symptoms may be nonspecific in the older patientsuspect heart failure.
• Consider heart failure diagnosis in patients with
fatigue, dyspnea, exercise intolerance, or low activity.
• Diagnosis may be facilitated by use of
echocardiography or serum markers of heart failure.
• Heart failure may be present in the older patient with
preserved systolic function especially in older women.
• Aggressive treatment of hypertension or diabetes,
when present, may improve heart failure outcomes.
• Treat symptoms with a goal of improving quality of life and
morbidity.
• Control blood pressure-systolic and diastolic.
• Treat ischemia.
• Control atrial fibrillation rate.
• Promote physical activity.
• Adjust medications for age- and disease-related changes in
kinetics and dynamics.
• Educate and involve patients, family members, or caregivers
in management of heart failure.
• Monitor weight.
• Consider use of multidisiplinary team approaches