HEART FAILURE

CARDIOVASCULAR DISEASE IN THE ELDERLY

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HEART FAILURE Michael W. Rich, MD

In the past two decades, heart failure has become increasingly recognized as a major public health concern in the United States and many other countries, a development which is largely attributable to the aging of the population.21,55 Not only is heart failure predominantly a disorder of the elderly, it may be considered the quintessential disorder of cardiovascular aging because it reflects the convergence of age-related changes in cardiovascular structure and function and the rising prevalence of hypertension, coronary heart disease, and valvular heart disease with advancing age. In this article, the epidemiology, pathophysiology, clinical features, and treatment of heart failure in older patients are systematically reviewed. EPIDEMIOLOGY

Heart failure affects approximately 4.9 million Americans, just under 2% of the population, and over 400,000 new cases are diagnosed each year.2,43 Both the incidence and prevalence of heart failure increase exponentially with advancing age.28Thus, heart failure is relatively rare in young adults, but the prevalence doubles with each decade after age 45 and approaches 10% in individuals over age Heart failure is currently the leading cause of hospital admission among individuals over age 65, accounting for approximately 700,000

hospitalizations each year.26In addition, heart failure is the primary indication for 3 million physician office visits each year,”’ and 80% of all hospitalizations and out-patient visits occur in patients over age 65.26Moreover, heart failure is listed as the principal cause of death in 43,000 patients each year? 43 88% of whom are over age 65.2s Because of its high prevalence and intensive medical resource usage, heart failure is the most costly cardiovascular disorder in the United States today, with estimated annual expenditures in excess of $20 billion.2 Hospitalization costs for heart failure alone exceed those for all myocardial infarctions and all cancers combined.@’ In the next 30 years, it is projected that the number of Americans over age 65 will double, and so too will the number of individuals at risk for the development of heart failure. And therein lies the impetus for the growing interest in heart failure and for the urgency in finding more effective strategies for its prevention and treatment. PATHOPHYSIOLOGY

The effects of aging on the cardiovascular system are discussed in detail elsewhere in this issue, and the following list outlines the principal changes directly relevant to the pathophysiology of heart failure.ss Increased systemic vascular impedance

From the Department of Medicine, Geriatric Cardiology Program, Washington University School of Medicine, St. Louis, Missouri

CARDIOLOGY CLINICS

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Impaired ventricular diastolic relaxation and compliance Diminished responsiveness to beta-adrenergic stimulation Altered myocardial energy metabolism Increased deposition of connective tissue in the media and adventitia of the large and medium-sized arteries results in decreased vascular elasticity and increased impedance to left ventricular ejection.38,84 These changes contribute directly to the progressive rise in prevalence of isolated systolic hypertension with advancing age that in turn contributes to the development of left ventricular hypertrophy and altered diastolic filling. Increased cardiac interstitial collagen content, compensatory myocyte hypertrophy in response to apoptosis, and impaired calcium flux during diastole further contribute to age-related impairments in left ventricular diastolic relax46, 84 These changes ation and c~mpliance.~~, lead to an increase in left ventricular end diastolic pressure and left atrial size and pressure, and they also predispose older individuals to the development of atrial fibrillation. Although the precise mechanism has not yet been fully elucidated, advancing age is associated with declines in the responsiveness of both p1 and p2 adrenergic receptors, resulting in reductions in maximum heart rate and contractility (p, effects) and impaired peripheral vasodilatation (p2effect).37Finally, aging is associated with an impaired capacity of the mitochondria to increase adenosine triphosphate (ATP) production in the face of increased demands.", 84 What are the clinical implications of the above changes? In a healthy older individual, resting left ventricular systolic function and cardiac output are well preserved, although preload and afterload may be increased (by impaired diastolic filling and increased vascu53, 58 The ability lar impedance, re~pectively).~~, of the aging heart to augment cardiac output in response to stress, however, whether physiologic (e.g., exercise) or pathologic (e.g., myocardial infarction, pneumonia, etc.), is markedly impaired.", 55 Recalling that cardiac output is determined by four principal factors -heart rate, contractility, preload, and afterload-and recognizing that all of these factors are adversely affected by the aging process, it is not surprising that the aging heart is often incapable of increasing cardiac output commensurate with increased demands and that heart failure often ensues.

Heart Failure With Normal Systolic Function An important feature of heart failure in the elderly is that it often occurs in the setting of normal or near normal left ventricular systolic function, as defined by a left ventricular ejec87 This tion fraction of greater than 45Y0.~~. syndrome, often referred to as diastolic heart failure, occurs in less than 10% of heart failure patients under age 65, but the frequency of diastolic heart failure increases with age, and recent studies suggest that 50% or more of heart failure patients over age 80 have preserved systolic function.I4,77, 80, 87 Most of these patients have underlying hypertension, coronary heart disease, or valvular heart but age-related changes in left ventricular diastolic filling are an important factor that predisposes older patients to the development of diastolic heart failure.77

CLINICAL FEATURES Etiology and Precipitating Factors

The cause of heart failure is similar in older and younger patients but is more often multifactorial in the elderly.55In the United States, at least 70% to 80% of all heart failure patients have hypertension or coronary heart disease.27 Valvular heart disease, especially calcific aortic stenosis and severe mitral regurgitation, are more common in the elderly than in younger patients, but idiopathic nonischemic dilated cardiomyopathy occurs less frequently.64Hypertrophic cardiomyopathy is typically diagnosed in children or young adults, but it has been recognized with increasing frequency in the elderly8,35 A clinically and hemodynamically similar disorder, hypertensive hypertrophic cardiomyopathy, is primarily a disorder of the elderly8,75 Cardiac amyloidosis is a rare cause of heart failure in younger patients, but it becomes increasingly more prevalent at advanced age, particularly in individuals over age 90F2 Infective endocarditis and high output cardiac failure are rare in the elderly, but, when present, the diagnosis is frequently 0verlooked.5~,74 Causes of high-output syndrome in the elderly include hyperthyroidism; chronic anemia; shunting due to arteriovenous malformations, a fistula, cirrhosis, or Paget's disease; and thiamine deficiency re-

HEART FAILURE

lated to alcoholism or prolonged use of loop diuretics.66 Apart from the underlying cause of heart failure, a host of other factors may serve as precipitants or contributory causes of acute heart failure exacerbations (Table l)?5 Multiple factors are frequently present in older patients, so it is important to consider the potential role of each of these factors in all elderly patients. Symptoms and Signs Heart failure is both overdiagnosed and underdiagnosed in the elderlys5 The reason for this apparent paradox is that the cardinal symptoms and signs of heart failure-exertional dyspnea and fatigue, orthopnea, edema, pulmonary rales, and an S, gallop -are neither sensitive nor specific markers of heart failure in the elderly. Thus, exertional dyspnea and fatigue may be caused by such diverse noncardiac processes as acute or chronic lung disease, anemia, thyroid dysfunction, depression, obesity, or poor physical conditioning, all of which occur commonly in the elderly. Similarly, rales may be caused by underlying lung disease or atelectasis, Table 1. COMMON PRECIPITANTS OF HEART FAILURE IN OLDER ADULTS

Myocardial ischemia or infarction Dietary sodium excess Excess fluid intake Medication noncompliance Iatrogenic volume overload Arrhythmias Atrial fibrillation or flutter Ventricular arrhythmias Bradyarrhythmias, esp. sick sinus syndrome Associated medical conditions Fever Infections, esp. pneumonia or sepsis Hyperthyroidism or hypothyroidism Anemia Renal insufficiency Thiamine deficiency Pulmonary embolism Hypoxemia from chronic lung disease Uncontrolled hypertension Drugs and medication Alcohol Beta blockers (including ophthalmological agents) Calcium channel blockers Antiarrhythmia agents Nonsteroidal anti-inflammatory drugs Corticosteroids Estrogen preparations Antihypertensive agents (e.g., clonidine, minoxodil)

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whereas peripheral edema may be caused by venous insufficiency, hypoalbuminea, liver disease, or renal insufficiency. Moreover, an S, gallop may merely reflect age-related diastolic dysfunction and is of little value in the diagnosis of heart failure in the elderly. Conversely, sedentary elderly patients may not report exertional symptoms, and atypical manifestations, such as confusion, irritability, lassitude, anorexia, nausea, or altered breathing (e.g., Cheynes-Stokes respirations) may be the only clinical indicators of heart failure.R5 In patients with significant cognitive dysfunction, the diagnosis may be especially difficult to establish. For these reasons, it is incumbent that the physician maintain a high index of suspicion for the diagnosis of heart failure in elderly patients with a variety of unexplained systemic complaints, while at the same time considering a wide range of diagnostic possibilities in all but the most overt cases of heart failure. Diagnostic Evaluation Given that the history and physical examination often fail to yield a definitive diagnosis, additional testing is frequently necessary. In 1995, the American College of Cardiology and American Heart Association Task Force on Practice Guidelines published recommendations for the initial evaluation of heart failure.' As in younger patients, the standard chest radiograph is of considerable value in diagnosing heart failure in the elderly. Although interpretation of the chest radiograph is straightforward when cardiomegaly, pulmonary vascular congestion, interstitial edema, and pleural effusions are present, the examination may be difficult to interpret if there is chronic lung disease, obesity, or an inadequate inspiratory effort. In addition, cardiomegaly need not be present, and pulmonary congestion may be subtle or absent. Echocardiography plays a crucial role in the evaluation of elderly individuals with heart failure, and it is recommended as part of the initial diagnostic assessment in virtually all cases.' This widely available noninvasive test provides detailed information about left and right ventricular size and function and an assessment of atrial size, valvular function, and the pericardium. Additional studies recommended as part of the initial evaluation include a complete blood count and standard blood chemistries,

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a urinalysis, an electrocardiogram, and a thyroid stimulating hormone (TSH) level (especially in the setting of atrial fibrillation).' In patients with a high probability of coronary heart disease who are suitable candidates for revascularization, a stress test or cardiac catheterization is also recommended.' Systolic Versus Diastolic Heart Failure

As discussed later in this article, the management of patients with diastolic heart failure differs from that of patients with systolic heart failure. Therefore, in addition to establishing a diagnosis of heart failure and determining the cause and precipitating factors, a primary goal of the initial diagnostic assessment is to differentiate systolic from diastolic heart failure. In this regard, certain clinical features may be For example, evidence for a prior myocardial infarction, alcoholism, a laterally displaced apical impulse, or an S, gallop would suggest systolic dysfunction. Conversely, an elderly woman with long-standing hypertension, no history of coronary disease, a sustained apical impulse, and an S, gallop or atrial fibrillation is more likely to have diastolic heart failure. No single feature of the history, physical examination, chest radiograph, or electrocardiogram reliably differentiates systolic from diastolic dysfunction. It is essential to assess left ventricular contractility with an echocardiogram, radionuclide angiogram, cardiac magnetic resonance study, or contrast left ventriculogram in any patient with new-onset heart failure or an unexplained clinical deterioration. Although systolic and diastolic heart failure are by no means mutually exclusive, from the therapeutic perspective it is useful to classify patients with a left ventricular ejection fraction of less than 40% to 45% as having predominantly systolic heart failure, and to consider those with an ejection fraction of 45% or greater as having predominantly diastolic heart failure; this classification scheme is used in the ensuing discussion. MANAGEMENT

The primary goals of heart failure management are to improve quality of life, reduce the frequency of heart failure exacerbations,

and extend survival. Secondary goals include maximizing independence, improving exercise capacity, enhancing emotional well being, and reducing resource use and cost of care. In elderly patients, improving quality of life and maintaining independence are often more important goals than increasing longevity. To achieve these goals, optimal heart failure management is comprised of three principal components: correction of the underlying cause whenever possible (e.g., valve replacement for severe aortic stenosis, coronary revascularization for severe ischemia), the judicious use of medications, and attention to the nonpharmacologic and rehabilitative aspects of care. These objectives may be best accomplished through the use of an interdisciplinary heart failure disease management team. Systolic Heart Failure

The pharmacotherapy of systolic heart failure is similar in older and younger patients. Current treatment options are listed in Table 2, and issues specific to the elderly are discussed below. Angiotensin Converting Enzyme Inhibitors. Angiotensin converting enzyme (ACE) mhibitors have been shown to improve survival, reduce hospitalizations, and enhance quality of life in a wide range of patients with left ventricular systolic dysfunction, including the elderly.50,68, 72, 73 A recent overview of the ACE inhibitor trials indicates that ACE inhibitors are at least as effective in the elderly as in younger patients.22Despite these findings, several studies have shown that age is a potent marker for lower ACE inhibitor usage rates, even in the absence of specific contra indication^.^^, 71 Although the reasons for the underprescription of ACE inhibitors Table 2. TREATMENT OPTIONS FOR SYSTOLIC HEART FAILURE

Angiotensin converting enzyme inhibitors Other vasodilators Hydralazine/nitrates combination Angiotensin I1 receptor antagonists (e.g., losartan) Digoxin Diuretics Beta adrenergic blocking agents Calcium channel blockers Antithrombotic agents Aspirin Coumadin

HEART FAILURE

in the elderly are unknown, concerns about adverse effects, particularly in patients over age 80, are likely to play an important role. Indeed, age-related alterations in kidney function may increase the risk of ACEinhibitor induced renal dysfunction and hy~ e r k a l e m i aSimilarly, .~~ older individuals may be more sensitive to the hypotensive effects of these drugs. Available evidence indicates that the beneficial effects of ACE inhibitors greatly outweigh the potential adverse effects, and age should not be considered a contraindication to the use of ACE inhibitors in appropriately selected patients.22 Based on data from randomized clinical trials, appropriate target dosages of ACE inhibitors in heart failure patients of all ages are: captopril50 mg TID, enalapril or lisinopril20 mg once daily, and ramipril 5 mg twice daily.50, 72, 73 Initial dosages should be lower in the elderly, with gradual upward titration to the goal dose, while carefully monitoring renal function, serum potassium, and blood pressure. Although most elderly patients will tolerate standard ACE inhibitor dosages without difficulty, in some cases adverse effects may limit upward titration. In this regard, it is worth noting that the recently completed ATLAS trial (Assessment of Treatment with Lisinopril and Survival) found that a very low dose of lisinopril(2.5 to 5 mg/d) was less effective than higher dosages in improving clinical Although higher doses are desirable, even low-dose ACE inhibition appears to be better than nothing. Finally, it is important to recognize that nonsteroidal anti-inflammatory drugs (NSAIDs), which are commonly used by older patients, antagonize the effects of ACE inhibitors (and other antihypertensive agents)76and that potassiumsparing diuretics increase the risk of hyperkalemia when used with ACE inhibitors. These drug combinations should be avoided whenever possible. Other Vasodilators. The role of angiotensin I1 receptor blockers (e.g., losartan, valsartan, irbesartan) in the management of heart failure remains undefined. In the recently published Evaluation of Losartan in the Elderly trial (ELITE), 722 patients 65-years-old or older with New York Heart Association class II-IV heart failure and a left ventricular ejection fraction of less than 40% were randomized to captopril or losartan and followed for 48 weeks.52Compared with captopril, losartan was associated with significantly fewer drug withdrawals because of adverse effects (12.2%

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versus 2O.8%), and mortality was also sigIn annificantly lower (4.8% versus 8.7Y0).~* other study comparing enalapril and candesartan alone or in combination, however, there was a trend favoring better outcomes with enalapril (unpublished data presented at the American Heart Association 70th Annual Scientific Session, Orlando, FL, November, 1997). Both of these studies were relatively small, and the discordant results could reflect the play of chance. Alternatively, the effects of angiotensin receptor blockers in heart failure may not be class effects, and losartan may be superior to other agents. Answers to these questions await the results of ongoing trials. In the meantime, losartan seems to be a suitable therapeutic alternative in elderly patients who are unable to tolerate ACE inhibitors. The recommended dose of losartan is 50 mg once daily,52and the most important side effects are hypotension and renal dysfunction. Another alternative to ACE inhibitors is the combination of hydralazine and isosorbide dinitrate, which has been shown to improve symptoms and reduce mortality in heart failure patients.", l2 The recommended dosages of these agents are 300 mg daily for hydralazine and 120 to 160 mg daily for isosorbide dinitrate. Common side effects with this combination include headache, dizziness, fatigue, and gastrointestinal disturbances. Occasionally, high doses of hydralazine may result in the drug lupus syndrome. Published data are sparse on the use of this drug combination in elderly patients. Digoxin. Digoxin increases myocardial contractility in individuals of all ages.83Because of changes in lean body mass and renal function, however, the therapeutic range of digoxin is lower in the elderly.83Appropriate digoxin concentrations in patients over 70years-old range from 0.5 to 1.3 ng/mL; higher levels are associated with increased toxicity but no greater efficacy.67, Until recently, the value of digoxin in the long-term management of patients with heart failure was controversial, and several studies suggested that digoxin could be safely withdrawn in many elderly patients receiving chronic therapy.I7 In the recently completed DIG study (Digitalis Investigation Group), 6800 patients with heart failure and an ejection fraction of less than 45% were randomized to digoxin or placebo and followed for an average of 37 months.70Although digoxin had no effect on overall mortality, heart failure deaths and hospitalizations were signifi-

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cantly reduced.70The effects of digoxin were similar across age groups, including patients over age 80 (William Williford, personal communication, 1998). Digoxin remains an important agent for heart failure management because of its beneficial effects on hospitalizations and quality of life. In the DIG study, side effects that occurred more frequently with digoxin than with placebo included nausea, vomiting, diarrhea, visual disturbances, supraventricular and ventricular arrhythmias, and atrioventricular Elderly patients may be more susceptible to the neurologic and cardiotoxic effects of digoxin, and 10% to 20% of older patients on chronic digoxin therapy develop signs or symptoms of toxicity at least once during the course of treatment.61It is important therefore to avoid hypokalemia and hypomagnesemia, which potentiate the toxic effects of digitalis, and to measure the serum digoxin concentration if toxicity is suspected. Routine monitoring of digoxin levels in the absence of suspected toxicity, however, is no longer recommended. Diuretics. Diuretics remain a cornerstone of heart failure therapy because they are the most effective agents for relieving pulmonary congestion and edema. There is little evidence that diuretics improve mortality or hospitalization rates, however, and elderly patients are more susceptible to diuretic-induced electrolyte disturbances, including hyponatremia, hypomagnesemia, and hypokalemia and hyperkalemia. In some patients with mild heart failure, a thiazide diuretic (e.g., hydrochlorothiazide) may be adequate, but most patients will require a loop diuretic, such as furosemide, bumetanide, or torsemide. In patients who are refractory to conventional doses of loop diuretics, the addition of metolazone or spiro78 Alternanolactone may facilitate diure~is.~, tively, intravenous diuretics, administered as intermittent boluses or as a continuous infusion, are usually effective in controlling pulmonary congestion and peripheral edema.15 Beta Blockers. Despite the well known negative inotropic and chronotropic effects of beta blockers, several studies have shown that these agents may reduce hospitalizations and mortality in patients with systolic heart failure.I6In the US Carvedilol Study, patients with heart failure and an ejection fraction of 35% or less experienced a 65% reduction in 6month mortality when treated with carvedilol as compared to placebo.48Hospitalizations

were also reduced, and quality of life and ejection fraction improved. The benefits were similar in patients with nonischemic or ischemic cardiomyopathy and in patients younger or older than 60 years.48Very few patients over 75 years-old were enrolled in the trial. The starting dose of carvedilol is 3.125 mg twice daily, and the dose should be gradually increased at 2-week intervals to a target dose of 25 to 50 mg twice a day. Contraindications to beta blockers include marked bradycardia, hypotension, severe decompensated heart failure, significant bronchospastic lung disease, and advanced atrioventricular block. Common side effects include fatigue and reduced exercise tolerance, especially during the titration phase, but these symptoms frequently resolve with continued therapy or dose reduction. Calcium Channel Blockers. Short-acting, immediate-release calcium channel blockers such as nifedipine, diltiazem, and verapamil have been associated with adverse outcomes in patients with systolic heart failure, and these agents are therefore contraindicated.', 2o The newer agents, amlodipine and felodipine, are associated with a more favorable safety profile,l3. 49 and data from the Prospective Randomized Amlodipine Survival Evaluation (PRAISE) indicate that amlodipine may reduce mortality in patients with nonischemic dilated ~ardiomyopathy,4~ a condition that is uncommon in the elderly. Based on available evidence, calcium channel blockers are not recommended for the routine treatment of systolic heart failure in elderly patients.' If a calcium channel blocker is needed to control angina or hypertension, however, amlodipine and felodipine are appropriate choices. Antithrombic Therapy. Aspirin, 75 to 325 mg daily, is recommended for all patients with known coronary heart disease regardless of age.3 Aspirin may also be beneficial in selected patients with cerebrovascular disease 69 In the absence of speor atrial fibrillati~n.~, cific indications, however, aspirin should probably be avoided in heart failure patients because it may attenuate the beneficial effects of ACE inhibitors,l0 and it also increases the risk of bleeding. Warfarin is indicated in patients with atrial fibrillation, rheumatic mitral valve disease, mechanical prosthetic heart valves, or prior thromboembolic events.19In other situations, the value of warfarin is unproven, and older patients are at increased risk for bleeding complications. When prescribing warfarin,

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the dosage should be adjusted to maintain the International Normalized Ratio (INR) in the range of 2.0 to 3.5. In summary, older patients with systolic heart failure should be managed in a similar fashion as younger patients. ACE inhibitors are the cornerstone of therapy, and the dose should be gradually titrated upwards until an optimal dosage is achieved. In patients unable to tolerate ACE inhibitors, the angiotensin I1 receptor antagonist losartan or the combination of hydralazine and nitrates are suitable alternatives. Diuretics should be given as needed for the treatment of pulmonary congestion and systemic edema. Digoxin is an important adjunctive agent in patients whose symptoms are not adequately controlled with vasodilators and diuretics, in patients with atrial fibrillation or an s, gallop, and in selected patients with severe left ventricular dysfunction (ejection fraction less than 25%). The role of beta blockers, such as carvedilol, continues to evolve, but such agents should be considered in stable patients with class I to I11 heart failure and no contraindications. In the absence of compelling indications for their use, calcium channel blockers should generally be avoided, and antithrombotic therapy should be reserved for specific situations as discussed earlier. Diastolic Heart Failure

Despite the fact that 30% to 50% of elderly heart failure patients have preserved left ventricular systolic function,77,8o treatment of diastolic heart failure remains largely empiric because there have been no large scale randomized trials evaluating the effects of specific pharmacologic agents. Diuretics are appropriate therapy for the relief of congestion and edema. It is important, however, to avoid overdiuresis, because intravascular volume depletion may result in underfilling of the left ventricle, with a resultant fall in stroke volume and cardiac output, as manifested by hypotension, cognitive impairment, or prerenal azotemia. In the United States, beta blockers, calcium channel blockers, and ACE inhibitors are the most frequently used agents for treating diastolic heart failure, and small studies have shown favorable hemodynamic and clinical effects with each of these drug classes in selected patients. By slowing heart rate and prolonging the diastolic filling period, beta blockers may in-

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crease stroke volume and reduce symptoms in patients with diastolic heart failure.77Beta blockers are also effective anti-ischemic agents, and they reduce left ventricular hypertrophy. In a recent randomized but unblinded study involving 158 heart failure patients with an ejection fraction of 40% or greater and an average age of 81 years, propranolol treatment was associated with improved survival compared to n~ntreatment.~ Calcium channel blockers exert a modest beneficial effect on diastolic function, and they also reduce ischemia and ventricular hyp e r t r ~ p h yIn .~~ addition, verapamil has been associated with improved symptoms, exercise capacity, and diastolic function in older patients with heart failure and an ejection fraction of 45% or greater.', '' Angiotensin converting enzyme inhibitors may improve symptoms in diastolic heart failure by enhancing left ventricular compliance and reducing h y p e r t r ~ p h y .In ~ ~one study involving 21 elderly patients (mean age 80 years) with diastolic heart failure, enalapril improved exercise capacity, left ventricular mass, and diastolic f ~ n c t i o n . ~ Additional agents that may be beneficial in selected patients with diastolic heart failure include nitrates and digoxin. Nitrates lower pulmonary and systemic venous pressure and relieve congestive symptoms.' Nitrates should be used with caution in patients with diastolic heart failure, however, because they may reduce stroke volume and cardiac output. Digoxin is often viewed as being contraindicated in patients with heart failure and normal systolic function. In the DIG study 988 heart failure patients with an ejection fraction of 45% or greater were randomized to digoxin or pla~ebo.~" As in patients with systolic heart failure, digoxin had no effect on mortality, but there was an 18% reduction in heart failure deaths and ho~pitalizations.~" Thus, digoxin may be a suitable agent for treating some patients with diastolic heart failure. Because of the lack of clinical trials addressing the management of diastolic heart failure, there is considerable variability in the therapeutic approach. In the absence of contraindications, it is reasonable to prescribe a beta blocker if the resting heart rate is greater than 75 or an ACE inhibitor if the resting heart rate is less than 75. Diuretics or nitrates should be used as needed to relieve congestive symptoms and edema. In patients who fail to respond to an adequate dose of one

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agent, substituting or adding an agent from a different class is appropriate. In refractory cases, the addition of digoxin should be considered.

tients were randomized to conventional physician-directed care or to conventional care supplemented by a nurse-directed multidisciplinary team. The study intervention included intensive patient education emphasizing the importance of dietary and medication compliance, individualized dietary instrucNonpharmacologic Aspects of Care tion, social service consultation to facilitate discharge planning, a detailed medication reHeart failure in older patients rarely occurs view designed to simplify the medication regas an isolated disease process, and manageimen, and close postdischarge follow-up by a ment is frequently confounded by a host of home health representative and the study medical, behavioral, psychological, social, team. The intervention continued for 90 days and economic factors (Table 3 ) . Moreover, following discharge, and during this period these factors frequently contribute to the high all-cause readmissions were reduced 44%, rate of rehospitalization in elderly heart failheart failure readmissions were reduced 569'0, ure which ranges from 30% to 50% within 3 to 6 months of initial discharge.24, readmissions for other reasons were reduced 29%, and the proportion of patients requiring 36, s6, R1 It follows that optimal heart failure multiple readmissions was reduced 61Y0.54Pamanagement in elderly patients requires aptients receiving the study intervention repropriate attention to all aspects of care, both ported improved quality of life, enhanced pharmacologic and nonpharmacologic, and compliance with medications and diet, and a that comprehensive heart failure management greater working knowledge of heart may be best accomplished through the use of f a i l ~ r e . ~Overall * , ~ ~ cost of care in 1995 dollars a multidisciplinary team approach. Indeed, was $460 lower per patient in the intervention numerous studies have now shown that an group as a result of the marked reduction in interdisciplinary team comprised of phyreadmissions. Importantly, during an addisicians, nurses, home care specialists, tional 9-month postintervention follow-up therapists, pharmacists, and other health properiod, heart failure readmissions remained fessionals can significantly reduce hospital29% lower in the intervention group, sugizations, improve quality of life, and decrease gesting a persistent beneficial effect of the health care costs in elderly heart failure patients,lX,32, 34, 54, 62, Xh program and implying additional cost saving~.~~ In 1995, results were reported from a proSince the publication of these findings, spective clinical trial involving 282 hospitalthere have been several additional studies ized heart failure patients 70 years of age or documenting improved clinical outcomes and older at increased risk for early readmission, reduced readmission rates using a variety of as indicated by a past history of heart failure, disease management strategies, some that multiple prior hospitalizations for any reason, were substantially less resource-intensive or heart failure precipitated by myocardial infarction or uncontrolled h y p e r t e n s i ~ nPa. ~ ~ (and therefore potentially more cost-effective) than our intervention.62,86 Although the optimal approach to heart failure disease management remains to be defined and may vary Table 3. FACTORS CONFOUNDING HEART FAILURE depending on the practice environment and MANAGEMENT patient characteristics, it is clear that such Multiple comorbid illnesses and other conditions programs substantially improve the overall Polypharmacy quality of care for older heart failure patients Noncompliance and that they are likely to reduce costs. Drug interactions Table 4 lists key elements of a comprehenDietary issues Psychosocial and financial concerns sive nonpharmacologic heart failure program. Depression Because not all components of the program Social isolation are appropriate for all patients, treatment Cost of medications must be individualized and adapted to acPhysical limitations Arthritis commodate the needs and circumstances of Neuromuscular disorders (e.g., stroke) each patient. For this reason, it is useful to Sensory deficits (e.g., visual, auditory) identify a single individual (e.g., a nurse case Cognitive dysfunction manager) to serve as team leader and to coor-

HEART FAILURE Table 4. NONPHARMACOLOGIC ASPECTS OF HEART FAILURE MANAGEMENT

Patient education Symptoms and signs of heart failure Specifics of when to contact nurse or physician about worsening symptoms Detailed discussion of all medications Emphasize importance of compliance Involve family/significant other as much as possible Dietary consultation Individualized and consistent with needs/lifestyle Sodium restriction (1.5-2 g/d) Weight loss, if appropriate Low fat, low cholesterol, if appropriate Adequate caloric intake Emphasize compliance while allowing flexibility Medication review Eliminate unnecessary medications Simplify regimen whenever possible Consolidate dosing schedule Social services Assess social support structure Evaluate emotional and financial needs Intervene pro-actively when feasible Daily weight chart Specific instructions on when to contact nurse or physician for changes in weight Support stockings to reduce edema Activity prescription (see text) Intensive followup Telephone contacts Home visits Outpatient clinic Contact information Names and phone numbers of nurse and physician 24-hour availability

dinate all aspects of the patient’s care. Although most of the items listed in Table 4 are self-explanatory, the role of exercise in elderly heart failure patients warrants further discussion. Activity Prescription

An overview of the goals and beneficial effects of cardiac rehabilitation in older patients is provided elsewhere in this issue. Although the same general principles apply to patients with heart failure, it is often necessary to tailor the program to suit individual needs. Traditionally, heart failure has been perceived as a contraindication to exercise, but it is now recognized that excessive activity restriction promotes muscular deconditioning and disuse atrophy that contribute to the progressive decline in functional capacity. In addition, numerous small studies have shown that low to moderate intensity aerobic exer-

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cise increases both maximal and submaximal exercise tolerance.’, 2y* 39 Although the effects of regular exercise on clinical outcomes in heart failure patients are still unknown, most experts now recommend some form of regular physical activity for all but the most severely limited heart failure patients.’, 31 Table 5 outlines the general approach to exercise prescription in older heart failure patients. In general, a comprehensive program should include flexibility exercises, strengthening exercises using light weights and frequent repetitions, and aerobic conditioning. In most cases, walking is the most appropriate form of aerobic exercise, and patients should be encouraged to do some walking at least 5 days each week, preferably every day. The duration of exercise must be individualized according to the patient’s baseline exercise capacity and comorbid conditions (e.g., arthritis, prior stroke, and so forth), but it is worth emphasizing that virtually any activity is better than no activity. A reasonable initial recommendation is for the patient to walk at a comfortable pace for a comfortable period and to gradually increase the duration (not the intensity) over several weeks to months. Once the patient can walk comfortably without stopping for at least 30 minutes, it may be appropriate to increase the intensity level, but in no case should the patient exceed a moderate level of intensity (i.e., 50% to 70% of maximum heart rate reserve). With regard to monitoring, in the absence of significant arrhythmias most patients with class I or I1 heart failure do not require professional supervision or monitoring (although exercising with a companion or in the presence of others is recommended). In patients with class I11 or IV heart failure, it may be desirable to initiate an exercise program in a monitored setting, but the value of long-term monitoring is unproven. In all cases, patients should be care-

Table 5. EXERCISE PRESCRIPTION FOR OLDER PATIENTS WITH HEART FAILURE

Components of conditioning program Flexibility exercises Strengthening exercises Aerobic conditioning Frequency of exercise: Daily, if possible Duration of exercise: Individualized; start low, go slow Intensity of exercise: Low to moderate (see text for details) Rate of progression: Gradual over weeks to months Monitoring: Heart rate, perceived exertion

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fully instructed about when to discontinue exercise and when to seek medical attention (e.g., prolonged chest pain, excessive dyspnea, dizziness, and so forth). Prevention

The prognosis for patients with established heart failure is poor, with average 5-year survival rates of approximately 50%. In addition, older age is associated with a worse prognosis, and fewer than 20% of octogenarians with heart failure remain alive after 5 years.27 Clearly, the best treatment for heart failure is prevention. Because coronary heart disease and hypertension are by far the most important causes of heart failure in Western societies, primary prevention of heart failure should focus on the traditional cardiac risk factors, including blood pressure and diabetes control, lipid management, and smoking cessation. In this regard, studies have shown that treatment of systolic and diastolic hypertension in the elderly reduces the incidence of heart failure 42 This benefit is by approximately 50%.41* most pronounced in the very elderly, who are at highest risk for developing heart failure.33* 41, 42 Similarly, the Scandinavian Simvastatin Survival Study (4s);‘)the Cholesterol and Recurrent Events trial and the West of Scotland primary prevention study6s have shown that cholesterol reduction decreases the risk of myocardial infarction in older and younger patients, and this effect, in turn, is likely to reduce the risk of heart failure. In patients with asymptomatic left ventricular systolic dysfunction (i.e., ejection fraction less than 40% without overt heart failure), ACE inhibitors reduce the rate of progression to clinical heart failure,”, 72 and these agents are therefore indicated for secondary prevention in this population. Whether treatment of subclinical diastolic dysfunction in the elderly can reduce the incidence of diastolic heart failure remains to be established, and this is an important question for future investigation. Ethical and End-of-Life Decisions

Not only is heart failure associated with a poor prognosis, but quality of life is often substantially impaired, and the risk of sudden arrhythmic death is ever-present. For these

reasons, it is important to address treatment intensity and end-of-life issues with the patient and family early in the disease process. Older patients should be encouraged to develop a living will and to appoint a durable power of attorney to serve as their advocate in the event they are no longer capable of making informed decisions regarding treatment. As the patient reaches the terminal stage of illness, it is also appropriate to discuss the circumstances of death, including whether the patient would prefer being at home or in a hospital, hospice, or other chronic care facility. Enlisting the help of a clergyman or other experienced professional is often invaluable when confronting these difficult issues. SUMMARY

Heart failure is predominantly a disorder of older adults, and to a large extent the epidemiology of heart failure reflects the convergence of age-related changes in the cardiovascular system and the rising prevalence of age-related cardiovascular diseases. The diagnosis of heart failure in the elderly is often difficult because of the presence of atypical symptomatology and comorbid conditions. Similarly, optimal treatment frequently poses a therapeutic challenge because of the high prevalence of confounding medical, behavioral, psychosocial, and economic factors. In addition, there is a paucity of data on the pharmacotherapy of heart failure in the very elderly (over age 80), and in the large proportion of older patients with heart failure and preserved left ventricular systolic function. Despite these difficulties, a number of therapeutic options, including ACE inhibitors, digoxin, and possibly beta blockers and angiotensin receptor antagonists, have been shown to favorably affect the clinical course of heart failure in elderly patients. In addition, several studies have documented the efficacy of multidisciplinary heart failure disease management programs for reducing hospital admission rates, improving quality of life, and decreasing cost of care. At present, the three greatest challenges in managing older heart failure patients are: (1) to more effectively implement proven treatments, such as ACE inhibitors, disease management systems, and antihypertensive therapy; (2) to develop effective therapies for the treatment of diastolic heart failure; and (3) to

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