Congestive heart failure in older adults.

Abstract

To the Editor: A recent series of articles has summarized available knowledge regarding congestive heart failure in older adults, from pathophysiology and etiology to clinical diagnosis and treatment.1–3 Although diastolic relaxation of the heart is a subject of interest to scientists from many different disciplines,4 few clinicians would disagree with Dr. Tresch about the difficulty of diagnosing diastolic dysfunction. However, recent systematic analysis has shown that the presence of jugular distention and radiographic redistribution at clinical examination is the best predictor of an increased filling pressure.5 The best findings for detecting systolic dysfunction, on the other hand, are abnormal apical impulse, radiographic cardiomegaly, and q waves or left bundle branch block on the electrocardiogram.5 We tend to disagree with Drs. Rich and Tresch on the real clinical utility of Doppler echocardiography to detect diastolic dysfunction in older patients because of the prevailing age-related variation in all the indices of diastolic performance.6 Dr. Aronow states that invasive procedures such as coronary angiography, angioplasty, or even surgical revascularization should not be based on age criteria although they should be restricted to selected persons. However, if it is recognized that treatment benefits are probably best restricted to selected patients, no data is available to guide such selection. Indeed, striking differences in the rate of use of invasive cardiac procedures in the United States, compared with Canada, have not resulted in improved long-term survival for older US patients.7 Comments on the pharmacologic management of congestive heart failure in older people should be prefaced by noting that older patients, especially women, have been systematically excluded from randomized controlled trials and that generalizability of the results is not possible.8 Even when this is assumed, the most effective medications are significantly underused in older patients,9 who appear to be at increased risk of receiving inadequate and potentially ineffective dosages.10 Any possible gender-specific difference, such as the possible interaction between estrogens and serum angiotensin-converting-enzyme activity,11 is completely un-explored. In our opinion, among the most notable advances that have occurred in the area of congestive heart failure are the findings of the efficacy of exercise therapy.12 In the past few years, at least six randomized clinical trials and several other reports have documented that there seem to be no heart-related contraindications to exercise training in patients with stable heart failure with systolic dysfunction.13,14 Once fitness improves, heart rate, blood pressure, sympathetic tone, and exercise-induced platelet activation also improve. It is important to stress that most previous studies of congestive heart failure in older persons have focused on survival. We share Dr. Parmley's provocative call for a real geriatric, multidisciplinary approach, with a new focus of therapy concentrating not merely on prolonging life but on maintaining a reasonable quality of life.15 The importance of physical performance as a major outcome cannot be overemphasized, given its relationship to patient well-being, satisfaction, and quality of life. Appropriate measures are needed that may not always be a value of ejection fraction. In older patients with heart failure, reduced levels of daily activity are more powerful predictors of death than conventional clinical measures.16 In addition, there is evidence supporting the contention that quality-of-life measures, including physical limitation, are not correlated with left ventricular ejection fraction. These considerations call attention to the critical need for the development of comprehensive registries and databases to examine more systematically the impact of therapeutic agents and nonpharmacologic approaches on traditional outcomes and on functional status and quality of life of older patients with congestive heart failure. Editors note: The above letter was referred to the authors of the original articles, and Dr. Aronow's letter follows.