Treatment of heart failure in the elderly: never say it's too late

Abstract

Komajda et al. have provided very important information on an essential and relatively unstudied group of heart failure (HF) patients—those 80 years of age and older.1 Their findings from the Euro Heart Failure Survey (EHFS) II provide unique information on the characteristics and outcomes in this group and secular trends in their management. In this editorial, we will try to place their findings in the broader context of HF management, highlighting what is known and, more importantly, what is not known about this patient group. HF is predominantly a disease of the elderly. The mean age of HF patients is >70 years in most developed countries, and the prevalence of HF rises dramatically with age, from 1–2% among individuals aged 45–54 years to >10% among those aged ≥75 years.2 Ageing predisposes to HF through multiple mechanisms. First, HF is a frequent outcome of virtually all cardiovascular diseases. Hence, patients with most cardiovascular diseases (i.e. hypertension, acute coronary syndromes, cardiac surgery, etc.) are prone to developing ventricular remodelling and HF when elderly. Secondly, even in the absence of any cardiovascular event, ageing is associated with reduced aortic and left ventricular (LV) compliance, with increased aortic impedance and abnormal LV diastolic function. These conditions lower the threshold for the development of HF when the heart is exposed to precipitating factors such as hypertension and/or tachyarrhythmias (especially atrial fibrillation). These last mechanisms explain why the clinical picture of HF in older patients differs substantially from that of the syndrome usually described and studied in randomized clinical trials (RCTs). Elderly patients with HF are more likely to be women (as their life span is longer), as well as more likely to suffer from hypertension, have a normal LV ejection fraction (EF), and suffer from co-morbidities.3,4 Compared with younger patients, … *Corresponding author. Tel: +39 030 3995573, Fax: +39 030 3700359, Email: metramarco{at}libero.it