heart failure geriatri

8/12/2019 heart failure geriatri

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Over 80% of all heart failure patients are 65 years and older. The

diagnosis and management of heart failure in older adults can be

challenging. However, with the correct clinical skill and experience,

most geriatric heart failure can be properly diagnosed and managed.

Management of geriatric heart failure can be simplified by following thisuseful mnemonic: DEFEATHeart Failure. This covers the essential

aspects of geriatric heart failure management:

Diagnosis, Etiology, Fluid, Ejection frAcion, and Treatment.


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Heart failure is a geriatric syndrome as most heartfailure patients are older adults. Heart failure is alsoa cardiac syndrome with complex and rapidlyevolving pathogenesis and treatment.

Unlike other cardiovascular disorders, heart failure isa clinical diagnosis that can be made at bedside andthe established evidence-based therapy for heartfailure can be easily implemented by generalist

physicians. The diagnosis and management of heartfailure in the elderly can be complicated by multipleco-morbidities and polypharmacy.


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The management of heart failure in a 75-year-oldelderly woman with normal left ventricular ejectionfraction may be complicated by lack of evidence toguide therapy, comorbidities such as hypertension,atrial fibrillation, diabetes mellitus, osteoarthritis,chronic kidney disease, and depression, andpolypharmacy related to these conditions.

The management of heart failure in the elderly isfurther made difficult by atypical presentation ofheart failure in older adults.


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How to management a geriatric

heart failure?


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DEFEAT - Heart Failure


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D = Diagnosis

E = Etiology

F = FluidEA = Ejection FrAction

T = Therapy


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The process begins with a

clinical Diagnosis, which must be

established.


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Heart Failure can be diagnosis with thissymptome:

1. Dyspnea or fatigue on exertion, with orwithout some degree of lower extremityswelling, is generally the most commonearly symptom of heart failure

2. Orthopnea and paroxysmal nocturnaldyspnea are relatively specific symptoms for

heart failure in older adults3. When prolonged and left untreated, edema

may also affect more proximal lowerextremity, scrotal area, and abdomen


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Etiology must be sought and determined.

Because heart failure is a syndrome and not

a disease, it is always associated with an

underlying cause. Hypertension and

coronary artery disease are the two most

common causes of heart failure in all ages,

including older adults


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Determination of the Fluid volume status by careful

examination of the external jugular veins in the neck is vital

to achieve euvolemia.

An elevated jugular venous pressure is the most specific

sign of fluid overload in heart failure and is the most

important physical examination in the initial and

subsequent examinations of an elderly heart failure patient.


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.

An echocardiography should be ordered to

obtain left ventricular Ejection frAction to

assess prognosis and guide Therapy.


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The general principle for the treatment of heartfailure in older adults is similar to that inyounger adults and can generally be divided

into symptom-relieving treatment and disease-modifying or life-prolonging treatment.

Symptom-relieving therapy for heart failure is

similar for both systolic and diastolic heartfailure.


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There is little evidence to guide therapy forelderly diastolic heart failure patients.Evidence-based therapy for systolic heartfailure involves the use of drugs that suppressneurohormones1. Renin-angiotensin-aldosterone system and

sympathetic nervous system,2. ACE inhibitor or angiotensin receptor

blocker,3. Beta blocker,4. Aldosterone antagonist in select patients,


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All elderly systolic heart failure patients should be treated with anACE inhibitor or an angiotensin receptor blocker if a patientcannot tolerate an ACE inhibitor due to cough or angioedema.

Chronic renal insufficiency is common in heart failure, and

should not be a reason for non use of these drugs.

All elderly systolic heart failure patients should also be treatedwith an approved beta-blocker, namely, carvedilol, metoprololextended release, or bisoprolol.

There is no need to maximize the dose of an ACE inhibitor (or anangiotensin receptor blocker) before initiating therapy with abeta-blocker.


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Metoprolol may be better tolerated by patientswith low systolic blood.

An aldosterone antagonist, such as

spironolactone, may be used in advanced heartfailure patients. However, it would be used withcaution as it may cause hyperkalemia,especially in those with impaired renal function.

Aldosterone antagonists may also be used inpatients with chronic hypokalemia receivingdiuretics.


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However, if left ventricular ejection fraction cannotbe determined, as in many developing nations, allgeriatric heart failure patients should be treated asif they have low ejection fraction, and should beprescribed an angiotensin-converting enzymeinhibitor and a beta-blocker. Diuretic and digoxinshould be prescribed for all symptomatic patientswith heart failure. An aldosterone antagonist may

be used in select patients with advanced systolicheart failure, carefully avoiding hyperkalemia


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Hypokalemia should be avoided and should

be treated as appropriate.The importance of

salt and fluid restriction must be emphasized

in all heart failure patients, especially in

those who are volume overloaded, and

require an increase of their diuretic dosage


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There are little evidence-based guidelines

for therapy of diastolic heart failure patients.

All symptomatic diastolic heart failure

patients, like systolic heart failure patients,

should be treated with diuretics, to achieve

euvolemia.


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There is currently no evidence that the use of ACE inhibitors or

beta-blockers reduces mortality or morbidity in diastolic heart

failure. However, diastolic heart failure patients are often

elderly and suffer from multiple comorbidities such as

hypertension, diabetes, coronary artery disease, atrialfibrillation, and chronic kidney disease, which may benefit from

the use of these drugs.

Digoxin and candesartan may be beneficial in reducing heartfailure hospitalizations in these patients.


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Most geriatric heart failure patients in the

developing nations may not be able to afford

echocardiography. When left ventricular

ejection fraction is unknown, all heart failure

patients should be considered as systolic

heart failure and should be treated

accordingly.


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Heart failure patients who cannot afford or

tolerate ACE inhibitors and beta-blockers

should be prescribed digoxin in low doses.

Digoxin is inexpensive, and may reduce

morbidity and mortality in these patients


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3. Determination of left ventricular Ejection frAction is the singlemost important test after a clinical diagnosis of heart failurehas been made, which should be used to guide Therapy.

4. When ejection fraction cannot be determined, all heart failure

patients should be prescribed an ACE inhibitor and a beta-blocker, and an aldosterone antagonist for selected patientswith advanced heart failure.

5. Low-dose digoxin should be prescribed for all heart failurepatients who cannot afford or tolerate ACE inhibitors or beta-

blockers. Diuretics should be used judiciously to achieve andmaintain euvolemia


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heart failure geriatri

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