Heart Failure in the Elderly [an Issue of Heart Failure Clinics]

175 Pages·2007·5.171 MB·English

HEARTFAILURE INTHE ELDERLY
CONTENTS
Editorial: Never Too Late to Drink From the Fountain of Youth xi
Ragavendra R. Baliga and James B. Young
Preface xiii
Wilbert S. Aronow
Epidemiology, Pathophysiology, and Prognosis of Heart Failure
in the Elderly 381
Sabu Thomas and Michael W. Rich
Heartfailure(HF)representsthequintessentialdisorderofcardiovascularaging,reflect-
ingtheconvergenceofage-relatedchangesinthecardiovascularsystemandotherorgan
systemsandtheincreasingprevalenceofcardiovasculardiseasesatolderage.Theprev-
alenceandincidenceofHFincreaseprogressivelywithadvancingage,andHFimposes
anenormousburdenonsocietyinmortality,morbidity,andassociatedhealthcarecosts.
DespitemajoradvancesintreatmentofHFoverthelast25years,theprognosisremains
poor,withmediansurvivalratesoflessthan5yearsinolderadults.Asthepopulation
ages,itisanticipatedthatthenumberofolderpeoplewithHFwillincreasedramatically
over thenext several decades.
DEFEAT Heart Failure: Clinical Manifestations, Diagnostic Assessment,
and Etiology of Geriatric Heart Failure 389
Ali Ahmed
Agingischaracterizedbyheterogeneity,bothinhealthandindisease.Olderadultswho
haveheartfailure(HF)oftenhaveatypicalanddelayedclinicalmanifestationsandmany
havediastolicHF.TheassessmentandmanagementofHFinolderadultsmaybesim-
plifiedbya5-stepprocesscalledDEFEATHF:(1)establishaclinicalDiagnosisofHF;(2)
establish an Etiology for HF, preferably in collaboration with a cardiologist; (3) deter-
mineFluidstatusandachieveeuvolemia;(4)determineleftventricularEjectionfrAction;
and (5) provideevidence-basedTherapy.
Role of Echocardiography in the Diagnostic Assessment and Etiology
of Heart Failure in the Elderly—Opacify, Quantify, and Rectify 403
Vincent L. Sorrell and Navin C. Nanda
Echocardiography offers comprehensive, noninvasive, and relatively inexpensive tools
for diagnosing cardiac pathology in the elderly. With an organized approach using
two-dimensional echocardiography and Doppler echocardiography, clinicians can
determine the systolic and diastolic left ventricular performance; estimate the cardiac
Æ Æ
VOLUME3 NUMBER4 OCTOBER2007 v
output, pulmonary artery, and ventricular filling pressures;and identify surgically cor-
rectable valve disease. Meanwhile, real-time three-dimensional echocardiography pro-
vides unprecedented volume data to quantify the left ventricular status. Tissue
Doppler-derivedmyocardialvelocityandstrainimagingdataprovideextremelyfinede-
tails about the regional variations in myocardial synchrony and predict responders to
cardiac resynchronization therapy. Thus, echocardiographic tools provide the basis for
determiningwhentoattempttorectifytheleftventriculardysfunctionwithstrategically
placed, biventricular pacemaker leads.
TreatmentofHeartFailurewithAbnormalLeftVentricularSystolicFunction
in the Elderly 423
Wilbert S. Aronow
Thisarticlesummarizesthefourstagesofheartfailure(HF)asdefinedbytheAmerican
CollegeofCardiologyandtheAmericanHeartAssociationanddiscussesthetreatments
forelderly patientswith HFandabnormalleft ventricular systolicfunction. The article
explainstheimportantroleofdiuretics,thefirst-linedrugsinthetreatmentofolderpa-
tients with HF and volume overload. Other treatments described include angiotensin-
converting enzyme inhibitors, angiotensin-receptor blockers, b-blockers, aldosterone
antagonists, isosorbide dinitrate plus hydralazine, digoxin, and calcium channel block-
ers. The article explains the role each of these plays and reports on studies that have
examined and compared varioustreatments.
Diastolic Heart Failure in the Elderly 437
Dalane W. Kitzman and Kurt R. Daniel
Mostelderlypatients,particularlywomen,whohaveheartfailurehaveanormalejection
fraction.Patientswhohavethissyndromehaveseveresymptomsofexerciseintolerance,
frequent hospitalizations, and increased mortality. The pathophysiology and treatment
are not well defined. Control of systemic hypertension may be a key to prevention
and treatment.Several largetrials ofspecific agents are currently underway.
Use of Diuretics in the Treatment of Heart Failure in the Elderly 455
Domenic A. Sica, Todd W.B. Gehr, and William H. Frishman
Diureticsaretoolsofconsiderabletherapeuticimportance.First,theyeffectivelyreduce
blood pressure, while at the same time decreasing the morbidity and mortality associ-
ated with hypertension. Diuretics are currently recommended as first-line therapy for
thetreatmentofhypertension.Inaddition,theyremainanimportantcomponentofheart
failuretherapy,inthattheyimprovethesymptomsofcongestion,whichtypifythemore
advanced stages of heart failure.This article reviews the modeof action of the various
diuretic classes and the physiologic adaptations that follow; sets up the basis for their
use in the treatment of volume-retaining states, particularly as applies to the elderly;
and reviewsdiuretic-relatedside effects that are normally encountered.
Heart Failure—Complicating Acute Myocardial Infarction 465
Wilbert S. Aronow
Thisarticleaddressesissuesrelatedtoacutemyocardialinfarction(MI)complicatedby
heart failure, particularly in elderly patients. Findings have shown that acute MI com-
plicated by congestive heart failure(CHF) is associated with a high mortality, and that
women with acute MI are more likely to be older and to develop CHF than men with
acuteMI.Ingeneral,managementofCHFcomplicatingacuteMIissimilarinolderand
youngerpatients.Actionsdiscussedincludehemodynamicmonitoring;theadministra-
tionofoxygen;andtheuseofmorphine,diuretics,nitroglycerin,angiotensin-converting
vi CONTENTS
enzyme inhibitors, angiotensin IIreceptorblockers, spironolactone, b-blockers, calcium
channelblockers,magnesium,digoxin,andpositiveinotropicdrugs.Thearticlealsodis-
cussesmeasuresfortreatingarrhythmiasandfordiagnosingmechanicalcomplications.
Inotropic Drugs and Neurohormonal Antagonists in the Treatment
of HF in the Elderly 477
Christopher M. O’Connor and Pradeep Arumugham
Heartfailure(HF)isthemostcommonreasonforhospitaladmissionamongindividuals
overage 65yearsand results in more than 1millionadmissions eachyear.The overall
annual death rate for HF is approximately 20%. HF results from decreased contractile
functionoftheheart,andneurohormonaldysregulationplaysamajorpartinthemor-
bidityandmortalityoftheheart.Thepurposeofthisarticleistoreviewrecentstudieson
inotropic drugs and neurohormonal antagonists used in the treatment of patients who
have HF,especially theelderly.
Interventional Therapies for Heart Failure in the Elderly 485
Srihari S. Naidu, S. Chiu Wong, and Richard M. Steingart
Theagingofapopulationrepletewithriskfactorsforheartfailure(HF)(coronaryheart
disease, diabetes, and hypertension) coupled with a declining age-adjusted mortality
rate forcoronaryartery and hypertensive heart diseases hascreated, and will continue
to create, a literal explosion in the prevalence of HF in the United States. Despite ad-
vances in maximal medical therapy, however, most patients who have symptomatic
HF can expect functional impairment, interludes of worsening symptomatology, and
ashortenedlifespan.Thisarticleupdatestheuseofinterventionaltherapiesforthetreat-
mentofelderlypatientswhohaveHFcausedbycoronaryarterydisease,valvularheart
disease, congenital heartdisease, myocardial disease,and renal vasculardisease.
Surgical Treatment of Heart Failure in the Elderly 501
Ramin Malekan and Steven L. Lansman
Heartfailure(HF)inelderlypatientswhomaybenefitfromsurgicaltherapyisusually
secondary to ischemic or valvular heart disease. When referring such patients for sur-
gery,lifeexpectancy,alongwiththeexpectations ofthepatientandfamilywithregard
tothesurgicaltreatment,mustbeconsidered.Thegoalsofcardiacsurgeryinthispatient
population are to maintain or improve cardiac function, decrease HF episodes, reduce
hospital admissions, andimprovefunctional class.Safersurgicaltechniquesdeveloped
duringthelasttwodecadeshaveallowedhigh-riskpatientswellintotheir80stoundergo
complexcardiacoperationswithdecreasingmorbidityandmortality.Successfulsurgical
intervention often leads to a more productive and independent life forelderly patients
whohaveHF.
Cardiac Resynchronization Therapy for Treatment of Heart Failure
in the Elderly 511
Jordana Kron and Jamie B. Conti
Congestiveheartfailureaffects5millionpatientseachyearandismorecommoninel-
derly patients. Cardiac resynchronization therapy (CRT) or biventricular pacing is the
simultaneous pacing of both ventricles, an approach that can improve symptoms and
survival in some heart failure (HF) patients. Although no randomized controlled trial
has evaluated CRT specifically in elderly patients, many of the patients included in
the landmark CRT trials were aged 70 and older. Data suggest that CRTis a safe and
efficacious treatment of HFin geriatricpatients.
CONTENTS vii
TreatmentofArrhythmiasandUseofImplantableCardioverter-Defibrillators
toImprove Survivalin ElderlyPatients with Cardiac Disease 519
Ilan Goldenberg and Arthur J. Moss
Patientswhohaveleftventriculardysfunctionandheartfailure(HF)areathighriskfor
ventriculartachyarrhythmiasandsuddencardiacdeath.Randomizedclinicaltrialshave
demonstrated that pharmacologic management with antiarrhythmic drugs has limited
efficacyforthepreventionofarrhythmicmortalityinthishigh-riskpopulation,whereas
implantation of a defibrillator was shown to be associated with a significant survival
benefit.Dataontheefficacyofdefibrillatortherapyinelderlypatients,inwhomcomor-
biditiesarecommon,arelimited.Inthisarticleweoutlinecurrentinformationonther-
apeutic modalities for the prevention of arrhythmic mortality in elderly patients who
haveleftventriculardysfunctionandHF,focusingmainlyondataonthebenefitofde-
vice therapy inthe olderagegroup.
Exercise Therapy for Elderly Heart Failure Patients 529
Jerome L. Fleg
Exerciseintoleranceisoneofthehallmarksymptomsofheartfailure(HF).Exercisetrain-
ingin thiscondition wasnotexploredas atherapeutic modalityuntil thepasttwode-
cades.Infact,bedrestwaspromotedasatreatmentforcertainformsofHFinthe1970s.
Overthepasttwodecades,however,datahaveshownconvincinglythatexercisetrain-
ingcanbeimplementedsafelyinpatientswhohaveHF,withsignificantimprovementin
functional capacity, various other physiologic variables, and quality of life. This article
reviews the accumulated literature in this area, with specific emphasis on the effects
of exercise training in older patients who have HF, a subset that may have the most
to gainfrom suchtraining.
End-of-Life Care in the Treatment of Heart Failure in the Elderly 539
John Arthur McClung
Much of the literature dedicated to the topic of medical care of dying patients has re-
volvedaroundterminalcareprovidedtopatientswhohaveneoplasticdiagnoses.Heart
failure (HF) presents its own unique challenges to the clinician. This article focuses on
specificclinicalrecommendationsandananalysisofsomeoftheethicalissuesinvolved
in the provision of care to elderlypatients in theterminal stages of HF.
Index 549
viii CONTENTS
FORTHCOMING ISSUES
January2008
Diastolic Dysfunction andHeart Failure
ManiVannan,MBBS, and Bertram Pitt,MD,
Guest Editors
April2008
Function Follows Form
Jagat Narula,MD, PhD,
GeraldD. Buckberg, MD,
and Bijoy Khandheria, MD,Guest Editors
July2008
The Role ofStatins inHeart Failure
GreggC. Fonarow,MD,Guest Editor
RECENT ISSUES
July2007
The Role ofSurgery, PartII
Stephen Westaby,MS, PhD,
and MarioC. Deng,MD,Guest Editors
April2007
The Role ofSurgery, PartI
Stephen Westaby,MS, PhD,
and MarioC. Deng,MD,Guest Editors
January2007
Current Advancesin Heart Transplantation
Mandeep R.Mehra,MD, GuestEditor
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HeartFailureClin3(2007)xi–xii
Editorial
Never Too Late to Drink
From the Fountain of Youth
RagavendraR.Baliga,MD,MBA JamesB.Young,MD
ConsultingEditors
In 1900 life expectancy at birth in the United millionofficevisitsintheUSalone[3].Theannual
States was 47 years. Today, it is about 78 years, expenditure for the management of heart failure
an increase of 64% (or 30 years). The United in this population isabout40billion dollars [3].
States(US)CensusBureauhaspredictedthatlife Thegoalsandprinciples oftreatmentofheart
expectancywillbeinthemid-80sby2050,anditis failure in the elderly are the same as in younger
expectedtoplateauinthelow90ssoonafterthat. individuals [4]. However, the management of
It has also been predicted that the US will have heart failure in the elderly is associated with sev-
5.3 million individuals over age 100 by the end eral distinctchallenges,including:a)thepresence
of this century. It is not surprising that the in- ofcomorbidities,suchasorthostatichypotension,
creaseinlifespanhasbeenaccompaniedbyanin- chronic obstructive pulmonary disease, atrial fi-
creaseintheburdenofheartfailuredevelopingin brillation, and renal insufficiency; b) the increas-
the elderly. As we age, there is more exposure to ing prevalence of heart failure due to left
pathologic states that cause or contribute to car- ventriculardiastolicdysfunction;c)thescantrep-
diac dysfunction, including hypertension, dyslipi- resentationoftheelderlyinclinicaltrials;d)ethi-
demia, and coronary heart disease. Indeed, one calissues,includingwhenpalliativecareshouldbe
could argue that the heart was made to last only offered to elderly patients and when patients
a few decades. Nonetheless, it is estimated that should be considered for more aggressive thera-
amongthe4millionUSresidentswhohaveheart piessuchas‘‘bridge-to-destination’’withmechan-
failure,70%areovertheageof60years[1].The icalcirculatoryassistdevices;ande)socialissues,
mortality of heart failure in the elderly is very suchastheelderlypatientwhofindsitdifficultto
high, particularly in advanced cases, and can be adheretoalow-saltmealduetolivingconditions
10% to 15% at 1 month, and 30% at the end of ortoaffordmedications. Infact,30%to50%of
1year[2].Notonlyisheartfailureamajorcause recurrentepisodesofheartfailureareduetonon-
forhospitalizationintheelderly,butitisalsothe compliance,whichalsocontributestoonethirdto
second most important reason for outpatient onehalfofallpatientsreadmittedforheartfailure
visits in older patients, with an estimated 12 within 6months ofinitial hospital discharge[5].
1551-7136/07/$-seefrontmatter(cid:2)2007ElsevierInc.Allrightsreserved.
doi:10.1016/j.hfc.2007.08.001 heartfailure.theclinics.com
xii EDITORIAL
In addition, elderly patients who have heart References
failure are often not on optimal therapy, such as
[1] HaldemanGA,CroftJB,GilesWH,etal.Hospital-
angiotensinconvertingenzymeinhibitorsorbeta-
ization of patients with heart failure: National
blockers,andveryfewareonaldosteroneantago-
HospitalDischargeSurvey,1985to1995.AmHeart
nists.Theprincipleofprimumnonnocere(firstdo
J1999;137(2):352–60.
no harm) may be an important reason that such [2] Gillum RF. Epidemiology of heart failure in the
life-saving therapies are not considered in elderly UnitedStates.AmHeartJ1993;126(4):1042–7.
patients[6].Inotherinstances,agapintheaware- [3] O’Connell JB, Bristow MR. Economic impact of
nessofthebeneficialeffectsoftreatment(suchas heartfailureintheUnitedStates:timeforadifferent
beta-blockers or aldosterone receptor blockade approach. J Heart Lung Transplant 1994;13(4):
[7])inelderlypatientsisanimportantreasonther- S107–12.
[4] HuntSA.ACC/AHA2005guidelineupdateforthe
apyisnotprescribed.Finally,thereluctanceofphy-
diagnosisandmanagementofchronicheartfailure
sicians to alter long-term therapy in the elderly
intheadult:areportoftheAmericanCollegeofCar-
patient because of the mistaken concept of ‘‘if it
diology/AmericanHeartAssociationTaskForceon
isn’tbroken,don’tfixit’’isanotherreasonlife-sav-
PracticeGuidelines(WritingCommitteetoUpdate
ingtherapiesarenotbeingprescribedforthesepa- the2001GuidelinesfortheEvaluationandManage-
tients who have heart failure. The most effective ment of Heart Failure). J Am Coll Cardiol 2005;
methodofmanagingthesechallengesisamultidis- 46(6):e1–82.
ciplinaryapproach[8,9],whichincludesnotonly [5] KrumholzHM,ParentEM,TuN,etal.Readmis-
aheartfailurespecialist,butalsoadedicatednurse sionafterhospitalizationforcongestiveheartfailure
[10],pharmacist,dietician,andsocialworker. among Medicare beneficiaries. Arch Intern Med
1997;157(1):99–104.
Inthisissue,guesteditedbyWilbertS.Aronow,
[6] Opasich C, Boccanelli A, Cafiero M, et al. Pro-
MD, leading experts in the field of heart failure,
grammetoimprovetheuseofbeta-blockersforheart
with a specific interest and expertise in managing
failureintheelderlyandinthosewithseveresymp-
thesituationintheelderly,haveelegantlydiscussed
toms:resultsoftheBRING-UP2Study.EurJHeart
theopportunitiesandchallengesinthisimportant Fail2006;8(6):649–57.
but often ignored patient population. They have [7] MasoudiFA,GrossCP,WangY,etal.Adoptionof
importantly emphasized the same principles of spironolactonetherapyforolderpatientswithheart
therapythatapplytoyoungerpatients[11].Payors failureandleftventricularsystolicdysfunctioninthe
are increasingly expecting that all patients who UnitedStates,1998–2001.Circulation2005;112(1):
have heart failure, including the elderly, receive 39–47.
[8] StewartS,McAlisterFA,McMurrayJJ.Heartfail-
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prolong survival. Arch Intern Med 2005;165(11):
days,’’ there will be zero-tolerance if such life-
1311.
saving therapies are not seriously considered in
[9] InglisSC,PearsonS,TreenS,etal.Extendingthe
the elderly. We concur with this aggressive horizoninchronicheartfailure:effectsofmultidisci-
philosophy. After all, the elderly continue to plinary, home-based intervention relative to usual
deservetodrinkfromthefountainofyouth.Itis care.Circulation2006;114(23):2466–73.
never too late to initiate life-saving therapiesd [10] EkmanI,AnderssonB,EhnforsM,etal.Feasibility
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[11] Hunt SA, Abraham WT, Chin MH, et al. ACC/
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HeartFailureClin3(2007)xiii
Preface
WilbertS.Aronow,MD
GuestEditor
Heart failure (HF) is the most common cause prognosis, clinical manifestations, diagnostic as-
ofhospitalizationintheUnitedStates.HFaffects sessment, etiology, and role of echocardiography
approximately 5 million people in the United in the diagnostic assessment and etiology of HF
States, and more than 500,000 new cases of HF are discussed. The treatment of HF in the
are reported each year. Approximately 300,000 elderly with an abnormal and with a normal
peopledieofHFeachyear.HFispredominantly LVEF, after acute myocardial infarction,
adiseaseoftheelderlywithprevalenceratesrang- and the use of diuretics, inotropic drugs, neuro-
ing from 1% in people younger than 50 years to hormonal antagonists, antiarrhythmic drugs,
10%inpeopleaged80yearsandolder.Approxi- angioplasty, surgical therapy, cardiac resynchro-
mately 80% of patients hospitalized with HF are nization therapy, exercise therapy, and use of
older than 65 years. Aging of the population is implantable cardioverter-defibrillators are also
contributingto anepidemicof HF. discussed. Finally, a very important article on
The prevalence of HF with a normal left end-of-life care in treating HF in the elderly is
ventricularejectionfraction(LVEF)alsoincreases discussed.
with age and is higher in older women than in Alloftheauthorswhohavecontributedtothis
older men. Although approximately half of pa- issuearenationallyandinternationallyrecognized
tients older than 60 years of age who have HF experts in cardiovascular disease in the elderly
have a normal LVEF, there are few randomized who are dedicated to improving care for older
controlled trials investigating the use of drugs in people who have cardiovascular disease. Their
the treatment of HF with a normal LVEF. The manyyearsofpersonalexperienceenablethemto
most important target for basic science and summarize and synthesize their respective topics
clinical investigation in the years ahead in HF in with unique insights that are highly beneficial to
theelderlyisthepreventionandtreatmentofHF thereader.Mysincereappreciationisextendedto
withanormal LVEF. each of them for their excellent contributions
This issue comprises 14 articles on HF in the to the articlesin this issue.
elderly. The epidemiology, pathophysiology,
Wilbert S. Aronow, MD
NewYorkMedicalCollege
Valhalla, NY, USA
A version of this article originally appeared in
ClinicsinGeriatricMedicine,Volume23,Issue1. E-mail address:[email protected]
1551-7136/07/$-seefrontmatter(cid:2)2007ElsevierInc.Allrightsreserved.
doi:10.1016/j.hfc.2007.07.018 heartfailure.theclinics.com
HeartFailureClin3(2007)381–387
Epidemiology, Pathophysiology,
and Prognosis of Heart
Failure in the Elderly
Sabu Thomas, MD, Michael W. Rich, MD*
WashingtonUniversitySchoolofMedicine,St.Louis,MO,USA
Althoughtheheartfailure(HF)syndromehas United States is 75 years (ie, half of all HF cases
been recognized for more than 2000 years, it occur in the 6% of the population 75 years of
has been only within the last 25 years that HF age or older). Therefore, it is not surprising that
hasemergedasamajorpublichealthconcern[1]. the incidence and prevalence of HF will increase
Aprincipalreasonforthisrelativelyrecentdevel- proportionately as the population ages.
opment is that HF is primarily a disorder of the Heartfailureisalreadythemostcostlycardio-
elderly, and only in the last half-century has life vasculardisorderintheUnitedStates,anditisthe
expectancy increased sufficiently to allow more leading cause of hospital admission among
HF cases to emerge. In the United States, mean Medicare beneficiaries. The estimated total direct
life expectancy at birth increased from 49 years and indirect cost for HF in the United States for
in 1900 to 77 years in 2000 [2]. Over the next 2006is$29.6billion.In2001,$4.0billionwaspaid
25 years, the number of people over age 65 will toMedicarebeneficiariesforHFhospitalizations,
double from 35 million to more than 70 million, an average of $5912 per discharge [4,5]. In light
withthelargestrelativegrowthoccurringinthose of the significant societal burden imposed by the
over age 85 [2]. Furthermore, as treatments and emerging HF epidemic, it is essential that
survival rates for other cardiovascular diseases health care providers and researchers in the field
improve, particularly hypertension and ischemic have an understanding of the epidemiology,
heart disease, more patients will be living and pathophysiology,andprognosisofthissyndrome,
dyingwithHF. particularly withinthe geriatric population.
Whataccountsforthepronouncedassociation
between HF and older age? In effect, HF can be
Pathophysiology
thought of as the quintessential disorder of
cardiovascular aging, representing the conver- HF results from any structural or functional
gence of age-related changes in cardiovascular cardiac disorder that impairs the ability of the
structure and function, aging changes in other ventriclestofillwithorejectblood,givingriseto
organ systems, and the progressive increase in a clinical syndrome that represents the end-stage
cardiovascular diseases in the elderly [3]. Indeed, or final common pathway of numerous cardiac
the median age for patients who have HF in the diseases. Coronary artery disease is the leading
cause of HF in the United States, followed by
hypertension,nonischemiccardiomyopathy(espe-
cially idiopathic cardiomyopathy), and valvular
A version of this article originally appeared in
heart disease [6,7].
ClinicsinGeriatricMedicine,Volume23,Issue1.
Inadditiontothesecauses,theeffectsofaging
* Washington University School of Medicine, 660
South Euclid Avenue, Campus Box 8086, St. Louis, itself on the cardiovascular system contribute
MO63110. substantially to the development of HF in the
E-mailaddress:[email protected](M.W.Rich). elderly (Box 1) [8]. Increased connective tissue
1551-7136/07/$-seefrontmatter(cid:2)2007ElsevierInc.Allrightsreserved.
doi:10.1016/j.hfc.2007.07.004 heartfailure.theclinics.com
382 THOMAS&RICH
age-associated impairment in endothelium-
Box1. Principaleffectsofcardiovascular dependent vasodilation reduces maximum coro-
aging narybloodflowandpredisposestoischemia,even
in the absence of fixedcoronary artery stenosis.
Increased systemic vascularimpedance,
The primary clinical implication of these
especially inthelarger arteries
changes is that the capacity of the heart to
Impaired left ventriculardiastolic
increase cardiac output in response to increased
relaxationandcompliance
demands is markedly attenuated with age. This
Diminished responsiveness to
attenuationisperhapsnotsurprising,becausethe
beta-adrenergic stimulation
four physiologic factors that determine cardiac
Impaired mitochondrialenergy
output (ie, heart rate, contractility, preload, and
productioninresponseto stress
afterload) are all affected adversely by the aging
Decline insinusnode function
process.
Impaired endothelial function, especially
Anotherimplicationofcardiovascularagingis
endothelium-mediated vasodilation
that HF in the elderly often is characterized by
preservedLVsystolicfunction.Patientswhohave
this syndrome exhibit HF symptoms despite
depositioninthemediaandadventitiaofthelarge having a normal or near-normal LV ejection
and medium-sized arteries results in decreased fraction (LVEF), as defined by an EFR45%–
vascular elasticity and increased impedance to 50%.Thissyndrome,oftenreferredtoasdiastolic
leftventricular(LV)ejection[9,10].Thesechanges HF,occursinmorethan50%ofHFpatientsover
lead to a progressive increase in systolic blood age 70years [13].
pressure with advancing age, which in turn con-
tributes to the development of LV hypertrophy
and altered diastolic filling. Increased cardiac in-
Prevalence
terstitialcollagencontent,compensatorymyocyte
hypertrophy in response to apoptosis, and More than 5 million Americans have clinical
impaired calcium flux during diastole further HF,representinganincreaseofover150%inthe
contribute to age-related impairments in LV past20years,andthisfigureisexpectedtodouble
diastolic relaxation and compliance [11]. These againwithinthenext25yearsbecauseoftheaging
changes lead to an increase in LV end-diastolic ofthepopulation[5,14].Similarly,thenumberof
pressure and left atrial size and pressure, and HF cases in Europe is expected to increase
they also predispose older individuals to atrial substantially overthe nexttwo decades[15].
fibrillation. In the United States, the overall population
Although the precise mechanism has not yet prevalence of HF is about 2.3%, but the pro-
beenfully elucidated, advancingage isassociated portion increases steeply with age. In the Fra-
with a decline in responsiveness to beta-1 and mingham Heart Study, for example, HF
beta-2 adrenergic stimulation, resulting in reduc- prevalence doubled with each decade after age
tions in maximum heart rate and contractility 50, increasing from 0.8% in people younger than
(beta-1 effects) and impaired peripheral vasodila- 50yearsto9.1%inpeopleaged80to89years[6].
tion (beta-2 effect) [12]. Aging is also associated Table 1 summarizes prevalence rates of HF as
with an impaired capacity of the mitochondria a function of age in various countries [6,16–26].
to increase adenosine triphosphate production In Europe, prevalence rates range from 0.4% in
in response to increased demands imposed by people younger than age 65 to 14.1% in those
physicalactivityorillness. aged 85years orolder[16,17,19].
Degenerative changes in the sinus node and Gender is also an important factor affecting
atria lead to a progressive decline in sinus node HF prevalence. The third National Health and
function and increased propensity for atrial ar- Nutrition Examination Survey, conducted from
rhythmias, especially atrial fibrillation. Impaired 1988 to 1994, estimated that the number of
sinus node function further limits the capacity of Americans with HF was 4.7 million, of which
the aging heart to increase cardiac output in 2.3millionweremenand2.4millionwerewomen
response to stress, and the so-called ‘‘sick sinus [27].Amongpeoplelessthan70yearsofage,HF
syndrome’’ is the leading cause of permanent is predominately a disorder of men, but among
pacemaker implantation in older adults. Finally, those older than age 70, women compose the