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 this
useful mnemonic: DEFEATHeart Failure. This covers the essential
aspects of geriatric heart failure management:
Diagnosis, Etiology, Fluid, Ejection frAcion, and Treatment.
The American College of Cardiology / American Heart
Association guidelines for chronic heart failure defines
heart failure as a complex clinical syndrome that can
result from any structural or functional cardiac disorder
that impairs the ability of the ventricle to fill with or eject
blood.


The Heart Failure Society of America heart failure
guidelines define heart failure as a syndrome caused by
cardiac dysfunction, generally resulting from myocardial
muscle dysfunction or loss and characterized by left
ventricular dilation or hypertrophy
Heart failure is a geriatric syndrome as most heart
failure patients are older adults. Heart failure is also
a cardiac syndrome with complex and rapidly
evolving pathogenesis and treatment.

Unlike other cardiovascular disorders, heart failure is
a clinical diagnosis that can be made at bedside and
the established evidence-based therapy for heart
failure can be easily implemented by generalist
physicians. The diagnosis and management of heart
failure in the elderly can be complicated by multiple
co-morbidities and polypharmacy.
The management of heart failure in a 75-year-old
elderly woman with normal left ventricular ejection
fraction may be complicated by lack of evidence to
guide therapy, comorbidities such as hypertension,
atrial fibrillation, diabetes mellitus, osteoarthritis,
chronic kidney disease, and depression, and
polypharmacy related to these conditions.

The management of heart failure in the elderly is
further made difficult by atypical presentation of
heart failure in older adults.
How to management a geriatric
heart failure?
DEFEAT - Heart Failure
D = Diagnosis
E = Etiology
F = Fluid
EA = Ejection FrAction
T = Therapy
The process begins with a
clinical Diagnosis, which must be
established.
Heart Failure can be diagnosis with this
symptome:
1. Dyspnea or fatigue on exertion, with or
without some degree of lower extremity
swelling, is generally the most common
early symptom of heart failure
2. Orthopnea and paroxysmal nocturnal
dyspnea are relatively specific symptoms for
heart failure in older adults
3. When prolonged and left untreated, edema
may also affect more proximal lower
extremity, scrotal area, and abdomen
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
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.

.
An echocardiography should be ordered to
obtain left ventricular Ejection frAction to
assess prognosis and guide Therapy.

The general principle for the treatment of heart
failure in older adults is similar to that in
younger 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 heart
failure.

There is little evidence to guide therapy for
elderly diastolic heart failure patients.
Evidence-based therapy for systolic heart
failure involves the use of drugs that suppress
neurohormones
1. Renin-angiotensin-aldosterone system and
sympathetic nervous system,
2. ACE inhibitor or angiotensin receptor
blocker,
3. Beta blocker,
4. Aldosterone antagonist in select patients,
All elderly systolic heart failure patients should be treated with an
ACE inhibitor or an angiotensin receptor blocker if a patient
cannot 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 treated
with an approved beta-blocker, namely, carvedilol, metoprolol
extended release, or bisoprolol.

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


Metoprolol may be better tolerated by patients
with low systolic blood.

An aldosterone antagonist, such as
spironolactone, may be used in advanced heart
failure patients.

However, it would be used with
caution as it may cause hyperkalemia,
especially in those with impaired renal function.
Aldosterone antagonists may also be used in
patients with chronic hypokalemia receiving
diuretics.
However, if left ventricular ejection fraction cannot
be determined, as in many developing nations, all
geriatric heart failure patients should be treated as
if they have low ejection fraction, and should be
prescribed an angiotensin-converting enzyme
inhibitor and a beta-blocker. Diuretic and digoxin
should be prescribed for all symptomatic patients
with heart failure. An aldosterone antagonist may
be used in select patients with advanced systolic
heart failure, carefully avoiding hyperkalemia
Digoxin should be used in low doses for patients who are
symptomatic despite appropriate therapy with an ACE inhibitor
(or an angiotensin receptor blocker) and a beta-blocker.

A daily dose of 0.125 mg may be sufficient for most patients
and may not require monitoring of serum digoxin levels.

Most heart failure patients need loop diuretics to achieve
euvolemia and remain euvolemic. Diuretics are known to
activate neurohormones and may be potentially
harmful. Therefore, after euvolemia is achieved diuretics
should be used in the lowest possible doses needed to
maintain euvolemia.
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
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.
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, atrial
fibrillation, and chronic kidney disease, which may benefit from
the use of these drugs.

Digoxin and candesartan may be beneficial in reducing heart
failure hospitalizations in these patients.
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.
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
1. Management of geriatric heart failure may be simplified
by the DEFEAT.
2. Careful history and physical examination often may help
make a clinical Diagnosis of heart failure in older adults
and determine an underlying Etiology of heart failure.
Determination of Fluid volume status by careful
examination of the external jugular veins is the single
most important physical examination during initial and
subsequent visits.
3. Determination of left ventricular Ejection frAction is the single
most important test after a clinical diagnosis of heart failure
has 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 patients
with advanced heart failure.

5. Low-dose digoxin should be prescribed for all heart failure
patients who cannot afford or tolerate ACE inhibitors or beta-
blockers. Diuretics should be used judiciously to achieve and
maintain euvolemia
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