Heart failure in Older Patients
A comprehensive approach in Zambia is necessary in managing heart failure in our Older Patients. To provide optimal care, physicians and other healthcare providers need to draw on knowledge from the fields of internal medicine, geriatrics, and cardiology. The acronym “MORE” is a mnemonic for what heart failure management should include: Multidisciplinary care, attention to Other (ie, comorbid) diseases, Restrictions (of salt, fluid, and alcohol), and discussion of End-of-life issues.
Did you know that Heart disease is one of the causes of death for both Older Persons Men and Women in the Zambia?. Every year, heart disease kills a number of Older Persons without family members knowing about the cause, making it responsible for 1 in 3 deaths, according to the Center of Excellence on Ageing [CEA].
While certainly the most recognizable term, heart disease is actually a range of conditions that affect the heart. This umbrella term includes diseases of the blood vessels, including and peripheral artery disease [PAD]; abnormal heart beats, or arrhythmias; heart defects you’re born with, or congenital heart disease; and the thickening or enlarging of the heart, a condition called cardiomyopathy.
• Not only does heart failure itself result in frailty, but its treatment can also put additional stress on an already frail patient. In addition, the illness and its treatments can negatively affect coexisting disorders.
• Common signs and symptoms of heart failure are less specific in older persons, and atypical symptoms may predominate.
• Age-associated changes in pharmacokinetics and the [geriatric aspect] must be taken into account when prescribing drugs for heart failure.
• Effective communication among health professionals, patients, and families is necessary as we look the Health and Well-Being for the Aged.
• Given the life-limiting nature of heart failure in frail Older Persons, it is critical for clinicians to discuss end-of-life issues with patients and their families as soon as possible.
Approximately 100,000 individuals in Zambia may have heart failure issues, and a similar number is likely to have undiagnosed heart failure. The prevalence of heart failure increases sharply with age, and it exceeds 5% among persons older than 65 years. Comparable data have been reported from the Zambian communities.
Among Zambian elderly patients aged 65 years and above with heart failure, the proportion of those with preserved left ventricular systolic function increases as does the proportion of women with the disease. The presence of some comorbid conditions, such as atrial fibrillation and renal dysfunction, increases with age in heart failure aged patients, whereas other diseases, such as diabetes and hypertension, behave in a more complex manner. The prevalence of these conditions increases until approximately 80 years of age, but decreases among the oldest heart failure patients. The presence of comorbidity in elderly heart failure patients not only affects prognosis, but it also may complicate therapy and increase the need for follow-up.
It is well recognized that a diagnosis of heart failure based merely on symptoms and physical examination is not reliable as you may come to know more especially when we do not have geriatric care in our Zambian health system. The diagnosis may be even more challenging in elderly patients because their symptoms (eg, fatigue, dyspnea, and edema) may be nonspecific and may be present in a large proportion of elderly primary care patients without heart failure. However, given the high prevalence of heart failure among elderly individuals, further diagnostic evaluation should be performed at a low threshold.
Echocardiography is the cornerstone of heart failure diagnosis. The use of natriuretic peptide tests (brain natriuretic peptide or N-terminal pro-brain natriuretic peptide) to rule out heart failure in symptomatic patients may be a feasible way to avoid unnecessary echocardiograms. However, peptide levels increase with age, even in patients without heart failure, which may complicate the use of these tests in elderly patients (ie, they have a low positive predictive value). Age-dependent cut-off values have been proposed and substantiated by data, but further geriatric studies are needed to establish the diagnostic use of natriuretic peptides in the elderly.
Over the past 25 years, numerous effective treatment options for patients with heart failure have emerged. Extensive clinical research has documented the efficacy of these pharmacologic and nonpharmacologic interventions. However, many trials included few, if any, elderly patients. Furthermore, almost all trials excluded patients with nonsystolic heart failure, which in practice prevented a large proportion of elderly heart failure patients from participating. Apart from a few dedicated trials, current knowledge about the effectiveness of various interventions in elderly patients with heart failure comes from extrapolation of subgroup analyses of the effect of age in the trials.
The use of diuretics is inevitable in the management of most patients with congestive heart failure. Although proof of their long-term beneficial effect in stable heart failure patients will likely never be available, diuretics are essential to managing fluid retention and for relief of congestion. Because of a greater degree of renal dysfunction, larger doses of diuretics are often needed in elderly patients, but at the same time, these patients appear to be at greatest risk for dehydration and prerenal azotemia during overly aggressive diuretic therapy. Meticulous monitoring of fluid status and electrolytes is essential in elderly patients during high-dose loop diuretic treatment, and although many patients can be safely managed in specialized outpatient clinics (see section on Multidisciplinary intervention), hospitalization may be necessary during intensive natriuresis.
Patients who present with gross or refractory edema may be treated successfully with combination therapy using metolazone (Zaroxolyn) in addition to a loop diuretic. This combination appears to be effective and safe, even in elderly patients, if electrolytes and fluid balance are adequately monitored.
The use of beta blockers in patients with heart failure due to leftventricular systolic dysfunction is well founded, based on 3 major randomized clinical trials.14-16 Indeed, beta blockers have been proven highly effective in reducing morbidity and mortality in heart failure. However, the mean age in these trials was 63 years, and 2 studies excluded patients older than 80 years of age. Reassuringly, subgroup analyses of the importance of age on the effect of beta blockers in these trials have not shown that the effect declines with increasing age.
Recently, the results of the Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors (SENIORS), which evaluated the effect of the beta blocker nebivolol in heart failure patients aged 70 years or more, have shown that beta blockade is also effective in elderly individuals. Interestingly, the latter trial also included patients with nonsystolic heart failure, making it particularly relevant to the geriatric heart failure population with respect to underlying pathophysiology. In the SENIORS trial, there was no interaction between left ventricular systolic function and effect of nebivolol on outcome.
Over the past several years of implementing beta-blocker therapy in the heart
failure patient population, there has been considerable concern about side effects, particularly in elderly patients. Comorbid conditions, such as orthostatic hypotension, preexisting conduction disturbances, chronic obstructive pulmonary disease, and peripheral artery disease, which are particularly common in elderly patients, were expected to limit the use of beta blockers in the oldest patients. However, several studies have shown that the incidence of side effects during beta-blocker uptitration is not greater in elderly patients, and an equal proportion of younger and elderly patients generally tolerate the treatment. It appears that elderly patients usually tolerate somewhat lower doses of beta blockers than younger patients. Because this was also the case in the randomized studies showing the effect of treatment independently of age,
it probably signifies that the beta-blocker doses needed to suppress the deleterious effects of the sympathetic nervous system in older patients are smaller. Although this should not remove focus from the importance of uptitration of beta blockers to the maximum tolerated dose in the elderly, it shows that patients can also benefit from smaller doses and, consequently, adherence to therapy should be strongly encouraged.
Causes of Heart Disease
The causes of heart disease also vary depending on the type of disease.
What Do You Know About Peripheral Arterial Disease ?
CAD and PAD are caused by atherosclerosis, or the buildup of cholesterol and other material called plaque in the arteries. This buildup of plaque can result in the narrowing of diameter of arteries, which will make it harder for blood to flow and can result in a heart attack or stroke in a number of people in our communities.
Atherosclerosis can be caused by modifiable lifestyle choices, like lack of physical activity, an unhealthy diet, being overweight or obese, and smoking tobacco.
Arrhythmias, on the other hand, are electrical abnormalities that can be caused by a variety of factors, including:
• Heart defects that you’re born with
• High blood pressure
• Tobacco use
• Excessive caffeine or alcohol consumption
• Drug use
• Certain over-the-counter medicines, prescription drugs, dietary supplements, and herbal remedies
Most congenital heart defects develop in the womb as the heart develops, about a month or so after conception. Certain medical conditions, medication, and genes may influence the development of heart defects. Sometimes, structural heart defects can occur in adults as the heart’s structure changes with age.
Researchers are still working to understand the exact causes of cardiomyopathy. Sometimes it's hereditary, or it may be caused by damage to the heart after a heart attack, years of untreated hypertension, heart valve abnormalities, or infection. It’s believed that certain disease, such as connective tissue disorders, hemochromatosis [the excessive buildup of iron in the body], and amyloidosis [the buildup of abnormal proteins], can cause a cardiomyopathy.
Risk Factors for Heart Disease
Certain coexisting health problems or lifestyle habits can make you more susceptible to heart disease. Some of these can be changed and some cannot.
• High blood pressure
• High cholesterol
• Being overweight or obese
• Tobacco use
• Diabetes or prediabetes
• Lack of physical activity
• An unhealthy diet
• A family history of heart disease
• A history of preeclampsia during pregnancy
• Age; being post-menopausal for women and being older than 45 for men
The Author is a Fellow of the United Nations International Institute on Ageing [INIA], Founder of the Center of Excellence on Ageing and Consultant with Zambia National Marketeers Credit Association.
[ZANAMACA]. E-mail:[email protected] or 0979-611-545