Heart failure diagnosis and prognosis in the elderly: the proof of the pudding is in the eating

The prevalence of heart failure (HF) increases with age, with the highest rates occurring in those aged .80 years. Older patients also have higher hospitalization rates, longer length of hospital stay, and are more often discharged to long-term care facilities. Moreover, the pathophysiology of HF in the elderly is increasingly complex, and may include abnormalities of diastolic function and arterial stiffness, diminished responsiveness to beta-adrenergic stimulation, impaired endothelial function, as well as the detrimental effects associated with multiple co-morbidities. Heart failure with preserved ejection fraction, seems to be the predominant clinical phenotype in elderly patients with signs and symptoms of HF. The treatment of HF in the elderly (especially in those with preserved ejection fraction) remains empirical due to the fact that these patients are usually excluded from randomized clinical trials. However, recent data suggest that the use of life-saving medications in the elderly can reduce new cardiac ischaemic events and re-hospitalizations and can improve outcome. –7 In a sub-analysis of the Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with Heart Failure (SENIORS) it was found that treatment with a b-blocker reduced the incidence of cardiac ischaemic events in patients with HF of ischaemic aetiology. In the CHARM (Candesartan in Heart Failure—Assessment of Mortality and Morbidity) trial, 7599 HF patients were randomized to treatment with candesartan or placebo; this included 3169 patients aged .70 years. Mean follow-up was 37.7 months. The proportional hazards model was used to estimate the effect of treatment on efficacy and safety within the following five age groups: ,50 years (8% of total cohort), 50–59 years (19%), 60–69 years (31%), 70–79 years (33%), and ≥80 years (9%). The risk of cardiovascular death or HF hospitalization (primary outcome) increased from 24% in the lowest age group to 46% in the highest age group (and mortality from 13 to 42%). The relative reduction in risk of the primary outcome with treatment was similar irrespective of age. Thus, the absolute benefit was greater in HF patients of more advanced age (3.8 patients avoided an adverse outcome per 100 patients treated in the lowest age group compared with 6.8 in the highest). Thus, the early recognition and treatment of HF, especially in the elderly, can lead to a reduction in long-term mortality and/ or morbidity. According to the European Society of Cardiology, the diagnosis of HF requires the presence of typical signs and symptoms and objective evidence of a structural or functional abnormality of the heart at rest (Figure 1). A common problem in everyday clinical practice is the delayed detection and diagnosis of HF in the elderly; this is often because in the majority of cases there is an overlap between signs and symptoms of HF and the patient’s various other co-morbidities. On the other hand, this overlap could also lead to over-diagnosis and unnecessary drug therapy. Moreover, limited access to echocardiography and the fact that age and co-morbidities (such as renal dysfunction and atrial fibrillation) may affect plasma levels of natriuretic peptides, further limits the diagnostic ability of the available tools and the adequate evaluation of elderly patients suspected of HF. Thus, standardized diagnostic criteria would be useful for the diagnosis of incipient HF, especially in primary care where gradual onset and a long period of mild symptoms can mask the diagnosis. The most common scores used for the diagnosis, definition, and classification of HF are presented in Table 1. However, most of these scores have only been used in clinical trials and epidemiological or population studies, they have not been evaluated extensively in a clinical setting, especially in the elderly. In this issue of the European Journal of Heart Failure Oudejans et al. describe how they screened a population of geriatric outpatients with suspected HF and confirmed the diagnosis in