Drug Therapy of Heart Failure in the Elderly

Michael W. Rich, MD


Am J Geriatr Cardiol. 2003;12(4) 

In This Article

Abstract and Introduction

Heart failure is a disorder that predominantly affects older adults, with more than 50% of heart failure hospitalizations occurring in persons over 75 years of age. Unfortunately, most of the major heart failure clinical trials have targeted middle-aged patients with systolic heart failure, and the applicability of these studies to elderly patients, particularly those with preserved left ventricular systolic function, remains uncertain. In this paper, current data on the pharmacotherapy of heart failure in older adults are reviewed, recommended approaches to managing systolic and diastolic heart failure are outlined, and the importance of preventive measures is emphasized.

Heart failure (HF) affects 4.8 million Americans and over 500,000 new cases are diagnosed each year.[1] Importantly, HF is predominantly a disorder of the elderly, with more than 75% of the nearly 1 million annual hospital admissions for HF occurring in persons >65 years of age, including more than 50% in persons age >75.[2] Indeed, HF is the leading cause of hospitalization and the most costly medical illness in the Medicare age group, with annual expenditures in excess of $20 billion.[3] Moreover, both the incidence and prevalence of HF are increasing, largely due to the aging of the population, and it is anticipated that there will be a doubling in the number of HF cases over the next 3 decades.

As HF has emerged as a major public health concern during the past 20 years, HF research has intensified. Indeed, there have now been hundreds of clinical trials evaluating the safety and efficacy of a broad range of pharmacologic therapies for the treatment of HF, and the results of these trials have led to the development of authoritative, evidence-based guidelines for HF management.[4,5] Unfortunately, most of these studies have focused primarily on middle-aged HF patients, who may differ in many important respects from older HF patients ( Table I ). As a result, the generalizability of HF trials to older HF patients has been questioned, and it has been estimated that a minority of older HF patients would have been suitable candidates for the HF trials, even if older age had not been an exclusion.[6] Furthermore, the impact of current HF therapies on clinical outcomes on a population-wide basis has been modest. For example, over a 15-year period there has been essentially no change in readmission rates among elderly HF patients ( Table II ).[7,8,9,10,11]

Despite limited data from clinical trials, clinicians must still provide appropriate care for the large number of elderly HF patients. The purpose of this paper, therefore, is to review currently available evidence for the management of HF in older adults, and to provide specific recommendations for the pharmacologic treatment of HF in the elderly.