Drug Therapy of Heart Failure in the Elderly

Michael W. Rich, MD

Disclosures

Am J Geriatr Cardiol. 2003;12(4) 

In This Article

Diastolic Heart Failure

The diagnosis and management of "diastolic" HF, i.e., HF with an LV ejection fraction ≥45% remains controversial and empiric, in part because there are no generally agreed-upon criteria for establishing the diagnosis,[33,34] and in part because there have been no major randomized treatment trials involving patients with this disorder. In general, patients with typical symptoms and signs of HF who respond favorably to diuretic therapy and who are found to have preserved LV systolic function may be considered to have diastolic HF. Evidence for impaired diastolic filling by echocardiography or elevated LV filling pressure by invasive testing provides support for the diagnosis. The value of an elevated brain natriuretic peptide level in the absence of clear-cut clinical features of HF remains uncertain.

The vast majority of elderly patients with diastolic HF have underlying hypertension (especially systolic hypertension) and/or coronary artery disease,[12,13] and most acute exacerbations are precipitated by uncontrolled hypertension, ischemia, or atrial fibrillation. Therefore, in the absence of definitive data from randomized trials, the foundation of therapy for diastolic HF is aggressive treatment of the underlying cause. Thus, blood pressure should be maintained no higher than 130-140/80-90 mm Hg, suitable investigation and treatment for ischemia should be undertaken, and atrial fibrillation should be treated either to restore sinus rhythm or to optimize rate control in accordance with current guidelines.

Judicious use of diuretics is indicated to maintain euvolemia, but overdiuresis should be avoided because excess reduction of LV preload will result in reduced stroke volume and cardiac output. Beyond diuretics, drug therapy for diastolic HF is undefined. Several small studies[35,36,37,38] have demonstrated favorable effects with ACE inhibitors, ARBs, blockers, and calcium channel blockers in selected patients with HF and preserved LV systolic function. These studies have fostered several ongoing trials designed to provide much needed data on the effects of these agents on major clinical outcomes ( Table IV ).[39] In addition, the DIG ancillary trial,[26,27] which involved 988 HF patients with ejection fractions >45%, most of whom were elderly, found that digoxin tended to reduce HF admissions in this population, although the benefit was not statistically significant.

Until additional information is available, many experts consider ACE inhibitors, blockers, and possibly ARBs as the most promising agents for treating diastolic HF. Support for the use of ACE inhibitors comes in part from the Heart Outcomes Prevention Evaluation (HOPE) trial,[40] in which patients aged ≥55 years with known vascular disease or diabetes derived significant benefit from long-term treatment with ramipril. More recently, the Losartan Intervention for Endpoint Reduction (LIFE) trial[41] found that patients 55-80 years of age with hypertension and LV hypertrophy by electrocardiographic criteria had improved outcomes with the ARB losartan compared with the blocker atenolol. Based on these findings, rational therapy for patients with diastolic HF, most of whom have hypertension or vascular disease, might start with an ACE inhibitor or ARB, with the addition of a blocker if the patient has known coronary artery disease. Further therapy might include the addition of a calcium channel blocker, especially if control of blood pressure, heart rate, or ischemia remains suboptimal.

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