Evolution of a Geriatric Syndrome: Pathophysiology and Treatment of Heart Failure With Preserved Ejection Fraction

Bharathi Upadhya, MD; Barbara Pisani, MD; Dalane W. Kitzman, MD

Disclosures

J Am Geriatr Soc. 2017;65(11):2431-2440. 

In This Article

Device Therapy

A wireless, implanted PA pressure monitor implanted in the distal PA during a right heart catheterization procedure (CardioMEMS) transmits hemodynamic data daily using a wireless transmitter. The CardioMEMS (CardioMEMS HF System, St. Jude Medical) Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients trial showed a significant reduction in HF hospitalizations.[96] Device therapy trials in HFpEF are summarized in Supplemental Table S1.

Prevention of HFpEF

Because most therapies tested have been relatively ineffective for established HFpEF, additional emphasis should be placed on prevention. Many reports suggest that the incidence of new HFpEF cases can be reduced by managing systolic hypertension, performing regular physical activity, preventing and treating obesity, and managing other aforementioned comorbidities, including diabetes mellitus, CAD, and AF.[48,81,84,97]

Published Guidelines for Treatment of HFpEF

Given the lack of positive clinical outcome trials, there is little evidence on which to base strong guideline recommendations. Therefore, the ACC/AHA consensus guideline recommendations are relatively sparse regarding management of HFpEF. In individuals with symptomatic HFpEF, diuretics are recommended to relieve symptoms due to volume overload (Class I, evidence level B), but optimal diuretic dosing regimens have not been clarified.[12] Control of hypertension is suggested as a treatment strategy for HFpEF (Class I, evidence level B),[12] based on data from studies in populations without HF. The blood pressure goals in the ACC/AHA guideline for individuals HF are similar to those in the general population, with the exception that the 2017 ACC/AHA HF guideline update became one of the first in the United States to recommend the lower systolic blood pressure target of 130 mmHg, based on the potent results of the Systolic Blood Pressure Intervention Trial (SPRINT).[12,98] In SPRINT, incident cases of HFpEF and HFrEF were significantly with intensive blood pressure reduction, specifically in individuals aged 75 and older.[99] ARBs and aldosterone antagonists receive a relatively weak recommendation (Class IIb, evidence level B) for decreasing hospitalizations of individuals with HFpEF.

Other ACC/AHA guideline recommendations include treatment of common comorbidities, including overt myocardial ischemia; restoration and maintenance of sinus rhythm; control of HR in individuals with permanent AF; treatment of anemia; and formal sleep assessment in individuals with HF suspected of having sleep disordered breathing or excessive daytime sleepiness. Cardioversion is recommended to restore sinus rhythm because catheter ablation of AF has had limited long-term success in individuals with HFpEF.[100] If cardioversion is unsuccessful, rate control and permanent anticoagulation are necessary.

Although exercise is the only strategy (other than diet) known to improve symptoms and exercise capacity (and probably quality of life), the Centers for Medicare and Medicaid Services excluded HFpEF in its 2014 decision to reimburse for cardiac rehabilitation for individuals with HF. It is unknown whether ET that begins outside of a monitored supervised setting is safe for older adults with HFpEF, although current ACC/AHA guidelines recommend moderate, regular physical activity for all individuals with HF, which seems reasonable.

HFpEF As a True Geriatric Syndrome

All the above confirms that HFpEF has emerged as a true geriatric syndrome, fulfilling all the following formal criteria.[101]

It is uncommon in younger persons but highly prevalent in older adults, particularly women aged 80 and older, in whom it comprises nearly 100% of new HF cases.

  • It is a chronic debilitating condition with multifactorial pathophysiology.

  • It is heterogeneous clinically, with underlying age-related changes, frequent multiple chronic comorbidities, and multiorgan involvement that render persons vulnerable to situational challenges.

  • It shares common risk factors—including older age, cognitive impairment, functional impairment, and impaired mobility.

  • It is strongly associated with functional decline and poor clinical outcomes.

  • It is associated with frequent hospitalizations and a high rate of readmissions due to noncardiac causes.

  • Diagnostic strategies to identify the underlying causes can be ineffective, burdensome, and costly.

Therapeutic management of the clinical manifestations can be helpful even in the absence of a firm diagnosis or clarification of the underlying causes. Thus, because of the inherent complexity of caring for older adults with cardiovascular disease, it will be fruitful for geriatricians and cardiovascular specialists to collaborate and develop a new model for treating individuals with HFpEF using geriatric principles.

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