Summary
Acute heart failure (AHF) is the most common cause of unplanned hospital admissions, and is associated with high mortality rates. Over the next few decades, the combination of improved cardiovascular disease survival and progressive ageing of the population will further increase the prevalence of AHF in developed countries. New recommendations on the management of AHF have been published recently, but as elderly patients are under-represented in clinical trials, and scientific evidence is often lacking, the diagnosis and management of AHF in this population is challenging. The clinical presentation of AHF, especially in patients aged > 85 years, differs substantially from that in younger patients, with unspecific symptoms, such as fatigue and confusion, often overriding dyspnoea. Older patients also have a different risk profile compared with younger patients: often heart failure with preserved ejection fraction, and infection as the most frequent precipitating factor of AHF. Moreover, co-morbidities, disability and frailty are common, and increase morbidity, recovery time, readmission rates and mortality; their presence should be detected during a geriatric assessment. Diagnostics and treatment for AHF should be tailored according to cardiopulmonary and geriatric status, giving special attention to the patient’s preferences for care. Whereas many elderly AHF patients may be managed similarly to younger patients, different strategies should be applied in the presence of relevant co-morbidities, disability and frailty. The option of palliative care should be considered at an early stage, to avoid unnecessary and harmful diagnostics and treatments.
Résumé
L’insuffisance cardiaque aiguë (ICA) est la première cause d’hospitalisations non programmées chez les personnes âgées. Elle est associée à des taux élevés de mortalité. Dans les pays développés, dans les prochaines décennies, l’amélioration de la survie des maladies cardiovasculaires, combinée au vieillissement de la population, va encore accroître sa prévalence. De nouvelles recommandations sur la prise en charge de l’ICA ont été récemment publiées, mais les preuves scientifiques concernant les patients âgés font souvent défauts car cette catégorie de patients sont sous-représentées dans les essais cliniques. Le diagnostic et la gestion de l’ICA dans cette population reste un défi. La présentation clinique de l’ICA, en particulier chez les patients âgés de plus de 85 ans, diffère sensiblement de celles des patients plus jeunes. Des symptômes non spécifiques tels que la fatigue et la confusion peuvent être au premier plan, bien plus que la dyspnée. Les patients âgés ont également un profil de risque différent des patients plus jeunes, en particulier avec la présence d’insuffisance cardiaque à fraction d’éjection conservée. Les infections sont des facteurs précipitant fréquents l’ICA. En outre, les comorbidités, le handicap, et la fragilité sont fréquents et augmentent la morbidité, le temps de récupération, les taux de réadmission, ainsi que la mortalité. Leur présence doit être recherchée au cours d’une évaluation gériatrique. Le diagnostic et le traitement de l’ICA doivent être adaptés à l’état cardiopulmonaire et à l’évaluation gériatrique, en accordant une attention particulière aux préférences des patients. Alors que de nombreux patients âgés atteints d’ICA peuvent être pris en charge comme les patients plus jeunes, des stratégies alternatives devraient être considérées en présence de comorbidités, de handicap et de fragilité significatifs. Les soins palliatifs devraient être envisagés dès la phase initiale dans certaines situations, afin d’éviter des traitements inutiles et/ou des démarches diagnostiques lourdes et délétères.
Background
Acute heart failure (AHF) is the term used to describe the rapid onset of symptoms and signs of heart failure ; it is a life-threatening condition with substantial short- and long-term mortality , which requires rapid diagnosis and treatment delivery to relieve symptoms and improve outcome.
AHF is currently the most common cause of unplanned hospital admissions in patients aged > 65 years in the Western World. The average age of patients admitted for AHF is 75 years, and specialists in geriatrics are increasingly involved in the interdisciplinary management of patients with AHF. Over the next few decades, the prevalence of AHF will increase further, especially in elderly patients, because of the combination of improved cardiovascular disease survival and progressive ageing of the population in developed countries .
New recommendations for the management of patients with AHF were published recently . “Young” (aged < 64 years) and “middle old” patients (aged 65–74 years) represent the typical AHF population, and can be managed according to general guidelines . However, because “old old” patients (aged 75–84 years) and, in particular, with increasing age, “oldest old” patients (aged > 85 years) differ substantially from younger patients in terms of the clinical characteristics of AHF and the prevalence of co-morbidities, disability and frailty, a reappraisal of the topic, with a special focus on elderly patients, is warranted.
In the present paper, we review current evidence and, as older patients are under-represented in clinical trials and evidence for an optimal treatment option for this special subgroup is lacking, we have added expert opinion, to provide guidance to practicing physicians and other healthcare professionals involved in the management of elderly patients (aged > 75 years) with AHF.
Methods
First, we created a group of experts composed of three senior clinicians (a cardiologist, a geriatrician and an intensivist), who determined, by consensus, the chapters that must be included in the paper. Next, two of these experts (the cardiologist and the geriatrician) searched the PubMed database for publications from the past 10 years (2005–2015), using a combination of the keywords “frailty”, “elderly”, “acute heart failure”, “diagnosis” and “prognosis”, and then selected the articles according to the following schema: firstly, after reading the abstracts; secondly, after reading the titles; and finally, after reading and analysing the articles in full. At each iteration, the decision was taken by consensus.
Clinical presentation of AHF in elderly patients
The clinical presentation of AHF in elderly patients differs significantly from that in younger patients. Patients with AHF aged > 75 years are more likely to be women and to have heart failure with preserved ejection fraction (HFpEF) compared with younger patients with AHF . Moreover, the proportion of patients with HFpEF seems to have increased in recent decades. Patients with HFpEF have similarly poor outcomes to patients with heart failure with reduced ejection fraction (HFrEF), but, in contrast to HFrEF, no effective disease-modifying treatment for HFpEF has been found so far. More interestingly, patients with HFpEF have a significantly higher burden of non-cardiac co-morbidities and mortality arising from non-cardiovascular causes compared with those with HFrEF .
The typical presentation of AHF includes symptoms and signs of congestion associated with normal or elevated blood pressure . The presence of exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, increasing bodyweight and peripheral oedema corroborate the diagnosis of AHF. With increasing age, however, atypical clinical presentations become more common, and may delay a correct diagnosis. Indeed, many of the elderly may not have dyspnoea because of their sedentary lifestyle, and report only fatigue or exhibit an altered mental state . Co-morbidities and/or cascading multiorgan failure may also substantially influence the clinical presentation . Table 1 summarizes the main differences in clinical characteristics between AHF patients younger and older than 75 years.
| Age < 75 years | Age ≥ 75 years | |
|---|---|---|
| Epidemiology | ||
| Incidence | < 0.2% | > 4% |
| Prevalence | < 5% | > 10% |
| Sex predominance | Male | Female |
| One-year mortality | < 20% | > 20% |
| Predominant co-morbidities | ||
| Cardiovascular risk factors | Cognitive impairment | |
| Chronic kidney disease | Loss of autonomy | |
| Pulmonary disease | ||
| Precipitating factors | ||
| Hypertension | Malcompliance | |
| Acute coronary syndrome | Pulmonary infection | |
| Predominant symptoms | ||
| Dyspnoea | Fatigue | |
| Dyspnoea | ||
| Confusion | ||
| Diagnostics | ||
| Natriuretic peptides | Normal cut-offs | Age-adjusted cut-off |
| LVEF | Often < 40% | Often > 40% |
| Chest radiography | Classic signs of pulmonary congestion | Often non-specific findings |
| Therapeutic interventions | ||
| Decongestive treatment | Diuretics/vasodilators | Tailored doses |
| Non-invasive ventilation | Frequent | Frequent, use with caution |
| Palliative intent | Rare | Frequent |
| Preventive interventions | ||
| Primary target | Improved survival | Improved quality of life and autonomy |
| Reduction of readmission | ||
| Mode of action | Optimal medical and device therapy | Geriatric rehabilitation |
| Cardiac rehabilitation | Nutritional counselling | |
| Patient empowerment | Multidisciplinary approach | |
Triage of AHF in the elderly
The initial evaluation of elderly patients presenting with AHF should, as for younger patients, not exceed 30–60 min and should focus on cardiopulmonary status to exclude haemodynamic instability and respiratory distress ( Fig. 1 ). Systolic blood pressure > 90 mmHg, heart rate < 40 or > 130 beats/min, severe arrhythmia, increased blood lactate concentration (> 2.0 mmol/L), low central-venous oxygen staturation (< 60%) and clinical evidence of peripheral hypoperfusion (cold and mottled skin, oligura, altered mental state) indicate haemodynamic instability. Precise evaluation of mental state in emergency situations may be challenging, especially in elderly patients with pre-existing neurological impairment.
