Treatment of heart failure in the elderly: Which drugs are essential and which should be avoided

Abstract

With improved health care and with population aging, heart failure (HF) has become a common disease among the elderly and is one of the principal causes of mortality in elderly age. But the pharmacological management of HF in the elderly has still not yet been defined, as the clinical context is complicated by comorbidities, and differs from that of younger adults. In general, elderly patients with HF should be treated according to current guideline recommendations, for which ACE-I, beta-blockers and anti-aldosterones constitute the cornerstone of therapy. Interesting prospects are opening up with the use of new drugs such as neprilysin inhibitors, which appear to reproduce in the elderly the positive effects observed in the young adult population, and ivabradine, which may substitute the traditional use (now probably obsolete) of digitalis. Currently, however, treatment of HF in elderly patients is characterized by insufficient drug titration and by a habitual underuse of the recommended therapies - this is partly due to prescription inertia and in part to the negative effect of polypharmacotherapy on patient adherence. Even if HF therapy is similar in older and younger patients, the presence in older patients of more comorbidities, and frailty, functional status, and socio-environmental factors related to aging require a multidisciplinary approach to care and, above all, an additional assessment aimed at personalizing the treatment.

Treatment and management of advanced heart failure in elderly

“…The pharmacological treatment of HF has made extraordinary progress in the last thirty years thanks to the introduction of Angiotensin-converting enzyme inhibitors ACEIs/angiotensin receptor blockers ARBs, β-blockers (β-Bs) and Mineralocorticoid receptor antagonist (MRAs), which have drastically reduced HF mortality independently of the disease severity and still today represent the cornerstone of the therapy for this syndrome [12] (Table 1).…”

“…Currently, treatment of HF in elderly patients is characterized by widespread underutilization of the recommended therapies and suffers from the lack of clinical trials carried out on this particular segment of the population. Subgroups of the elderly population such as the over-80s are in fact totally devoid of specific therapeutic references, and a clinical picture such as HFpEF, which inevitably will be diagnosed more and more in the future, has not yet received adequate attention in the scientific literature [12].…”

“…Successful PC must involve shared care through a multidisciplinary approach. Patients and their caregivers should be able to easily communicate with primary care, specialist palliative care services and the specialized AHF service, according to the resources of each centre [5,14,15] The PAL-HF (Palliative Care in Heart Failure) trial, a single-centre study of 150 patients, showed that interdisciplinary palliative care intervention in AHF patients resulted in greater benefits in QoL, anxiety, depression and spiritual wellbeing compared with usual care alone [4][5][6][7][8][9][10][11][12][13][14]. The SWAP-HF (Social Worker-Aided Palliative Care Intervention in High-risk Patients with Heart Failure) trial showed that patients at high risk for mortality from HF frequently overestimate their life expectancy and a structured social worker-led palliative care (PC) intervention enhances prognostic understanding and patient-physician communication regarding goals of care [5,17].…”