Treatment of systolic and diastolic heart failure in the elderly

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF should be stopped. Patients with HF and an abnormal left ventricular ejection fraction (LVEF) (systolic heart failure) or normal LVEF (diastolic HF) should be treated with diuretics if fluid retention is present; with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation; and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL. A multidisciplinary approach should be used with nurse monitoring of the condition. In a home-bound patient, a homemaker should be hired.