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Heart failure in the elderly: epidemiology, mechanisms, and management
Rudolf A de Boer1, Mahmoud Abdellatif2, Johann Bauersachs3
1Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Dr. Molewaterplein 40, Rotterdam 3015GD, The Netherlands.
Insights
Heart failure (HF) risk significantly increases after age 70 due to biological aging processes impacting the heart. Current therapies may be limited by comorbidities and frailty in elderly patients.
Area of Science:
- Cardiology
- Gerontology
- Molecular Biology
Background:
- Heart failure (HF) disproportionately affects the elderly, with incidence rising sharply after age 70.
- Biological aging involves myocardial alterations like impaired autophagy, mitochondrial dysfunction, and inflammaging, increasing HF risk.
- Sex differences exist in HF phenotypes, with women prone to HF with preserved ejection fraction and men to HF with reduced ejection fraction.
Purpose of the Study:
- To review the impact of biological aging on heart failure pathogenesis.
- To discuss the challenges and considerations for treating HF in elderly patients.
- To highlight the need for tailored therapeutic strategies and advanced care planning.
Main Methods:
- Literature review and synthesis of current research on aging and heart failure.
- Analysis of age-related pathophysiological mechanisms affecting the myocardium.
- Discussion of guideline-recommended therapies, comorbidities, and device interventions in older adults.
Main Results:
- Aging compromises cardiac energy homeostasis, promotes cell loss, and increases HF risk through mechanisms not targeted by current therapies.
- Comorbidities, frailty, and age-specific physiological changes (e.g., low blood pressure) often limit full-dose guideline-recommended medical therapy in the elderly.
- The risk-benefit ratio of device therapies requires careful evaluation due to competing non-cardiac risks.
Conclusions:
- Aging-related mechanisms are critical contributors to heart failure but are not addressed by current standard treatments.
- Treatment of HF in the elderly necessitates careful consideration of comorbidities and individual patient factors, often requiring dose adjustments or alternative strategies.
- Timely discussions regarding advanced care planning and end-of-life decisions are essential for elderly patients with heart failure.
Abstract:
There is no consensus on an age cut-off for being considered elderly, but the majority of patients with heart failure (HF) have an advanced age. The lifetime risk for developing HF is ∼25%, with a sharp increase in incidence after the age of 70. The lifetime risk for men and women is almost equal, but women exhibit a higher propensity towards developing HF with preserved ejection fraction, whereas men are more prone to HF with reduced ejection fraction. During the biological ageing process, several systemic and local pathophysiological alterations impact the myocardium, including impaired autophagy and proteostasis, mitochondrial dysfunction, and oxidative stress, as well as cellular senescence, clonal haematopoiesis of indeterminate potential, and chronic low-grade inflammation or inflammaging. Collectively, these changes compromise cardiac energy homeostasis and promote cell loss and dysfunction, increasing the risk of HF. Despite their relevance, these ageing-related mechanisms are hitherto not addressed by guideline-recommended medical therapy. Guideline-recommended medical therapy remains the cornerstone of HF treatment across age groups, including in elderly patients who tolerate it. However, a high burden of comorbidities and several features specific to advanced age, such as low blood pressure and frailty, often preclude full-dose guideline-recommended medical therapy. Similarly, the risk-benefit ratio of device therapies needs careful consideration in light of competing non-cardiac risks due to comorbidities that are prevalent in this population. Finally, HF is a mortal condition, and advanced care planning and end-of-life decisions should be discussed in a timely manner in elderly patients.
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