Raya Kheirbek is a Geriatrician and Palliative Medicine Physician at the Washington DC VAMC and an Associate Professor of Medicine at George Washington University School of Medicine and Health Sciences in Washington, DC. Correspondence: Raya Kheirbek (rekheirbek@gwu.edu)
Author disclosures The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
A post-hoc analysis of patients by age found no difference in mortality between patients aged 70 to 79 years and those ≥ 80 years, with a persistent benefit in fewer hospitalizations. Digoxin continues to be recommended as a reasonable medication for treating symptomatic HFrEF. However, caution is advised in older patients, especially women, who are at higher risk of digoxin toxicity.
No current evidence exists that digoxin adds any benefits for patients with HFpEF of any age and therefore, it should not be used.
Diuretics
Diuretic therapy is important for managing shortness of breath and congestion related to fluid volume overload in patients with HF. Although diuretics have not been shown to reduce mortality in patients with HF, they are the mainstay treatment for patients with HFpEF.32 In a post-hoc analysis of the DIG study, diuretic use was associated with increased risk of mortality and hospitalizations in patients aged > 65 years.33 Hyponatremia is one of the most serious adverse effects (AEs) with these agents and occurs in about one-fifth of elderly patients taking diuretics.
In severe cases hyponatremia can cause a range of problems, including weakness, confusion, postural giddiness, postural hypotension, falls, transient hemiparesis, and seizures. In older patients with diminished renal reserve, diuretics are more likely to precipitate prerenal uremia than it does in younger patients. Prerequisites for diuretic use are an accurate diagnosis, careful monitoring of blood pressure and serum electrolytes, and regular review of their efficacy, AEs, and the need for continued treatment.
Statins
The Controlled Rosuvastatin Multinational Trial in Heart Failure demonstrated that low-dose rosuvastatin (10 mg/d) does not improve survival among patients with moderate-to-severe ischemic cardiomyopathy but could reduce the rate of CV hospitalizations.34 Patients in this study had a mean age of 73 years, and 41% of them were aged ≥ 75 years. However, the study used a low-dose rosuvastatin, and patients with several common comorbidities were excluded. Evidence exists that treatment with other statins may improve outcomes in patients with HF. There is also evidence that among elderly patients with HF, low serum total cholesterol is independently associated with a worse prognosis.35
Comorbidities
Anemia
In patients with iron-deficiency anemia (ferritin 15-100 ng/mL or 100-299 ng/mL with transferrin saturation < 20%) and symptomatic HFrEF (LVEF ≤ 40% with NYHA II to IV HF), oral iron replacement had no effect on exercise capacity as measured using change in peak oxygen uptake.36 However, IV iron replacement might be a reasonable option to improve functional status and quality of life (QOL) for patients with HF.37 In these studies, participants were aged < 75 years, and there is no evidence that treating other types of anemia improves outcomes in patients with HF.
Hypertension
The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that controlling blood pressure to a goal systolic pressure of < 120 mm Hg is associated with significant reduction in the mortality among patients with increased CV risk (aged > 75 years, vascular disease, kidney injury, or a Framingham Risk Score >15%).38 The SPRINT study included patients aged > 75 (25%); however, the study excluded older adults living in nursing homes and those with diabetes mellitus, symptomatic HF, dementia, or stroke. The subgroup analysis did not stratify patients based on age nor provided sufficient evidence regarding treatment targets for this vulnerable population. Therefore, clinicians cannot draw any conclusions about managing hypertension among patients with HF from this study.
