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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #26, #28

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LEARNING OBJECTIVES

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Learning Objectives

  • Understand the effects of aging on cardiovascular structure and function, and how these changes predispose to the development of heart failure.

  • Describe the clinical features—including symptoms, signs, and results of diagnostic tests—that distinguish heart failure in older adults from heart failure occurring during middle age.

  • Describe nonpharmacologic aspects of care for older adults with heart failure.

  • Understand current treatment of heart failure with reduced and preserved ejection fraction in older adults.

  • Discuss management of heart failure in patients approaching the end of life.

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Key Clinical Points

  1. Cardiovascular aging is associated with extensive changes in cardiac and vascular structure and function that predispose older adults to the development of heart failure.

  2. The clinical features of heart failure, including symptoms, signs, and diagnostic test results, often differ in older adults with heart failure compared to those in younger patients.

  3. Management of heart failure with reduced ejection fraction (HFREF) is generally similar in older and younger patients, but must be individualized in older patients with competing morbidities and in accordance with goals of care.

  4. To date, no pharmacologic agents have been shown to reduce mortality or substantially improve clinical outcome in patients with heart failure and preserved ejection fraction (HFPEF); therefore, treatment of this condition remains empiric.

  5. Nonpharmacologic therapies, including lifestyle changes and multidisciplinary care interventions, play a fundamental role in optimizing care and outcomes for older patients with heart failure.

  6. The overall prognosis for heart failure in older adults is poor, and it is therefore essential to incorporate goals of care and end-of-life planning into the clinical decision-making process, especially as symptoms progress and quality of life declines.

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INTRODUCTION

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Heart failure may be defined as an inability of the heart to pump sufficient blood to meet the metabolic needs of the body’s tissues or the ability to do so only at the expense of elevated intracardiac pressures. Heart failure represents a clinical syndrome rather than a specific diagnosis, and, to a large extent, it is a geriatric syndrome in much the same way that dementia and incontinence are geriatric syndromes. Indeed, heart failure may be viewed as the quintessential disorder of cardiovascular aging since, as discussed later in this chapter, extensive age-related changes in cardiovascular structure and function, in conjunction with the rising prevalence of cardiovascular diseases with advancing age and declines in premature cardiovascular deaths, all contribute to an exponential rise in heart failure with advancing age. Thus, although the clinical syndrome of heart failure has been recognized by physicians for more than 2000 years, it has only been within the past three decades that it has been identified as a major public health concern, a development that is largely attributable to the aging of the population.

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EPIDEMIOLOGY AND ECONOMIC IMPACT

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Despite progressive declines in age-adjusted mortality rates ...

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