Essentials of Diagnosis
Exertional dyspnea, fatigue, orthopnea, lower-extremity swelling.
Pulmonary rales, elevated jugular venous pressure, peripheral edema.
Echocardiography reveals left ventricle systolic or diastolic dysfunction.
General Principles in Older Adults
Incidence and prevalence of heart failure (HF) increase exponentially with age, reflecting the increasing prevalence of hypertension and coronary heart disease (CHD) at older age and the marked reduction in cardiovascular reserve that accompanies normative aging. There is a 4-fold increase in the incidence of HF between ages 65 and 85 years. Although the incidence of HF is higher in men than in women at all ages, women comprise slightly more than half of prevalent HF cases because of the higher proportion of women among older adults.
HF is currently the most common cause of hospitalization in the Medicare age group; more than 70% of the nearly 1 million annual hospitalizations for HF involve persons older than age 65 years. HF is also a major source of chronic disability in older adults, and is the most costly Medicare diagnosis-related group.
Primary prevention of HF is feasible through aggressive treatment of the major conditions that cause HF (ie, hypertension and CHD). Antihypertensive therapy reduces the risk of incident HF by as much as 64% in older adults. The greatest benefit is seen in octogenarians with systolic hypertension. Similarly, treatment of other coronary risk factors may prevent or delay the onset of CHD, thus reducing the risk of HF.
Symptoms include exertional shortness of breath, effort intolerance, fatigue, cough, orthopnea, paroxysmal nocturnal dyspnea, and swelling of the feet and ankles. However, exertional symptoms are less prominent in older adults in part because of reduced physical activity. Conversely, altered sensorium, irritability, lethargy, anorexia, abdominal discomfort, and gastrointestinal disturbances are more common symptoms of HF in older adults (see Chapter 7, “Atypical Presentations of Illness in Older Adults”).
Signs of HF include tachycardia, tachypnea, an S3 or S4 gallop, pulmonary rales, elevated jugular venous pressure, hepatojugular reflux, hepatomegaly, and dependent edema. In severe HF, the pulse pressure may be narrowed, and there may be signs of impaired tissue perfusion, such as diminished cognition. Depending on the cause of HF, additional findings may include severe hypertension, a dyskinetic apical impulse, a murmur of aortic or mitral origin, or peripheral signs of endocarditis. As with symptoms, the signs of HF in older adults are often nonspecific or atypical.
The chest x-ray can assess for presence of pulmonary edema or cardiomegaly and rule out other causes of dyspnea (pneumonia, pneumothorax). Of note, up to 40% of HF patients with elevated pulmonary capillary wedge pressure have no radiographic evidence of congestion.