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  • Exertional dyspnea, fatigue, orthopnea, lower extremity or abdominal swelling.

  • Pulmonary rales, elevated jugular venous pressure, peripheral edema.

  • Echocardiography reveals left ventricle systolic or diastolic dysfunction.

General Principles

Heart failure (HF) is a growing worldwide epidemic, affecting over 23 million individuals, and >550,000 new cases are diagnosed each year in the United States alone. The incidence and prevalence of HF increase exponentially with age, reflecting the increasing prevalence of hypertension and coronary heart disease (CHD) at older ages and the marked reduction in cardiovascular reserve that accompanies normative aging. In the United States, >60% of patients with HF are 65 years of age or older. Although the incidence of HF is higher in men than in women at all ages, women compose slightly more than half of prevalent HF cases because of the higher proportion of women among older adults and somewhat better prognosis for HF in women compared to men.

HF is currently the most common cause of hospitalization in the Medicare age group. More than 70% of the approximately one million annual hospitalizations for HF involve persons older than age 65 years, and >20% of HF patients are readmitted within 30 days. HF is also a major source of chronic disability in older adults, and it is the most costly Medicare diagnosis-related group.


Primary prevention of HF is feasible through aggressive treatment and prevention of the major risk factors for HF (ie, hypertension and CHD). Antihypertensive therapy significantly reduces the rate of incident systolic and diastolic HF in older adults, and the greatest benefit is seen in octogenarians with systolic hypertension. Similarly, treatment of other coronary risk factors (diabetes, hyperlipidemia, tobacco use, obesity) may prevent or delay the onset of CHD, thus reducing the risk of HF.

Clinical Findings

A. Symptoms & Signs

Symptoms include exertional shortness of breath, effort intolerance, fatigue, cough, orthopnea, paroxysmal nocturnal dyspnea, abdominal bloating, 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 16, “Atypical Presentations of Illness”).

Signs of HF include tachycardia, tachypnea, an S3 or S4 gallop, pulmonary rales, elevated jugular venous pressure, hepatojugular reflux, hepatomegaly, abdominal swelling, 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 or cool and clammy skin. 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 ...

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