Hone your skills at diagnosing and treating CHF in the elderly.
Congestive heart failure (CHF) in the elderly is a quiet, complicated problem. The condition, which can stem from a range of structural or functional cardiac disorders, is compounded by the effects of old age. CHF often goes undiagnosed, particularly in mild cases, and yet even with the best therapy it is associated with an annual mortality of 10%. In fact, heart failure is the most common reason for hospital admission in the group older than 65, with 900,000 admissions a year in the US alone.
Gender, Ethnic Divide
Older women tend to have diastolic dysfunction more frequently than older men because the 50+ year-old female heart tolerates a heavy afterload better than the male and is less prone to decompensation at that early age. Men typically develop CAD at an earlier age. Note that hypertension is the number one cause of CHF in the older female.
Some ethnic differences also exist. Heart failure is found more commonly in African-Americans primarily due to the high prevalence of hypertension, with the highest prevalence of CHF found in older black females.
Systolic v. Diastolic
Heart failure is categorized as systolic if the left ventricular ejection fraction (LVEF) is between 35–45% or diastolic if LVEF is normal. In the group older than 65, heart failure is typically associated with preserved LV systolic function, whereas those younger than 65 tend to have systolic LV dysfunction because of coronary artery disease and nonischemic dilated cardiomyopathy. Diastolic heart failure is described echocardiographically as a small stiff ventricle with a thickened wall. The small ventricle does not have enough blood for a normal cardiac output. Fifty percent of heart failure cases are diastolic in nature. Clinically, the signs and symptoms of diastolic and systolic heart failure are practically identical, even though jugular venous distention and an S3 heart sound may be more common in systolic failure.
Causes & Symptoms
Remember that heart failure is not a primary illness, but is the end result of other ailments. The most common causes are coronary artery disease, hypertension, cardiomyopathy and valvular heart disease. The history, if obtainable, has critical value. The clinical signs and symptoms of heart failure are common: dyspnea on exertion is the most common complaint and can worsen to dyspnea at rest. The prevalent symptoms are common to both the younger and older population afflicted with CHF. However, the elderly may complain only of fatigue, weakness, dizziness, or altered mentation. Dyspnea may be so severe that it is present with eating. In about 14% of patients, JVD may be absent. Systemic congestion may lead to varicosities that can subsequently seep fluid with resulting superficial thrombophlebitis.
The presentation of a patient dyspnea carries an extensive differential diagnosis from heart failure, MI, pulmonary embolism to pneumonia, sepsis, bronchitis, asthma, chronic obstructive pulmonary disease. Heart failure, right sided, can be a complication of long-standing COPD. Infections can precipitate the susceptible elderly to an MI and to congestion or vice versa. Iatrogenic heart failure is an entity to avoid and usually results form well-meaning but overzealous hydration of the frail elderly who may present in various hypovolemic states. Other co-morbidities may confound the clinical picture. The elderly with underlying lung cancer or pulmonary metastases may present with a clinical picture of congestive heart failure. Non-compliance, voluntary or otherwise due to dementia, polypharmacy, or abuse may contribute to the development of CHF. That is one critical reason for a clear line of communication to exist between the primary care physician and the various specialists rendering care to the elderly with various co-morbidities.
Diagnosis & Treatment
Echocardiography remains the mainstay of diagnosis and displays the LVEF, which has diagnostic and prognostic value. Two-dimensional echocardiography (2DE) and Doppler echocardiography can show LV function (systolic and diastolic), cardiac output, PA pressures, ventricular filling pressures and valvular status. Real-time echocardiography (3DE) provides even more details about the volume status of the left ventricle. The elderly with mild or severe valvular disease can be appropriately categorized and treated.
The EP has a large armamentarium as well as access to a multidisciplinary team consisting of the internist, cardiologist (non-invasive and invasive) and cardiothoracic surgeon. A useful supplement to the diagnosis of CHF is the measurement of brain natriuretic peptide (BNP), which can also gear the EP during the evaluation of dyspnea without a known history of CHF. Note that Pro-BNP level tends to be higher in older patients, females and patients with renal insufficiency (with or without CHF). The elevated BNP may be due to volume expansion from renal failure or left ventricular hypertrophy. Thus, a low BNP value is more useful to exclude CHF in the renally impaired patient than an elevated level. The BNP level in obese patients is usually lower than the non-obese patient. The BNP value does not differentiate between systolic and diastolic heart failure. Patients with an elevated BNP level with stable or unstable angina have been found to have a higher mortality than those with a lower level. Patients with more than one cause for dyspnea may still have an elevated BNP (CHF and pneumonia, for example).
Airway management is a critical first step as the elderly with HF can promptly fatigue and require emergent intubation. Diuretics such as Furosemide are the first-line therapy to decrease venous congestion. In the elderly, age-related decline in renal function and decreased circulating volume may limit their use. Be mindful that prior diuretic use may be associated with hypokalemia, hypomagnesemia, predisposing the elderly to ventricular arrhythmias and digoxin toxicity. Monitor for hyponatremia. For pulmonary edema, an extreme of CHF, morphine and IV nitrates are adjuncts. Within the first twelve hours of presentation in the ED, ACE-inhibitors can be initiated as second-line therapy. Be prepared to correct any arrhythmias and have a standby transcutaneous pacemaker available as a bridge to transvenous pacemaker. The elderly with CHF after myocardial infarction is treated similarly as the younger adult. Once stabilized, the CHF patient with CAD or valvular disease, will need an angiogram, followed by angioplasty or definitive surgery (CABG or valve replacement). The ideal treatment of CHF, like most diseases, is of course, prevention via compliance with maintenance medications for HTN, CAD, exercise, and diet.
In summary, heart failure is a serious illness extolling a heavy burden on society. Within three months of the initial ED visit, more than 60% of the elderly with CHF experienced recurrent visit, hospitalization or death. This is the disease to watch and stay abreast of as the US population ages and a potential epidemic of heart failure settles in. A meticulous eye to the history and physical exam, prompt and aggressive ED treatment in a multidisciplinary fashion can give the elderly with CHF a chance to survival to discharge from the hospital.