Management of Chronic Heart Failure in Older Patients

Chronic heart failure is largely a condition of older age, and its management has changed substantially in recent years. In this lecture, Prof. Hidenori Arai of Kyoto University reviews how heart failure is recognised, classified and treated in older patients, and why care must go beyond drug therapy.

The lecture covers the definition, typical symptoms and diagnostic work-up of heart failure, its strong link with ageing and its poor prognosis, and the importance of controlling risk factors such as diabetes, obesity and hypertension early. It outlines the ACC/AHA stages and the classification by ejection fraction, noting that the oldest patients predominantly have heart failure with preserved ejection fraction (HFpEF) and carry more comorbidities.

A central part of the session is modern drug treatment: the evidence behind ARNI and SGLT2 inhibitors, and the "fantastic four" approach in heart failure with reduced ejection fraction (HFrEF), which allows therapy to be optimised much faster than conventional step-by-step titration, alongside its high cost. Treatment options for HFpEF are also discussed.

Because many patients are frail, the lecture addresses frailty, sarcopenia, cachexia and the obesity paradox, and the role of exercise, nutritional support, cardiac rehabilitation and a multidisciplinary heart failure team. It closes with open questions on treating the very old, polypharmacy, cost, cognitive decline, home care and telemedicine.

Questions and answers

What is the "fantastic four" in heart failure with reduced ejection fraction?

It is the combination of an ARNI, a beta-blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor. Starting all four early allows therapy to be optimised in about four weeks instead of around six months. The lecture shows markedly better outcomes than with an ACE inhibitor or ARB plus a beta-blocker, although the cost is high.

Why does frailty matter when managing heart failure in older patients?

Most patients with heart failure are old and often frail, sarcopenic or cachectic, which worsens prognosis. Management therefore combines drug therapy with exercise, nutritional support, cardiac rehabilitation and a multidisciplinary team, while taking polypharmacy and cognitive decline into account.

Learn more about this topic in our series of webinars and expert lectures from the International Association of Gerontology and Geriatrics (IAGG): link

*Provided by International Association of Gerontology & Geriatrics (IAGG) & Federation of Geriatric Education (FGE)

Speakers

• Prof. Hidenori Arai

Learning objectives

• Describe the clinical features, diagnostic work-up and ACC/AHA stages of heart failure.
• Distinguish HFrEF, HFmrEF and HFpEF and explain why HFpEF predominates in older patients.
• Summarise the evidence for ARNI and SGLT2 inhibitors and the rapid introduction of the "fantastic four" in HFrEF.
• Outline the current drug treatment of HFpEF.
• Explain the impact of frailty, sarcopenia, cachexia and the obesity paradox, and the role of exercise, nutrition, cardiac rehabilitation and the multidisciplinary team.