Heart Failure Medications & Treatment for Elderly Populations

Heart failure or congestive heart failure is a condition in which the heart cannot pump blood efficiently. Consequently, oxygen- and nutrient-rich blood does not reach the vital organs and the rest of the body. As a result, patients with heart failure develop symptoms such as shortness of breath, fatigue, swelling in the legs and stomach area, rapid weight gain, and changes in mental status, making it difficult to think clearly. These symptoms can be severe enough to make everyday activities difficult, like walking or getting dressed.

Approximately 8 out of 10 heart failure patients are over the age of 65 years. Please continue reading to learn more about the treatment of heart failure in elderly patients.

What is heart failure?

Heart failure occurs when the heart muscle is too stiff or too weak. In many cases, it can be both. Keep in mind that heart failure does not mean the heart has stopped working. It just means the heart does not function as well as it should. It can be of the following types:

Left ventricular dysfunction (left-sided heart failure) is when the left ventricle does not pump as well, causing fluid to back up in the lungs, with symptoms such as shortness of breath. This is the most common type of heart failure.
Right ventricular dysfunction (right-sided heart failure) is typically caused by left-sided heart failure, causing fluid to back up in the abdomen and legs, with symptoms such as swelling. Heart valve disease or certain lung conditions can also cause right-sided heart failure.
Systolic heart failure, also known as heart failure with reduced ejection fraction (HFrEF), develops when the heart is weakened and enlarged, leading to the heart muscle not contracting effectively. More specifically, systolic failure happens when the heart is pumping less than or equal to 40% ejection fraction (EF). In other words, the left ventricular ejection fraction is 40% or less.
Diastolic heart failure, also known as heart failure with preserved ejection fraction (HFpEF), where the heart has difficulty filling with blood due to stiff heart muscle. This leads to impaired blood flow to the rest of the body. Diastolic heart failure is more common in females than males.

What causes heart failure?

Damage to the heart muscle is commonly caused by myocardial infarction (heart attack), and coronary artery disease,

High blood pressure is another common cause of heart failure.

Less common causes include valvular heart disease, where heart valves do not work properly. This can be due to heart valves being too narrow or leaky, heart rhythm disorders, congenital heart disease, or an infection causing inflammation of the heart muscle.

Other conditions such as diabetes, thyroid disorders, anemia, and high blood cholesterol are also risk factors.

Additional causes of acute heart failure include allergic reactions, severe infections, and viral infections that affect the heart.

Risk factors for developing heart failure also include advancing age. Excessive alcohol consumption, unhealthy diet, and smoking are also associated with an increased risk of heart failure.

Certain medications can cause or worsen heart failure. Examples include diabetes medications such as metformin, pioglitazone (Actos), and rosiglitazone (Avandia), nonsteroidal anti-inflammatory drugs (NSAIDs), and some medicines used to treat high blood pressure, irregular heart rhythms, cancer, eye problems, and infections. Other medications that can exacerbate heart failure include decongestants, vasodilators, and certain mental health medications.

Which medication is commonly ordered for heart failure patients?

Various medications are used for the management of heart failure in all age groups, including younger patients and older adults.

Heart failure treatments can help to reduce symptoms such as fatigue, swelling, and shortness of breath. In addition, heart failure therapy can improve energy levels, allowing heart failure patients to be physically active. Medications can also slow the progress of the condition. Healthcare providers sometimes prescribe medical therapy for relative risk reduction if someone has certain risk factors to prevent heart disease leading to heart failure.

Many heart failure patients need to take multiple medications. Different medications are used to treat different symptoms or underlying causative factors.

How is chronic heart failure treated in the elderly?

Heart failure is a complex clinical syndrome. Management of heart failure in older adults usually follows these steps (called DEFEAT for short):

Establishing the Diagnosis
Identifying the Etiology or cause
Determining the Fluid volume status
Obtaining the left ventricular Ejection fraction
And
Starting Treatment

What medications are used for heart failure in the elderly?

The prevalence of heart failure increases with advancing age. Unfortunately, there isn’t much data on clinical practice guidelines that are specifically intended for elderly HF patients. In general, treatment for severe chronic heart failure in older heart failure patients follows the recommendations and current guidelines for younger patients. However, doctors need to keep in mind comorbidities, such as cognitive impairment, renal dysfunction like chronic kidney disease, and chronic obstructive pulmonary disease (COPD), in elderly patients with heart failure.

Therefore, cardiovascular and renal outcomes can have a major influence on heart failure treatment (choice of drug) in older patients with a heart failure diagnosis. Elderly persons who have multiple medical problems are usually on several medications. Therefore, possible drug interactions can play a significant role in choosing heart failure treatments in the elderly population. In addition, previous tolerability of adverse drug reactions can limit the choice of medications.

In general, the pharmacological treatment for HF patients, including elderly HF patients, mainly consists of beta blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin II receptor blockers (ARBs), and diuretics. Additionally, an angiotensin receptor-neprilysin inhibitor, a mineralocorticoid receptor antagonist, a vasodilator, warfarin, and digoxin may be used. HF patients may need to be prescribed a combination of medical therapy, including one or more of those medications.

In addition to medications, heart failure treatment may consist of surgery to correct an underlying problem that caused the heart failure. Surgical procedures may include coronary bypass surgery, implantable cardioverter defibrillator (ICD) placement, ventricular assist devices, heart valve repair or replacement, cardiac resynchronization therapy, or heart and lung transplantation. It is worth noting that some of these procedures are high-risk and may not be appropriate for elderly patients. Therefore, heart failure therapy in the elderly population sometimes consists of comfort measures only.

What medications are administered to manage severe heart failure?

Management of heart failure depends on the underlying cause. Treatment frequently includes lifestyle changes and medications to treat heart failure itself or another health condition that is causing the heart to become weak. Some of the medications used to treat heart failure include:

Angiotensin-converting enzyme (ACE) inhibitors

ACE inhibitors lower blood pressure, improve blood flow, and decrease the workload of the heart. Examples include enalapril (Vasotec) and lisinopril (Zestril).

Angiotensin II receptor blockers (ARBs)

These medications have the same effects as ACE inhibitors and are an option for people who cannot tolerate ACE inhibitors. Examples include losartan (Cozaar), candesartan (Atacand), and valsartan (Diovan).

Beta blockers

Beta blockers slow the heart rate and lower blood pressure, allowing the heart to work more efficiently. Examples include metoprolol (Lopressor) and carvedilol (Coreg).

Angiotensin receptor plus neprilysin inhibitor (ARNI)

This is a combination of two blood pressure medicines. It is used to reduce cardiovascular hospital admission in heart failure patients with a reduced ejection fraction. An example is sacubitril-valsartan (Entresto).

Diuretics

These drugs, also called water pills, increase urine production and prevent fluid buildup in the body, including the lungs, thereby relieving shortness of breath and improving quality of life. An example is furosemide (Lasix).

Potassium-sparing diuretics

These drugs are used to increase life expectancy in advanced heart failure patients with reduced ejection fraction. Examples include spironolactone (Aldactone) and eplerenone (Inspra).

Sodium-glucose cotransporter-2 (SGLT2) inhibitors

These medications help to lower blood sugar and are frequently prescribed for type 2 diabetes, along with diet and exercise. However, they can also lower the risk of hospitalization and cardiovascular mortality in heart failure patients, even in the absence of diabetes. Examples include canagliflozin (Invokana), empagliflozin (Jardiance), and dapagliflozin (Farxiga).

Digoxin or digitalis (Lanoxin)

This medication helps the heart to pump more efficiently and slows the heart rate. It is often prescribed to heart failure patients with heart rhythm abnormalities like atrial fibrillation.