What is the management of acute decompensated heart failure (ADHF) with preserved ejection fraction (EF) in the elderly?

Management of Acute Decompensated Heart Failure with Preserved Ejection Fraction in the Elderly

Diuretics are the cornerstone of treatment for acute decompensated heart failure with preserved ejection fraction (HFpEF) in elderly patients to control sodium and water retention and relieve symptoms of congestion. 1

Initial Management of Acute Decompensation

• Loop diuretics are the first-line treatment for fluid overload in acute HFpEF, with furosemide being the most commonly used agent 1
• Initial parenteral dose should be greater than or equal to the patient's chronic oral daily dose, with serial adjustments based on response 1
• When diuresis is inadequate, consider:
  • Higher doses of intravenous loop diuretics 1
  • Addition of a thiazide diuretic (e.g., metolazone) for sequential nephron blockade and enhanced diuretic synergy 1
• For refractory cases, ultrafiltration may be considered for patients with obvious volume overload 1

Hemodynamic Stabilization

• Careful monitoring of blood pressure is essential as elderly patients with HFpEF often have hypertension that requires treatment 1
• In patients with hypotension and tachycardia, evaluate for atrial fibrillation which is common in elderly HFpEF patients 1
• For patients with AF and rapid ventricular response:
  • In the absence of pre-excitation, intravenous beta-blocker administration or a non-dihydropyridine calcium channel antagonist is recommended to slow ventricular response 1
  • Intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with HF 1

Medication Management During Hospitalization

• Patients with HFpEF receiving guideline-directed medical therapy should continue these medications except in cases of hemodynamic instability 1
• Common precipitating factors for acute HF should be identified and addressed promptly 1
• Electrolytes, urea nitrogen, and creatinine should be monitored during medication titration, especially with diuretics 1
• Renal dysfunction at admission predicts poor response to unloading therapy and is associated with worse outcomes 2

Special Considerations for Elderly Patients

• Elderly patients require careful medication titration with lower starting doses and more gradual increases 3, 4
• Monitor for orthostatic hypotension, which is common in elderly patients and can be exacerbated by aggressive diuresis 3
• Be vigilant for renal impairment in volume-depleted elderly patients on diuretics 4
• Consider low-dose continuous infusion of furosemide (5-6 mg/hour) which can be effective and well-tolerated in elderly patients with acute HF 5

Management of Comorbidities

• Adequate treatment of hypertension and myocardial ischemia is important in HFpEF 1
• Control of ventricular rate in patients with atrial fibrillation is essential 1
• The heart rate-limiting calcium channel blocker verapamil may improve exercise capacity and symptoms in HFpEF patients 1
• Address other common comorbidities such as diabetes mellitus, iron deficiency, obesity, and thyroid dysfunction 4

Transitioning to Chronic Management

• SGLT2 inhibitors have shown efficacy in reducing cardiovascular death, HF hospitalizations, and urgent visits for HF in elderly HFpEF patients 4
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors should be considered for long-term management regardless of diabetes status 1, 4
• Supervised exercise training should be considered after stabilization as it provides substantial improvements in exercise capacity and quality of life 1
• A multidisciplinary team approach is recommended, including HF specialist cardiologist, HF nurse, geriatrician, dietician, and other specialists as needed 4

Pitfalls to Avoid

• Avoid excessive diuresis which may lead to renal dysfunction and electrolyte abnormalities 1, 2
• Do not abruptly discontinue beta-blockers in HF patients as this can lead to rebound tachycardia and worsening HF 3
• Avoid non-dihydropyridine calcium channel blockers in patients with decompensated HF 1, 3
• Be cautious with medication doses in elderly patients due to higher prevalence of polypharmacy, cognitive decline, and impaired kidney and liver functions 4