What is the effect of aging on systolic and diastolic heart function in the elderly?

Effect of Aging on Cardiac Function in the Elderly

In the elderly, diastolic function is more impaired than systolic function, with aging having a greater impact on ventricular filling characteristics than on ejection fraction. 1

Age-Related Changes in Cardiac Function

• Aging is associated with decreases in the elastic properties of the heart and great vessels, leading to increased systolic blood pressure and increased myocardial stiffness 1
• Ventricular filling decreases with age due to structural changes in the heart (fibrosis) and because of a decline in relaxation and compliance 1
• These deleterious effects on diastolic function are exacerbated by a decrease in beta-adrenergic receptor density and a decline in peripheral vasodilator capacity, both characteristic of elderly patients 1
• Aging has a greater impact on ventricular filling characteristics (diastolic function) than on ejection fraction (systolic function) 1, 2

Diastolic Dysfunction in the Elderly

• Heart failure with preserved ejection fraction (diastolic heart failure) is most prevalent among elderly women, most of whom have hypertension, diabetes mellitus, or both 1, 3
• Aging is characterized by impaired early diastolic relaxation, decreased peak early filling rate, increased peak atrial filling rate, and a decreased E/A ratio 1
• The rate of ventricular relaxation decreases with age due to structural changes in the heart and because of a decline in relaxation and compliance 1
• The prevalence of diastolic abnormalities increases with age, from 2.8% in individuals aged 25-35 years to 15.8% among those older than 65 years 4

Systolic Function in the Elderly

• Systolic function, as measured by ejection fraction, is generally preserved in elderly patients despite the presence of diastolic dysfunction 1, 5
• Even in the presence of pressure overload conditions like aortic stenosis, elderly patients maintain preserved systolic function while exhibiting more pronounced diastolic impairment 5
• The adaptation of systolic function to aging appears more robust compared to diastolic function 5, 2

Clinical Implications

• Diastolic heart failure is more common than systolic heart failure in the elderly 2
• Elderly patients with diastolic heart failure tend to be women with hypertrophied, hyperdynamic left ventricles, and chronic hypertension 3
• The morbidity and mortality associated with heart failure and preserved ejection fraction may be nearly as profound as that with low ejection fraction 1
• Frequent and repeated hospitalizations characterize patients with heart failure and normal ejection fraction 1

Risk Factors and Prevention

• Independent predictors of diastolic abnormalities include arterial hypertension, left ventricular hypertrophy, and coronary artery disease 4
• In the absence of these predisposing conditions, diastolic abnormalities (4.3%) or diastolic dysfunction (1.1%) are rare, even in subjects older than 50 years 4
• Additional risk factors for diastolic dysfunction include high body mass index, high body fat mass, and diabetes mellitus 4
• Baroreceptor sensitivity decreases progressively with aging at a rate of approximately 1% function per year after age 40, affecting the autonomic nervous system 6

Management Considerations

• Treatment of diastolic heart failure in the elderly should focus on controlling blood pressure, heart rate, reducing central blood volume, and alleviating myocardial ischemia 1
• Beta-blockers may be beneficial to lower heart rate and increase diastolic filling period 1
• Verapamil-type calcium antagonists may improve relaxation in patients with diastolic dysfunction 1
• ACE inhibitors may improve relaxation and cardiac distensibility directly, with potential long-term effects through regression of hypertrophy 1
• Diuretics may be necessary for episodes of fluid overload but should be used cautiously to avoid excessive preload reduction 1