How is Heart Failure with preserved Ejection Fraction (HFpEF) with associated and independent lung and blood conditions managed in ageing individuals?

Management of HFpEF with Associated Lung and Blood Conditions in Aging Individuals

SGLT2 inhibitors (empagliflozin or dapagliflozin) are the first-line disease-modifying therapy for elderly patients with HFpEF who have concurrent lung and blood conditions, as they significantly reduce heart failure hospitalizations without negatively affecting pulmonary function or hematologic parameters. 1, 2

Diagnostic Approach for HFpEF in Elderly Patients

• HFpEF is defined as heart failure with left ventricular ejection fraction ≥50%, with symptoms/signs of HF caused by structural/functional cardiac abnormalities and either elevated natriuretic peptides or objective evidence of cardiogenic congestion 3
• Elderly patients with HFpEF often have multiple comorbidities that can mask or exacerbate HF symptoms, requiring careful evaluation 3
• Diagnostic workup should include:
  • ECG to identify rhythm disorders (particularly atrial fibrillation), LV hypertrophy, and prior myocardial injury 3
  • Transthoracic echocardiogram to assess cardiac structure, function, and pulmonary pressures 3
  • Blood tests for thyroid, renal, and hepatic function 3
  • Evaluation for specific HFpEF mimics that may require different treatment approaches (e.g., cardiac amyloidosis, hypertrophic cardiomyopathy) 3

Management of HFpEF with Pulmonary Comorbidities

• Coexisting COPD significantly increases mortality risk in very elderly HFpEF patients (≥85 years), requiring special attention to pulmonary management 4
• For HFpEF patients with COPD:
  • Optimize COPD management according to standard guidelines while monitoring for drug interactions 1
  • Use cardioselective beta-blockers cautiously when needed for rate control in AF 1
  • SGLT2 inhibitors are particularly beneficial as they don't affect respiratory function 3
  • Regular monitoring of pulmonary function and symptoms is essential 4

Management of HFpEF with Hematologic Conditions

• Assess for and treat iron deficiency, which is common in elderly HF patients and contributes to symptoms 5
• For patients with anemia or other blood disorders:
  • Evaluate the underlying cause (nutritional, chronic disease, blood loss) 3
  • Consider iron supplementation when appropriate 5
  • Monitor for worsening renal function, especially with diuretic use 5

Pharmacological Management Algorithm

1. First-line therapy for all elderly HFpEF patients:

   • SGLT2 inhibitors (empagliflozin or dapagliflozin) - shown to reduce HF hospitalizations by approximately 20% in randomized trials 6, 2

2. Management of fluid overload:

   • Loop diuretics at the lowest effective dose to manage congestion and improve symptoms 2
   • Careful monitoring of renal function and electrolytes, especially in elderly patients 5

3. For patients with atrial fibrillation (common in elderly HFpEF):

   • Rate control strategy is generally preferred over rhythm control 2
   • Beta-blockers are preferred for rate control (use cardioselective agents in patients with COPD) 2
   • Anticoagulation based on CHA₂DS₂-VASc score 1

4. Additional therapies to consider:

   • Mineralocorticoid receptor antagonists (MRAs) like spironolactone for patients with LVEF closer to 50% 2
   • Angiotensin receptor blockers (ARBs) for selected patients, especially with hypertension 2

Special Considerations for Elderly Patients

• Age-related changes in pharmacokinetics and pharmacodynamics require careful medication dosing and monitoring 7
• Elderly patients (≥85 years) with HFpEF have different clinical characteristics compared to younger elderly (65-84 years):
  • Higher prevalence of hypertension and atrial fibrillation 8
  • More likely to be white women 8
  • Higher risk of non-cardiovascular death 8
• Polypharmacy increases the risk of adverse drug interactions and side effects, requiring regular medication review 3
• Impaired renal function is common and may necessitate dose adjustments of ACEIs, ARBs, and MRAs 3

Management of Common Comorbidities

• Hypertension: Target blood pressure <130/80 mmHg using appropriate medications 2
• Diabetes: Preferentially use SGLT2 inhibitors given their additional heart failure benefits 2
• Atrial fibrillation: Rate control strategy with anticoagulation based on stroke risk 3
• Obesity: Encourage supervised exercise training and dietary interventions for weight loss 6
• Gout: Consider xanthine oxidase inhibitors (allopurinol) for prophylaxis; avoid NSAIDs in symptomatic HF patients 3

Monitoring and Follow-up

• Regular assessment of volume status, renal function, and electrolytes, especially with diuretic and MRA therapy 1
• Monitoring for disease progression and treatment response through symptom assessment and biomarkers 3
• Education on self-care, including medication adherence, dietary restrictions, and symptom monitoring 6

Common Pitfalls to Avoid

• Delaying initiation of SGLT2 inhibitors, which have proven benefits in reducing hospitalizations 2
• Overdiuresis leading to worsening renal function in volume-depleted elderly patients 5
• Failure to recognize and treat specific HFpEF mimics that require different treatment approaches 3
• Undertreatment of elderly patients due to concerns about medication side effects 7