What is the recommended management for a 79‑year‑old woman with chronic heart failure?

Management of Chronic Heart Failure in a 79-Year-Old Woman

For a 79-year-old woman with chronic heart failure, initiate ACE inhibitors (or ARNi if HFrEF) plus beta-blockers as foundational therapy, add loop diuretics for symptomatic fluid overload, and strongly consider SGLT2 inhibitors regardless of diabetes status, as this combination provides the greatest mortality and morbidity benefit in elderly patients. 1, 2, 3

Initial Pharmacological Approach

First-Line Therapy: ACE Inhibitors or ARNi

• ACE inhibitors are the cornerstone of treatment for patients with reduced left ventricular systolic function (ejection fraction <40%), providing mortality reduction and symptom improvement 1
• Start with low doses and titrate gradually to target maintenance doses proven effective in large trials 1
• In elderly patients, ACE inhibitors are effective and well-tolerated, though age-related renal impairment requires careful monitoring 1
• For patients already on ACE inhibitors with persistent symptoms, consider switching to sacubitril/valsartan (ARNi), which provides superior outcomes in HFrEF across all age groups including elderly patients 4, 3

Initiation protocol for ACE inhibitors in elderly patients:

• Review and potentially reduce diuretic doses 24 hours before starting to minimize hypotension risk 1
• Begin dosing in the evening when supine to reduce blood pressure effects 1
• Monitor blood pressure, renal function (creatinine, BUN), and electrolytes at 1-2 weeks after each dose increment, then at 3 months, then every 6 months 1, 2
• Avoid NSAIDs and initially avoid potassium-sparing diuretics during titration 1

Beta-Blockers: Mandatory Add-On Therapy

• Beta-blockers are recommended for all stable patients with HFrEF (NYHA class II-IV) already on ACE inhibitors and diuretics, providing mortality reduction and preventing disease progression 1, 3
• In elderly patients, beta-blockers are surprisingly well-tolerated when patients with sick sinus syndrome, AV block, and obstructive lung disease are excluded 1
• Do not withhold beta-blockers based on age alone 1
• Continue beta-blockers during acute exacerbations unless true hemodynamic instability exists 2

Diuretics: Essential for Symptomatic Relief

• Loop diuretics are essential when fluid overload manifests as pulmonary congestion or peripheral edema, providing rapid improvement in dyspnea and exercise tolerance 1, 2
• Always administer diuretics in combination with ACE inhibitors 1
• In elderly patients, thiazides are often ineffective due to reduced glomerular filtration rate (GFR <30 mL/min), so use loop diuretics as first-line 1
• For insufficient response: increase loop diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 1
• Monitor for hyperkalaemia more frequently in elderly patients, especially when combining aldosterone antagonists with ACE inhibitors 1

Mineralocorticoid Receptor Antagonists (MRA)

• Spironolactone is recommended in advanced heart failure (NYHA class III-IV) in addition to ACE inhibitors and diuretics to improve survival and reduce morbidity 1, 3
• Use only if hypokalaemia persists after ACE inhibitor and diuretic initiation 1
• Start with 1-week low-dose administration, check serum potassium and creatinine after 5-7 days, and recheck every 5-7 days until stable 1
• Elderly patients require more vigilant monitoring for hyperkalaemia, particularly when combined with ACE inhibitors 1

SGLT2 Inhibitors: Critical Modern Addition

• SGLT2 inhibitors (dapagliflozin) significantly reduce cardiovascular and all-cause mortality irrespective of diabetes status and should be added to foundational therapy 3, 5
• Dapagliflozin is effective across the spectrum of ejection fractions, including HFpEF (LVEF >40%), which is common in elderly women 4, 6, 5
• In elderly patients (76% of DELIVER trial participants were >65 years), safety and efficacy profiles remain favorable 6
• Can be used in patients with eGFR as low as 25 mL/min/1.73 m² 6

Management Based on Ejection Fraction Phenotype

Heart Failure with Reduced Ejection Fraction (HFrEF, LVEF ≤40%)

Quadruple therapy is the goal:

1. ACE inhibitor/ARNi
2. Beta-blocker
3. MRA (if NYHA III-IV)
4. SGLT2 inhibitor 3, 7

Heart Failure with Preserved Ejection Fraction (HFpEF, LVEF >40%)

• HFpEF is particularly common in elderly women and presents with severe exercise intolerance despite preserved ejection fraction 8, 9
• Loop diuretics for symptomatic fluid overload 1, 5
• SGLT2 inhibitors provide benefit across the ejection fraction spectrum, including HFpEF 6, 5
• Beta-blockers to lower heart rate and increase diastolic filling period 1
• Consider high-dose ARB to reduce hospitalizations 1
• Avoid excessive preload reduction with aggressive diuresis, as this can reduce stroke volume and cardiac output 1

Non-Pharmacological Management

Patient Education and Self-Management

• Explain heart failure pathophysiology, symptom recognition, and when to contact healthcare providers 1
• Daily weight monitoring with instructions to increase diuretics and alert the team if sudden weight gain occurs 1, 2
• Sodium restriction to <6 g/day when necessary, particularly in severe heart failure 1
• Fluid restriction of 1.5-2 L/day in severe heart failure 1
• Avoid excessive alcohol intake and smoking cessation 1

Physical Activity

• Encourage daily physical activity in stable patients to prevent muscle deconditioning 1
• Exercise training programs are appropriate for NYHA class II-III patients 1, 9
• Rest is not encouraged in stable conditions 1

Travel and Environmental Considerations

• Advise about potential problems with long flights, high altitudes, and hot humid climates when on diuretics and vasodilators 1

Critical Monitoring and Follow-Up

Laboratory Monitoring

• Check blood pressure, renal function (creatinine, BUN, eGFR), and electrolytes (sodium, potassium) at 1-2 weeks after each medication dose change, at 3 months, then every 6 months 1, 2
• Monitor daily fluid intake/output and daily weights during active diuretic therapy 2

Multidisciplinary Care

• Enroll in multidisciplinary heart failure management programs to reduce rehospitalization and mortality 10
• First follow-up within 10 days of any hospitalization 1
• Vigilant follow-up with increased access to healthcare 1

Special Considerations for Elderly Patients

Age-Related Pharmacological Adjustments

• Relief of symptoms may be more important than prolongation of life for many older patients, requiring individualized goal-setting 1
• Elderly patients are more susceptible to digoxin toxicity; use low initial doses if prescribed 1
• Higher proportion of elderly patients experience hypotension with standard HF therapies; monitor blood pressure closely 1
• Venodilating drugs (nitrates) and arterial dilators (hydralazine) should be administered carefully due to hypotension risk 1

Comorbidity Management

• Elderly patients frequently have hypertension, renal failure, diabetes, stroke, arthritis, and anemia requiring polypharmacy 1
• Avoid NSAIDs and COX-2 inhibitors, which increase hyperkalaemia risk and worsen heart failure 1
• Multiple drug interactions must be anticipated and monitored 1

Common Pitfalls to Avoid

• Never discontinue ACE inhibitors or beta-blockers reflexively during acute exacerbations unless true hemodynamic instability exists 2
• Avoid premature discontinuation or underdosing of diuretics, which leaves patients congested and at high risk for readmission 2
• Do not stop diuretics in the setting of mild worsening renal function; mild rises in BUN and creatinine are generally tolerated and should not automatically trigger discontinuation 2, 11
• Avoid excessive diuresis before initiating or uptitrating ACE inhibitors, as this increases risk of hypotension and acute kidney injury 1, 2
• Monitor for hyperkalaemia more vigilantly in elderly patients, especially with combined MRA and ACE inhibitor therapy 1
• Do not use thiazide diuretics when eGFR <30 mL/min except synergistically with loop diuretics 1