A Practical Guide to Heart Failure in Older People

Heart failure is effectively a disease of older people. Eighty percent of patients are over 65 years old, and the majority of these are over 75. This figure is likely to increase significantly in the next two decades. The prognosis is worse than that of most cancers and heart failure is the commonest reason for hospital admission in the over 65s.
The problems associated with treating heart failure in older patients are more diverse and complex than in those who are younger. The diagnosis in older patients is easily overlooked and as they were excluded from most heart failure treatment trials there has been a reluctance to treat them optimally (fewer than 20% are prescribed conventional medicines). They have multiple co-morbidities which are poorly managed, they are repeatedly hospitalised, and suffer social isolation.

These important age-related treatment and management problems have been largely ignored and this book aims to redress the balance. It provides a concise, comprehensive account of the epidemiology, pathogenesis, diagnosis, treatment, management and end-of-life care of elderly patients with heart failure, based on published studies.

A Practical Guide to Heart Failure in Older People is essential reading for geriatricians, cardiologists, general hospital physicians, family practitioners and specialist nurses.

• Specifically addresses the particular needs of the elderly, a largely ignored group who constitute the majority of patients with heart failure

• Presents a concise yet comprehensive account of the evidence relating to the diagnosis, treatment and management of heart failure in this population

• Improves awareness of the various roles within the management team


Contents
Chapter 1 Introduction

Christopher Ward

1.1 A Working Definition of Heart Failure

1.2 What do We Mean by ‘Older People?’

1.3 The Expectations of Older Patients

1.4 Age-Related Problems in Heart Failure Treatment and Management

1.5 The Level of Evidence for Treating Older Patients

References




Chapter 2 Epidemiology

Christopher Ward

2.1 Epidemiology, Demography and Prognosis

2.2 Heart Failure with Preserved Left Ventricular Systolic Function

2.3 Prevalence, Incidence and Prognosis

2.4 Age and Prognosis

2.5 The Effects of Gender and Race on Prevalence and Prognosis

2.6 The Increasing Prevalence of Heart Failure and Longevity

2.7 The Implications of Epidemiological and Demographic Data

References



Chapter 3 Heart Failure and the Aging Heart

Helen Oxenham

3.1 Introduction

3.2 Overt and Subclinical Cardiovascular Disease in Older People

3.3 Mitral Annular Calcification

3.4 Age-Related Changes to Cardiac Structure and Function

3.5 Other Relevant Age-Related Changes

3.6 Responses of the Aging Cardiovascular System to Exercise, Normal Daily Activities and to Other Physiological Stresses

3.7 he Pathogenesis of Heart Failure

3.8 The Impact of Age-Related Changes to the Cardiovascular System on the Responses to Myocardial Damage

3.9 The Prevention of Heart Failure in Older People

References



Chapter 4 Aetiology

Christopher Ward

4.1 Classification of the Aetiologies of Heart Failure

4.2 The Importance of Identifying the Aetiology

4.3 Specific Aetiologies

4.4 Post-Myocardial Infarction Heart Failure

4.5 Valvular Disease

4.6 The Cardiomyopathies

4.7 Atrial Fibrillation

References




Chapter 5 Diagnosis

Christopher Ward

5.1 Diagnostic Guidelines

5.2 Symptoms and Signs: Sensitivity and Specificity

5.3 Objective Evidence of Left Ventricular Systolic Dysfunction

5.4 Diagnostic Difficulties in Older Patients

5.5 Diagnosis, Patient Management and Clinical Profile

References




Chapter 6 Pharmacological Treatment

Miles D. Witham

6.1 Introduction

6.2 ACE Inhibitors

6.3 Beta-Blockers

6.4 Spironolactone

6.5 Diuretics

6.6 Digoxin

6.7 Hydralazine and Nitrates

6.8 Adding Angiotensin Receptor Blockers to ACE Inhibitors

6.9 Treating the Underlying Cardiovascular Disease

6.10 Medications to Avoid

6.11 Prescribing for Heart Failure with Preserved Systolic Function

6.12 Prescribing for Multiple Comorbidities

6.13 Prescribing at the End of Life

References




Chapter 7 Non-Pharmacological Management

Sinéad P. McKee and Miles D. Witham

7.1 Exercise Training

7.2 Types of Exercise Programme

7.3 Smoking

7.4 Diet

7.5 Alcohol

7.6 Vaccinations

7.7 Psychological Interventions

References




Chapter 8 Comorbidity

Andrew Elder


8.1 Introduction

8.2 The Prevalence of Comorbidities

8.3 The Implications of Comorbidity

8.4 Specific Comorbidities in Heart Failure

References




Chapter 9 Treatment and Management in Primary Care

Alan Begg

9.1 Introduction

9.2 The Role of Primary Care and the Patient Population

9.3 Heart Failure Registers, Data Collection and Audit

9.4 Heart Failure in General Practice

9.5 Treatment and Management

9.6 Specific Problems in Treating Older Patients

References




Chapter 10 The Role of the Specialist Nurse

Sinéad P. McKee

10.1 Introduction

10.2 The Role of the Specialist Nurse

10.3 Clinic-Based versus Home-Based Service

10.4 Multidisciplinary Team Liaison

10.5 Specific Issues Affecting Older Patients

10.6 End of Life Care

10.7 Specialist Nurses and Education

References




Chapter 11 The Role of the Heart Failure Specialist

Maheshwar Pauriah, Aaron K.F. Wong and Chim C. Lang

11.1 Introduction

11.2 The Role of the Heart Failure Specialist

11.3 The Provision of a Diagnostic Service and Patient Assessment

11.4 Management of Patients with Acute or Worsening Heart Failure Symptoms

11.5 Optimization of Heart Failure Treatment

11.6 Treatment of Reversible Causes of Heart Failure

11.7 Treatment of Concomitant Diseases

11.8 Multidisciplinary Care

References



Chapter 12 Hospitalization
Andrew Hannah

12.1 The Epidemiology of Hospitalization

12.2 The Aetiology of Heart Failure in Hospitalized Patients

12.3 Classification and Diagnosis of Acute Heart Failure

12.4 Causes and Precipitants of Hospitalization

12.5 Treatment of Acute Heart Failure

12.6 Management of the Common Cardiac Causes of Hospitalization for Heart Failure

12.7 Outcomes in Patients Hospitalized for Heart Failure

12.8 Strategies to Reduce Admissions and Readmissions in Patients with Heart Failure

References




Chapter 13 Models of Care and Disease Management Programmes

Martin Wilson and Stephen J. Leslie

13.1 Introduction

13.2 Disease Management Programmes

13.3 Disease Management Programmes: The Evidence

13.4 Guidelines and Critical Care Pathways

13.5 Remote and Rural Issues

13.6 Telecardiology in Heart Failure

13.7 Conclusions

References



Chapter 14 Palliative and Supportive care for Patients with Advanced and Terminal Heart Failure

Christopher Ward, Francis G. Dunn, Shona M.M. Jenkins and Martin Leiper

14.1 What is Palliative Care?

14.2 Age-Related Problems and the Provision of Palliative Care

14.3 Advanced and Terminal Heart Failure

14.4 Management of Specific Symptoms

14.5 Home and Hospital Care

14.6 Withdrawal of Conventional Drugs

14.7 The Palliative Care Needs of Heart Failure Patients

14.8 Palliative Care Strategies for Heart Failure

14.9 Timing the Introduction of Different Palliative Care Strategies

14.10 Cardiological Issues

14.11 The Management Implications of Advanced Heart Failure

14.12 Control of Symptoms Using Mostly Generic Treatments

14.13 Support in the Community: The Gold Standard Framework and Advanced Care Planning

14.14 Terminal Heart Failure: Identifying the Dying Patient and Providing End-of-Life Care

References