Michael A. Borger, MD, PhD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.
Tirone E. David, MD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.

Systolic murmurs in older adults require investigation with echocardiography. The most common cause is aortic sclerosis, which does not require therapy, followed by aortic stenosis. Surgery is indicated for aortic stenosis in patients with symptoms (fatigue, shortness of breath, angina and/or syncope) and in asymptomatic patients with left ventricular dysfunction or marked hypertrophy. Older aortic stenosis patients can undergo surgery with minimal increased risk, excellent long-term outcomes, and marked improvements in quality of life. Such patients may be referred directly to cardiac surgeons in order to limit age discrimination that may be present within the medical community.
Key words: aortic stenosis, congestive heart failure, aortic valve replacement, quality of life, outcomes.

Wilbert S. Aronow, MD, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY, USA.

The American College of Cardiology/American Heart Association guidelines recommend that patients with asymptomatic left ventricular systolic dysfunction or with congestive heart failure (CHF) be treated with angiotensin-converting enzyme (ACE) inhibitors plus beta-blockers unless there are contraindications to the use of these drugs. Beta-blockers have been demonstrated to significantly reduce all-cause mortality associated with abnormal or normal left ventricular ejection fraction in older and younger patients with CHF. An angiotensin receptor blocker should not be administered to patients with CHF who are being treated with a beta-blocker plus ACE inhibitor, but should be given to patients with CHF treated with beta-blockers who cannot tolerate ACE inhibitors due to cough, angioneurotic edema, rash or altered taste sensation.
Key words: congestive heart failure, left ventricular ejection fraction, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptors blockers.

This morning I saw three consults at the Toronto General Hospital for the typical geriatric reasons: they were not safe for discharge, can we make them better so they can go home, and they no longer need surgical attention.

However, one of the key underlying problems for each patient was cardiac function. The first patient had underlying left ventricular dysfunction, predominantly diastolic, with atrial fibrillation and she presented with acute cholecystitis. Her management was significantly altered because of her cardiac condition; she received percutaneous drainage rather than emergency cholecystectomy. The second patient had systolic left ventricular dysfunction with a grade III ventricle, and was further impaired after a new myocardial infarction. She was slow to recover post-mitral valve replacement and CABG x 4. The final patient was a long-term (10 years) liver transplant survivor who now had congestive heart failure (CHF) that was compromising her ability to return home.

Cardiac disease is still the most important cause of morbidity and mortality in older patients. Exertional angina pectoris is of course common, but it has much less impact on the quality of life than does heart failure. I would suspect that most primary care physicians manage several patients with CHF, and although modern treatments have improved the outcomes for these patients, they also have made the management much more complex. This issue of Geriatrics & Aging focuses on this crucial issue in older patients.

Although shortness of breath (SOB) is the hallmark of CHF, not all patients with SOB have CHF, and not all patients with CHF complain of SOB. In fact, the diagnosis can often be quite challenging. Making the diagnosis of CHF is one of the areas covered in Dr. William Kostuk’s article on “Initial Evaluation of the Older Patient with Suspected Heart Failure”. Drs. Ali Ahmed and Phillip Thornton review the “Pharmacological Management of Systolic Heart Failure in Older Adults”. Health care experts have been predicting a growing epidemic of older patients with CHF, so Jane Oshinowo’s article on “Maximizing Quality of Life and Optimizing Health Care Utilization by Older Adults with CHF” is particularly relevant. Our continuing medical education segment also focuses on CHF, as Dr. Wilbert Aronow reviews the “Evidence for the Use of Beta-blockers in Congestive Heart Treatment in Older Persons”. Even our Biology of Aging column this month is relevant to CHF: Dr. Michihisa Jougasaki discusses “Age-related Cardiorenal Changes and Predisposition to Congestive Heart Failure”. The careful reader will be completely up-to-date in managing CHF in older patients after reviewing these articles. However, the pace of change in cardiac treatments is so rapid that it is likely that we will be reviewing this topic once again in one or two years time.
Enjoy this issue.

D'Arcy Little, MD, CCFP, Academic Fellow, Department of Family and Community Medicine, University of Toronto, and Director of Medical Education, York Community Services, Toronto, ON.

Introduction
Congestive heart failure (CHF) is a serious common, condition. It qualifies as one of the most important contributors to cardiovascular morbidity and mortality in the developed world. Due to the burgeoning elderly population, as well as to new treatments for acute myocardial infarction which are allowing more patients to survive with impaired ventricular function, the incidence of CHF will continue to increase dramatically.¹ While significant improvements in CHF therapy have been made in the last few decades with the development of angiotensin-converting enzyme inhibitors (ACE inhibitors), as well as a clarification of the role of beta-blockers in therapy, additional strategies are still needed to further reduce progression of disease and consequent morbidity and mortality.^1,2 Angiotensin receptor blockers (ARB) may represent an additional approach to the treatment of CHF with the possibility for improved outcomes. Despite physiological explanations that would make such an assertion sound, significant supporting clinical data are currently lacking.

Congestive Heart Failure

Nariman Malik, BSc, MD
Contributing Author,
Geriatrics & Aging.

Congestive heart failure (CHF) is a condition that affects individuals of all ages but is predominantly a medical condition of the elderly. In the elderly, it reflects the consequences of age-related changes in the cardiovascular system compounded by an increasing prevalence of hypertension, coronary artery disease and valvular heart disease.¹ Heart failure is a complex clinical syndrome characterized by cardiac function that is inadequate to meet the circulatory demands of the body or only does so at abnormally elevated filling pressures.^2,3 The ventricular dysfunction is either systolic or diastolic. A wide variety of etiologies is involved in heart failure; however, the underlying cause is an inability of the heart to properly fill or empty the ventricle. In general, the etiologies of heart failure in the elderly are the same as those in younger patients, although the clinical presentation can be quite different.³

CHF is the leading cause of admissions to hospital in individuals over the age of 65.^2,4 In the United States, it is considered the most expensive cardiovascular disorder because of its high incidence and intensive use of medical resources; estimated costs related to this condition are in excess of $20 billion per year.

Michele Kohli, BSc

Congestive heart failure (CHF), a clinical syndrome caused by failure of the left or right ventricle, is a leading cause of chronic illness in older persons. In the United States, CHF is the most common cause of hospitalization among those aged 65 years and above. Each year, approximately 400,000 Americans are diagnosed with CHF. Few statistics regarding CHF in Canada have been compiled, but the Heart and Stroke Foundation estimates that 200,000 to 300,000 Canadians have the syndrome. The incidence of CHF appears to be increasing in both Canada and the United States.

An individual's risk of developing CHF increases exponentially as a person ages (See Figure 1), due to age-related changes in the heart structure and function. Physiological and pathological alterations affecting heart rate, preload, afterload and contractile states of the heart reduce cardiac output (See More Fat, Less Specialized Cells in Old Heart). Concurrent changes in the kidney, respiratory and nervous systems may further impair the function of the heart. Congestive heart failure is a syndrome with multiple etiologies.

Early diagnosis of CHF greatly improves the success of treatment.