Jane Oshinowo, RN(EC), BScN, PNC, Primary Health Care Nurse Practitioner, York Community Services, Staff Nurse, St. Michael’s Hospital, Toronto, ON.

Heart failure is a serious illness characterized by impaired quality of life, decreased survival and frequent hospitalization, which mainly affects older adults. As the population ages, there is concern that congestive heart failure-related costs will place an undue strain on the health care system unless more cost-effective management is implemented. Various multidisciplinary strategies researched have demonstrated improved quality of life, reduced hospitalization, a trend towards decreased mortality, and a potential for cost savings.
Key words: heart failure, quality of life, cardiac nurse, disease management, cost.

Ali Ahmed, MD, MPH, FACP, FACC, Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, Department of Epidemiology and International Health, School of Public Health and Geriatric Heart Failure Clinic, University of Alabama at Birmingham; Section of Geriatrics and Geriatric Heart Failure Clinic, VA Medical Center; and Alabama Heart Failure Project, Alabama Quality Assurance Foundation; Birmingham, AB, USA.
Phillip L. Thornton, PhD, CGP, FASCP, Department of Pharmacy Practice, Auburn University James I. Harrison School of Pharmacy and Department of Medicine, Division of Gerontology and Geriatric Medicine and Geriatric Heart Failure Clinic, University of Alabama at Birmingham; Birmingham, AB, USA.

Heart failure is common in older adults and is associated with high mortality and hospitalization rates, and is the only cardiovascular syndrome with increasing incidence and mortality. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers reduce mortality and hospitalization rates for heart failure patients with left ventricular systolic dysfunction. Unfortunately, these life-saving drugs continue to be underutilized. ACE inhibitors and beta-blockers should be prescribed to all eligible systolic heart failure patients. Generalist physicians, who care for most heart failure patients, are perfectly capable of prescribing these life-saving drugs to older adults with systolic heart failure and should be encouraged to do so.

William J. Kostuk MD, FRCPC, FACC, FACP, Professor of Medicine, University of Western Ontario; Cardiologist, University Campus London Health Sciences Centre, London, ON.

Heart failure is the most rapidly rising cardiovascular condition in Canada. At times, the clinical presentation of heart failure may not make the diagnosis obvious. The diagnosis of heart failure should be considered when an older individual presents with complaints of exertional dyspnea or fatigue. In such individuals, the physician should not assume the symptoms are merely the result of age, obesity or chest disease. Physical examination and a few simple investigations,reviewed here, can be extremely helpful and may delay or even prevent the progression to symptomatic disease.
Key words: heart failure, diagnosis, dyspnea, fatigue, evaluation in older adults.

Jagdish Butany, MBBS, MS, FRCPC and Manmeet S. Ahluwalia, MBBS, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.

With advancing age, the cardiovascular system undergoes subtle but progressive changes that result in altered function. The endocardium becomes thicker and opaque, left ventricular (LV) wall thickness increases and there is increased interstitial fibrosis in the myocardium. Although myocyte size increases, the number of myocytes decreases, as does the number of cells in the conduction system. The decrease in the filling rate of LV in early diastole is accompanied by a greater rate of filling in late diastole augmented by atrial contraction. Maximum achievable heart rate and ejection fraction (with exercise) decreases. All these changes make increasing age a significant independent risk factor for heart failure, the most common reason for hospitalisation in patients older than 65 years.
Key words: aging, cardiovascular disease, myocardium, fibrosis, heart failure.

Ali Ahmed, MD, MPH, FACP, Assistant Professor, Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine and Department of Epidemiology and International Health, School of Public Health, Scientist, Center for Aging and Center for Outcomes and Effectiveness Research and Education, University of Alabama at Birmingham; Staff Physician, Heart Failure Clinic and Section of Geriatrics, Veterans Affairs Medical Center; Member, Heart Failure Project, Alabama Quality Assurance Foundation, Birmingham, AL, USA.

Heart Failure: A Geriatric Syndrome
Heart failure (HF) is a "geriatric syndrome" as much as it is a "cardiac syndrome." The prevalence of HF in Canada is over 350,000 and between 25% and 40% of patients are dead within one year of diagnosis.¹ Most HF patients are 65 years of age and older,² and both the incidence and prevalence of HF increase with age.³ Over 90% of all HF-related deaths occur in persons 65 years of age and older.⁴ HF is the number one hospital discharge diagnosis for this group of patients.5 Diagnosis and management of HF in older adults is complicated by functional impairment, multiple comorbidities, polypharmacy and left ventricular systolic dysfunction (LVSD).^6,7

Historic Role of Digitalis in Heart Failure
Digitalis glycosides are present in the leaves of the foxglove, Digitalis purpurea (digitoxin) or Digitalis lanata (digoxin), or in the seeds of Strophanthus gratus (ouabain).

Tawfic Nessim Abu-Zahra, BSc, MSc

Presently, the standard therapy for heart failure consists of treatment with an angiotensin-converting enzyme (ACE) inhibitor, furosemide (Lasix) or other loop diuretic, and the possible use of a b-blocker or a positive inotropic agent such as digoxin (Lanoxin).¹ The goals of this therapy are to decrease blood volume, increase cardiac contractility and inhibit the neuroendocrine effects of the renin-angiotensin-aldosterone system (RAAS). Since ACE inhibition suppresses aldosterone release, treatment with ACE inhibitors was considered sufficient for blocking the effects of aldosterone in patients with heart failure.^1,2 Thus, the addition of the aldosterone receptor antagonist spironolactone (Aldactone) was considered unnecessary and, given the threat of hyperkalemia, continued to be contraindicated.1 However, contrary to this conventional view, results of the Randomized Aldactone Evaluation Study (RALES) have shown that spironolactone treatment can reduce morbidity and mortality in patients with severe heart failure.

Gene Therapy May Play a Role in Reversing Heart Failure

In a potential breakthrough, a study has shown that failing heart muscle cells loaded with a gene called SERCA2a begin acting normal again.

Dr. Roger J. Hajjar and colleagues harvested muscle cells from 10 failed hearts removed from patients who had received heart transplants. The team injected these heart cells with a virus (vector) carrying the gene that makes SERCA2a, allowing the gene to become part of the cell's genetic code. Within 24 hours the gene induced overproduction of SERCA2a allowing the failed heart cells to begin beating and contracting at levels similar to those seen in normal hearts.

These results support the premise that gene-based therapies may offer a new modality for treating heart failure. However, further research should be conducted to see if improving the ability of cells to contract could lead to an improvement in symptoms and increased rates of survival for patients with heart failure.

Source: Journal of the American Heart Association 1999;2308-2311.

Neil Fam, BSc, MSc

Heart failure can be defined as a pathophysiological syndrome in which the heart fails to pump an adequate flow of blood to meet the metabolic demands of the body. This condition carries extremely high morbidity and mortality, with a five year survival rate of 50%. It is also one of the most common reasons for hospital admission in Canada. As our population ages, heart failure is becoming increasingly prevalent, placing serious strain on health care resources. In the past decade, medications such as angiotensin converting enzyme (ACE) inhibitors have been shown to improve survival in patients with heart failure. However, mortality has remained high. New research has focused on the use of b-blockers, a class of drugs traditionally used in the treatment of angina and myocardial infarction. Recently, two large randomised trials, the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II) and the Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF) clearly demonstrated a survival benefit in heart failure patients taking b-blockers. This article summarizes the main findings of these studies and outlines the practical use of b-blockers in heart failure.

An understanding of the pathophysiology underlying heart failure is helpful in the selection of appropriate medical therapy.