George A. Heckman, MD, MSc, FRCPC, Assistant Professor of Medicine, Department of Medicine, McMaster University, Hamilton, ON.
Robert S. McKelvie, MD, PhD, FRCPC, Professor of Medicine, Department of Medicine, McMaster University Hamilton, ON.

Heart failure (HF) is usually associated with reduced left ventricular ejection fraction, but approximately 50% of all patients with HF have a preserved ejection fraction. The mortality and morbidity associated with this condition, which may be the most common form of HF in older persons, is substantial and is on the rise. Currently, there are few evidence-based therapies demonstrated to be beneficial for this condition. The usual therapeutic recommendations consist of the aggressive management of the comorbidities and fluid balance associated with this form of HF. Disease management programs may improve outcomes among older persons with HF and preserved ejection fraction.
Key words: heart failure, diastolic dysfunction, preserved ejection fraction, treatment, clinical outcome.

Sonal Singh, MD, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Yoon K. Loke, MBBS, MD, University of East Anglia, School of Medicine, Health Policy and Practice, Norwich, UK.

Cardiovascular disease is the leading cause of mortality among older adults with type II diabetes. The thiazolidinediones (rosiglitazone and pioglitazone) lower blood sugar levels among individuals with type II diabetes. The thiazolidinediones have favourable effects on surrogate markers of cardiovascular disease such as microalbuminuria, carotid intimal thickness, and blood pressure. Emerging evidence from recent randomized clinical trials has confirmed both that thiazolidinediones increase the risk of heart failure, and that rosiglitazone increases the risk of myocardial infarction among those with type II diabetes. Clinicians should avoid thiazolidinediones for older individuals with type II diabetes who are at risk for cardiovascular events as the negative cardiovascular effects of the thiazolidinediones outweigh any potential benefits on surrogate markers.
Key words: thiazolidinediones, pioglitazone, rosiglitazone, heart failure, myocardial infarctions.

The burden of heart failure is rapidly rising. Heart failure is associated with substantial mortality, morbidity, and economic cost, which disproportionately affect older adults. Heart failure among older individuals is frequently complicated by geriatric syndromes, including frailty, functional decline, cognitive impairment, and atypical clinical presentations. Understanding the nature of these geriatric syndromes and their impact on the assessment and management of heart failure is a critical component to diagnosing and delivering appropriate care to these patients. In this article we review the geriatric aspects of heart failure.
Key words: geriatric syndrome, heart failure, older adults, diagnosis, frailty.

Indranil Dasgupta, MD, MPh, MBA, Clinical Assistant Professor of Medicine, Division of Cardiology, Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.
Marc A. Tecce, MD, Clinical Assistant Professor of Medicine, Division of Cardiology, Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.
Bernard L. Segal, MD, Professor of Medicine and Director, Division of Cardiology, Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.

Disorders of the mitral valve such as mitral valve prolapse (MVP), mitral regurgitation, and, to a lesser degree, mitral stenosis are relatively common forms of heart disease. According to the Women’s Heart Foundation, MVP is the most common condition of the heart valves, and while it is more frequently diagnosed in young women, data from the Framingham study suggest that, overall, MVP affects equal numbers of men and women. These conditions often progress over years, frequently causing symptoms among affected older adults. Understanding the etiology, diagnosis, management, and treatment of mitral valve disease is vital for this population. Medical advances and other factors have allowed the general population to live longer, making mitral valve disease significantly more prevalent. An understanding of the details of the physical exam, ECG changes seen in these disorders, x-ray findings, and echocardiographic and catheterization data are critical to providing the necessary standard of care for older adults.
Key words: mitral regurgitation, mitral stenosis, mitral valve prolapse, older adults, heart failure.

Silja Majahalme, MD, PhD, FESC, Cardiologist and Clinical Hypertension Specialist, Appleton Heart Institute/Appleton Cardiology Associates, Appleton, WI, USA.

Heart failure (HF) is an increasing problem in the older adult population, specifically among women. The majority of health care expenses are generated in the last few years of life, and hospitalization for HF is one of the major medical conditions influencing the expenditure. The nature of women’s HF differs from men: coronary artery disease is the most common etiologic factor for HF in men while women more often suffer from hypertensive heart disease, which results in stiffness of the left ventricle with relaxation problems, and diastolic HF. Most commonly there is a long history of poorly controlled hypertension. In acute situations these patients often present with florid edema and congestion along with significantly elevated blood pressure levels, which are both challenging to treat. This short review covers issues related to gender differences in etiology and epidemiology of HF, and evaluates current evidence for drug therapies.
Key words: epidemiology, heart failure, gender, myocardial infarction, hypertension.

Molly Thangaroopan, MD, FRCPC, Senior Fellow, Cardiology (Echocardiography), University Health Network, Toronto, ON.
Anusha Jegatheeswaran, MD, Resident, Cardiac Surgery, University of Toronto, University Health Network, Toronto, ON.
Vivek Rao, MD, FRCPC, Staff Surgeon and Associate Professor, University of Toronto, University Health Network, Toronto, ON.
Jagdish Butany, MBBS, MS, FRCPC, Staff Pathologist, University Health Network, Professor, University of Toronto, Toronto, ON.

Deaths from cardiovascular diseases have been declining in many countries; however, the incidence and prevalence of heart failure continues to increase in most countries. This is related, at least in part, to the increasing proportion of older people, a fact that is emphasized by the nearly three-fold increase in the incidence of heart failure in women. Good medical treatments are now available, and for refractory cases there are increasing numbers of surgical interventions available and new ones being devised. The morbidity and mortality associated with heart failure are higher than those associated with any other chronic condition. This article addresses the basis of heart failure, its appropriate management, and some of the newer treatments available.
Key words: heart failure, therapy, surgical treatment, ventricular assist devices.

Diego H. Delgado, MD, Division of Cardiology and Transplant, Toronto General Hospital, Toronto, ON.

The incidence of heart failure is rising rapidly, and it is currently the most common cardiovascular disease. Approximately 20–40% of patients with heart failure have preserved left ventricular systolic function, and an impairment of ventricular relaxation is considered the primary cause. There is controversy surrounding the definition of diastolic dysfunction and the diagnostic criteria for diastolic heart failure. Moreover, there are few studies on therapy for diastolic heart failure, which makes the management of these patients a real challenge.

Key words: heart failure, treatment, diagnosis, diastolic dysfunction.

Robert E. Hobbs, MD, The Kaufman Center for Heart Failure, Department of
Cardiology, Cleveland Clinic Foundation, Cleveland, OH, USA.

Guidelines for managing heart failure recommend angiotension-converting enzyme (ACE) inhibitors, beta-blockers, diuretics, digoxin, and aldosterone antagonists as standard therapy in order to improve morbidity and mortality. Angiotensin receptor blockers (ARBs) are considered second-line agents for patients who are intolerant of ACE inhibitors due to cough or angioedema. Because ACE inhibitors do not completely block the formation of angiotensin II and aldosterone, add-on therapy with an ARB has been evaluated in several clinical trials. In general, the results were mixed. Combination therapy with an ACE inhibitor and an ARB may improve morbidity and probably mortality, but with an increased incidence of hypotension, hyperkalemia, and azotemia. This approach could be considered in patients who remain symptomatic despite optimal doses of standard agents.

Key words: angiotensin receptor blockers, ACE inhibitors, heart failure, vasodilators, hyperkalemia.

Michihisa Jougasaki, MD, PhD, Institute for Clinical Research, National Hospital Kyushu Cardiovascular Center, Kagoshima, Japan.

Congestive heart failure (CHF) has become an increasingly important health care issue in the older population. The prevalence of cardiovascular diseases such as hypertension, coronary artery disease and valvular heart disease increase with advancing age. In addition, age-related structural and functional changes in the cardiovascular system, such as impaired ventricular diastolic relaxation, altered energy metabolism, decreased sympathetic nervous activities and increased systemic vascular resistance, predispose older people to the development of CHF. Renal function decreases in older people, and the adequacy of renal function is important in delaying progression of CHF. Renal condition should be carefully monitored to prevent adverse effects in the treatment of CHF in older patients.

Key words: heart failure, renal function, aging, heart, kidney.