Heart Failure Reviews

, Volume 17, Issue 4–5, pp 555–562 | Cite as

Heart failure with preserved ejection fraction in the elderly: scope of the problem

  • Ken Kaila
  • Mark J. Haykowsky
  • Richard B. Thompson
  • D. Ian Paterson
Article
First Online:

Abstract

Heart failure is an epidemic in the elderly and has become a leading cause for hospitalization and death. Heart failure with preserved ejection fraction (HFPEF) is more common than heart failure with reduced ejection fraction (HFREF) but disease identification remains challenging. Current criteria rely on symptoms of poor exercise tolerance, preserved ejection fraction and laboratory evidence for elevated filling pressures. Each of these clinical parameters is difficult to evaluate in the elderly and reduce the certainty of diagnosis. Aging is associated with changes in the peripheral vasculature, pulmonary function, oxygen transport and skeletal muscle function, all key determinants of exercise capacity. Furthermore, co-morbid conditions such as chronic obstructive pulmonary disease are common in the elderly and cloud the interpretation of symptoms. The choice of ejection fraction (EF) 45–50% as preserved appears arbitrary as there is evidence that the lower limit for EF in elderly women is much higher. B-type natriuretic peptide has emerged as a popular blood biomarker of heart failure and increased filling pressures but appears to have trouble discriminating HFPEF from normal elderly controls. Regardless of the difficulties in diagnosis, several population studies show that HFPEF incidence and prevalence are on the rise especially in those >70 years of age. Co-morbid diseases are common in HFPEF, and these patients often die from non-cardiac causes. Future studies need to emphasize a holistic approach to HFPEF and identify whether there are diagnostic or therapeutic targets outside of the heart.

Keywords

Heart failure with preserved ejection fraction Diagnosis Epidemiology Elderly Aging 
This is a preview of subscription content, log in to check access.

Notes

Acknowledgments

Drs. Paterson, Haykowsky and Thompson’s research on Heart Failure with Preserved Ejection Fraction is supported by the Canadian Institutes of Health Research (MOP 106551) and Alberta Innovates-Health Solutions (PAB01014).

Conflict of interest

Dr Ian Paterson has received study medication from Servier Canada Inc. Drs. Kaila, Haykowsky and Thompson have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS, Ganiats TG, Goldstein S, Gregoratos G, Jessup ML et al (2001) ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 38:2101–2113PubMedCrossRefGoogle Scholar
  2. 2.
    Liao L, Allen LA, Whellan DJ (2008) Economic burden of heart failure in the elderly. Pharmacoeconomics 26:447–462PubMedCrossRefGoogle Scholar
  3. 3.
    Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C et al (2010) Heart disease and stroke statistics-2010 update: a report from the American Heart Association. Circulation 121:e46–e215PubMedCrossRefGoogle Scholar
  4. 4.
    Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM (2006) Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 355:251–259PubMedCrossRefGoogle Scholar
  5. 5.
    Tribouilloy C, Rusinaru D, Mahjoub H, Souliere V, Levy F, Peltier M, Slama M, Massy Z (2008) Prognosis of heart failure with preserved ejection fraction: a 5 year prospective population-based study. Eur Heart J 29:339–347PubMedCrossRefGoogle Scholar
  6. 6.
    McCullough PA, Khandelwal AK, McKinnon JE, Shenkman HJ, Pampati V, Nori D, Sullivan RA, Sandberg KR, Kaatz S (2005) Outcomes and prognostic factors of systolic as compared with diastolic heart failure in urban America. Congest Heart Fail 11:6–11PubMedCrossRefGoogle Scholar
  7. 7.
    McDonald K (2008) Diastolic heart failure in the elderly: underlying mechanisms and clinical relevance. Int J Cardiol 125:197–202PubMedCrossRefGoogle Scholar
  8. 8.
    Heart Failure Society Of A (2006) HFSA 2006 comprehensive heart failure practice guideline. J Card Fail 12:e1–e2CrossRefGoogle Scholar
  9. 9.
    Paulus WJ, Tschope C, Sanderson JE, Rusconi C, Flachskampf FA, Rademakers FE, Marino P, Smiseth OA, De Keulenaer G, Leite-Moreira AF et al (2007) How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 28:2539–2550PubMedCrossRefGoogle Scholar
  10. 10.
    Betik AC, Hepple RT (2008) Determinants of VO2 max decline with aging: an integrated perspective. Appl Physiol Nutr Metab 33:130–140PubMedCrossRefGoogle Scholar
  11. 11.
    Haykowsky MJ, Ezekowitz JA, Armstrong PW (2004) Therapeutic exercise for individuals with heart failure: special attention to older women with heart failure. J Card Fail 10:165–173PubMedCrossRefGoogle Scholar
  12. 12.
    Fleg JL, Lakatta EG (1988) Role of muscle loss in the age-associated reduction in VO2 max. J Appl Physiol 65:1147–1151PubMedGoogle Scholar
  13. 13.
    Esposito F, Mathieu-Costello O, Shabetai R, Wagner PD, Richardson RS (2010) Limited maximal exercise capacity in patients with chronic heart failure: partitioning the contributors. J Am Coll Cardiol 55:1945–1954PubMedCrossRefGoogle Scholar
  14. 14.
    Mancini DM, Walter G, Reichek N, Lenkinski R, McCully KK, Mullen JL, Wilson JR (1992) Contribution of skeletal muscle atrophy to exercise intolerance and altered muscle metabolism in heart failure. Circulation 85:1364–1373PubMedGoogle Scholar
  15. 15.
    Wilson JR, Mancini DM, Dunkman WB (1993) Exertional fatigue due to skeletal muscle dysfunction in patients with heart failure. Circulation 87:470–475PubMedGoogle Scholar
  16. 16.
    Ershler WB, Sheng S, McKelvey J, Artz A, Denduluri N, Tecson J, Taub D, Brant LJ, Ferrucci L, Longo DL (2005) Serum erythropoietin and aging: a longitudinal analysis. J Am Geriatr Soc 53:1360–1365PubMedCrossRefGoogle Scholar
  17. 17.
    Sharma G, Goodwin J (2006) Effect of aging on respiratory system physiology and immunology. Clin Interv Aging 1:253–260PubMedCrossRefGoogle Scholar
  18. 18.
    Ware JH, Dockery DW, Louis TA, Xu XP, Ferris BG Jr, Speizer FE (1990) Longitudinal and cross-sectional estimates of pulmonary function decline in never-smoking adults. Am J Epidemiol 132:685–700PubMedGoogle Scholar
  19. 19.
    Pedersen F, Raymond I, Mehlsen J, Atar D, Hildebrandt PR (2005) Prevalence of diastolic dysfunction as a possible cause of dyspnea in the elderly. Am J Med 118:25–31PubMedCrossRefGoogle Scholar
  20. 20.
    Melenovsky V, Borlaug BA, Rosen B, Hay I, Ferruci L, Morell CH, Lakatta EG, Najjar SS, Kass DA (2007) Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction. J Am Coll Cardiol 49:198–207PubMedCrossRefGoogle Scholar
  21. 21.
    Cheng S, Xanthakis V, Sullivan LM, Lieb W, Massaro J, Aragam J, Benjamin EJ, Vasan RS (2010) Correlates of echocardiographic indices of cardiac remodeling over the adult life course: longitudinal observations from the Framingham Heart Study. Circulation 122:570–578PubMedCrossRefGoogle Scholar
  22. 22.
    Chung AK, Das SR, Leonard D, Peshock RM, Kazi F, Abdullah SM, Canham RM, Levine BD, Drazner MH (2006) Women have higher left ventricular ejection fractions than men independent of differences in left ventricular volume: the Dallas Heart Study. Circulation 113:1597–1604PubMedCrossRefGoogle Scholar
  23. 23.
    Kaku K, Takeuchi M, Otani K, Sugeng L, Nakai H, Haruki N, Yoshitani H, Watanabe N, Yoshida K, Otsuji Y et al. (2011) Age- and gender-dependency of left ventricular geometry assessed with real-time three-dimensional transthoracic echocardiography. J Am Soc EchocardiogrGoogle Scholar
  24. 24.
    Dokainish H, Sengupta R, Pillai M, Bobek J, Lakkis N (2008) Assessment of left ventricular systolic function using echocardiography in patients with preserved ejection fraction and elevated diastolic pressures. Am J Cardiol 101:1766–1771PubMedCrossRefGoogle Scholar
  25. 25.
    Persson H, Lonn E, Edner M, Baruch L, Lang CC, Morton JJ, Ostergren J, McKelvie RS (2007) Diastolic dysfunction in heart failure with preserved systolic function: need for objective evidence: results from the CHARM Echocardiographic Substudy-CHARMES. J Am Coll Cardiol 49:687–694PubMedCrossRefGoogle Scholar
  26. 26.
    Ingle L, Cleland JG, Clark AL (2008) Perception of symptoms is out of proportion to cardiac pathology in patients with “diastolic heart failure”. Heart 94:748–753PubMedCrossRefGoogle Scholar
  27. 27.
    Januzzi JL, Jr (2006) Natriuretic peptide testing: a window into the diagnosis and prognosis of heart failure. Cleve Clin J Med 73:149–152, 155–147Google Scholar
  28. 28.
    Fabbian F, De Giorgi A, Pala M, Tiseo R, Portaluppi F (2011) Elevated NT-proBNP levels should be interpreted in elderly patients presenting with dyspnea. Eur J Intern Med 22:108–111PubMedCrossRefGoogle Scholar
  29. 29.
    Goto T, Ohte N, Wakami K, Asada K, Fukuta H, Mukai S, Tani T, Kimura G (2010) Usefulness of plasma brain natriuretic peptide measurement and tissue Doppler imaging in identifying isolated left ventricular diastolic dysfunction without heart failure. Am J Cardiol 106:87–91PubMedCrossRefGoogle Scholar
  30. 30.
    Kitzman DW, Gardin JM, Gottdiener JS, Arnold A, Boineau R, Aurigemma G, Marino EK, Lyles M, Cushman M, Enright PL (2001) Importance of heart failure with preserved systolic function in patients > or =65 years of age. CHS Research Group. Cardiovascular Health Study. Am J Cardiol 87:413–419PubMedCrossRefGoogle Scholar
  31. 31.
    Barker WH, Mullooly JP, Getchell W (2006) Changing incidence and survival for heart failure in a well-defined older population, 1970–1974 and 1990–1994. Circulation 113:799–805PubMedCrossRefGoogle Scholar
  32. 32.
    Kalogeropoulos A, Georgiopoulou V, Psaty BM, Rodondi N, Smith AL, Harrison DG, Liu Y, Hoffmann U, Bauer DC, Newman AB et al (2010) Inflammatory markers and incident heart failure risk in older adults: the Health ABC (Health, Aging, and Body Composition) study. J Am Coll Cardiol 55:2129–2137PubMedCrossRefGoogle Scholar
  33. 33.
    Klapholz M, Maurer M, Lowe AM, Messineo F, Meisner JS, Mitchell J, Kalman J, Phillips RA, Steingart R, Brown EJ Jr et al (2004) Hospitalization for heart failure in the presence of a normal left ventricular ejection fraction: results of the New York Heart Failure Registry. J Am Coll Cardiol 43:1432–1438PubMedCrossRefGoogle Scholar
  34. 34.
    Lee DS, Gona P, Vasan RS, Larson MG, Benjamin EJ, Wang TJ, Tu JV, Levy D (2009) Relation of disease pathogenesis and risk factors to heart failure with preserved or reduced ejection fraction: insights from the Framingham heart study of the national heart, lung, and blood institute. Circulation 119:3070–3077PubMedCrossRefGoogle Scholar
  35. 35.
    Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, Carnethon MR, Dai S, de Simone G, Ford ES et al (2011) Heart disease and stroke statistics-2011 update: a report from the American Heart Association. Circulation 123:e18–e209PubMedCrossRefGoogle Scholar
  36. 36.
    Yoon SS, Ostchega Y, Louis T (2010) Recent trends in the prevalence of high blood pressure and its treatment and control, 1999–2008. NCHS Data Brief, pp 1–8Google Scholar
  37. 37.
    Bhatia RS, Tu JV, Lee DS, Austin PC, Fang J, Haouzi A, Gong Y, Liu PP (2006) Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med 355:260–269PubMedCrossRefGoogle Scholar
  38. 38.
    Tribouilloy C, Rusinaru D, Mahjoub H, Tartiere JM, Kesri-Tartiere L, Godard S, Peltier M (2008) Prognostic impact of diabetes mellitus in patients with heart failure and preserved ejection fraction: a prospective five-year study. Heart 94:1450–1455PubMedCrossRefGoogle Scholar
  39. 39.
    Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE (2001) Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 285:2370–2375PubMedCrossRefGoogle Scholar
  40. 40.
    Rusinaru D, Leborgne L, Peltier M, Tribouilloy C (2008) Effect of atrial fibrillation on long-term survival in patients hospitalised for heart failure with preserved ejection fraction. Eur J Heart Fail 10:566–572PubMedCrossRefGoogle Scholar
  41. 41.
    Braunstein JB, Anderson GF, Gerstenblith G, Weller W, Niefeld M, Herbert R, Wu AW (2003) Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure. J Am Coll Cardiol 42:1226–1233PubMedCrossRefGoogle Scholar
  42. 42.
    Hebert LE, Scherr PA, Beckett LA, Albert MS, Pilgrim DM, Chown MJ, Funkenstein HH, Evans DA (1995) Age-specific incidence of Alzheimer’s disease in a community population. JAMA 273:1354–1359PubMedCrossRefGoogle Scholar
  43. 43.
    Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA (2003) Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol 60:1119–1122PubMedCrossRefGoogle Scholar
  44. 44.
    Helzner EP, Scarmeas N, Cosentino S, Tang MX, Schupf N, Stern Y (2008) Survival in Alzheimer disease: a multiethnic, population-based study of incident cases. Neurology 71:1489–1495PubMedCrossRefGoogle Scholar
  45. 45.
    Havranek EP, Masoudi FA, Westfall KA, Wolfe P, Ordin DL, Krumholz HM (2002) Spectrum of heart failure in older patients: results from the National Heart Failure project. Am Heart J 143:412–417PubMedCrossRefGoogle Scholar
  46. 46.
    Heckman GA, Patterson CJ, Demers C, St Onge J, Turpie ID, McKelvie RS (2007) Heart failure and cognitive impairment: challenges and opportunities. Clin Interv Aging 2:209–218PubMedGoogle Scholar
  47. 47.
    McLennan SN, Pearson SA, Cameron J, Stewart S (2006) Prognostic importance of cognitive impairment in chronic heart failure patients: does specialist management make a difference? Eur J Heart Fail 8:494–501PubMedCrossRefGoogle Scholar
  48. 48.
    Fuat A, Hungin AP, Murphy JJ (2003) Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 326:196PubMedCrossRefGoogle Scholar
  49. 49.
    Cepoi V, Onofriescu M, Segall L, Covic A (2011) The prevalence of chronic kidney disease in the general population in Romania: a study on 60,000 persons. Int Urol NephrolGoogle Scholar
  50. 50.
    Halbert RJ, Natoli JL, Gano A, Badamgarav E, Buist AS, Mannino DM (2006) Global burden of COPD: systematic review and meta-analysis. Eur Respir J 28:523–532PubMedCrossRefGoogle Scholar
  51. 51.
    Zafrir B, Paz H, Wolff R, Salman N, Merhavi D, Lewis BS, Amir O (2011) Mortality rates and modes of death in heart failure patients with reduced versus preserved systolic function. Eur J Intern Med 22:53–56PubMedCrossRefGoogle Scholar
  52. 52.
    Henkel DM, Redfield MM, Weston SA, Gerber Y, Roger VL (2008) Death in heart failure: a community perspective. Circ Heart Fail 1:91–97PubMedCrossRefGoogle Scholar
  53. 53.
    Lee DS, Gona P, Albano I, Larson MG, Benjamin EJ, Levy D, Kannel WB, Vasan RS (2011) A systematic assessment of causes of death after heart failure onset in the community: impact of age at death, time period, and left ventricular systolic dysfunction. Circ Heart Fail 4:36–43PubMedCrossRefGoogle Scholar
  54. 54.
    Tehrani F, Phan A, Chien CV, Morrissey RP, Rafique AM, Schwarz ER (2009) Value of medical therapy in patients > 80 years of age with heart failure and preserved ejection fraction. Am J Cardiol 103:829–833PubMedCrossRefGoogle Scholar
  55. 55.
    Arias E (2010) United States life tables, 2006. Natl Vital Stat Rep 58:1–40Google Scholar
  56. 56.
    Zannad F, Agrinier N, Alla F (2009) Heart failure burden and therapy. Europace 11(Suppl 5):v1–v9PubMedCrossRefGoogle Scholar
  57. 57.
    Philbin EF, Rocco TA Jr, Lindenmuth NW, Ulrich K, Jenkins PL (2000) Systolic versus diastolic heart failure in community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors. Am J Med 109:605–613PubMedCrossRefGoogle Scholar
  58. 58.
    Yancy CW, Lopatin M, Stevenson LW, De Marco T, Fonarow GC (2006) Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. J Am Coll Cardiol 47:76–84PubMedCrossRefGoogle Scholar
  59. 59.
    Smith GL, Masoudi FA, Vaccarino V, Radford MJ, Krumholz HM (2003) Outcomes in heart failure patients with preserved ejection fraction: mortality, readmission, and functional decline. J Am Coll Cardiol 41:1510–1518PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Ken Kaila
    • 1
  • Mark J. Haykowsky
    • 3
  • Richard B. Thompson
    • 2
  • D. Ian Paterson
    • 1
  1. 1.Division of CardiologyUniversity of Alberta HospitalEdmontonCanada
  2. 2.Department of Biomedical EngineeringUniversity of AlbertaEdmontonCanada
  3. 3.Department of Rehab MedicineUniversity of AlbertaEdmontonCanada

Personalised recommendations