Symptoms and treatment of heart failure in the elderly: we detect it in a timely manner! Prevention of diseases of the cardiovascular system

Some changes in the heart and blood vessels usually occur with age, but there are many other changes that are common age-related factors that can lead to heart disease if left untreated.

The heart has two sides - the atria. The right atrium pumps blood to the lungs to take in oxygen and get rid of carbon dioxide. The left atrium delivers oxygen-rich blood to the body.

Blood flows from the heart through arteries, which branch out and get smaller and smaller as they travel through the tissues. In tissues, they become small capillaries.

Capillaries are where the blood delivers oxygen and nutrients to the tissues and also receives carbon dioxide and waste products back from the tissues. The vessels then begin to gather together in large veins that return blood to the heart.

Age-related changes in the heart

The heart has a natural pacing system that controls the heartbeat. In some of the pathways of such a system, fibrous tissue and fatty deposits (cholesterol) can develop. The heart muscle loses some of its cells.

These changes can cause your heart rate to slow down.

A slight increase in the size of the heart, especially the left ventricle, is not uncommon. The wall of the heart thickens, so the amount of blood the chamber can hold may actually decrease despite an increase in the overall size of the heart. The heart may fill with blood more slowly.

Cardiac changes cause, as a rule, a change in the ECG. The ECG of normal, healthy older adults will differ slightly from that of healthy young adults. Abnormal rhythms (arrhythmias), such as atrial fibrillation, are more common in older people. They may be caused by heart disease.

Normal changes in the heart also refer to the accumulation of the "ageing pigment" lipofuscin in it. Cardiac muscle cells degenerate a little. The valves inside the heart that control the direction of blood flow thicken and become stiffer. Heart murmurs are caused by valve stiffness quite often in the elderly.

Age-related changes in blood vessels

Receptors called baroreceptors control blood pressure and make changes to help the body keep blood pressure relatively constant when a person changes position or pace of activity. Baroreceptors become less sensitive with aging. This may explain why many older people suffer from orthostatic hypotension, a condition in which blood pressure drops when a person moves from lying or sitting to standing. This leads to dizziness because the blood flow to the brain is reduced.

The walls of the capillaries are slightly thickened. This can lead to somewhat slower metabolism and waste.

The heart's main artery (aorta) becomes thicker, stiffer, and less flexible. This is probably due to changes in the connective tissue of the walls of blood vessels. This contributes to the increase blood pressure and makes the heart work harder, which can lead to thickening of the heart muscle (hypertrophy). Other arteries also thicken and become stiffer. In general, most older adults experience mild increases in blood pressure.

Age-related changes in the blood

The blood itself changes slightly with age. Normal aging leads to a decrease in the total amount of water in the body. As part of this, the fluid involved in the bloodstream decreases, so the blood volume decreases somewhat.

The number of red blood cells in the blood (and, accordingly, hemoglobin and hematocrit) are reduced. This contributes to rapid fatigue. Most white blood cells remain at the same level, although some white blood cells that are responsible for immunity (lymphocytes) decrease in number, reducing their ability to fight bacteria. This reduces the body's ability to fight infection.

The influence of age-related changes

Under normal circumstances, the heart continues to supply enough blood to all parts of the body. However, the aging of the heart may somewhat reduce the ability to tolerate increased loads, because due to age-related changes, the possibility of additional pumping of blood into the heart has decreased, thus, the reserve functions of the heart have become lower.

Some factors that can increase the workload on the heart include:

Some medicines
- Emotional stress
- Extreme physical activity
- Disease
- Infections
- Injuries

Angina pectoris (chest pain caused by a temporary decrease in blood flow to the heart muscle), shortness of breath on exertion, and heart attacks can lead to coronary heart disease.

May occur Various types abnormal heart rhythms (arrhythmia).

Anemia is also possible, it is associated with malnutrition, chronic infections, loss of blood from gastrointestinal tract, or with complications of other diseases or side effects various medicines.

Atherosclerosis (hardening of the arteries) is very common. Fat deposits(cholesterol plaques) inside the blood vessels cause them to constrict and can completely block blood vessels.

Heart failure is also very common among the elderly. In people over the age of 75, congestive heart failure is 10 times more common than in young adults.

Ischemic heart disease is quite common, very often as a result of atherosclerosis.

Diseases of the heart and blood vessels are also quite common in older people. Common disorders include high blood pressure and orthostatic hypotension.

Heart valve disease is quite common. Aortic stenosis, or narrowing of the aortic valve, is the most common valve disease in the elderly.

A transient ischemic attack (TIA) or stroke can occur if blood flow to the brain is interrupted.

Other problems with the heart and blood vessels include the following:

blood clots
- Deep vein thrombosis
- Thrombophlebitis
- Diseases of the peripheral vessels, resulting in intermittent pain in the legs when walking (lameness)
- Varicose veins

Prevention of age-related changes in the cardiovascular system

You can help your circulatory system (heart and blood vessels). Cardiovascular disease has risk factors that you should control and try to reduce:

High blood pressure,
- cholesterol level,
- diabetes,
- obesity
- smoking.

Eat heart-healthy foods that are low in saturated fat and cholesterol, and control your weight. Follow your doctor's recommendations for treating high blood pressure, high level cholesterol or diabetes. Reduce tobacco consumption, or quit smoking altogether.

Exercise can help prevent obesity, and it helps people with diabetes control their blood sugar levels. Exercise can help you maintain your abilities for as long as possible and reduce stress.

Regular check-ups and examinations of your heart are necessary:

Check your blood pressure. If you have diabetes, heart disease, kidney disease, or other conditions, your blood pressure should be checked more closely.
- If your cholesterol level is normal, you should recheck it every 5 years or more often. If you have diabetes, heart disease, kidney disease, or other conditions, your cholesterol levels should be checked more closely.
- Moderate physical exercise are one of the best things you can do to keep your heart and the rest of your body healthy for as long as possible. Please consult with your physician before starting new program exercises.
- Exercise moderately and within your capacity, but do it regularly.
- People who eat less fat and smoke less tend to have fewer blood pressure problems and less heart disease than those who smoke fatty foods.

Question: What advice can you give to people who want to lose weight?

Answer: Hello, Ksenia Sergeevna! We talk about moderation all the time. I don't think people know what moderation is. You can eat foods that you really like, but eat a little less of them. It is not necessary to completely abandon them. Don't even think about giving them up! Better try to diversify your favorite dishes with others that are no less tasty and healthy.

Question: Doctor, have you ever violated your diet?

Answer: Hello Alexandra! I became a nutritionist not because I love learning about nutrients, but because I love to eat. Ironically, when I was writing an article about stomach shrinkage, my own stomach was getting bigger. I gained 9 kilos! My cholesterol level was 238! I realized that I was not following my own recommendations. I received alarm signal after checking cholesterol levels. In a month I lost 5 kilos and my cholesterol dropped to 168. key role playing a plate of healthy oatmeal, which I consumed every morning. I added a handful of almonds, pistachios, walnuts, pecans, as well as some cherries, raspberries, pomegranate. Every day I ate this healing food. In addition, I ate three pieces of oily fish a week. I also worked physical activity half an hour every day. What is very important - I did not refuse any of my favorite dishes. In fact, on the day I was going to check my cholesterol again, I stopped by my friend, who cooked a dinner of pork chop and various sauces. I ate one chop and realized that it might not be the best good idea the day I'm going to check my cholesterol. But the most interesting thing was that my cholesterol level dropped by 70 points. Imagine what my cholesterol level would have been if I hadn't eaten a pork chop before!

Question: What is your opinion on hormones and menopause? Do they slow down aging?

Answer: Good day! The concept of estrogen replacement therapy is based on this. The only difficulty lies in the side effects of this concept, which potentially increase women's risk of developing heart disease. There are estrogen-rich foods that can help keep skin nice and soft. soy is good source these substances. Beans and legumes are generally high in phytoestrogens. Flax is also a source of these substances. The main thing is that these foods should be consumed throughout your life, and not wait until you are 50 years old. Start eating these foods from childhood, but in moderation. Many people believe that the more soy or other foods they eat, the healthier they will be. In Japanese culture, for example, soy is not a staple food. A handful of green soybeans and a small amount of tofu will suffice. You don't have to eat a whole kilo of tofu. A lot doesn't mean it's useful.

Question: How strongly do genetic data influence the aging process? Can you do something to control your genes?

The population in developed countries is steadily aging, gradually increasing specific gravity cardiovascular diseases (CVD) in the structure of morbidity. And the number of elderly patients at the appointment with a cardiologist is gradually increasing.

Most common cardiovascular disease in the elderly

Most often, older people are affected by:

• cardiac ischemia;
• arterial hypertension;
• stenosing atherosclerosis of the main arteries;
• violation of the heart rhythm.

The position of cardiologists

In the course of numerous clinical studies, it has been proven that the age of the patient cannot be an obstacle to the active medical and surgical treatment of most cardiovascular diseases. Moreover, the treatment of these diseases in the elderly is more often more effective than in middle-aged and young people.

As for other age groups, the main goal of curing the elderly is:

• improve the quality of human life;
• increase the life expectancy of the patient.

It is important to note that for a doctor who is familiar with the basics of geriatrics, who is well aware of the features of clinical pharmacology in the elderly, in most cases both of these goals are achievable.

Stable ischemic heart disease in the elderly

The elderly make up the majority of patients suffering from coronary heart disease. Nearly three-quarters of deaths from this disease occur in people over 65 years of age. Nearly eighty percent of people who die from myocardial infarction are in this age group. In more than fifty percent of cases, the death of people over 65 years of age occurs from complications of coronary artery disease.

Chronic heart failure currently affects at least two percent of the population in developed countries. Every year heart chronic insufficiency develops in 1% of people over 60 years of age and in 10% of people over 75 years of age. Elderly patients, in the event of the appearance of this disease, are prescribed:

• inhibitors;
• b-blockers;
• diuretics;
• spironolactone.

With the syndrome of weakness of the sinus node, intracardiac blockades, they resort to the implantation of a pacemaker. For the successful cure of the disease in the elderly, it is important to timely identify and eliminate or correct concomitant diseases, which are often latent and asymptomatic. This means in particular:

• exhaustion;
• thyroid dysfunction;
• anemia;
• liver disease;
• metabolic disorders;
• kidney disease, etc.

Doctors are convinced that the risk of complications in the case of planned invasive studies in the elderly is higher than in the young, but to a small extent. That's why elderly age should not become an obstacle to referring patients for coronary angiography, which will help diagnose and treat the disease.

From prenatal development to old age, there are age features of cardio-vascular system. Every year there are new changes that ensure the normal functioning of the body.

The aging program is embedded in the human genetic apparatus, which is why this process is an invariable biological law. According to gerontologists real term life expectancy is 110-120 years, but this moment depends only on 25-30% of inherited genes, everything else is an influence environment which affects the fetus while still in the womb. After birth, you can add ecological and social conditions, health status, etc.

If you add everything together, not everyone can live more than a century, and there are reasons for that. Today we will consider the age-related features of the cardiovascular system, since the heart with numerous vessels is the “engine” of a person, and life is simply impossible without its contractions.

How does the fetal cardiovascular system develop in the womb?

Pregnancy is a physiological period during which a new life begins to form in a woman's body.

All intrauterine development can be divided into two periods:

• embryonic– up to 8 weeks (embryo);
• fetal- from 9 weeks to childbirth (fetus).

The heart of the future man begins to develop as early as the second week after the fertilization of the egg by the spermatozoon in the form of two independent heart germs, which gradually merge into one, forming a semblance of a fish heart. This tube grows rapidly and gradually moves down into the chest cavity, where it narrows and bends, taking on a certain shape.

At week 4, a constriction is formed, which divides the organ into two sections:

• arterial;
• venous.

At week 5, a septum appears, with the help of which the right and left atrium appears. It is at this time that the first pulsation of a single-chamber heart begins. At week 6, heart contractions become more intense and clearer.

And by the 9th week of development, the baby has a full-fledged four-chamber human heart, valves and vessels for moving blood in two directions. The complete formation of the heart ends at week 22, then only the muscle volume increases and the vascular network expands.

You need to understand that such a structure of the cardiovascular system implies some distinctive features:

1. Prenatal development is characterized by the functioning of the "mother-placenta-child" system. Oxygen, nutrients, as well as toxic substances enter through the umbilical vessels ( medications, alcohol breakdown products, etc.).
2. Only 3 channels work - an open oval ring, botalla (arterial) and arantia (venous) duct. This anatomy creates parallel blood flow as blood flows from the right and left ventricles to the aorta and then through the systemic circulation.
3. Arterial blood from the mother to the fetus goes through the umbilical vein, and saturated with carbon dioxide and metabolic products returns to the placenta through 2 umbilical arteries. Thus, it can be concluded that the fetus is supplied with mixed blood when, as after birth, arterial blood flows strictly through the arteries, and venous through the veins.
4. The pulmonary circulation is open, but a feature of hematopoiesis is the fact that oxygen is not wasted on the lungs, which during intrauterine development do not perform the function of gas exchange. Although not accepted a large number of blood, but this is due to the high resistance created by non-functioning alveoli (respiratory structures).
5. The liver receives about half of the total blood delivered to the baby. Only this organ boasts the most oxygenated blood (about 80%), while others feed on mixed blood.
6. It is also a feature that the blood contains fetal hemoglobin, which differs best ability bind with oxygen. This fact is connected with the special sensitivity of the fetus to hypoxia.

It is this structure that allows the baby to receive vital oxygen with nutrients from the mother. The development of the baby depends on how well a pregnant woman eats and leads a healthy lifestyle, and the price, mind you, is very high.

Life after birth: features in newborns

Termination of the connection between the fetus and the mother begins immediately with the birth of the baby and as soon as the doctor bandages the umbilical cord.

1. With the first cry of the baby, the lungs open and the alveoli begin to function, reducing resistance in the pulmonary circulation by almost 5 times. In this regard, the need for the arterial duct stops, as it was necessary before.
2. The heart of a newborn baby is relatively large and equals approximately 0.8% of body weight.
3. The mass of the left ventricle is greater than the mass of the right.
4. A full circle of blood circulation is carried out in 12 seconds, and blood pressure averages 75 mm. rt. Art.
5. The myocardium of the born baby is presented in the form of undifferentiated syncytium. Muscle fibers are thin, do not have transverse striation and contain a large number of nuclei. Elastic and connective tissue is not developed.
6. From the moment the pulmonary circulation is launched, active substances are released that provide vasodilatation. Aortic pressure significantly exceeds compared with the pulmonary trunk. Also, features of the neonatal cardiovascular system include closure of bypass shunts and overgrowth of the annulus ovale.
7. After birth, the subpapillary venous plexuses are well developed and located superficially. The walls of the vessels are thin, elastic and muscle fibers are poorly developed in them.

Attention: the cardiovascular system has been improving for a long time and completes its full formation in adolescence.

What changes are typical for children and adolescents

The most important function of the circulatory organs is to maintain a constancy of the body's environment, supply oxygen and nutrients to all tissues and organs, excretion and removal of metabolic products.

All this happens in close interaction with the digestive, respiratory, urinary, vegetative, central, endocrine system etc. Growth and structural changes in the cardiovascular system are especially active in the first year of life.

If we talk about the features in children's, preschool and teenage years, the following distinguishing features can be distinguished:

1. By 6 months, the mass of the heart is 0.4%, and by 3 years and beyond, about 0.5%. The volume and mass of the heart increases most intensively in the first years of life, as well as in adolescence. In addition, it happens unevenly. Up to two years, the atria grow more intensively, from 2 to 10 years, the entire muscular organ as a whole.
2. After 10 years, the ventricles increase. The left one is also growing faster than the right one. Speaking about the percentage ratio of the walls of the left and right ventricles, the following figures can be noted: in a newborn - 1.4: 1, at 4 months of life - 2: 1, at 15 years old - 2.76: 1.
3. All periods of growing up in boys, the size of the heart is larger, with the exception of from 13 to 15 years old, when girls begin to grow faster.
4. Up to 6 years, the shape of the heart is more rounded, and after 6 it acquires an oval, characteristic of adults.
5. Up to 2-3 years, the heart is located in a horizontal position on an elevated diaphragm. By the age of 3-4, due to an increase in the diaphragm and its lower standing, the heart muscle acquires oblique position with a simultaneous flip around the long axis and the location of the left ventricle forward.
6. Up to 2 years, the coronary vessels are located according to the loose type, from 2 to 6 years they are distributed according to the mixed type, and after 6 years the type is already main, characteristic of adults. The thickness and lumen of the main vessels increase, and the peripheral branches are reduced.
7. In the first two years of a baby's life, differentiation and intensive growth myocardium. A transverse striation appears, muscle fibers begin to thicken, a subendocardial layer and septal septa are formed. From 6 to 10 years of age, the gradual improvement of the myocardium continues, and as a result, the histological structure becomes identical to adults.
8. Up to 3-4 years, the instruction for the regulation of cardiac activity involves the innervation of the nervous sympathetic system, which is associated with physiological tachycardia in babies of the first years of life. By the age of 14-15, the development of the conductor system ends.
9. Children early age have a relatively wide lumen of the vessels (in adults 2 times already). Arterial walls are more elastic and that is why the rate of blood circulation, peripheral resistance and blood pressure are lower. Veins and arteries grow unevenly and do not match the growth of the heart.
10. Capillaries in children are well developed, the shape is irregular, tortuous and short. With age, they settle deeper, elongate and take on a hairpin shape. The permeability of the walls is much higher.
11. By the age of 14, a full circle of blood circulation is 18.5 seconds.

The heart rate at rest will be equal to the following figures:

Heart rate according to age. You can learn more about the age-related characteristics of the cardiovascular system in children from the video in this article.

Cardiovascular system in adults and the elderly

Age classification according to WHO is equal to the following data:

1. Young age from 18 to 29 years.
2. Mature age from 30 to 44 years.
3. Average age from 45 to 59 years old.
4. Elderly age from 60 to 74 years.
5. Senile age from 75 to 89 years.
6. Long-livers from 90 years and older.

All this time, cardiovascular work is undergoing changes and has some features:

1. During the day, the heart of an adult pumps more than 6,000 liters of blood. Its dimensions are equal to 1/200 of the body part (for men, the mass of the organ is about 300 g, and for women, about 220 g). The total volume of blood in a person weighing 70 kg is 5-6 liters.
2. The heart rate in an adult is 66-72 beats. in min.
3. At the age of 20-25, the valve flaps thicken, become uneven, and in the elderly and senile age, partial muscle atrophy occurs.
4. From the age of 40, calcium deposits begin, at the same time, atherosclerotic changes in the vessels progress (see), which leads to a loss of elasticity of the blood walls.
5. Such changes entail an increase in blood pressure, especially this trend is observed from the age of 35.
6. With aging, the number of red blood cells decreases, and, consequently, hemoglobin. As a result, you may experience drowsiness fast fatiguability, dizziness.
7. Changes in the capillaries make them permeable, which leads to a deterioration in the nutrition of body tissues.
8. With age, myocardial contractility also changes. In adults and the elderly, cardiomyocytes do not divide, so their number may gradually decrease, and connective tissue is formed at the site of their death.
9. The number of cells of the conducting system begins to decrease from the age of 20, and in old age their number will be only 10% of the original number. All this creates the prerequisites for the violation of the rhythm of the heart in old age.
10. Starting from the age of 40, the efficiency of the cardiovascular system decreases. Increases endothelial dysfunction, both in large and small vessels. This affects changes in intravascular hemostasis, increasing the thrombogenic potential of the blood.
11. Due to the loss of elasticity of large arterial vessels, cardiac activity becomes less and less economical.

Features of the cardiovascular system in the elderly are associated with a decrease in the adaptive capacity of the heart and blood vessels, which is accompanied by a decrease in resistance to adverse factors. It is possible to ensure maximum life expectancy by preventing the occurrence of pathological changes.

According to cardiologists, in the next 20 years, diseases of the cardiovascular system will determine almost half of the mortality of the population.

Attention: for 70 years of life, the heart pumps about 165 million liters of blood.

As we can see, the features of the development of the cardiovascular system are really amazing. It is amazing how clearly nature has planned all the changes to ensure normal human life.

To prolong your life and provide happy old age must adhere to all recommendations for healthy lifestyle life and heart health.

The title of the article may be bewildering for a practitioner, because both in the clinic and in the hospital, heart failure (HF) occurs mainly in elderly patients. Accordingly, why talk about the “features” of managing this category of patients, if they constitute the dominant cohort of patients with HF?

Indeed, HF is a disease whose relevance increases significantly with age. Despite the enormous achievements of medical science in the field of cardiology, the prevalence of heart failure is constantly growing, primarily due to the increase in life expectancy of people, including those with cardiovascular diseases. As a result, in modern society a significant proportion of people over 60-65 years of age suffer from heart failure of one severity or another, while a few decades ago many of them would have simply died from the underlying cardiovascular disease in more young age.

In this regard, a somewhat paradoxical situation arises - although HF prevails in elderly patients, practitioners are poorly versed in the features of managing elderly patients, especially those with the most problematic age group– 75-80 years and older. Even doctors of the “older generation” did not see elderly patients with HF so often, they met with them mainly in the hospital, regarding acute decompensation and end-stage HF, and the treatment of such patients was mainly symptomatic. Today, cardiologists diagnose HF on early stages, including asymptomatic HF and HF with preserved left ventricular (LV) function, and have been managing such patients for many years using pathogenetic treatment that has proven to have a serious beneficial effect on patient survival. Therefore, the questions of how to properly treat an elderly patient with HF are becoming increasingly relevant in order to provide him with a decent quality of life and its maximum duration, but at the same time avoid numerous side effects associated with aggressive multiple therapy. different drugs in older patients (usually with a large number of concomitant diseases and risk factors).

At the same time, foreign scientists are increasingly differentiating elderly patients with HF into two conditional subgroups - "younger" age (up to 75 years) and the elderly (≥75 years). While “younger” older people are being actively studied in various clinical trials, older patients are most often simply not included in them. However, this category of patients is becoming more common, it requires adequate treatment, which probably has a number of important features, and significant gaps in our knowledge about this are becoming increasingly apparent.

Let us consider the data covered in the reviews of foreign authors on this topic over the past few years.

Risks of HF in the elderly: key figures and trends

The frequency of HF increases sharply in men and women after 40-50 years, reaching a significant value among individuals old age(over 75-80 years old). If in the general population HF occurs in 2-3% of the population, then in people aged about 70 years, the frequency of this pathology increases several times and reaches an average of 10%, and over the next decade of life, the prevalence of HF has time to double and among 80-year-olds is almost 20%. The average age of HF patients is 75 years. Moreover, if at a younger age the risk of heart failure (as well as cardiovascular disease in general) in women is relatively low compared to men, then in old age the prevalence of heart failure in men and women is approximately the same.

The figure shows the distribution of the incidence of HF among individuals different ages and gender according to the annual report of the American Heart Association (AHA), which includes key statistics and trends in the epidemiology of cardiovascular and cerebrovascular diseases (2009) .

Numerous studies and registries unequivocally indicate an increase in the prevalence of HF among older people in last years(H. Johansen et al., 2003; J.M. Arnold et al., 2006, etc.). This is due to a number of reasons, primarily the significant advances in practical cardiology in the treatment of cardiovascular diseases and the reduction in the risk of death of many cardiac patients at a younger age. As a result, although cardiopathology causes fewer deaths and acute cardiovascular events, it more often leads to a gradual decrease in the functionality of the cardiovascular system, which, in light of the increase in life expectancy of people, means an increase in the number of elderly patients with heart failure. This is the inevitable today. flip side medals in the achievements of modern medicine.

For the same reason, HF is one of the leading causes of hospitalization among the elderly. The reason for inpatient treatment can be both acute HF due to the underlying cardiovascular pathology, and manifestations of the progression of chronic HF with a gradual increase in decompensation. As a result, the treatment of HF in the elderly is becoming an increasingly costly health care item for society.

Thus, the geriatric problems of heart failure are currently among the key aspects of modern cardiology and practical healthcare in general.

Current issues of HF in the elderly

There is reason to believe that in elderly patients with HF, as well as cardiovascular diseases in general, has a number clinical features which requires a special approach to the management of such patients. Symptoms of HF in the elderly are often atypical, masked by comorbidities ( chronic diseases respiratory system, chronic renal dysfunction, coronary heart disease, peripheral vascular disease, anemia, metabolic disorders, etc.), as well as natural age-related changes(decreased tolerance to physical activity, weight loss due to dystrophic processes, age-related features of the cardiovascular system), so the diagnosis of heart failure in such patients is difficult.

Older people, even without known cardiovascular pathology, usually have an increase in arterial wall stiffness, increased arterial pressure lability (according to A. Sclater, K. Alagiakrishnan, 2004, orthostatic hypotension occurs in a third of all patients over 65 years of age), a tendency to bradycardia, sclerotic and fibrosing processes in the myocardium and vascular walls, a decrease in cardiac output and deterioration in other functional parameters, especially during exercise. Against the background of these changes, age-related disorders of glomerular filtration in the kidneys and a decrease in the functional abilities of the respiratory system additionally contribute to stagnant processes in peripheral tissues and lungs.

However old man with HF without comorbidity is extremely rare. In this case, as a rule, one has to deal with multiple concomitant diseases of various organs and systems. According to J.B. Braunstein et al. (2003) at least two thirds of all patients with HF, in addition to the main cardiovascular pathology that caused HF, also have ≥2 concomitant diseases of a non-cardiac nature; more than 25% of patients, while the number of such concomitant diseases is at least 6. The most common non-cardiac comorbidities are renal dysfunction, anemia, chronic obstructive pulmonary disease (COPD), depression, arthritis, neurological and metabolic disorders. This must be taken into account both when assessing the patient's condition and when developing a treatment regimen. Some of these diseases are directly independent risk factors that adversely affect the prognosis of a patient with HF (for example, kidney failure, anemia), others indirectly complicate the management of the patient by masking or exacerbating symptoms, worsening the results of some diagnostic tests, reducing the functional abilities of the body and requiring therapy that is contraindicated in HF or causes undesirable side effects. In addition, for a number of reasons, elderly patients are particularly susceptible to cachexia, which is associated with an extremely poor prognosis in HF (often worse than in malignant neoplasms).

Due to cerebrovascular pathology, which very often occurs in elderly patients, as well as due to a decrease in cognitive abilities, memory, a critical attitude towards themselves and their well-being, due to depression and other psychoneurological reasons, elderly patients underestimate the symptoms or cannot correctly present their complaints and anamnesis to the doctor. For the same reason, as a rule, compliance worsens significantly.

Experts from the European Society of Cardiology (ESC) also note that older people are more likely to have heart failure with preserved LV ejection fraction (EF), which further complicates diagnosis and requires special approaches to the management of patients. According to M.R. Zile, D.L. Brutsaert (2002), the prevalence of diastolic HF (i.e., with preserved LV EF) is 15% at age<50 лет, 33% в возрасте 50-70 лет и 50% у лиц старше 70 лет. Еще 15% больных СН преклонного возраста имеют очень небольшую систолическую дисфункцию (ФВ ЛЖ 45-54%), не обусловливающую клиническую симптоматику. Это связано с тем, что СН у пожилых больных чаще имеет гипертензивное происхождение. Главными причинами диастолической СН являются гипертрофия левого желудочка при артериальной гипертензии (доминирующая причина у пожилых лиц), гипертрофическая кардиомиопатия, аортальный стеноз, рестриктивная кардиомиопатия.

In addition, older people tend to take certain drugs constantly, often in large quantities. As a result, predicting the impact of all this therapy on the cardiovascular system and avoiding adverse effects is quite difficult, especially given the reduced functional abilities of the kidneys and liver. All this not only increases the predisposition to heart failure, but also causes a number of difficulties for the diagnosis and management of this pathology in an elderly patient. Thus, angiotensin-converting enzyme (ACE) inhibitors and some diuretics can worsen kidney function in the presence of renal pathology. Many drugs contribute to the development of anemia, edema, thromboembolic or hemorrhagic disorders, and other adverse events. Non-steroidal anti-inflammatory drugs (NSAIDs) not only cause serious side effects such as upper gastrointestinal bleeding, but also reduce the effectiveness of diuretics and ACE inhibitors by contributing to sodium and fluid retention in the body.

However, all these important questions, unfortunately, remain insufficiently studied. Elderly patients (75 years and older) rarely participate in clinical trials. At the same time, this is the main part of HF patients (at least half of the total population of persons with HF). In addition, even if the study is intended to include older patients, as a rule, patients with multiple comorbidities are excluded, which significantly limits the study of the real population of older people with HF. As a result, it is currently difficult to draw any clear conclusions about how much the features of the course of HF at an older age (≥75 years) influence the strategy of patient management.

In 2002, American scientists A. Heiat, C.P. Gross and H.M. Krumholz analyzed how actively elderly patients with heart failure are included in randomized clinical trials. The authors analyzed the publications presented in the Medline database for the period from 1985 to 1999. It turned out that the patients included in the studied studies differed significantly from the real population of people with heart failure: the average age of participants in these studies with heart failure is 61 years, while the average age of patients with heart failure in real life, as already mentioned, is 75 years, and elderly people (75 years and older) make up at least half of the entire population of people with heart failure, and people over 65 years old make up about 80%. At the same time, over the analyzed decade and a half, there was no statistically significant trend towards an increase in the average age of patients included in HF studies, and this means that, at least by the beginning of the new millennium, there was no progress in this regard. The review authors concluded that clinical trials focus on a relatively small (and probably not the most significant) proportion of patients with HF - younger individuals.

In this regard, elderly patients with HF have a number of the following features that affect the effectiveness of therapy and clinical outcomes.

As a result, the conclusions drawn from the results of randomized clinical trials do not fully reflect the clinical usefulness of these data for the actual practice of treating patients with heart failure. And although many important aspects can be clarified precisely in such studies, it should still be understood that significant differences between the existing evidence and the actual effectiveness of the recommended treatment regimens can be explained precisely by this.

Diagnosis of HF in the elderly

The diagnosis of HF in an elderly patient often requires an active diagnostic search. This is due to atypical symptoms, comorbidities, and a number of features of the course of heart failure (LV systolic function is often preserved).

Nevertheless, key diagnostic approaches remain standard. The diagnosis of HF requires clinical evidence of HF with objective evidence of systolic and/or diastolic dysfunction (preferably by echocardiography).

In the presence of dyspnea, which is not explained or not fully explained by other causes, it is useful to determine the content of brain natriuretic peptide (BNP). The normal content of BNP and/or the terminal region of its precursor NT-proBNP (<100 и <400 пг/мл соответственно) имеет высокую негативную диагностическую ценность, то есть позволяет с высокой вероятностью исключить СН; высокие уровни BNP и NT-proBNP (>400 and >2000 pg/ml, respectively) usually indicate HF, although they are less clearly correlated with its presence than low levels of these indicators - with the absence of this pathology. Unfortunately, the average levels of BNP and NT-proBNP (100-400 and 400-2000 pg/ml, respectively) are not very informative for diagnosis. Of particular importance is the determination of BNP and NT-proBNP for the differential diagnosis of HF and COPD or the detection of HF against the background of known COPD.

For the correct diagnosis and assessment of the condition of an elderly patient with heart failure, American experts recommend using the DEFEAT-HF mnemonic rule. The "D" in DEFEAT stands for "Diagnosis" and this implies that HF ​​is a clinical diagnosis that must be made prior to echocardiography (especially given that approximately half of elderly patients with heart failure have preserved LV EF on echocardiography). The letter "E" means "etiology" (Etiology) and draws the attention of doctors to the fact that HF ​​is not an independent disease, but only a syndrome, always secondary, and therefore always requires a search for the underlying cardiovascular pathology that caused HF. It is especially important to detect myocardial ischemia and its cause (obliterating atherosclerosis of the coronary vessels, thrombosis/thromboembolism, etc.). The letter "F" refers to the need to assess the volume status (Fluid volume), which allows you to properly treat the patient to achieve euvolemia and thereby significantly reduce the risk of hospitalizations for heart failure and the length of the patient's stay in the hospital. The volemic status determines the possibility of prescribing such fundamentally important drugs for HF patients as β-blockers, which can only be used in stable patients in euvolemia. The most useful for assessing the patient's volemic status is the determination of pressure in the jugular veins of the neck. The letters "EA" stand for "ejection fraction" (Ejection frAction) and draw attention to the need to determine the state of LV systolic function. The results of echocardiography are extremely important for assessing the patient's prognosis, as well as for determining the treatment strategy, and are the most informative data after making a clinical diagnosis. Finally, the letter "T" stands for "treatment" (Treatment/Therapy), which must be evidence-based and take into account all the features of the diagnosis of heart failure in this patient; optimally, the therapy of a patient with HF should be based on the official clinical recommendations of experts from international / national cardiology societies.

Features of the management of an elderly patient with heart failure

Most aspects of the problem of differences in management strategies for elderly people with HF remain poorly understood. But some features of the management of this specific category of patients are already evident from the few evidence that is now at our disposal. A practitioner should take these features into account when working with such patients both on an outpatient basis and in a hospital.

Despite the lack of evidence regarding the management of elderly patients with HF, experts believe that the key approaches to the treatment of this category of patients are basically the same as in the general population of patients with HF. But it should always be remembered that in older people this therapy is predominantly empirical, recommended not so much in connection with the convincing evidence obtained in randomized clinical trials, but on the basis of extrapolation of the findings obtained for patients of younger age.

Thus, the optimal treatment regimen for an elderly patient with HF should include the fight against risk factors, teaching the patient self-control, taking medications that eliminate symptoms (diuretics, digoxin, inotropic support), improve the quality of life and favorably affect the prognosis (ACE inhibitors, angiotensin II receptor blockers (ARB II), aldosterone antagonists, β-blockers), the use of various non-drug interventions (cardioresynchronization, ultrafiltration, implantation of cardioverter defibrillators (ICDs), heart transplantation, etc.), as well as the treatment of concomitant diseases. The few evidence that has been obtained directly for patients of advanced age (70-80 years and older) usually confirms the effectiveness of therapeutic interventions for them that have proven to be effective and safe in younger patients with HF, which makes it possible to carry out this empirical extrapolation.

Thus, one of the few examples of studies that focused on elderly patients with heart failure is the SENIORS study (2005). The authors studied the efficacy of the β-blocker nebivolol in patients ≥70 years of age with heart failure (regardless of LV EF). It turned out that the use of this drug for an average of 21 months provided a reduction in the risk of death from all causes and the frequency of hospitalizations for cardiovascular reasons. Previous studies on the use of β-blockers in patients with HF included predominantly younger patients (in any case, patients older than 80 years were included in the studies very rarely) and with reduced LVEF, although sub-analyses pooling data on the elderly indicated that the effectiveness of drugs in them is comparable to the results of studies for the entire population of patients with HF. The SENIORS results provided important evidence that β-blockers have a beneficial effect on survival and clinical outcomes in older patients, including those with preserved LV EF. Thus, β-blockers are now convincingly indicated for all patients with HF, regardless of age and state of LV systolic function.

Also of interest are data from a population cohort study by D.D. Sin, F.A. McAlister (2002), who included 11,942 elderly patients with heart failure (mean age 79 years). Although this study was not prospective and randomized, it provided important evidence that the beneficial effect of β-blockers on survival in this category of patients persists, including with a large number of comorbidities. β-blockers reduced the risk of all-cause death, the risk of death from HF, and the risk of hospitalization for HF. The benefits of drugs were significant in all subgroups of study participants, including those with ≥2 comorbidities. This may also support the use of β-blockers even in elderly patients with multiple comorbidities, although appropriate prospective studies are required for definitive conclusions.

However, some features of the management of elderly patients remain insufficiently studied in randomized clinical trials, although there are undoubtedly differences from the therapy of younger patients in this regard.

So, when prescribing drugs to elderly patients, it is very important to remember the peculiarities of the functioning of the urinary system. Even in the absence of nephrological pathology, renal function declines with age, and in individuals older than 75–80 years, creatinine clearance may be<50 мл/мин даже без какого-либо заболевания со стороны почек. Кроме того, диуретики менее эффективны в этой возрастной группе, учитывая склонность пожилых лиц к нарушениям выведения натрия и воды из организма, особенно на фоне использования ингибиторов АПФ и/или БРА II. Поэтому диуретики в старшем возрасте следует применять с особой осторожностью, медленно титруя дозы препаратов и контролируя вес тела пациента и уровень электролитов в крови. Еще один специфический аспект применения диуретиков у пожилых больных касается того факта, что у таких пациентов часто имеются проблемы с выведением мочи – частичное недержание (чаще у женщин) или, наоборот, затрудненное мочеиспускание (обычно у мужчин). Применение диуретиков усугубляет эту проблему, вынуждая пациента чаще испытывать неприятные ощущения и ассоциированные с непроизвольным или затрудненным мочевыделением сложности. При этом больные обычно стесняются говорить о таких проблемах с лечащим врачом и просто самостоятельно прекращают или ограничивают прием диуретиков на свое усмотрение. Поэтому врач, назначающий диуретики пожилому пациенту с СН, должен активно интересоваться наличием проблем с мочеиспусканием и помогать больному в их решении, а также акцентировать внимание на исключительной важности рационального приема диуретиков. Многие специалисты уверены, что недержание мочи и затруднения при мочеиспускании являются важными составляющими проблемы низкого комплайенса у пожилых больных с СН, значение которых на сегодняшний день врачи недооценивают .

A number of cautions apply to β-blockers. The value of β-blockers for individuals with HF is so great that experts do not recommend stopping their use even in the presence of relative contraindications, such as mild COPD, for example. Reasons for not taking β-blockers in a patient with HF may be more serious problems: heart rate (HR)<60 уд/мин, систолическое артериальное давление <100 мм рт. ст., интервал PR >0.24 s, signs of hypoperfusion of peripheral tissues, atrioventricular block II-III degree, severe COPD, bronchial asthma, severe obliterating atherosclerosis of the arteries of the lower extremities. However, if the physician decides to continue taking β-blockers in non-severe COPD, he should take into account that in this case, drugs can aggravate symptoms and reduce exercise tolerance. For elderly patients with heart failure, this is especially true, given the reduced functional reserves of the lungs and cardiovascular system in old age.

In elderly patients, the hypertensive etiology of HF becomes relevant (ischemic etiology dominates at a younger age). Therefore, rational antihypertensive therapy in these patients is of particular importance in the management of HF. However, there are some pitfalls in this regard as well. When using all drugs that affect blood pressure (ACE inhibitors, ARBs II, diuretics, β-blockers, etc.), regardless of the purpose for which they are prescribed, it should be remembered that older patients often develop orthostatic (postural) hypotension due to increased vascular stiffness and impaired baroreflex. Considering that older people are generally very prone to falls for various reasons and to serious injuries on this basis (including a hip fracture), older people should be very careful in prescribing all drugs that have an antihypertensive effect, slowly titrate doses, and carefully monitor drug tolerance. If such problems arise, one should strive to cancel or limit the use of those antihypertensive drugs that have a symptomatic effect (for example, nitrates, diuretics), if possible, in favor of drugs that have a proven effect on survival (ACE inhibitors, β-blockers, etc.).

Digoxin has not yet been considered as a drug that improves the survival of patients with heart failure. However, it has been shown that the use of this drug reduces the risk of hospitalizations for HF, ie, it still favorably affects the prognosis (DIG, 1997). It should be noted, however, that in the DIG study, digoxin showed a convincing reduction in the risk of hospitalizations (for any reason and for heart failure in particular) only for a larger group of patients with LV systolic dysfunction; in a small subgroup of patients with diastolic HF (LV EF >45%), a similar trend was also observed, but it failed to reach statistical significance, probably due to the small number of participants. It is possible that other studies will confirm the benefits of digoxin in individuals with diastolic HF.

However, a post hoc analysis of the DIG study (A. Ahmed et al., 2006) showed that clinical outcomes depended on the doses of digoxin used and were more favorable at low doses of this drug. If digoxin is administered at standard doses of 0.25 mg/day, it does not really affect the survival of patients, although it reduces the risk of hospitalizations. But at lower doses (0.125 mg/day and below), the drug may also reduce mortality. The authors showed that at low concentrations of digoxin in the blood serum (0.5-0.9 ng / ml), the risk of not only hospitalizations, but also death from all causes decreases. This was also true for the subgroup of patients ≥65 years of age, in connection with which the experts concluded that in patients with heart failure, including the elderly, digoxin at low doses is indicated as a drug that favorably affects survival. At the same time, the use of doses ≤0.125 mg/day does not require routine monitoring of the concentration of digoxin in the blood serum. In cases where the patient continues to experience symptoms on such doses of digoxin, it is recommended to determine the level of the drug in the blood before increasing the dose to 0.25 mg / day. An increase in the concentration of digoxin in the blood serum above 0.9 ng / ml should be avoided.

Treatment of diastolic HF, so common in older patients, is predominantly empirical, as the evidence base on this issue is limited. Obviously, the most important components of therapy for such patients are blood pressure control, the use of cardioprotective drugs that have demonstrated a beneficial effect on myocardial remodeling (ACE inhibitors, ARB II, calcium channel blockers), prevention and treatment of myocardial ischemia, and control of heart rate and rhythm.

It is also important to draw the attention of physicians to the fact that atrial fibrillation is more common in older people with HF (ATRIA, 2001; J. Heeringa et al., 2006). The ATRIA study (2001) showed that about 70% of all patients with atrial fibrillation are over 65 years of age, 50% are over 75 years of age. At the same time, in the population of patients with heart failure, the risk of atrial fibrillation is from 10 to 30% (V-HeFT, 1993; W.G. Stevenson et al., 1996; SOLVD, 1998). Unfortunately, elderly people are practically not represented in clinical studies on the combination of atrial fibrillation and HF. Meanwhile, there are several problematic issues that need to be clarified with the help of evidence for this particular category of patients. Thus, a constant concern of practitioners in elderly patients with atrial fibrillation and HF is anticoagulant therapy, given the increased risk of thromboembolic and, at the same time, hemorrhagic complications, especially from the cerebral vessels. To date, experts believe that the risk of hemorrhagic complications in elderly patients with atrial fibrillation and heart failure is somewhat overestimated by doctors, causing a large number of unjustified refusals from adequate anticoagulation (M. Man-Son-Hing, A. Laupacis, 2003). Although there is little to no evidence on this topic, the risks and benefits of anticoagulant therapy should be weighed very carefully and all possible extraneous causes of an increase in the likelihood of hemorrhages (for example, the use of NSAIDs, which is practiced by many older people in connection with arthritis and other chronic inflammatory diseases), should be carefully weighed.

To control heart rate in atrial fibrillation against the background of heart failure, β-blockers are most indicated - as drugs that have proven a beneficial effect on the survival of patients, including in old age. I.A. Nasr et al. (2007) in their meta-analysis confirmed that these drugs are effective and safe in individuals with atrial fibrillation and HF, even with COPD. However, in cases where β-blockers are contraindicated or not effective enough, digoxin is also recommended. The benefit of a heart rate control strategy remains understudied. According to some data, the effectiveness of biventricular pacing and ablation of the atrioventricular node is approximately the same, regardless of the age of the patients, the state of systolic function, and the severity of heart failure.

With regard to non-pharmacological treatment of HF in elderly patients, at present, clinical recommendations on this subject are the same for people of any age. Although older patients were underrepresented in relevant clinical trials, separate sub-analyses confirmed that the efficacy of cardioresynchronization, ICD, and other approaches was also high in older patients with HF. Thus, in the MADIT II substudy (2003), a group of 204 patients older than 75 years was studied. The findings demonstrated that CDI was associated with a 46% reduction in overall mortality (p=0.04), which was an even greater impact on survival than in the subgroup of patients.<75 лет, где было зарегистрировано снижение общей смертности на 32% (p=0,02). Однако следует учитывать, что из этого и других подобных исследований изначально исключались пациенты с высоким риском смерти вследствие цереброваскулярной или другой сердечно-сосудистой патологии. Это может вести к различиям между реальной эффективностью ИКД в общей популяции пожилых лиц с СН и теми данными, что были получены в клинических исследованиях. В связи с этим ИКД в настоящее время является стандартной рекомендацией только для пожилых пациентов с СН без высокого риска смерти. У лиц с множественными сопутствующими заболеваниями и другими факторами риска решение о возможности и целесообразности ИКД пока остается в ведении лечащего врача.

In the case of HF of ischemic origin, reperfusion should be considered. The effectiveness of coronary artery revascularization was also confirmed for people over 75 years of age (B. Lernfelt et al., 1990; A.Z. LaCroix et al., 1990). According to A.Z. LaCroix et al. (1990) even with atypical symptoms of coronary artery disease, revascularization provided a 3-year survival of elderly patients at the same level as in younger patients with typical symptoms of the disease. But one should be aware of multiple comorbidities, which in real clinical practice can significantly affect the effectiveness of revascularization in an elderly patient (N.K. Wenger et al., 2005).

Of the comorbidities, depression is also noteworthy, which occurs in the majority of elderly patients with HF (up to 25% in the general population; up to 70% among hospitalized patients, according to B. Stuart, 2007). Depression significantly impairs compliance and self-management prospects, which are so necessary in the treatment of HF, so depressive disorders should be actively treated. At the same time, drug treatment of depression against the background of HF requires caution. The use of tricyclic antidepressants increases the level of norepinephrine and increases the risk of various complications from the cardiovascular system (arrhythmias, postural hypotension). More indicated antidepressants in the presence of cardiopathology are selective serotonin reuptake inhibitors. However, the drugs of this series are not completely safe - they can contribute to hyponatremia, so their use makes it necessary to control the level of electrolytes in the blood.

Conclusion

Despite advances in modern cardiology, the management of elderly patients with HF remains a challenge, especially in severe HF. The average survival of such patients is less than 3 years, because with severe HF, 25-50% of elderly patients die within 1 year. The number of such patients is constantly growing, and the practitioner is increasingly faced with difficult clinical decisions. At the same time, at present, the evidence base regarding this complex category of patients remains with many "white spots". Most of the answers to questions that are relevant to us are still received “the old fashioned way”, that is, empirically, at best, extrapolating evidence from studies that included younger patients to elderly patients. This is probably quite reasonable in many cases, since the fundamental methods of treatment should not differ significantly regardless of the age of the patients, but in relation to elderly patients, one should still be aware of a number of specific risks that can significantly impair the effectiveness and safety of the approaches we used to rely on.

We have prepared this publication to draw the attention of practitioners and scientists to this topical issue. We hope that the evidence presented, the warnings and the expert's conclusions will help in your daily practice.

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