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Non-cardiac so as not to lower preload excessively and thereby
reduce stroke volume and cardiac output.
Non-compliance to the prescribed regimen (salt, liquid,
(3) Beta-blockade could be instituted to lower heart rate
and increase the diastolic filling period.
Recently co-prescribed drugs (anti-arrhythmics other than
(4) Verapamil-type calcium antagonists may be used for
amiodarone, beta-blockers, NSAIDs, verapamil, diltiazem)
. the same reason.107 Some studies with verapamil
Alcohol abuse have shown a functional improvement in patients
Renal dysfunction (excessive use of diuretics)
with hypertrophic cardiomyopathy.108
(5) A high dose of an ARB may reduce hospitalizations.109
Pulmonary embolism
Thyroid dysfunction (e.g. amiodarone)
Heart failre treatme?t i? the elderly
Heart failure occurs predominantly among elderly patients
with a median age of about 75 years in community studies.
Atrial fibrillation
Ageing is frequently associated with co-morbidity.
Other supraventricular or ventricular arrhythmias
Frequent concomitant diseases are hypertension, renal
. failure, obstructive lung disease, diabetes, stroke, arth-
Myocardial ischaemia (frequently symptomless), including
myocardial infarction ritis, and anaemia. Such patients also receive multiple
Appearance or worsening of mitral or tricuspid
drugs, which includes the risk of unwanted interactions
and may reduce compliance. In general, these patients in
Excessive preload reduction (e.g. due to diuretics
general have been excluded from randomized trials. Relief
of symptoms rather than prolongation of life may be the
most important goal of treatment for many older patients.
ACE-i?hibitors a?d ARBs
prevalence of diastolic dysfunction in patients with heart
failure symptoms and a normal systolic function in the
ACE-inhibitors and ARBs are effective and well-tolerated
community. There is still little evidence from clinical
in elderly patients in general.
trials or observational studies on how to treat heart
failure with PLVEF.
Diretic therapy
Heart failure with PLVEF and heart failure due to dias-
tolic dysfunction are not synonymous. The former diagno-
In the elderly, thiazides are often ineffective because of
sis implies the evidence of preserved LVEF and not that
reduced glomerular filtration rate. In elderly patients,
left ventricular diastolic dysfunction has been
hyperkalaemia is more frequently seen with a combi-
nation of aldosterone antagonsist and ACE-inhibitors or
The diagnosis of isolated diastolic heart failure
NSAIDs and coxibs.
requires evidence of abnormal diastolic function, which
may be difficult to assess. Precipitating factors should be
identified and corrected, in particular tachy-arrhythmias
should be prevented and sinus rhythm restored whenever
Beta-blocking agents are surprisingly well tolerated in
possible. Rate control is important. Treatment approach
the elderly if patients with such contraindications as
is similar to patients without heart failure.106
sick sinus node, AV-block and obstructive lung disease
are excluded. Beta-blockade should not be withheld
because of increasing age alone.
Pharmacological therapy of heart failre with PLVEF or
diastolic dysf?ctio?
Cardiac glycosides
The following recommendations are largely speculative
because of the limited data available in patients
Elderly patients may be more susceptible to adverse
with PLVEF or diastolic dysfunction (in general, Class of
effects of digoxin. Initially, low dosages are recom-
recommendation IIa, level of evidence C).
mended in patients with elevated serum creatinine.
There is no clear evidence that patients with primary
diastolic heart failure benefit from any specific drug
Vasodilator age?ts
(1) ACE-inhibitors may improve relaxation and cardiac Venodilating drugs, such as nitrates and the arterial
distensibility directly and may have long-term dilator hydralazine and the combination of these drugs,
effects through their anti-hypertensive effects and should be administered carefully because of the risk of
regression of hypertrophy and fibrosis. hypotension.
1136 ESC Guidelines
Table 20 Recommended components of care and following
programmes (class level of evidence C)
It is essential to recognize and correct precipitating
Use a multi-disciplinary team approach
factors for arrhythmias, improve cardiac function and
Vigilant follow-up, first follow-up within 10 days of
reduce neuro-endocrine activation with beta-blockade,
ACE inhibition, and possibly, aldosterone receptor
Discharge planning
antagonists (Class of recommendation I, level of evi-
Increased access to health care
dence C).
Optimizing medical therapy with guidelines
Early attention to signs and symptoms (e.g. telemonitoring)
Ve?triclar arrhythmias
Flexible diuretic regimen
Intense education and counselling
In patients with ventricular arrhythmias, the use of
Inpatient and outpatient (home-based)
anti-arrhythmic agents is only justified in patients Attention to behavioural strategies
with severe, symptomatic, sustained ventricular tachy- Address barriers to compliance
Early attention to signs and symptoms (e.g. telemonitoring)
cardias and where amiodarone should be the preferred
Flexible diuretic regimen
agent (Class of recommendation IIa, level of evidence
ICD implantation is indicated in patients with heart
failure and with life threatening ventricular arrhyth-
(1) optimize existing therapy, e.g. beta-blockade
mias (i.e. ventricular fibrillation or sustained ventricu-
(2) add long-acting nitrates
lar tachycardia) and in selected patients at high risk of
(3) if not successful, add amlodipine or felodipine
sudden death (Class of recommendation I, level of
(4) consider coronary revascularization.
evidence A).95,96,110 112
If hypertension is present
Atrial fibrillatio? .
optimize the dose of ACE-inhibitors, beta-blocking
agents, and diuretics.40
For persistent (non-self-terminating) atrial fibrillation,
add spironolactone or ARBs if not present already
electrical cardioversion could be considered, although
if not successful, try second generation dihydropyridine
its success rate may depend on the duration of atrial
fibrillation and left atrial size (Class of recommen-
dation IIa, level of evidence B).
In patients with atrial fibrillation and heart failure and/
Care a?d follow-p
or depressed left ventricular function, the use of anti-
arrhythmic therapy to maintain sinus rhythm should be
See also Table 20.
restricted to amiodarone (Class of recommendation I,
An organized system of specialist heart failure care
level of evidence C) and, if available, to dofetilide
(Class of recommendation IIa, level of evidence B).113 improves symptoms and reduces hospitalizations (Class
of recommendation I, level of evidence A) and mortality
In asymptomatic patients beta-blockade, digitalis
(Class of recommendation IIa, level of evidence B) of
glycosides or the combination may be considered for
patients with heart failure.71,114 118
control of ventricular rate (Class of recommendation
It is likely that the optimal model will depend on local
I, level of evidence B). In symptomatic patients with
circumstances and resources and whether the model is
systolic dysfunction digitalis glycosides are the first
designed for specific sub-groups of patients (e.g. sever-
choice (Class of recommendation IIa, level of evidence
ity of heart failure, age, co-morbidity, and left ventri- [ Pobierz całość w formacie PDF ]