Management of Congestive Cardiac Failure in Elderly People

Introduction:

Heart failure can occur in two ways: the heart’s ventricles (chambers in the heart) cannot pump blood hard enough during systole (ventricular contraction), called systolic heart failure, or when the ventricles are not filled with enough blood during diastole (ventricular filling), called diastolic heart failure. In both cases, blood flows back to the lungs, causing congestion or fluid buildup; therefore, it is also called congestive heart failure.

Congestive heart failure affects millions of people worldwide, ultimately leading them to death. Several heart diseases, such as ischemia and valvular disease, impair the heart's ability to pump out blood and, over time, can ultimately cause the heart to fail. Cardiac failure can affect the left and right ventricles or both ventricles simultaneously. The prevalence of heart failure is dramatically influenced by age. 85 % of heart failure occurs in people aged 65 years and above.

What Is the Mechanism of the Heart?

The heart squeezes out a specific amount of blood each minute, known as cardiac output (the number of beats in a minute), which is multiplied by the volume of blood squeezed out with each heartbeat (stroke volume). This process is called the normal ejection process, and during this process, not all the stroke volume comes out with each beat, and some amount remains in the left ventricle until the next beat. The normal ejection fraction is around 50-70%. Between 40-50% is considered borderline and anything about 40 % or less indicates systolic heart failure, as the heart squeezes out only a small amount of blood per beat. In diastolic heart failure, the heart squeezes out enough blood but does not fill it appropriately in the ventricle. In this case, the stroke volume is low, but the ejection fraction will be normal.

What Causes Heart Failure?

• Ischemic heart disease is one of the most common causes of heart failure caused by coronary artery atherosclerosis or plaque buildup. In this case, less blood and oxygen get through the coronary artery to the heart tissues, damaging the myocardium (heart’s tissues).

• Long-standing hypertension is another common cause of heart failure. When the arterial pressure is increased in the systemic circulation, it becomes for the left ventricle to pump blood into the hypertensive systemic circulation.

• Dilated cardiomyopathy is another cause in which the heart’s chamber dilates or grows bigger in size to fill up the ventricle with a large amount of blood. It stretches the muscle walls, increasing contraction strength.

• Aortic stenosis is referred to as the narrowing of the aortic valve opening.

• Hypertrophic cardiomyopathy is an abnormal ventricular wall thickening, often belongs to a genetic cause.

• Restrictive cardiomyopathy is when the heart muscles get stiffer and less compliant.

• Other conditions such as infections, diabetes, alcoholism, etc.

What Are the Signs and Symptoms of Heart Failure?

In case of left ventricular heart failure-

• Tachypnea (fast breathing).

• Pulmonary edema (collection of fluid in the lungs).

• Cyanosis (bluish discoloration of the skin).

• Enlarged apex beat.

• S3 gallop rhythm (extra heart sound referred to as third heart sound).

• Heart murmurs (sound of blood flowing through the heart).

In case of right ventricular failure -

• Abdominal distension.

• Right upper quadrant abdominal pain.

• Epigastric fullness.

• Change of bowel habits (constipation, diarrhea, and malabsorption).

• Bilateral leg swelling.

• The yellowish coloration of the sclera (bilirubin).

Other signs -

• Dilated pupils.

• Decreased blood pressure.

• Ascites (buildup of fluid in the abdomen).

• Pale gray skin.

• Dyspnea (difficulty breathing).

• Orthopnea (difficulty breathing while lying).

• Crackles (abnormal breath sounds).

• Cough.

• Nausea and vomiting.

• Fatigue.

• Decreased urine output.

• Anxiety.

• Confusion.

• Weak pulse.

How Is Heart Failure Diagnosed?

Certain tests can be done in patients with suspected heart failure, such as

• Blood Tests - To check whether there is anything in the blood that might indicate heart failure or any other illness.

• Electrocardiogram (ECG) - For signs of myocardial infarction or hypertrophy.

• Chest X-Ray - To check whether the heart size is bigger than usual or if there is fluid in the lungs.

• Echocardiogram - It is an ultrasound scan in which sound waves are used to examine the heart.

What Are the Treatment Options?

This can be categorized further into the following:

1. If the patient presents without any symptoms of heart failure or structural heart disease but is at risk of heart failure due to other associated diseases, then treating the associated diseases, such as hypertension and lifestyle modification, is considered. In addition, drugs, including angiotensin-converting enzyme (ACE) inhibitors, diuretics, and betablockers, can also be used.

2. If the patient has structural heart disease, but without any symptoms of heart failure, then drugs like ACE inhibitors, diuretics, and beta blockers are used along with lifestyle modification. Devices like implantable cardioverter defibrillators (ICD) are inserted to detect and stop irregular heartbeats in selected patients.

3. If the patient presents with prior or current symptoms of heart failure or structural heart disease, in that case, lifestyle modification, including drugs like ACEI, diuretics, beta-blockers, aldosterone antagonists, Hydralazine, etc., are used, and devices such as biventricular pacemakers (a device that helps the ventricles to contract normally) and implantable defibrillators are administered.

4. If the patient with refractory heart failure requiring specialized interventions is present, then extraordinary measures like heart transplantation or permanent mechanical support are considered.

How to Manage Cardiac Failure in Elderly Patients?

Often, the elderly patient will present with non-specific symptoms; they may not show classic underlying angina but instead present with fatigue and shortness of breath with exertion, which can be easily misdiagnosed with geriatric syndromes (impaired vision and hearing, frailty, and impaired cognitive function). Certain lifestyle changes that can help prevent heart failure-

• Smoking cessation.

• Maintaining high blood pressure, high cholesterol, and diabetes.

• Staying physically active.

• A heart-healthy diet.

• Maintaining a healthy weight.

• Reducing and managing stress.

Conclusion:

Heart failure is not a disease but a syndrome caused by many diseases, and elderly patients are always a challenge in this case because their tissue is more fragile and associated with co-morbidities and various medications. However, with proper diagnosis and therapeutic interventions, we can markedly improve the care of heart failure patients, and also, with new device technologies, symptoms can be relieved with improved survival.