Heart failure in geriatric outpatients: diagnosis, prognosis and treatment

The ageing of the population and improved survival following acute cardiac events have led to an increased prevalence of heart failure (HF), especially in the elderly. Establishing the presence of HF based only on signs and symptoms is often inaccurate. Additional investigations (e.g. echocardiography) are recommended but may be difficult in patients with a wide range of comorbidity and in a setting without direct access to echocardiography, such as in geriatric practice or primary care. The main focus of this thesis is to optimize the diagnostic management of geriatric patients suspected of HF. In addition, the prognosis and evidence-base for drug treatment of geriatric patients with established HF is studied. The pivotal study population consisted of 206 patients (mean age 82 years, 70% women) referred to the geriatric outpatient clinic for a variety of reasons who presented with symptoms of breathlessness, fatigue, or ankle swelling. All participants underwent a diagnostic work-up including clinical history, physical examination, electrocardiography, chest X-ray, laboratory tests (including N-terminal pro B-type Natriuretic Peptide (NT-proBNP) levels), and echocardiography. In case of HF, patients were treated according to the guidelines of the European Society of Cardiology (ESC). An expert panel consisting of a cardiologist, general practitioner, pulmonologist and geriatrician determined the presence of HF applying the diagnostic criteria for HF of the ESC, using all available diagnostic information, as well as 6-months follow-up data. Heart failure was present in 94 of 206 participants (46%). In our geriatric cohort loss of appetite, lower body mass index and absence of wheezing were independently associated with the presence of HF, as were age, male gender and nocturnal dyspnoea. Of all additional diagnostic tests (excluding echocardiography) NT-proBNP had the most profound effect on the c-statistic. With these variables we developed a diagnostic rule that accurately predicts the presence or absence of HF (negative predictive value 0.89; positive predictive value 0.88), in 84% of the patients. Half of the geriatric outpatients with HF died within three years. Comorbidity summarized in the Charlson Comorbidity Index, was the strongest predictor of mortality, independent of the severity of HF. The evidence supporting the use of cornerstone drugs (diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists) in elderly HF patients is scarce as we determined in a systemic review. The mean age of participants of randomised controlled trials of these drugs was in the order of 65 years. Concluding, in almost half of geriatric patients suspected of new, slow onset HF, HF is actually present. The presentation of HF in this group is often atypical (e.g. loss of appetite and weight loss). The diagnostic algorithm developed in this thesis, based on findings from history taking, physical examination and levels of NT-proBNP, accurately establishes the presence or absence of HF in the majority of geriatric patients suspected of HF with only 15% of patients needing additional investigations (i.e. echocardiography). The prognosis of geriatric patients with HF is mainly driven by comorbidity. Given the paucity of evidence based data to guide drug therapy in elderly patients with HF, future research should especially focus on this growing group of patients.