Optimal Management of Heart Failure in Older Adults

Core Pharmacological Strategy

The American College of Cardiology recommends that all older adults with heart failure and reduced ejection fraction should receive first-line combination therapy with ACE inhibitors (or ARBs if intolerant) plus beta-blockers, initiated at low doses with gradual titration, as this approach reduces mortality even in patients ≥65 years of age 1, 2, 3
The American Heart Association suggests starting both ACE inhibitors and beta-blockers simultaneously in all older adults with heart failure with reduced ejection fraction (HFrEF), regardless of symptom severity, as high-quality evidence demonstrates reduced morbidity and increased survival 2, 3
Beta-blockers specifically reduce mortality in older adults ≥65 years, though they do not significantly improve quality of life or reduce hospitalizations in this age group 1, 2

The European Society of Cardiology recommends adding aldosterone antagonists (spironolactone or eplerenone) for persistent symptoms despite ACE inhibitor and beta-blocker therapy 3, 7
The American College of Cardiology suggests considering SGLT2 inhibitors as part of the four-pillar approach for HFrEF, with proven mortality benefit 7

The European Heart Journal recommends addressing renal dysfunction, diabetes, anemia, thyroid dysfunction, and atrial fibrillation as these commonly exacerbate heart failure in elderly patients 4, 5
The American Heart Association suggests calculating creatinine clearance to adjust dosing of renally excreted drugs (most ACE inhibitors, digoxin) 4

The American College of Cardiology recommends referring to specialist for consideration of cardiac resynchronization therapy (CRT) or implantable cardioverter-defibrillator (ICD) in patients with persistent symptoms despite optimal medical therapy 1, 2
The European Society of Cardiology suggests considering palliative care, including opiates for symptom relief, in terminal elderly patients with refractory symptoms 5, 7