Management of Hypertension and Heart Failure in Elderly Patients

Diagnostic Evaluation

The American College of Radiology recommends obtaining transthoracic echocardiography (TTE) with tissue Doppler imaging as the first-line diagnostic test to assess for diastolic dysfunction, left ventricular hypertrophy, and ejection fraction in elderly patients with exertional dyspnea 1.
In elderly primary-care patients with shortness of breath on exertion, unrecognized heart failure is present in 16% of cases, with HFpEF (12%) being four times more common than HFrEF (3%) 1.
NT-proBNP or BNP levels should be used to support or exclude heart failure diagnosis, with NT-proBNP >500 having 75% sensitivity and 83% specificity for HFrEF 1.

A complete metabolic panel, including serum creatinine, electrolytes, and estimated GFR, should be performed to assess renal function before medication adjustments 2 3.

Left atrial volume index and strain rate should be assessed, as they are significantly reduced in both HFrEF and HFpEF compared to non-HF patients 1.
E/e' ratio should be estimated to assess left ventricular filling pressure 1.
Right ventricular systolic function should be evaluated using tissue Doppler imaging, as RV dysfunction has prognostic significance 1.
Longitudinal and circumferential strain should be assessed using speckle tracking, as HFpEF patients demonstrate significantly impaired strain despite preserved ejection fraction 1.

The European Society of Cardiology recommends initiating combination antihypertensive therapy immediately, rather than monotherapy, to provide more effective BP control and reduce cardiovascular events 4 5.
A RAS blocker (ACE inhibitor or ARB) plus a dihydropyridine calcium channel blocker (CCB) should be used as initial therapy 4 5.
The target blood pressure should be systolic BP 120-129 mmHg and diastolic BP <80 mmHg, provided treatment is well tolerated 4 5.

If HFpEF is diagnosed, RAS blocker and diuretic therapy should be continued for BP control and symptom management 7.
If HFrEF is discovered (EF <40%), beta-blocker is mandatory for mortality benefit 7.
ACE inhibitor or ARB should be titrated to maximum tolerated dose 7 8.

BP should be rechecked within 2-4 weeks of initiating therapy, and orthostatic hypotension should be assessed 3 4 9.
Metabolic panel should be repeated to check potassium and creatinine 2 6.
Symptom response (dyspnea, fatigue, exercise tolerance) should be evaluated 1.

Excessive diastolic BP lowering (avoid DBP <60 mmHg) should be monitored, as it increases fall risk and may worsen coronary perfusion 8 10.
The ALARA principle ("as low as reasonably achievable") should be used if the patient cannot tolerate target BP of 120-129 mmHg 4 5 9.
Frailty should be screened using validated clinical tests, as moderate-to-severe frailty may warrant less aggressive BP targets (140/90 mmHg) 9 10.