10.2217/1745509X.2.2.253 © 2006 Future Medicine Ltd ISSN 1745-509X Aging Health (2006) 2(2), 253–275 253 R EVIEW Managing heart failure in the very old Gastone Sabbadini 1† , Marco Metra 2 , Andrea Di Lenarda 1 , Savina Nodari 2 , Gianfranco Sinagra 1 & Livio Dei Cas 2 † Author for correspondence 1 Cardiovascular and Internal Medicine Department, "Ospedali Riuniti" and University of Trieste, Italy 2 Institute of Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Italy E:mail: metramarco@libero.it Keywords: cardiovascular aging, cardiovascular disease, comorbidity, heart failure management, very old The very old carry most of the burden of mortality and morbidity created by heart failure and, therefore, they have the greatest need of assistance and care. Disappointingly, the highest level of evidence for the optimal management of the syndrome has been generated by clinical trials that have insufficiently enrolled people aged 75 years or over, so that the efficacy and safety of current heart-failure therapies remains uncertain in these patients. In the absence of straightforward guidance, the very old should be managed pragmatically, tailoring strategies to the individual needs of the patient in order to achieve an acceptable compromise between improvements in quality and quantity of life. To best meet this goal, the risk of adverse effects of any therapeutic intervention should be carefully weighed against the expected benefits, taking concomitant diseases and treatments into the greatest consideration due to their potential to interfere negatively with heart-failure management and prognosis. As adherence to and safety of therapies are major issues in the long-term management of the very old with heart failure, appropriate follow-up strategies, including the active participation of the patient, should be adopted. Heart failure (HF) is one of the most serious problems currently facing healthcare systems in the western world, as evidenced by the alarming growth rate, heavy burden of hospitalizations and deaths, and high management costs, which have led to the categorization of this syndrome as a new epidemic [1,2]. HF is a disorder predominantly affecting the elderly (people aged 65 years or older) [3], and its prevalence increases exponentially with advanc- ing age up to rates exceeding 10% among the very old (aged ≥75 years) [4,5]. In this segment of the population, HF represents the leading cause of recurrent and protracted hospitalizations, accounting for larger inpatient care expenditures than those due to any other medical problem [6]. Most importantly, HF is a very disabling condi- tion with a poor prognosis, which can severely prejudice the quality of life (QoL) of older peo- ple while drastically shortening their life expect- ancy; as age advances and comorbidity increases, prognosis progressively worsens [7,8], so that the oldest and sickest patients have 1-year mortality rates higher than 60% [9]. Notwithstanding these figures, the elderly – primarily those aged 75 years or older, of female gender, with preserved left ventricular (LV) systolic function, and major comorbidities – have been significantly under-represented in large pharmacological trials and, therefore, a rigorous application of evidence-based guide- lines on HF management is extremely difficult in these populations [10]. Moreover, clinical tri- als have poorly explored end points measuring QoL and functional independence, which rep- resent relevant goals in the treatment of patients of advanced age, sometimes even more perti- nent than those related to survival. Based on these issues, there is currently substantial uncer- tainty regarding how to manage the very old with HF. Heart failure pathophysiology in the very old An accurate knowledge of the basic mechanisms underlying HF is fundamental to its optimal treatment. With this in mind, there are several reasons to dedicate the greatest attention to the very old, in whom the pathophysiology of HF may be exceptionally complex due to the intri- cate relationships existing among age-related cardiovascular (CV) changes, superimposed heart disease(s) and concomitant cardiac and noncardiac illnesses (Figure 1). HF can result from any CV disorder that impairs the ability of the ventricle(s) to eject (systolic dysfunction) and/or accept blood (diastolic dysfunction) [201]. Among a wide range of pathophysiological abnormalities, exaggerated neurohormonal activation occur- ring in response to initial cardiac injury plays a key role in cardiac remodeling/dysfunction and, thereby, in the progression of the HF clinical syndrome [11]. For reprint orders, please contact: reprints@futuremedicine.com