Internationally, people over 65 years of age are identified as elderly, while China defines 60 years of age or older as elderly. Cardiovascular diseases are highly prevalent in the elderly and are the main cause of death and disability in the elderly. The prevalence of heart failure in the elderly will increase significantly due to the aging process of the population and the development of medical technology that allows the survival of patients who previously died from acute myocardial infarction, stroke and acute heart failure. In the United States, at least 20% of people over the age of 65 are hospitalized for heart failure. And more than three-quarters of those hospitalized for heart failure are elderly. Our survey showed that the prevalence of heart failure among 65-74 year olds was 1.3%. Although there is such a close relationship between old age and heart failure, heart failure in the elderly has not been well studied, and this particular population is usually excluded from large-scale clinical studies, while the clinical characteristics and treatment of elderly patients with heart failure have their special characteristics and should be the focus of our attention. I. Etiology and pathogenesis of heart failure in the elderly The manifestations of cardiovascular aging include increased arterial stiffness, increased systolic pressure, decreased diastolic pressure and increased pulse pressure; large and small coronary artery sclerosis leading to myocardial ischemia; increased left ventricular mass, myocardial fibrosis and amyloidosis of the myocardium; pericardial thickening affecting the diastolic function of the heart; decreased response to β-adrenergic; atrial fibrillation, sinus node malfunction, atrioventricular conduction block; valve calcification, etc. The main causes of heart failure in the elderly remain coronary artery disease and hypertension, but degenerative damage in the elderly, including valve and myocardium, should not be underestimated. Approximately one-third of elderly patients with heart failure have a combination of organic valve disease, which is not a continuation of valve disease in youth, but a specific type of pathology with ischemic, degenerative, and hypertensive damage. The incidence of heart failure with surviving systolic function is higher in the elderly than in the young, and is more pronounced in patients with hypertension, diabetes mellitus, and women. Elderly patients with heart failure may have a combination of clinical conditions such as hypertension, renal insufficiency (about 30%), obstructive pulmonary disease (about 39%), diabetes, stroke, arthritis, anemia (about 39%), depression (about 25%) and a combination of multiple medications such as NSAIDs that may exacerbate heart failure. Statistically, roughly two-thirds of elderly heart failure patients have more than two non-cardiac comorbidities, and about 25% have a combination of six. In addition to acute conditions such as acute myocardial infarction and mitral tendon rupture, triggers have a significant impact on heart failure in the elderly, so prevention and control of triggers is an important part of the prevention and treatment of heart failure in the elderly. Common triggers include: ① infectious diseases, especially respiratory infections, which are the first cause (more than 20%); ② acute myocardial infarction, long-term myocardial ischemia and coronary artery insufficiency under various stress conditions (more than 10%); ③ arrhythmias (7%), especially tachyarrhythmias, especially atrial fibrillation; ④ excessive increase in preload due to blood transfusion, fluid transfusion or excessive salt intake in diet; ⑤ influence of drugs that inhibit myocardial contractility; ⑥ effects of exertion, fatigue and atrial fibrillation. (5) the influence of drugs that inhibit myocardial contraction; (6) exertion and emotional excitement; (7) severe anemia and hyperthyroidism; (8) pulmonary embolism, etc. The diagnosis of heart failure in the elderly is still the main symptom of heart failure, but the specificity of this symptom is reduced because they may be combined with pulmonary disease, de-adaptation status, obesity and so on. Weakness is also common, but coexisting thyroid abnormalities, lung disease, anemia, and depression can also lead to similar symptoms. Atypical symptoms such as confusion, nausea, diarrhea, anorexia, unexplained sweating, and chronic cough are also commonly seen in elderly patients. The diagnostic significance of the signs of heart failure is limited in the elderly due to the high number of underlying co-morbidities. Lower limb edema, for example, may also result from impaired venous return, sedentary lifestyle, and the use of calcium antagonists. The third heart sound and pulmonary warp = replacement of the heartbeat, which is a weevil in the “lotus” 6 miscellaneous banter, can help detect myocardial ischemia, especially the presence of old myocardial infarction, and suggest arrhythmias such as atrial fibrillation or atrioventricular block. A chest radiograph can show pulmonary stasis as well as pulmonary infection with an enlarged heart. Echocardiography can evaluate the patient’s systolic and diastolic function and cardiac structure. biomarkers such as BNP can also help in diagnosis and provide prognostic information. III. Treatment of heart failure in the elderly Treatment goals for heart failure in the elderly: Although improving prognosis is very important, improving symptoms, quality of life and reducing hospitalization for heart failure are equally important. Control of cardiovascular risk factors such as hypertension, hyperlipidemia and hyperglycemia is equally important for the elderly, but specific target values still need to be explored. Other contributing factors such as anemia, abnormal renal function, thyroid disease, infections, and the combined use of medications that exacerbate heart failure should also be addressed. Health education for patients and family members should be enhanced so that they understand the symptoms of heart failure exacerbation, medication considerations, dietary modifications, and the importance of physical activity. Restricting salt and water intake, monitoring body weight, and adjusting the amount of diuretics based on body weight are important for preventing episodes of acute heart failure. Influenza vaccination can reduce hospital admissions for acute episodes of heart failure in older adults. With regard to drug therapy, there is concern whether drugs that have proven effective in previous clinical trials, especially neuroantagonists, are equally safe and effective in the elderly. Although the elderly account for the majority of heart failure patients, there is a lack of clinical trials directly targeting elderly patients with heart failure for safety reasons, but there is reason to believe that the use of these drugs in the elderly could be equally beneficial. The place of ACEIs in the management of heart failure is well established. A randomized controlled clinical study of 34 ACEIs in systolic heart failure showed that ACEIs reduced all-cause mortality and the composite endpoint of cardiovascular death and hospitalization for heart failure in both those over and under 60 years of age. However, when ACEIs are used in the elderly, especially at adequate doses in younger people, renal function, blood potassium, and the presence of postural hypotension should be monitored intensively. Regarding the place of ARB in the management of heart failure in the elderly, the Val-HeFT study compared the efficacy of valsartan with that of placebo in systolic heart failure at a mean age of 62.5 years and a mean follow-up of 27 months, with no difference between the two groups in terms of all-cause mortality and a composite of all-cause mortality and cardiovascular complications (including successful cardiopulmonary resuscitation, hospitalization for heart failure, and use of intravenous positive inotropes and vasodilators). At the endpoint, the relative risk was reduced by 13.2% (97.5% CI, 0.77C0.97) in the valsartan group. However, no benefit of valsartan was found in the subgroup analysis of older adults aged 65 years or older. In the CHARM-Added study, which compared the cardiovascular benefit of adding candesartan to ACEI compared with placebo in patients with systolic heart failure in 18% of those over 75 years of age, candesartan reduced the composite endpoint of cardiovascular death and heart failure admission by 15% (P=0.011). The CHARM-Alternative study conducted in patients who could not tolerate ACEI compared the efficacy of candesartan with placebo. The mean age of patients enrolled was 66.5 years, with 23.5% over 75 years of age, and the composite endpoint of cardiovascular death and heart failure hospitalization decreased by 30% in the candesartan group (P < 0.001). It is suggested that ARBs can be used in elderly heart failure patients who cannot tolerate ACEIs. Older adults usually tolerate beta-blockers well, but achieving the so-called target dose in younger people is relatively difficult. The efficacy of bisoprolol and betalactam extended-release tablets in patients with systolic heart failure was verified in CIBIS II and MERIT-HF, both of which enrolled patients with a mean age of 60 years or older, and 32% of patients over 70 years in the MERIT-HF study. A meta-analysis of five clinical trials including three beta-blockers (carvedilol, betaxolol extended-release tablets, and bisoprolol) by Dulin et al. showed that the use of beta-blockers in older adults over 65 years of age also reduced mortality with an RR of 0.76 [95% CI, 0.64C0.90], similar to younger adults. the CIBIS III study was also conducted in older patients aged ≥65 years and enrolled a total of The CIBIS III study was also conducted in older patients ≥65 years of age, enrolling 1010 heart failure patients with LVEF ≤35%, and was designed to further investigate the priority of ACEI versus β-blockers in the initial treatment of heart failure. The results showed that β-blockers and ACEIs were equally safe and effective as initial therapy, and that the combination was more beneficial. The SENIORS study specifically evaluated the efficacy of the beta-blocker nebivolol in elderly patients with heart failure, enrolling patients aged 70 years or older with a mean age of 76 years and a follow-up of 21 months. The primary endpoint was the composite endpoint of all-cause death and hospitalization for cardiovascular events, suggesting that nebivolol reduced the primary endpoint by 14% (p=0.039). Diuretics may improve symptoms although they do not improve the prognosis of patients with heart failure. Thiazide diuretics are ineffective if creatinine clearance is <30 ml/min, and tab diuretics do not fail until creatinine clearance is <10 ml/min. Most elderly people need to use tab diuretics due to reduced renal function. The correct use of diuretics is quite critical in the treatment of heart failure in the elderly. Although there is a lack of evidence-based medical evidence on the direct effect of diuretics on cardiovascular prognosis, most clinical studies on ACEI, ARB and β-blockers for heart failure have been conducted in the context of diuretic use. Underuse of diuretics and poor control of heart failure symptoms are not conducive to the addition of ACEIs, ARBs, and beta-blockers. Overuse increases the risk of hypotension, renal impairment, and electrolyte abnormalities. the mean age of patients enrolled in the RALES study was 65 years, and in its subgroup analysis, spironolactone treatment reduced all-cause mortality equally in patients over or under 67 years of age. Spironolactone has a limited diuretic effect and exerts mainly its anti-myocardial fibrosis effect. In the Dig study on digoxin, the mean age of patients enrolled was 63 years, and about a quarter were over 70 years old, with some patients with surviving systolic function. Although digoxin did not reduce overall mortality, it reduced heart failure readmissions and improved symptoms in patients with heart failure. Because of the reduced metabolism and frequent combination of multiple drugs in the elderly, and the narrow therapeutic concentration window of digoxin, some studies have shown that digoxin blood levels <0.5 ng/ml are better than >0.9 ng/ml, so close monitoring of digoxin blood levels is required. Acute left heart failure, mainly systolic heart failure episodes, can be helped by brief use of dobutamine, dobutamine, and positive inotropic drugs such as amrinone and milrinone to help patients through the acute phase, but long-term use increases mortality in patients with heart failure. Despite the lack of clear evidence-based medical evidence in the elderly, the combination of hydrazidiazide and isosorbide nitrate is also justified in patients who cannot tolerate ACEI or beta-blockers due to evidence from the V-HeFT series of clinical trials. Although amlodipine and extended-release felodipine are available for patients with systolic heart failure combined with hypertension, they do not improve the patient’s prognosis because they do not improve the prognosis. Therefore, for this group of patients, try to adjust ACEI, ARB, and beta-blockers to the maximum tolerated dose or target dose and consider them if blood pressure remains uncontrolled, but they can also be used if the patient has a combination of refractory angina. Non-dihydropyridine calcium antagonists should not be used for systolic heart failure, but they can be considered for certain heart failure with surviving systolic function, such as hypertrophic cardiomyopathy and combined with rapid atrial fibrillation. Because of recent advances in BNP in the diagnosis of heart failure, less physical activity in the elderly, poorer specificity of heart failure symptoms and susceptibility to drug side effects, the Time-CHF study was conducted to evaluate whether there is a difference in prognosis between BNP-guided anti-heart failure therapy and conventional symptom-guided therapy in the elderly over 60 years of age. There was no difference between the two treatments for the primary endpoint of all-cause hospitalization (p=0.39), and BNP-guided therapy reduced the secondary endpoint of hospitalization for heart failure (HR, 0.68 [95% CI, 0.50-0.92]; p=0.01), but guidance was limited in older adults >75 years of age. Several studies have also investigated whether statins can improve prognosis in older patients with heart failure.The CORONA study enrolled patients over 60 years of age with systolic heart failure to see if 10 mg of reservactin daily could reduce a combined endpoint including cardiovascular death, nonfatal stroke, and myocardial infarction. The mean age of enrolled patients was 73 years, 41% were 75 years or older, and the mean follow-up was 32.8 months. No benefit was found for treatment with resulvastatin on the primary endpoint, but hospitalization rates for cardiovascular events were reduced and safety was good. In this group, diuretics were used in 88%, ACEI or ARB in 92%, beta-blockers in 75%, aldosterone receptor antagonists in 39%, and digitalis in 32%, indicating that “conventional therapy” is widely accepted. This study is a good attempt to show the importance of neuroantagonist-based therapy in the treatment of heart failure in the elderly, where resulvastatin failed to improve the prognosis of heart failure patients. And the reduction in hospitalizations for cardiovascular events is also relevant to some extent, because the goal of treatment of heart failure in the elderly to improve prognosis is as important as improving symptoms and quality of life. Heart failure with surviving systolic function in the elderly is a very important component, and there is a lack of strong evidence-based medical evidence for the treatment of this category of heart failure. The appropriate use of diuretics is important in this group of patients because increased water load from various causes accounts for a large part of the morbidity, but attention needs to be paid to electrolyte disturbances and renal abnormalities resulting from excessive diuresis. The PEP-CHF investigated whether perindopril reduced the composite endpoint of all-cause death and unplanned hospitalization for heart failure in older patients aged 70 years and older with surviving systolic function, despite high expectations for ACEIs and ARBs in this category. Patients enrolled with a mean age of 76 years and a median follow-up of 2.1 years improved heart failure hospitalization, cardiac function, and 6-minute walk test distance, although no positive results were obtained for the primary endpoint. 3023 patients with surviving systolic heart failure were enrolled in the CHARM-Preserved study, with a mean age of 67 years and 27% of those aged 75 years or older. The I-PRESERVE study further sought to evaluate whether irbesartan could reduce the composite endpoint of all-cause death and hospitalization for cardiovascular reasons in patients over 60 years of age with surviving systolic heart failure, and found no benefit not only in the primary endpoint, but also in some secondary endpoints. The results were not only no benefit in the primary endpoint but also no significant clinical benefit in some of the secondary endpoints. In a meta-analysis of these three clinical studies, no reduction in all-cause death and hospitalization for heart failure was found with the RAAS blockers described above. Analysis of the previously mentioned SENIORS study found that the clinical effect of nebivolol in heart failure with surviving systolic function was similar to that of those with impaired left ventricular systolic function. Further analysis revealed that in the nebivolol group, the doses tolerated were categorized as: intolerant (0 mg), low dose (1.25-2.5 mg), moderate dose (5 mg), and high dose (10 mg), with a primary endpoint benefit found in both the moderate and high dose groups, while in the low dose group the benefit was not significant and the primary endpoint events were increased in the intolerant group. Of course patient intolerance may be related to their underlying disease, but it also suggests that we use the maximum tolerated dose or target dose possible in the elderly, as in the young. Pharmacologic therapy is primarily considered in elderly heart failure, but cardiac resynchronization therapy can be performed judiciously. There have also been clinical studies of heart transplantation in selected older adults that have achieved the same clinical outcomes as younger adults, but with a slight increase in procedure-related complications and relatively few rejection reactions. With increasing life expectancy and advances in cardiovascular therapeutic techniques, the incidence of heart failure in the elderly is expected to increase in the future. The lack of typicality of heart failure symptoms in the elderly requires clinicians to be more vigilant in their diagnosis. Existing experience in the treatment of heart failure in relatively young patients can generally be used judiciously in older patients, but the reduced physiological function, combined medications, and increased co-morbidities in the elderly require adequate vigilance for adverse drug effects such as abnormal renal function, postural hypotension, and electrolyte abnormalities, while focusing on the effectiveness of drug therapy. Due to the lack of evidence-based medical evidence applicable to heart failure in the elderly, relevant clinical trials should be actively and cautiously conducted to provide scientific basis for the treatment of heart failure in the elderly and to individualize treatment accordingly.