Heart failure associated with hypertension in the elderly mainly refers to heartfailure with normalleftventricularejectionfraction (HFNEF) or heart failure with preservedleftventricularejectionfraction (HFPEF) due to hypertension in the elderly. heartfailurewithpreservedleftventricularejectionfraction,HFPEF), i.e., predominantly diastolic cardiac insufficiency; in addition, heart failure with reduced left ventricular ejection fraction (heartfailurewithreducedleftventricularejectionfraction,HFPEF) is also included in the elderly with hypertension combined with coronary artery disease and/or diabetes mellitus. heartfailurewithreducedleftventricularejectionfraction,HFREF, i.e., predominantly systolic cardiac insufficiency.
1.Characteristics of the elderly
The definition of old age: Western countries ≥ 65 years old; China ≥ 60 years old. 80 years old and above belong to old age. The literature does not mention uniformly, such as young old age, middle-aged old age, old old age, and long-lived old age. The time division is also not completely clear. Therefore it may affect the results of the analysis of old age and old geriatric diseases. We follow the above definitions without being too rigid.
From the anatomical point of view, all organs of the human body except the heart and prostate are atrophied in old age; and many physiological functions of the human body are in a linear decline. If the age of 30 is taken as the base point (100%) for optimal body function, then studies have found that at the age of 60, cardiac output (when quiet) decreases by about 20%, liver and kidney blood flow decreases by about 30%, and lung function decreases by about 30%. Therefore, elderly people are prone to medication toxicity. From the point of view of medication, with the degenerative changes of the body in old age, the absorption, distribution, metabolism and excretion of drugs in the body are very different from those of young people in every aspect. Especially with the atrophy and decreasing function of liver, kidney and other important internal organs, the metabolism and excretion of drugs are slow and the accumulation increases, and the usual dose of drugs can cause poisoning.
2.Epidemiological status
Framingham heart study found that the prevalence of hypertension was 27% under 60 years old, 75% around 60-79 years old, and 93% over 80 years old, which shows that the prevalence of hypertension increases with age; while the control rate of hypertension decreases with age: 38 The control rate of hypertension decreases with age: below 60 years old is 38%, around 60-79 years old is 28%, and above 80 years old is 23%. A sample survey of hypertension in China also found that the prevalence of hypertension among people aged 64-74 years was 41.9% in 1991 and reached 48.6% in 2000-2001, indicating that the prevalence of hypertension in the elderly in China is also increasing year by year.
Heart failure (CHF) is one of the major risks to human health in the 21st century. The aging of the population, increased prevalence of hypertension and coronary heart disease, myocardial infarction, and decreasing death rate of CHF have all caused CHF to rise. Domestic data show that: the prevalence of CHF in 2002 was 0.9%, and the total number of heart failure in China is estimated to be about 6 million, with inpatient mortality accounting for 40% of cardiovascular disease, while CHF hospitalization accounts for only 20% of cardiovascular disease in the same period, and the mortality rate of heart failure patients is significantly higher than the total mortality rate of inpatient cardiovascular disease in the same period. U.S. data show that: about 5 million people suffer from CHF, an annual increase of 500,000, 12-15 million visits per year, 300,000 deaths from CHF / year, CHF 5-year mortality rate of more than 50%, similar to malignant tumors! The Framingham study found that the 5-year survival rate for heart failure was 25% for men and 38% for women, which was 6-7 times higher than the mortality rate for the general population of the same age group. This shows that heart failure has a high prevalence and mortality rate and a poor prognosis!
The Framingham study found an 80% incidence of heart failure in hypertensive patients, and clinical trials such as SHEP and Syst-EUR reported that the risk of heart failure was 3-4 times higher in hypertensive patients than in healthy individuals, and more than 2 times higher in elderly patients than in young and middle-aged hypertensive patients. The epidemiological survey of heart failure in China found that hypertension accounted for about 23.6% of the causes of heart failure.
3. Pathogenesis and pathophysiology
As mentioned above, the cardiac output at rest is significantly lower in “healthy” elderly people than in young people. Therefore, elderly people are of low blood volume type and have poor cardiac reserve function. The long-term presence of hypertension and other risk factors promotes endothelial insufficiency, myocardial or vascular remodeling and fibrosis, which can cause left ventricular hypertrophy and even myocardial infarction, leading to subclinical diastolic and/or systolic ventricular dysfunction and eventually overt heart failure.5 The early stage is dominated by left ventricular diastolic dysfunction, when the ventricular hypertrophy and ventricular systolic function are still normal, while the long-term hypertensive heart Afterload increases, myocardial compliance decreases, ventricular filling abnormalities and filling pressure rises, cardiac output decreases, pulmonary venous hypertension, which can cause pulmonary or body circulation stasis; late ventricular dilatation, there will be left ventricular systolic insufficiency, followed by the development of total heart failure.
4.Clinical manifestations and characteristics
4.1 Triggering causes.
Very complex, the most common ones are respiratory tract infection and arrhythmia.
4.1.1 Respiratory tract infection: especially smoking, chronic bronchitis on the basis. Increased metabolism during fever increases the cardiac load and accelerates the heart rate, which both intensifies myocardial oxygen consumption and reduces myocardial blood supply and oxygenation by shortening the diastolic period and reducing coronary blood perfusion; endotoxin directly damages myocardial cells; if pulmonary infection occurs, it further reduces myocardial oxygenation.
4.1.2 Arrhythmias: Commonly seen in tachyarrhythmias, with atrial fibrillation being the most common. Heart rate >150 beats/min can lead to rapid heart rate and increased myocardial oxygen consumption; shortened diastolic phase and insufficient coronary blood flow; insufficient ventricular filling, resulting in decreased cardiac output. It can also induce tachycardia cardiomyopathy and cause heart failure when it lasts for a long time.
4.1.3 Other: overexertion, emotional excitement, etc.
4.2 Normal ejection fraction heart failure is common
Epidemiological data show that HFNEF accounts for about 30%-50% of all heart failure patients; European congestive heart failure survey data show that HFNEF accounts for 50.5% and 40.1% of heart failure in those over and under 80 years of age, respectively; the results of the 2005 ADHERE study in the United States showed that among the registered heart failure patients, left ventricular ejection fraction (LVEF ) was normal or mildly abnormal in about 50% of the registered heart failure patients; it was mostly seen in elderly women, primary hypertensive disease, diabetes mellitus, and left ventricular hypertrophy, often with coronary artery disease or atrial fibrillation.
4.3 Lack of specificity of symptoms and signs.
Sometimes the symptoms are very atypical and non-specific. Elderly hypertensive patients present with complaints of dyspnea and shortness of breath manifesting less! but may have cough, weakness and dizziness. Objective examination of shortness of breath, lung woven grass (13) strands folding old elderly more unable to use shortness of breath or fatigue to distinguish the nature of heart failure, easy to misdiagnose and mistreat!
Hypertensive emergencies, atrial fibrillation, and left ventricular hypertrophy are the main manifestations. Heart shadow is not large, pulmonary stasis, normal or near normal EF (EF>45%), and abnormal Doppler echocardiography diastolic function index.
4.4 Many comorbidities and difficulties in drug therapy
Elderly patients often have more comorbidities and poor systemic status. They often have pulmonary infections, which are sometimes difficult to control; gastrointestinal disorders, nutritional disorders; imbalance of in and out, water and sodium retention, electrolyte disorders; some patients also have psychiatric and psychological disorders (depression or anxiety), vascular dementia, etc.
Pharmacological treatment is difficult and can only be done with reference to evidence-based medicine and guidelines for adults with hypertension and heart failure – and therefore should be individualized and prudent. Specific patients beta-blockers, renin-angiotensin system inhibitors, etc. may have limited application.
5. Treatment strategy and drug selection
The current standard of care for heart failure has changed from the traditional conventional treatment of heart failure – “cardiotonic, diuretic, vasodilator” to a new “conventional treatment” or “standard treatment” based on neuroendocrine antagonists. “ACEI/ARB, b-blockers, diuretics (sometimes with digoxin)”. Evidence-based medical research has confirmed that contemporary treatments – neuroendocrine doctrine, cardiac synchronization (CRT, CRT-D) – have been highly successful. For example, antagonizing the RAS system reduces heart failure mortality by 25-30%; β-Blocker reduces heart failure mortality by 30-40%; CRT, CRT-D reduces heart failure mortality by 30%.
5.1 Treatment strategy for heart failure complicated by hypertension in the elderly
The principles of heart failure and hypertension guidelines and expert consensus for the elderly should be taken into account, and the specific age (early or old age or even longevity), systemic and other target organ status and prognosis should be evaluated —— treatment medication shall be individualized and comprehensive treatment is important, including lifestyle modification and psychotherapy.
The goal of blood pressure lowering in the elderly: according to the existing hypertension guidelines and the results of clinical trials of hypertension combined with heart failure in the elderly (China’s hypertension prevention and treatment guidelines, WHO/International Society of Hypertension hypertension prevention and treatment guidelines, JNC7, Expert Consensus on the diagnosis and treatment of hypertension in the elderly, the Hypertension Lowering Treatment in Elderly Hypertensive Patients Study-HYVET, etc.), the goal of blood pressure control in the elderly ≥ 60 years of age should be <130/ 80 mmHg, senior old aged ≥80 years should be <150/80 mmHg, and diastolic blood pressure ≥70 mmHg in patients with pure systolic hypertension (J-shaped curve).
5.2 Drug selection according to guidelines
The treatment of HFNEF/HFPEF (diastolic failure predominant) in principle should focus on several aspects: aggressive control of blood pressure to achieve the target; control of atrial fibrillation heart rate and rhythm; application of diuretics: to relieve pulmonary stasis and peripheral edema; hemodynamic reconstruction therapy: for patients with coronary artery disease with symptomatic or verifiable myocardial ischemia; reversal of left ventricular hypertrophy and improvement of diastolic function: ACEI, ARB, β receptor blockers, etc. The application of digoxin is not recommended; if there is also systolic heart failure, the latter should be treated. And according to the characteristics of the elderly, the drug should be titrated in small doses to start. However, there is a lack of sufficient evidence-based medical evidence, mainly for physiological abnormalities and original etiology!
Regarding the treatment of hypertension-associated heart failure in the elderly if HFREF (systolic failure predominant) is mainly the following: asymptomatic – ACEI or ARB, β-blockers; symptomatic – diuretics are the basis, ACEI or ARB, beta-blockers, aldosterone antagonists, (digoxin); and treatment of comorbid diseases.
At present, the accumulated evidence-based medical evidence is more adequate! β-blockers, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), aldosterone antagonists, diuretics and digoxin as the basic drugs recommended by domestic and international guidelines for the treatment of heart failure, the first four are neuroendocrine inhibitors, which can relieve the symptoms of heart failure, reduce the rate of death, and improve the prognosis, thus confirming the heart failure The basic research results are correct, that is, the basic mechanism of heart failure is myocardial remodeling, the latter originates from sympathetic nervous system and RAAS overexcitation ……
5.3 Focus on the treatment of heart failure complicated by hypertension in the elderly
The treatment of HFREF in the old elderly can be referred to the guidelines, but there is a lack of evidence-based medicine in the treatment of HF in the old elderly. the PEP-CHF study included patients with chronic heart failure in middle-aged elderly people aged R70 <80 years in addition to the old elderly. The others were small trials. Thus evidence-based medicine is not strong enough to be clinically referable and must be individualized according to characteristics! And the old elderly HYVET study belongs to the treatment of hypertension, which includes for the secondary prevention effect of heart failure, for non-phase C and D results.
The HYVET (TheHYpertensionintheVeryElderlyTrial) Study of Older Elderly Patients with Hypertension.17 This study was an international multicenter, randomized, double-blind, placebo-controlled trial designed to study the prevention of fatal and nonfatal stroke in older elderly patients with hypertension aged 80 years and older. The results showed a 30% reduction in all strokes (p=0.06), a 21% reduction in all-cause mortality (p=0.019) and a 64% reduction in heart failure (p<0.0001) in the indapamide±perindopril group compared with the control group. This study showed that.
1. anti-hypertensive therapy based on indapamide 1.5 mg (maintenance dose) ± perindopril reduced stroke morbidity and total morbidity and mortality in older elderly patients.
2. treatment with indapamide ± perindopril has a very significant benefit in reducing heart failure events and composite cardiovascular events.
3. Efficacy is seen early and the treatment regimen is safe.
In a smaller study, Italian scholars14 observed 818 elderly people aged 65-101 years (mean 79 years) with acute care heart failure and continued ACEI after discharge in 550 cases (67.2%). RESULTS: Age and physical disability were negatively associated with ACEI use 1 year after hospital discharge; the morbidity and mortality rate was reduced by 40% in those with ACEI (HR: 0.60; CI: 0.42-0.88); the reduction in morbidity and mortality was more pronounced in physically disabled elderly (HR: 0.35; 95% CI: 0.19-0.64). A beneficial effect of ACEI was found in this population.
Elderly people have extremely poor compensatory capacity, other organ functions are equally reduced, nutrition and water and electrolyte, acid-base balance are easily disturbed, drug therapy needs to be carefully selected for application, and clinical trials cannot be generalized to this group of elderly people! Treatment should be individualized. Such as low blood pressure, low heart rate, low cardiac output can not be forced to add ACEI/ARB, beta-blockers, to ensure that the treatment based on the use of rational and refined drugs. Use calcium antagonists with caution and apply diuretics, ACEI or ARB, β-blockers, digoxin, and aldosterone receptor antagonists in small doses initially according to guideline principles. Take care to prevent or reduce interactions with other drugs. Closely monitor liver and kidney function and choose drugs with low impact (e.g. hepatic and renal dual-channel ACEI fosinopril). Pay attention to the problem of compliance with long-term treatment, especially psychological guidance and family work for patients with cognitive impairment, and promote long-acting single-tablet combinations with clinical evidence, such as ACEI or ARB with diuretics; ACEI or ARB with calcium antagonists. Simple application and increased adherence.
5.4 New drug advances
New drugs for the treatment of hypertension and/or heart failure offer promise. Including recombinant human brain natriuretic peptide (rhBNP) for acute heart failure, calcium sensitizer – levoximondan. Direct renin inhibitors – Aliskiren inhibits renin at its source, and the efficacy and safety of treatment of hypertension is very positive, with international large-scale clinical trials underway – the ASPIRHIGHERE study, including 14, among them the Cardioprotection Study (ALOFT). Tolvaptan, a vasopressin receptor antagonist, blocks arginine vasopressin (AVP), the antidiuretic hormone receptor (V2 receptor), counteracts the antidiuretic effect of AVP, preserves sodium and diuresis, improves hemodynamics in heart failure patients, prevents ventricular remodeling, and reduces mortality. Clinical trials have been and are being conducted for the treatment of heart failure, especially in elderly patients, and the If inhibitor Ivabradine reduces heart rate by slowing the frequency of sinus node impulse delivery, and the SHIFT trial demonstrated a decrease in mean heart rate, further reducing mortality and hospitalization by about 25% on top of the best treatment. The combination of Chinese and Western medicines, such as Drabanerabic cardiac capsules, has been proved in clinical studies to have multi-link, multi-path and equivocal efficacy, and has a certain future in elderly patients.
Summary
The atrophy and diminished function of internal organs and poor heart reserve function in the elderly. Both hypertension and heart failure increase in prevalence and morbidity and mortality with age in the elderly; HFNEF/HFPEF are mostly seen in elderly patients with hypertension, but the diagnosis rate is low in China. evidence-based medical evidence for HFREF treatment is sufficient; however, there is a lack of definite and definite evidence for HFNEF/HFPEF treatment. In particular, there are still no large-scale clinical studies to date in the elderly that provide definitive improvement in the prognosis of diastolic heart failure, and ACEI and ARB have failed to benefit patients with heart failure with normal left ventricular systolic function in terms of improved prognosis. The observation of new drugs, including combined Western and Chinese therapeutic agents, deserves attention. As the geriatric society progresses, more attention should be paid to future research in the treatment of hypertensive heart failure in the elderly!