Diagnostic Challenges and Management Complexities in Heart Failure Tackled

This morning I saw three consults at the Toronto General Hospital for the typical geriatric reasons: they were not safe for discharge, can we make them better so they can go home, and they no longer need surgical attention.

However, one of the key underlying problems for each patient was cardiac function. The first patient had underlying left ventricular dysfunction, predominantly diastolic, with atrial fibrillation and she presented with acute cholecystitis. Her management was significantly altered because of her cardiac condition; she received percutaneous drainage rather than emergency cholecystectomy. The second patient had systolic left ventricular dysfunction with a grade III ventricle, and was further impaired after a new myocardial infarction. She was slow to recover post-mitral valve replacement and CABG x 4. The final patient was a long-term (10 years) liver transplant survivor who now had congestive heart failure (CHF) that was compromising her ability to return home.

Cardiac disease is still the most important cause of morbidity and mortality in older patients. Exertional angina pectoris is of course common, but it has much less impact on the quality of life than does heart failure. I would suspect that most primary care physicians manage several patients with CHF, and although modern treatments have improved the outcomes for these patients, they also have made the management much more complex. This issue of Geriatrics & Aging focuses on this crucial issue in older patients.

Although shortness of breath (SOB) is the hallmark of CHF, not all patients with SOB have CHF, and not all patients with CHF complain of SOB. In fact, the diagnosis can often be quite challenging. Making the diagnosis of CHF is one of the areas covered in Dr. William Kostuk’s article on “Initial Evaluation of the Older Patient with Suspected Heart Failure”. Drs. Ali Ahmed and Phillip Thornton review the “Pharmacological Management of Systolic Heart Failure in Older Adults”. Health care experts have been predicting a growing epidemic of older patients with CHF, so Jane Oshinowo’s article on “Maximizing Quality of Life and Optimizing Health Care Utilization by Older Adults with CHF” is particularly relevant. Our continuing medical education segment also focuses on CHF, as Dr. Wilbert Aronow reviews the “Evidence for the Use of Beta-blockers in Congestive Heart Treatment in Older Persons”. Even our Biology of Aging column this month is relevant to CHF: Dr. Michihisa Jougasaki discusses “Age-related Cardiorenal Changes and Predisposition to Congestive Heart Failure”. The careful reader will be completely up-to-date in managing CHF in older patients after reviewing these articles. However, the pace of change in cardiac treatments is so rapid that it is likely that we will be reviewing this topic once again in one or two years time.
Enjoy this issue.