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PATIENT CASE

An 86-year-old woman with a history of heart failure with preserved ejection fraction (HFpEF) is admitted to the hospital for worsening shortness of breath and fatigue. She has multiple coexisting conditions including hypertension (HTN), chronic kidney disease, chronic obstructive pulmonary disease (COPD), anemia, mild cognitive impairment, gait instability, and urinary incontinence. She lives in an assisted living facility and requires help with her medications, grocery shopping, and housework. She uses a walker and had a mechanical fall 4 months prior to admission. She has been hospitalized 3 times in the past year and will require subacute rehabilitation after hospital discharge to regain the ability to perform self-care activities including toileting, bathing, and dressing. She wants to discuss her long-term prognosis.

EPIDEMIOLOGY

  • The prevalence of heart failure (HF) increases with age and exceeds 1 in 10 persons over the age of 80 years in the United States (Figure 14-1).1

  • The risk of hospitalization for HF increases markedly with age for men and women (Figure 14-2).

  • Persons 85 years of age and older make up an increasing proportion of all hospitalizations for HF in the United States (Figure 14-3).

  • Although the majority of older persons hospitalized with HF in the United States have HFpEF,2 most persons with heart failure with reduced ejection fraction (HFrEF) are also over 65 years of age.

  • More than 80% of deaths attributable to HF in the United States occur in persons over 65 years of age, and approximately 60% occur in persons over 75 years of age.

Figure 14-1

Prevalence of heart failure in the United States by age and gender: National Health and Nutrition Examinations Survey, 2009-2012. (Data from Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update. A report from the American Heart Association. Circulation. 2015;131(4):e275.)

Figure 14-2

Incidence of heart failure hospitalization in the United States by age, gender, and race, 2005-2011: The Atherosclerosis Risk in Communities study. (Data from Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update. A report from the American Heart Association. Circulation. 2015;131(4):e276.)

Figure 14-3

Age distribution of hospitalizations for heart failure in the United States, 2000 and 2010. (Reproduced from National Center for Health Statistics, Data brief no. 108, October 2012.)

AGE-RELATED PHYSIOLOGIC CHANGES

  • Cardiovascular changes with aging contribute to the development of HF, in particular HFpEF. These changes include the following:3

    • Increased arterial stiffness as manifested by rising arterial pulse wave velocity (Figure 14-4), systolic blood pressure, and pulse pressure.

    • Impaired endothelium-mediated vasodilatation with reduced peak ...

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