Heart failure in the elderly: epidemiology, mechanisms, and management

There is no consensus on an age cut-off for being considered elderly, but the majority of patients with heart failure (HF) have an advanced age. The lifetime risk for developing HF is ∼25%, with a sharp increase in incidence after the age of 70. The lifetime risk for men and women is almost equal, but women exhibit a higher propensity towards developing HF with preserved ejection fraction, whereas men are more prone to HF with reduced ejection fraction. During the biological ageing process, several systemic and local pathophysiological alterations impact the myocardium, including impaired autophagy and proteostasis, mitochondrial dysfunction, and oxidative stress, as well as cellular senescence, clonal haematopoiesis of indeterminate potential, and chronic low-grade inflammation or inflammaging. Collectively, these changes compromise cardiac energy homeostasis and promote cell loss and dysfunction, increasing the risk of HF. Despite their relevance, these ageing-related mechanisms are hitherto not addressed by guideline-recommended medical therapy. Guideline-recommended medical therapy remains the cornerstone of HF treatment across age groups, including in elderly patients who tolerate it. However, a high burden of comorbidities and several features specific to advanced age, such as low blood pressure and frailty, often preclude full-dose guideline-recommended medical therapy. Similarly, the risk-benefit ratio of device therapies needs careful consideration in light of competing non-cardiac risks due to comorbidities that are prevalent in this population. Finally, HF is a mortal condition, and advanced care planning and end-of-life decisions should be discussed in a timely manner in elderly patients.