心力衰竭论坛 坛主  施海明  周京敏

     Chronic heart failure(CHF) accompanied by higher comorbidity and mortality is increasing in line with advancing age. Previous landmark randomised clinical trials were mostly conducted in younger systolic HF patients with an average age of < 63 years and a left ventricular ejection fraction of < 40%. However， in “real world”， the majority of patients with CHF are older(often > 75 years). Such cases are less often treated by HF specialists， are more symptomatic， and almost half have preserved systolic function. It raised serious concerns about extrapolating the available evidence from a younger to an elderly HF population. Does age really make a big difference in HF management? We are not sure. There are physiological， pathological and pharmacological differences. Age-dependent structural and functional changes are seen in elderly patients， such as increases in sympathetic activity， left ventricular wall diameter， myocardial fibrosis and apoptosis， coronary sclerosis and aortic stiffness. As a consequence， both systolic and diastolic dysfunctions are more frequent in older compared to younger patients. Moreover， with age there is a significant shift in phenotype from systolic to diastolic HF， especially in patients with hypertension and/or diabetes and in women. Morbidity and mortality increase with systolic and/or diastolic HF. In comparison to younger HF patients， the physiological reduction in cognitive function， lung function and renal function is more frequently seen in the elderly. Therefore， older patients may respond differently to drugs， both in terms of efficacy and tolerability， particularly when combined with a range of other drugs. How should we manage CHF in the elderly in view of the above mentioned biological difference? Should we follow the same guidelines as for a younger age group? Do we have sufficient evidence to convince ourselves? For instance， there is some evidence available about beta blocker therapy in the elderly. A prospective Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with HF (SENIORS) and several retrospective subgroup (elderly) analyses of landmark clinical trials in stable systolic HF have provided data supporting the use of beta blocker as baseline therapy in HF in the elderly. However， beta blocker is still less frequently used in elderly compared to younger patients. One reason is that available data on elderly patients are not as convincing as the data pertaining to their younger counterparts. There is uncertainty or a lack of consensus about whether beta blockers are equally beneficial and well tolerated in elderly HF patients as in younger ones， and the same applies to other therapies such as ACE inhibitor， angiotensine receptor blocker and aldosterone receptor antagonist. The issue of target doses is frequently discussed， since they are in many cases difficult to achieve in the elderly. The question is whether we should use the same target dose in the elderly as that in younger patients.   Theoretically， the most effective dose is the highest dose tolerated， which may differ across different age groups. Is it wise to adopt “the highest dose tolerated” instead of “the target dose”? While it is probably reasonable to adopt “the highest dose tolerated”， it certainly requires further investigation. Another frequently discussed issue is tolerability in the elderly. Some studies as well as experience indicate that both ACE inhibitors and beta blockers are well tolerated by elderly patients. Are they equally well tolerated by 65 and 85 year olds? Probably not. Most studies of the so-called “elderly” usually comprise a population of around 65–75 years and the very elderly group (octogenarians)， i.e. > 80 years old， is rarely studied. Moreover， tolerability is one thing and efficacy is another. Due to the present lack of clinical data， we are trying to extrapolate the available evidence from younger patients to an elderly HF population. The question is whether this has been validated and how wrong can the interpretation be. Paradoxically， older patients seem to derive more benefit than younger ones， although this type of relationship may not be linear. This senior HF population is generally less studied， both experimentally and clinically， than younger populations and we have more questions than answers. I sometimes wonder how we are treating our HF patients.

     HF management is known to be complex， particularly in the elderly.This special issue of HF in the elderly involves many aspects such as diastolic dysfunction， biomarkers， functional markers， typical CHF phenotype in the elderly， medications， palliative care， comorbidity， atrial fibrillation， ICD and CRT， compliance etc.
 
     I strongly feel that the time has finally come to undertake active research to gain a better understanding of the fundamental basis of HF in the elderly and provide more detailed documentation on the subject of evidence-based HF management in the elderly. We need more clinical trial data showing unequivocal improvement in outcomes and a clear-cut favourable benefit–risk analysis in typical older HF patients in spite of their comorbidities and polypharmacy. We also need more basic research on novel therapeutic approaches. Last but not least， HF in the elderly should be given a higher priority not only by professionals in the field， but also by those responsible for allocating funds.

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