Management of congestive heart failure in the elderly patient.

Coronary artery disease, hypertension, valvular heart disease, and cardiomyopathies are the commonest causes of CHF in elderly patients. Almost half of elderly patients with CHF have normal LV ejection fraction. LV ejection fraction must be measured before knowing how to treat CHF. Underlying causes of CHF should be treated when possible. Precipitating causes of CHF should be treated. Diuretics are the first-line drug in the treatment of CHF. ACE inhibitors reduce mortality in patients with CHF and should be administered with diuretics to patients with CHF and abnormal or normal LV ejection fraction. Oral isosorbide dinitrate plus hydralazine improves survival in patients with CHF, and should be administered to patients with CHF and abnormal or normal LV ejection fraction who cannot tolerate ACE inhibitor therapy or in whom CHF persists despite therapy with diuretics plus ACE inhibitors. Digoxin should be administered to patients with a rapid ventricular rate associated with supraventricular tachyarrhythmias. Digoxin should be administered to patients with CHF in sinus rhythm and abnormal LV ejection fraction that does not respond to diuretics plus ACE inhibitors or in patients unable to tolerate ACE inhibitors or other vasodilator therapy. Digoxin should not be given to patients with CHF in sinus rhythm with normal LV ejection fraction. Calcium channel blockers are contraindicated in patients with CHF and abnormal LV ejection fraction but may be used to treat CHF with normal LV ejection fraction. The use of beta blockers in the treatment of CHF with abnormal LV ejection fraction is experimental. However, beta blockers might improve clinical symptoms in patients with CHF and normal LV ejection fraction by slowing heart rate, thereby increasing LV diastolic filling time and increasing LV end-diastolic volume. Maintenance of sinus rhythm will also increase LV diastolic filling time in patients with CHF and normal LV ejection fraction.