Pharmacological therapy of chronic heart failure in the elderly

In the last years, the treatment of heart failure has radically changed, as did the knowledge of this complex and heterogeneous clinical syndrome. The comprehension of the pathophysiologic mechanisms involved in the progression of this disease highlighted the central role of various neurohormonal mechanisms. Antagonism of these systems was demonstrated to be the only strategy which favorably modifies the natural history of heart failure. However, the evolution and updating of guidelines of heart failure treatment should be considered as the first step in the development of strategies aimed at extending these principles to the "real world" and in particular to elderly patients, who are different from patients typically enrolled in heart failure trials. In spite of the relative lack of data on the efficacy of evidence-based treatment in daily clinical practice, the recommendations of heart failure guidelines should also be applied to elderly patients. However, it has to be taken into account the specificity of elderly patients, because of the presence of frequent comorbidities, contraindications, drug intolerance, and potential pharmacologic interactions. The inappropriate prescription, dosage and follow-up in patients treated with digitalis and spironolactone may be associated with a high rate of serious adverse events. Otherwise, in spite of the large amount of evidence about their efficacy, ACE-inhibitors and beta-blockers are largely underprescribed. Low-starting dosages and gradual up-titration may guarantee a good tolerability and long-term efficacy of these drugs also in elderly patients. Diagnosis and treatment of diastolic heart failure remain an unsolved issue. Further researches are needed on the efficacy of treatments in this clinical setting and, in particular, to define simple and reliable diagnostic indexes in elderly patients with preserved systolic function. Finally, the development of new multidisciplinary and effective models for the management of the ever-growing number of patients with heart failure is of utmost urgency.