Treatment of congestive heart failure in older persons

OBJECTIVE: To review the management of congestive heart failure (CHF), with emphasis on older adults. DATA SOURCES: A computer-assisted search of the English language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles. STUDY SELECTION: Studies on the management of CHF were screened for review. Studies in older people and recent studies were emphasized. DATA EXTRACTION: Pertinent data were extracted from the reviewed articles. Emphasis was on studies involving the older persons. Relevant articles were reviewed in depth. DATA SYNTHESIS: Available data about the management of CHF, with emphasis on studies involving older people, were summarized. CONCLUSIONS: Left ventricular ejection fraction (LVEF) should be measured in all older persons with CHF. Underlying causes of CHF should be treated when possible. Precipitating causes of CHF should be treated. Older persons with CHF associated with an abnormal LVEF should be treated with a low sodium diet and with diuretics plus angiotensin-converting enzyme (ACE) inhibitors. If CHF persists, digoxin should be added to the therapeutic regimen. If CHF still persists, isosorbide dinitrate plus hydralazine should be added. If CHF still persists, a beta blocker should also be used. Calcium channel blockers should not be used. Older persons with CHF associated with a normal LVEF should be treated with a low sodium diet and with diuretics plus ACE inhibitors. If CHF persists, a beta blocker or isosorbide dinitrate plus hydralazine or a calcium channel blocker should be added to the therapeutic regimen. If sinus rhythm is present, digoxin should not be used. The role of angiotensin II receptor antagonists such as losartan in the treatment of CHF is under investigation.