One Size Doesn't Fit All: Treating HF in Special Populations

Despite the fact that heart failure (HF) is a prevalent condition in women, African Americans, and the elderly, the recommendations based on trial data derived from predominately younger white male study populations are generally applied to these groups.

According to the HFSA, however, “there are etiologic and pathophysiologic considerations specific to these groups that warrant attention if care and outcomes are to be optimized.” Based on data from subgroup analyses of randomized HF trials and the results of cohort studies, the HFSA has developed recommendations specific for the aforementioned special populations as part of the 2010 HFSA Heart Failure Practice Guideline, published in the Journal of Cardiac Failure.

Elderly Patients with Heart Failure:

• As with younger patients, it is recommended that elderly patients, particularly those age >80 years, be evaluated for HF when presenting with symptoms of dyspnea and fatigue.
• Beta blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction. In the absence of contraindications, these agents are also recommended in the very elderly (age >80 years).
• As in all patients, but especially in the elderly, careful attention to volume status, the possibility of symptomatic cerebrovascular disease, and the presence of postural hypotension is recommended during therapy with ACE inhibitors, beta blockers and diuretics.

Heart Failure in Women:

• Beta blocker therapy is recommended for women with HF with symptomatic LV systolic dysfunction and asymptomatic LV systolic dysfunction
• ACE inhibitor therapy is recommended as standard therapy in all women with symptomatic or asymptomatic LV systolic dysfunction.
• ARBs are recommended for administration to symptomatic and asymptomatic women with an LVEF ≤40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency.
• The combination of hydralazine/isosorbide dinitrate is recommended as standard therapy for African American women with moderate to severe HF symptoms who are on background neurohormonal inhibition.

Heart Failure in African Americans:

• Beta blockers are recommended as part of standard therapy for African Americans with HF due to symptomatic LV systolic dysfunction and asymptomatic LV systolic dysfunction
• ACE inhibitors are recommended as part of standard therapy for African-American patients with HF from symptomatic or asymptomatic LV systolic dysfunction.
• ARBs are recommended as substitute therapy for HF in African Americans intolerant of ACE inhibitors.
• A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy in addition to beta blockers and ACE-inhibitors for African Americans with LV systolic dysfunction and New York Heart Association (NYHA) class III or IV HF, or NYHA class II HF

To access the full 2010 HFSA guideline, click here.