MANAGEMENT OF GERIATRIC HEART FAILURE PATIENTS WITH COMORBIDITIES. LEFT VENTRICULAR ASSIST DEVICES AS PERMANENT THERAPY

Abstract

Heart failure (HF) is a major global cause of death, representing a significant clinical and public health challenge, with over 26 million people affected worldwide. In the United States, approximately 6.3 million individuals are currently living with HF, and this number is expected to rise by 46%, reaching more than 9 million by 2030. This increase is largely driven by factors such as an aging population and the widespread prevalence of risk factors like hypertension, coronary artery disease, and obesity. The economic impact of HF is also substantial. In the US, the direct medical costs for HF patients currently total $39 billion annually, with projections showing a rise to $53 billion by 2030. A number of comorbidities, such as hypertension (HTN), atrial fibrillation (AF), and diabetes mellitus (DM), are frequently seen in patients with heart failure (HF) and are also associated with poorer clinical outcomes. Common comorbidities in heart failure (HF) patients, including atrial fibrillation, peripheral artery disease (PAD), cerebrovascular events (CVI), valvular heart disease, ischemic heart disease, acute myocardial infarction, chronic kidney disease (CKD), diabetes mellitus, chronic obstructive pulmonary disease (COPD), and hypertension, are often interconnected in their pathophysiology, contributing to the development and progression of HF. Treatment for heart failure (HF) involves a combination of nonpharmacologic, pharmacologic, and invasive approaches aimed at managing and potentially reversing its effects. Nonpharmacologic interventions vary based on disease severity and typically include sodium and fluid restriction in the diet, appropriate physical activity, and careful monitoring of weight gain. Pharmacologic options include a broad range of medications such as diuretics, vasodilators, inotropic agents, anticoagulants, beta blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), digoxin, nitrates, B-type natriuretic peptides (BNPs), I(f) inhibitors, angiotensin receptor-neprilysin inhibitors (ARNIs), soluble guanylate cyclase stimulators, sodium-glucose cotransporter-2 inhibitors (SGLT2Is), and mineralocorticoid receptor antagonists (MRAs). Invasive treatments for heart failure (HF) encompass several procedures aimed at improving heart function and survival. These include electrophysiological interventions such as pacemakers, cardiac resynchronization therapy (CRT) devices, and implantable cardioverter-defibrillators (ICDs). Revascularization procedures, like coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), may also be performed. Other options include valvular surgery, ventricular restoration, extracorporeal membrane oxygenation (ECMO), ventricular assist devices (VADs), and in severe cases, heart transplantation. The advent of mechanical circulatory support, particularly continuous-flow left ventricular assist devices (CF-LVADs), has provided a new perspective on prolonging survival for patients with end-stage heart failure. These devices offer the potential not only to extend life but also to serve as a viable long-term solution, addressing the shortage of donor organs for heart transplants. However, LVADs are not without their drawbacks, as they come with device-related complications and have raised concerns about whether they genuinely improve patients' quality of life