[Guidelines, heart failure and the elderly]

Abstract

Heart failure (HF) guidelines have recently introduced several innovations in pharmacological therapeutic options. Specifically, for HF with reduced ejection fraction, an intensive therapeutic strategy of early initiation and rapid up-titration of guideline-directed medical therapy is now recommended in all patients to reduce the risk of HF rehospitalization or death. In clinical practice, however, this approach is not always feasible in the elderly population due to the coexistence of multiple geriatric conditions such as frailty, comorbidities in addition to the risk of adverse drug effects, general prescribing inertia and the unmet need for close follow-up during drug up-titration. As for HF with preserved ejection fraction, sodium-glucose cotransporter 2 inhibitors have been shown to significantly reduce the composite outcome of HF hospitalization and cardiovascular mortality. However, these drugs have not yet been proven effective in some cardiomyopathies, as these were not included in clinical trials. This review aims to provide a critical analysis of current HF guidelines, illustrating their limits in real-world applicability through a cardio-geriatric lens reinterpretation of recent evidence.