Eclipse of heart problems in elderly population

Research funded by the British Heart Foundation (BHF) and published in the journal Heart this week has found that many of the oldest members of society have issues with heart function which are simple and relatively inexpensive to treat but which routinely go undiagnosed.

The epidemiological analysis involved 376 participants from the Newcastle 85+ study, all aged between 87 and 89 years. It forms an element of Newcastle University’s work as part of the Newcastle Initiative on Changing Age and the Newcastle Institute for Social Renewal.

I spoke to cardiologist Professor Bernard Keavney, who led the study, to find out more about the results of the research he and his colleagues conducted, why the heart problems of so many elderly people are going unrecognised, and what can be done to improve rates of diagnosis…

What prompted you to carry out this study?
Heart failure is a condition characteristic of older populations; the older you are, the higher your risk of heart failure. In the UK and elsewhere, admissions to hospital for heart failure are responsible for consuming a very large portion of the health budget. Caring for older people who are admitted to hospital with heart failure is one of the largest single expenditures for the NHS each year, so this is a serious problem in a demographic that is increasing hugely. The fastest growing segment of society at the moment is the 85 and over age group; this is the demographic in which heart failure is most prevalent.

However, there was limited information before this study on the prevalence of heart dysfunction in this age group. In particular the realisation has dawned that it is important to catch heart dysfunction – where the heart isn’t working as well as it should – early and treat it with appropriate medications. In this way it may be possible to prevent the transition to heart failure which triggers admissions to hospital, with the attendant large healthcare costs and poor quality of life. We did not have a snapshot of any epidemiological study with large numbers of 85 year olds which tells us how big a problem this is, so that’s why we did the study.

Were you surprised by what you found?
Yes, we were. The heart has to go through two processes every time it pumps blood. The first thing is to relax and allow blood to flow into the heart. The second thing is obviously to pump it out. Both processes are active. The relaxation of the heart requires energy, and it’s something you don’t do as well as you get older. Diastole is the name given to the period when the heart relaxes. As people get older an increasing proportion of cases of heart failure are due to the heart being less able to relax – diastolic dysfunction. That was what we expected to confirm, as many other studies had found a high prevalence of diastolic dysfunction. That’s very important, but of limited applicability at the moment because there are no known treatments for diastolic dysfunction.

Surprisingly, we found that systolic dysfunction – when the heart is not pumping strongly enough – has a higher prevalence in this age group than previous studies in younger people had suggested. Unlike diastolic dysfunction, there are proven treatments for systolic dysfunction which we should be giving to at least some of these people. If we did, and if we knew about their condition, we could administer treatments that have been proven in clinical trials to be highly efficacious.

Is it a case that heart failure can only be fended off by treatments for systolic dysfunction?
We found that roughly a quarter of those in the study – a very high number – had a systolic heart problem. Most of these exhibited breathlessness, answering a questionnaire in which it became clear that their daily affairs were limited by it.

Breathlessness is a classic symptom of heart dysfunction, along with fatigue and fluid retention among others. The next step will be trying to find out how to implement these findings in terms of detecting a problem and trialling treatment. If they’re breathless their symptoms may well be down to troubles with the heart. If we treat them this may improve and they would have a better quality of life. It’s not just prevention; it’s about quality of life. It is important to be clear that from this epidemiological survey we cannot say, ‘If you give this treatment, there will be this level of improvement’.

Do you think it will be possible to develop treatments for diastolic dysfunction?
It’s a very active area of research, but we desperately need a better understanding of diastolic dysfunction. It seems that a degree of diastolic dysfunction – a bit of stiffening of the heart – happens as people age, and it may be that we can’t get around that. We know that diastolic dysfunction is more common if you’re female and if you’ve had high blood pressure.

It may be that good blood pressure control may play a part in avoiding diastolic dysfunction, but once it is established we don’t know what to do for it. No treatment has been shown to work. I think this is because we don’t understand the cause at the fundamental cellular and cardiac-energetic levels. That is a focus of very active research, with many groups throughout the world looking into it.

Why do you think heart problems in elderly people so often go undiagnosed?
I think symptoms in older people often do not get run down as energetically as they are in younger people. Ours is not one, but many studies have suggested that there’s a degree of inequity of access and that, as people get older, they are less likely to receive the investigation and the treatment that younger people presenting with a similar complex of symptoms would get.

The study’s co-author Dr Joanna Collerton has made the point that, as people get older, it’s not so clear what to do. You can prescribe medication, but many are already taking drugs for other conditions which will sometimes interact to the patient’s detriment. There can be all sorts of reasons why an old person doesn’t do well on multiple drugs. As Dr Collerton has said, these people are often excluded from clinical trials on the grounds of age.

There’s very little epidemiological evidence on this age group and there is also very little clinical trial data. We have provided some epidemiological evidence with this study. Most of the clinical trials are in much younger populations, and I think it’s recognised that we need to have elderly patient specific clinical trials in far greater numbers than we have had so far.

What are the next steps for your research?
If patients present with possible heart failure, the current National Institute for Health and Clinical Excellence (NICE) guidelines are to use a Brain Natriuretic Peptide (BNP) test to rule-out heart problems. If the BNP is normal, it’s very unlikely that the patient will have significant heart failure, and you can start to look for other causes of their symptoms. If the BNP is high, you refer them for an echocardiogram (ECHO), which is what we did in the home.

We want to test the NICE guidelines for this age group, because BNP rises with age, making the cut-off much more difficult to establish in older patients. If we were to find that the BNP test misses many patients with heart problems, the next thing is to suggest offering home ECHO. We’ve shown that home ECHO works very well in terms of the data you can obtain, and it’s more than acceptable to the patients. In a younger population, the pick-up rate would not be high enough to justify it, but in a population with such a high prevalence of left ventricular systolic dysfunction, it would seem to be efficacious to go about screening the breathless elderly. In other words, if an older person presents with breathlessness it might make sense to cut out the BNP test and go straight to ECHO. That would involve a change in guidelines which we obviously cannot advocate without further research.