Hashemi Ashkan, Kwak Min Ji, Goyal Parag
Program for the Care and Study of the Aging Heart, Department of Medicine, Weill Cornell Medicine, 420 East 70th St, New York, NY, LH-36510063, USA.
Division of Geriatric and Palliative Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA.
Drugs Aging. 2025 Feb;42(2):95-110. doi: 10.1007/s40266-024-01165-2. Epub 2025 Jan 18.
There are several pharmacologic agents that have been touted as guideline-directed medical therapy for heart failure with preserved ejection fraction (HFpEF). However, it is important to recognize that older adults with HFpEF also contend with an increased risk for adverse effects from medications due to age-related changes in pharmacokinetics and pharmacodynamics of medications, as well as the concurrence of geriatric conditions such as polypharmacy and frailty. With this review, we discuss the underlying evidence for the benefits of various treatments in HFpEF and incorporate key considerations for older adults, a subpopulation that may be at higher risk for adverse drug events. Key considerations for older adults include: the use of loop diuretics, mineralocorticoid receptor antagonists (MRAs), and sodium glucose co-transporter-2 (SGLT2) inhibitors for most; angiotensin receptor blockers/ angiotensin receptor-neprilysin inhibitors (ARB/ARNIs) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) as add-on therapies for some, though risk of geriatric conditions such as falls, malnutrition, and/or sarcopenia must be considered; and beta blockers for a smaller subset of patients (with consideration of deprescribing for some, though data are lacking on this approach). Naturally, when making clinical decisions for older adults with cardiovascular disease, it is critical to consider the complexity of their conditions, including cognitive and physical function and social and environmental factors, and ensure alignment of care plans with the patient's health goals and priorities.
有几种药物被吹捧为射血分数保留的心力衰竭（HFpEF）的指南指导药物治疗。然而，重要的是要认识到，患有HFpEF的老年人还面临着因药物的药代动力学和药效学的年龄相关变化以及老年疾病（如多重用药和衰弱）的并发而导致药物不良反应风险增加的问题。通过本综述，我们讨论了各种治疗方法对HFpEF有益的潜在证据，并纳入了对老年人的关键考虑因素，这一亚群体可能发生药物不良事件的风险更高。对老年人的关键考虑因素包括：大多数情况下使用袢利尿剂、盐皮质激素受体拮抗剂（MRAs）和钠葡萄糖协同转运蛋白2（SGLT2）抑制剂；血管紧张素受体阻滞剂/血管紧张素受体脑啡肽酶抑制剂（ARB/ARNIs）和胰高血糖素样肽-1受体激动剂（GLP-1RAs）作为某些患者的附加治疗方法，但必须考虑跌倒、营养不良和/或肌肉减少症等老年疾病的风险；以及一小部分患者使用β受体阻滞剂（对于一些患者考虑逐渐停用，尽管缺乏关于这种方法的数据）。当然，在为患有心血管疾病的老年人做出临床决策时，至关重要的是要考虑他们病情的复杂性，包括认知和身体功能以及社会和环境因素，并确保护理计划与患者的健康目标和优先事项相一致。
