Resistant oedema and heart failure in older patients
THE CONTEXT
Persistent oedema despite oral loop diuretics may require intensified diuresis, particularly when renal impairment accompanies severe chronic heart failure. Older patients also have specific treatment and tolerability considerations.
Intensifying diuretic treatment
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An intravenous loop diuretic infusion, such as furosemide at 5–10 mg/hr, may initiate diuresis when oedema persists despite oral treatment.
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Adding a thiazide diuretic, such as bendroflumethiazide 5 mg daily, may augment diuresis.
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Combination treatment requires care to avoid excessive fluid loss, hyponatraemia and hypokalaemia.
Heart failure in old age
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The incidence rises with age; heart failure affects 5%–10% of people in their eighties.
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Common causes include coronary artery disease, hypertension and calcific degenerative valvular disease.
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Diastolic dysfunction is often prominent, particularly in patients with a history of hypertension.
Treatment considerations in older patients
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ACE inhibitors and ARBs improve symptoms and mortality, but postural hypotension and renal impairment occur more frequently than in younger patients.
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SGLT2 inhibitors reduce hospitalisation due to heart failure.
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Loop diuretics are usually required, but may be poorly tolerated in patients with urinary incontinence and in men with prostate enlargement.