Balancing Therapy and Quality of Life in Aging Heart Failure Patients

The number of heart failure therapies shown to be beneficial in randomized clinical trials has expanded over the past decade. However, evidence-based therapies are underutilized in patients over 65 years old — the very group most likely to have heart failure. The American Heart Association (AHA) has come forward to provide guidance to clinicians treating this population by issuing a first-of-its-kind scientific statement on the topic, titled “Optimizing Heart Failure Care in the Older Adult” and published in Circulation.

“We felt there was a need to provide a structured approach to patient-centered, evidence-based heart failure care in a way that balances the mortality benefit of guideline-directed medical therapy (GDMT) with health-related quality-of-life considerations in older individuals,” says Cleveland Clinic cardiologist and Director of Heart Failure Population Health Trejeeve Martyn, MD, MSc, who served as vice chair of the writing committee for the scientific statement.

The statement summarizes the treatment effects and safety profiles of guideline-supported medications and devices for heart failure in older adults and discusses methods for optimizing dosages while managing multimorbidity, polypharmacy, frailty and social needs in this population.

Don’t withhold treatment, but proceed with caution

The authors reviewed age-stratified data from clinical trials, focusing on participants aged 65 to 74 years and participants ≥ 75 years old. They found that older patients eligible for GDMT were less likely to be prescribed these medications than their younger counterparts. This implementation gap persists despite available data from randomized trials showing no diminished treatment benefit from GDMT as patients age.

“If a patient is older and otherwise robust, I would not withhold aggressive medical therapy due to their age, but I would proceed with caution,” Dr. Martyn notes. “Rates of side effects differ among individuals, as do pharmacodynamics and changes in kidney function. For these reasons, in certain older patients, I may use a lower starting dose of a medication and titrate carefully.”

Dr. Martyn and his colleagues work closely with Cleveland Clinic cardiovascular pharmacists to ensure medications and doses are prescribed appropriately. Adding pharmacists to a multidisciplinary care team is recommended in the new AHA statement.

“When formulating a treatment plan, we consider adding agents that may provide benefit, but we also look for ways to eliminate medications that may be duplicative or unnecessary,” he says. “Being mindful of potential polypharmacy issues, this can be an opportunity to replace two blood pressure medications with a single combination agent or to swap out one of therapies with a medication that treats both blood pressure and heart failure.”

Holistic approach required

A substantial portion of the scientific statement is devoted to clinical strategies and possible outcomes in four domains — medical, mind/emotion, physical and social — that should be assessed and considered when weighing heart failure treatment for an older adult.

“We advocate for a multidomain management approach to optimizing evidence-based care in this population,” Dr. Martyn says. “This includes providing strategies for addressing frailty, fall risk, nutritional status, cognitive health, pill burden, comorbidities and illnesses that factor into compliance and outcome. The overarching aim is to holistically help ensure treatment plans meet the complex needs of older patients with heart failure.”

Pinpointing treatment goals

Shared decision-making is recommended for determining a patient’s goals for treatment. The authors provide advice on developing individual care plans and include tools that can help identify patients’ values and preferences. “Quality of life is particularly important in this age group,” Dr. Martyn notes. “We recommend having an open discussion with your patient about their goals for treatment.”

Another section discusses barriers that limit adherence to therapies, including both well-recognized issues (e.g., dislike of taking pills, side effects or limited insurance coverage) and understudied issues such as suboptimal health literacy, cognitive impairment and underestimation of benefit. Practical recommendations to overcome these barriers and increase adherence are provided.

Use of digital health technologies

The statement also touches on the use of digital health technologies in older adults. Dr. Martyn is intrigued by the potential of such tools to improve heart failure management across populations. His own work as Cleveland Clinic principal investigator and co-author in early clinical testing of an implantable inferior vena cava congestion sensor (JACC Heart Fail. 2026 Epub 3 Mar) established the early feasibility of patients self-managing their diuretics when they receive information from an implanted device on a smartphone application. He strongly encourages representation of all groups when studying digital health tools in cardiovascular disease.

“When we are evaluating new digital heart failure tools, it’s important that we don’t bias enrollment by including only individuals who are young or techno-literate,” Dr. Martyn says. “We need to ensure the tools are user-friendly for older patients and their families.”

An additional perspective

“Age alone should not determine whether an older adult receives effective heart failure therapy,” says Abdulla Damluji, MD, PhD, MBA, MPH, Director of Cleveland Clinic’s Cardiovascular Center on Aging. “The clinical task is to match treatment to the person’s health, function and priorities, with careful attention to frailty, cognition and the burden of medications. We should ask what patients hope treatment will help them do, and then use that answer to guide care. Preserving independence and relieving symptoms belong alongside survival as explicit goals of treatment.”

An effective treatment plan must be one the patient can carry out at home, adds Dr. Damluji, who was not involved in development of the AHA statement. “For an older adult with heart failure, factors such as memory, mobility, medication costs and caregiver support can determine whether a prescription results in better health,” he says. “Understanding these circumstances is part of delivering evidence-based care.”