Screening for Heart Failure in the Elderly and the Competition of Co-Morbidity. What if we Could Prevent Heart Failure from Reaching the Finish Line First?

Heart failure is a disease of old age and casts a dark shadow over the last phase of life in many elderly people. This is confirmed by the striking prevalence of heart failure in elderly UK nursing home residents reported by Dr Hancock and colleagues in this journal.1 The authors emphasized the feasibility of potential screening for heart failure in this specific population. In the concomitant editorial, Dr Hoes elegantly assessed the validity of a hypothetical heart failure screening programme in the elderly.2 While many of the World Health Organization (WHO) screening criteria appear to be met, we agree with Dr Hoes that it is too early to implement such a screening programme in the absence of randomized evidence. In addition, we would like to place a note of caution on screening for failing hearts in the disabled and oldest of the old. Only few diseases in the elderly match the burden of morbidity and poor survival associated with heart failure.3,4 Therefore, timely diagnosis and initiation of treatment could potentially prevent substantial numbers of hospitalizations and deaths related to heart failure in the elderly. However, in contrast to younger patient groups, approximately half of the elderly diagnosed with heart failure in the general population will not die from cardiovascular causes.5 Moreover we must realize that due to the frailty and compression of co-morbitiy that accompanies heart failure in these older persons (and especially in nursing home residents),6 other competing non-cardiac causes of death are expected to take over rapidly and thereby reduce the benefit of screening in the elderly.7 These phenomena constitute some of the main arguments against screening for cancer in elderly persons and determine the upper age limits in most such screening guidelines. With the ageing of the population and the ever improving prognosis of acute cardiac conditions, increasing numbers of heart failure patients in the future will be a harsh reality. Joint efforts of cardiologists, primary care physicians, and cardiovascular researchers are warranted to halt this oncoming tide. However, one may argue whether the most desirable way to achieve this would be through screening for the late stages of the disease itself. Focusing on more effective preventive measures for major risk factors throughout the life course may well be a more logical option.8 More research on both determinants and outcomes of heart failure, specifically in the elderly,9,10 is needed to fuel this discussion. Conflict of interest: none declared.