Should we Screen for Heart Failure in the Elderly?

This editorial refers to ‘High prevalence of undetected heart failure in long-term care residents: findings from the Heart Failure in Care Homes (HFinCH) study’, by H.C. Hancock et al., published in this issue on pages 158–165. The prevalence of heart failure has increased during the preceding decades and will continue to increase in the future. This trend is mainly attributable to ageing of the population and improved survival of heart failure.1 Heart failure primarily occurs in the elderly; the mean age at diagnosis is ∼752 and is characterized by a high prevalence of co-morbidity and a poor prognosis. In a recent study among geriatric outpatients, 3-year survival in patients with newly diagnosed heart failure (mean age 83 years) was only 44%.3 Although available studies clearly show that the prevalence of heart failure in the elderly is high and sharply increases with age, prevalence estimates in the elderly population at large remain scarce, mainly because of major limitations in the methods applied to establish heart failure (most notably state-of-the-art echocardiography to determine systolic and diastolic LV function is often lacking) and the limited sample size of most studies. As a consequence, valid estimates of the prevalence of the two major ‘subtypes’ of heart failure, i.e. heart failure with reduced EF (HFrEF) and heart failure with preserved EF (HFpEF), are rare. This distinction is, however, important for daily practice, since management strategies in HFrEF and HFpEF differ considerably.4 The study by Hancock et al., published in the current issue, adds important information to the body of evidence on heart failure in the elderly for several reasons.5 First, the methods applied to assess the prevalence of heart failure were ‘as state-of-the art as possible’ in this setting with elderly (mean age 84 years) residents of long-term care facilities with multiple co-morbidity. In particular, echocardiographic measurements of both systolic and diastolic ventricular function were performed in all but 6 of the 405 participants, and the interobserver variability of these measurements was extremely low. Secondly, the sample size of the study (399 older men and women aged ≥65 years from 33 care facilities) is higher than in most earlier studies, yielding relatively narrow 95% confidence intervals (95% CIs) for the prevalence estimates of both HFrEF and HFpEF. In addition, the authors assessed the presence of heart failure in patients with a previously recorded diagnosis of heart failure. The main findings of the study were a prevalence of heart failure of 22.8% (95% CI 18.8–27.2%), with a prevalence of HFrEF of 8.5% (95% CI 6.0–11.7%) and of HFpEF of 14.3% (95% CI 11.2–18.1%). Importantly, of those with HFrEF, ∼50% had been previously diagnosed with heart failure, while ∼90% of those with HFpEF were newly detected. This leads to a prevalence of newly detected heart failure of 19% (of which the vast majority is HFpEF), while only 24% of those with a diagnosis of heart failure in the primary care files could be confirmed as heart failure. The latter finding confirms earlier studies that a false-positive diagnosis of heart failure is common in the primary care setting.6 Such a very high prevalence of one in five of previously unknown heart failure in this elderly population, in conjunction with similarly high prevalences observed in other screening studies among elderly populations [e.g. 15% in nursing home patients,7 7% in the elderly population at large,8 21% (about half of these had HFpEF) in older COPD patients,9 and 28% (83% of these had HFpEF) among older diabetes patients]10 raises the question of whether screening for heart failure in the elderly at large, or in specific subgroups, is warranted. Why screen for congenital hypothyroidism in neonates, cervical cancer in women, colorectal cancer in 55–75 year olds, and not for heart failure in the elderly? In Table 1, the Wilson–Jungner criteria for assessing the validity of a screening programme are shown.11 These criteria, although published almost 45 years ago and never meant to be carved in stone, are still considered an adequate approach to guide decisions on the usefulness of screening programmes. Below, the 10 criteria will be briefly discussed for screening for heart failure. Although aspects, such as evidence for the optimal screening interval, other than the 10 Wilson–Jungner criteria are important in the weighing of the pros and cons of screening for heart failure in the elderly, a quick analysis shows that almost all of the 10 criteria are at least partly met. Clear evidence that screening for heart failure in the elderly will be beneficial at reasonable costs and that these benefits outweigh the potential side effects of screening, is, however, lacking, despite the high prevalence of undetected heart failure in these patients and especially in certain subgroups. Clearly, the current benefits of screening for HFpEF, the most prevalent type of heart failure in the elderly, are limited; this may change when the current search for effective treatments in these patients becomes successful. Trials assessing the effect of screening for HFrEF may very well show that such a strategy is worthwhile. Meanwhile, it is, however, too early to implement heart failure screening programmes. One cannot help to think now and again, however, when other screening programmes, such as for prostatic cancer, are strongly advocated, that screening for heart failure is potentially more beneficial and certainly will have fewer side effects. Conflict of interest: none declared.