Managing heart failure in the very old

The very old carry most of the burden of mortality and morbidity created by heart failure and, therefore, they have the greatest need of assistance and care. Disappointingly, the highest level of evidence for the optimal management of the syndrome has been generated by clinical trials that have insufficiently enrolled people aged 75 years or over, so that the efficacy and safety of current heart-failure therapies remains uncertain in these patients. In the absence of straightforward guidance, the very old should be managed pragmatically, tailoring strategies to the individual needs of the patient in order to achieve an acceptable compromise between improvements in quality and quantity of life. To best meet this goal, the risk of adverse effects of any therapeutic intervention should be carefully weighed against the expected benefits, taking concomitant diseases and treatments into the greatest consideration due to their potential to interfere negatively with heart-failure management and prognosis. As adherence to and safety of therapies are major issues in the long-term management of the very old with heart failure, appropriate follow-up strategies, including the active participation of the patient, should be adopted.