Heart failure in special populations

Despite considerable elucidation of the heart failure syndrome, two important special clinical situations arise that require additional perspectives: “special populations” of patients affected with heart failure; and important clinical comorbidities that may accompany heart failure. The prototypical special populations are women, the elderly, and minorities. Each of these groups is frequently underrepresented in clinical trials but is seemingly overrepresented in clinical practice. Available data, largely derived from post-hoc subgroup analyses of the major clinical initiatives in heart failure, have yielded several prevailing themes pertinent to all three groups: the compelling influence of hypertension on the genesis of heart failure; questions regarding efficacy of current medical treatment regimens; and the concern that morbidity and possibly mortality due to heart failure may be more problematic. Despite these concerns, there are no substantial data to suggest that treatment algorithms should vary as a function of gender, age, or race. Whereas most clinical trials in heart failure exclude the patient with significant renal, pulmonary, or thyroid diseases, the prevalence of these comorbidities in heart failure is not insignificant and the contribution to excess morbidity and mortality in heart failure can be substantial.