MSGM Clinical Case Discussion July 2026

Heart Failure Treatment in Frail Older Adults: Balancing Guidelines and Individual Needs

Prepared by Dr Siti Khairizan Rahim

Supervised by Dr Rizah Mazzuin Razali

Case Summary

Heart failure in older adults significantly aggravates frailty, malnutrition and cachexia and impacts overall prognosis. Frailty causes further functional decline, hospitalisation, longer hospital stays and a higher mortality rate. While malnutrition in heart failure is due to appetite loss, malabsorption, and a catabolic condition that leads to cachexia, it is also similarly linked to a higher risk of mortality. The case below is one of the common scenarios in the hospital, and treatments must be carefully adjusted to account for the severity of heart

failure, presence of comorbidities, frailty status and prognosis of the patient.

September 2025

Mr TSA is a 75-year-old gentleman with underlying diabetes mellitus, hypertension, dyslipidaemia, and chronic kidney disease stage 3a (baseline creatinine 109) under Klinik Kesihatan follow-up. He lives alone and is independent in instrumental and basic activities of daily living. His Clinical Frailty Scale score is 4 and NYHA Class II.

He noticed that both legs had been swollen for 2 months, causing slow walking, shortness of breath and reduced effort tolerance, but denied palpitations or chest pain. He went for a medical check-up at a private centre. Investigations were performed and found to have acute decompensated heart failure, with an echocardiogram showing EF 40%, dilated LV and normal valves. He was then started on anti-failure medications and restriction of fluid to 800 ml per day and discharged home.

His laboratory investigations are as follows:

Blood investigations results

Hb 10.5 g/dl

Urea 11/ Na 128/ K 3.4/ creatinine 150

T. Cholesterol 6.0 /TG 1.8/ HDL 1.3/ LDL 3.0

Hba1c 9.2%

The list of medications:

Previous medications from KK	New medications added
T. Losartan 100mg OD T. Metformin 1 g BD T. Atorvastatin 20mg OD	T. Spironolactone 12.5mg OD T. Bisoprolol 2.5mg OD T. Dapagliflozin 10mg OD T. Aspirin/Glycine 100/45mg OD T. Frusemide 40mg PRN

Questions:

1. Why is the Hb level reduced in heart failure patients?

2. Should the restriction of fluid be applied to all heart failure patients?

3. What is the impact of the four pillars of HFrEF therapy on survival? Which anti-failure medication has significant effects on HFpEF?

December 2025

He complained of blistering skin rashes over both legs, associated with redness for 2 weeks. He went to the nearby Klinik Kesihatan at the beginning and was given oral cloxacillin for a week. He has become homebound for the past 1 month and is NYHA Class III. However, the skin condition worsened despite completing a course of antibiotics, and he sought further treatment at the emergency department.

Upon review in the Emergency Department

Conscious and full GCS

Blood pressure (BP) was 93/50 with HR 66 bpm

Repeat BP 76/40 with HR 68 bpm

Glucose 5.2 mmol/L

He was started on IVI Noradrenaline, and BP picked up to 102/58, HR 89 bpm.

Examinations:

JVP not raised

Lungs were clear

CVS DRNM

Lower limbs:

The skin was erythematous from the foot to the thigh with bullous rashes scattered on both distal legs. Pitting pedal edema until mid-shin bilaterally.

ECG showed Sinus rhythm, Q wave at V2-V4 with ST depression at V5-6, lead I and AVL

His laboratory investigations are as follows:

Blood investigations results

Hb 11.2g/dl

WCC 9.8

CRP 194

Urea 26/ Na 146/ K 4.8/ creatinine 189

T. Cholesterol 5.2/ TG 1.7/ HDL 1.3/ LDL 2.6

Hba1c 8.0%

Iron 2.7 / TSAT 11%

Diagnosis was given as:

1. Septic shock secondary to partially treated bullous cellulitis

2. Chronic stasis eczema and tinea pedis of bilateral lower limbs

3. Acute kidney injury secondary to multifactorial (over-diuresis/dehydration, septic shock, drug-induced)

4. Iron deficiency anaemia

He was admitted to the acute geriatric ward and given further treatment.

Question:

1. Why are the elderly prone to over-diuresis and dehydration? Explain the physiological changes in thirst response for the elderly.

2. Iron therapy in heart failure patients. What is the evidence?

Mr TSA was improving on the third day of admission and was able to wean off inotropic support. His renal function improved to baseline, and his latest blood pressure was 110/58 with HR of 68 bpm.

Question:

1. Which anti-failure medication should be started first? and the next sequence.

2. If the patient’s heart failure symptoms are progressive and lead to recurrent admissions, when should the patient be referred to palliative care?

References:

1. Anand IS, Gupta P. Anemia and iron deficiency in heart failure: Current concepts and emerging therapies. Circulation. 2018;138(1):80–98.

doi:10.1161/CIRCULATIONAHA.118.030099.

2. Kato NP, et al. Fluid restriction for patients with heart failure: Current evidence and future perspectives. J Pers Med. 2024;14(7):741. doi:10.3390/jpm14070741.

3. Straw S, McGinlay M, Witte KK. Four pillars of heart failure: contemporary

pharmacological therapy for heart failure with reduced ejection fraction. Open Heart. 2021;8:e001585. https://doi.org/10.1136/openhrt-2021-001585

4. Stolfo, D., Sinagra, G., Savarese, G. (2022). Evidence-based therapy in older

patients with heart failure with reduced ejection fraction. Cardiac Failure Review, 8, e16. https://doi.org/10.15420/cfr.2021.34

5. Cleland JG, McGowan J, Clark A, Freemantle N. The evidence for beta blockers in

heart failure. BMJ. 1999 Mar 27;318(7187):824-5. doi: 10.1136/bmj.318.7187.824.

PMID: 10092240; PMCID: PMC1115260.

6. Rolls, B. J., Phillips, P. A. (1990). Aging and disturbances of thirst and fluid

balance. Nutrition Reviews, 48(3), 137–144. https://doi.org/10.1111/j.1753-

4887.1990.tb02915.x

7. Anker SD, et al. Ferric carboxymaltose in patients with heart failure and iron

deficiency (FAIR-HF). N Engl J Med. 2009;361(25):2436–2448. doi:10.1056/NEJMoa0908355.

8. Anker, S. D., Butler, J., Khan, M. S., Abraham, W. T., Greene, S. J., Lam, C. S. P.,

colleagues. (2025). Systematic review and meta-analysis of intravenous iron therapy in heart failure with iron deficiency. Nature Medicine. Advance online publication.

https://doi.org/10.1038/s41591-025-03671-1

9. Rogers JG, et al. Palliative care in heart failure: The PAL-HF randomized controlled trial. J Am Coll Cardiol. 2017;70(3):331–341. doi:10.1016/j.jacc.2017.05.030.