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Cardiovascular Disease and the Elderly

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CARDIOVASCULAR DISEASE AND THE ELDERLY Dorothy D. Sherwood, MD, FACP * * * * * * * Physiological effects of aging: Decreased compliance, LV hypertrophy, * Lack of ... – PowerPoint PPT presentation

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Title: Cardiovascular Disease and the Elderly


1
Cardiovascular Disease and the Elderly
  • Dorothy D. Sherwood, MD, FACP

2
So who are you calling old?
3
Introduction
  • The clinical manifestation of CHD in older
    patients represents the effect of the disease
    superimposed on the physiological effects of age.
  • At autopsy, 50 of elderly women and 75 of
    elderly men have obstructive CAD
  • Octogenarians comprise 5 of the US population
    but 20 of the hospitalizations for MI.
  • Coronary arteriography- older individuals have
    worse disease than the younger.

4
Clinical Manifestations/Angina
  • Typical angina only 40 have this
  • Dyspnea this is related to ischemia on a stiff
    hypertrophied left ventricle raising PA pressure
  • Nausea and vomiting, syncope
  • Secondary MI post pneumonia, fractured hip.
  • Pulmonary Edema much more common presentation in
    the elderly
  • Lack of angina based on sedentary life style due
    to co-morbid conditions.

5
Myocardial Infarction in the Elderly
  • Increased mortality due to increase co morbid
    conditions, more extensive CHD, and lesser use of
    beneficial therapies.
  • When comparing treatment provided to those over
    75 vs. under 75
  • Thrombolysis 5 vs. 39
  • PTCA 7 vs. 29
  • CABG- 5 vs. 11
  • Asa 57 vs. 82

6
Intervention in the Elderly
  • Octogenarians with unstable angina treated
    medically have an event-free-one- year survival
    of 55
  • Stenting outcomes are similar in the older vs.
    younger group although some studies show excess
    non-Q wave MI and vascular complications.
  • CABG 3 year survival 77 vs. 54 with medical
    therapy alone 5 year survival vs. stenting 66
    vs 55
  • 4.7 mortality rate in octogenarians but
    hospital course is prolonged and complicated.

7
Management of Risk Factors in the Elderly
  • Smoking
  • Increased Bp
  • Increased Heart Rate
  • Increased PV resistance
  • Increased catecholamines
  • Increased susceptibility to clotting
  • Decreased HDL

8
Management of Risk Factors in the Elderly
  • Smoking continued
  • Cessation reduces mortality by 25 to 50 most MI
  • Interventions Strong Physician Advice, Support
    Groups, Pharmacological Therapies, Telephone
    follow up.
  • Nicotine replacement is safe
  • Cardiac Rehab Program provides the counseling.

9
Management of Risk Factors in the Elderly
  • Hypertension
  • Present in gt60 of adults over age 60.
  • Individuals 55 to 65 do no have htn, have a 90
    lifetime risk of developing it.
  • Isolated systolic hypertension is the most common
    in this age group 60 to 75 of the cases
    primarily due to diminished arterial compliance.
  • Threefold increase in risk of MI, LVH, renal
    dysfunction, stroke and cardiovascular mortality

10
Management of Risk Factors in the Elderly
  • ISH
  • CAD risk varies directly with the systolic and
    pulse pressure and inversely with the diastolic
    pressure - i.e. worse outcomes in elderly with
    low diastolic pressure
  • Cardiovascular events can occur if the diastolic
    pressure is reduced below the level needed to
    maintain perfusion. Goal should be 65 or gt in
    patients with CAD and 60mm Hg in patients without
    CAD

11
Management of Risk Factors in the
Elderly/Hypertension
  • Treatment Efficacy
  • Sodium restriction to 2 grams usual diet is 4
    grams one tsp of salt is 2 grams.
  • TONE trial in patients form 60 to 80 placed on
    weight loss diet, salt restricted diet or both
    those patients dropped BP 2 to 4 mm Hg systolic
    and 1 to 2 mm Hg diastolic
  • Not much bang for the buck and elderly do have
    trouble with salt restriction. None the less
    worth 30 seconds of education at each visit.

12
Management of Risk Factors in the
Elderly/Hypertension
  • Treatment Efficacy
  • Over 15,693 patients over the age of 60 with
    systolic hypertension have been studied.
  • Number needed to treat to prevent one major CV
    event
  • 18 men, 38 women
  • 19 over 70, 39 under 70
  • 16 with prior CV disease, 37 without
  • SHEP trial attained BP 143/68 with therapy,
    155/72 with placebo stroke 5.5 in treated, 8.2
    in placebo, ¼ decrease in cardiac events, and
    reduced LV mass index.

13
Management of Risk Factors in the
Elderly/Hypertension
  • Treatment efficacy
  • HYVET trial all patients over 80 3800
    patient. - placebo or indapamide ( thiazide
    diuretic) and perindopril ( ace inhibitor)
  • Fatal stroke 6.5 vs. 10
  • Death from all caused 47.2 vs 59.6
  • Goal BP in patients over 80 in this study was
    150/80

14
Management of Risk Factors in the
Elderly/Hypertension
  • Choosing the right drug
  • Start low go slow
  • Remember their barro-receptors dont work so
    dont drop them fast.
  • The all get orthostatic to what degree is
    important

15
Management of Risk Factors in the
Elderly/Hypertension
  • Choosing the right drug continued
  • Diuretics
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Calcium channel blockers (CCBs)
  • Angiotensin receptor blockers (ARBs) and
  • Renin Inhibitor
  • Central Alpha Agonist
  • Alpha Blocker
  • Beta-blockers.

16
Management of Risk Factors in the
Elderly/Hypertesnion
  • Choosing the right drug
  • Most elderly will require combination therapy
  • Most octogenarians do not want diuretics
  • Avoid beta blocker for first line treatment
    unless otherwise indicated.
  • Consider cost

17
Management of Risk Factors in the
Elderly/Hypertension
  • Choosing the right drug
  • Low dose combination therapy
  • 1) greater efficacy
  • 2) 24-hour efficacy with once-a-day dosing (if
    the correct combination of drugs is utilized)
  • 3) a greater response rate than monotherapy
  • 4) fewer side effects than monotherapy
  • 5) fewer metabolic side effects than monotherapy
    and
  • 6) the possibility that the combination drugs
    result in a lower per patient cost than higher
    dose monotherapy (

18
Management of Risk Factors in the
Elderly/Hypertension
  • Choosing the right drug
  • Combination
  • Amolodipine/benazepril (Lotrel)
  • Lisinopril/hydrocholothiazide (Zesoretic)
  • Additions
  • Diuretic or calcium channel blocker to above
  • Further addition
  • Aliskerin ( Tekturna)
  • Beta blocker
  • Central alpha agonist
  • Peripheral alpha blockers.

19
Management of Risk Factors in the
Elderly/Hypertension
  • Summary
  • Among elderly less than 80, initiate therapy with
    systolic pressures greater than 140mm Hg and
    diastolic pressure greater than 90 mm Hg.
  • Among elderly over 80 with ISH initiate therapy
    between 150 to 160 systolic and goal should be
    150 systolic avoid diastolic hypotension ( less
    than 60).

20
Management of Risk Factors in the
Elderly/Hyperlipidemia
  • Total cholesterol levels increase with age
    primarily from an increase in the LDL-cholesterol
  • Multiple studies have shown that a high LDL and
    low HDL in the elderly is associated with
    significant CHD risk.

21
Management of Risk Factors in the
Elderly/Hyperlipidemia
  • Benefits of lipid lowering drugs in the elderly
  • 4S trial simvastatin trial 1000 patients over
    65 with angina or prior MI treatment reduced
    all cause mortality by 34, mortality from MI by
    43 , and revascularization by 41
  • CARE trial 1200 patients over 65
  • Treatment prevented 225 hospitalizations and 207
    events in the elderly 121 and 150 in the young
  • LIPID trial treatment with pravastatin
  • needed to treat in elderly vs. young to prevent
    event 20 to 30 vs. 40 to 70

22
Management of Risk Factors in the
Elderly/Hyperlipidemia
  • Further studies
  • PROSPER trial ages 70 to 82 pravastatin 40
    vs. placebo- 5000 participants Reduction in
    coronary death and nonfatal MI but not decrease
    in all cause mortality
  • SAGE trial age 65 to 80 80 mg atorvastatin
    vs. 40 mg of pravastatin decrease in major CV
    events with intensive therapy and decrease in
    mortality

23
Management of Risk Factors in the
Elderly/Hyperlipidemia
  • Barriers to treatment
  • Misconception that benefit of treatment will take
    years really is shown in 6 months improves
    endothelial dysfunction in days
  • Fear of increased risk of side effects in the
    elderly no studies have shown this side
    effects same in the elderly as the young
  • Cost not issue with generics

24
Management of Risk Factors in the
Elderly/Hyperlipidemia
  • Primary prevention limited data on lipid
    lowering in the aged
  • Greater than 40 of those over 65 meet the NCEP
    guidelines for treatment
  • There is a 37 incidence of subclinical vascular
    disease in patients over 65 as measured by EKG,
    Echo, and AAI ( lt 0.9)
  • Over 50 of elderly people will die from Cad
  • The Cardiovascular Health Study 9 patients over
    age 65 without known heart disease ) did suggest
    significant benefit from primary prevention in
    the older population

25
Management of Risk Factors in the Elderly/Aspirin
  • Aspirin therapy has been proven to be of greater
    benefit in the elderly with CAD than in the
    young.
  • Use it and use it with PPI except in the
    acute setting when clopidogrel is also being
    used.
  • Aspirin in primary prevention in men is proven
    in women, is controversial weigh risk benefit.

26
Management of Risk Factors in the Elderly/ACE
inhibitor, Beta Blocker
  • ACE inhibitor and Beta Blockers are effective
    post MI and should be used. Start with low doses
    and titrate up. Be alert to side effects based
    on decreased creatinine clearance and reduced
    beta receptors.

27
Management of Risk Factors in the Elderly/Exercise
  • Benefits
  • Improvement of exercise tolerance
  • Reduction of symptoms 
  • Reduction of cholesterol levels
  • Reduction of cigarette smoking
  • Improvement in psychosocial well-being and
    reduction of stress
  • Lowering of blood pressure
  • Barriers Lack of physician Rx, economic,
    logistics, cost

28
Management of Risk Factors in the Elderly/Exercise
  • Diagnosis that qualify for Finley Ewing Cardiac
    Rehabilitation .
  • Heart attack
  • Atherosclerotic heart disease
  • Angina pectoris
  • Abnormal stress test
  • Valvular heart disease
  • Pacemaker or AICD
  • Heart failure
  • Angioplasty or artherectomy
  • Coronary artery bypass surgery
  • Heart transplant
  • Potential benefits of Cardiac Rehabilitation
    include

29
Atrial Fibrillation
  • Briefly elderly benefit most from warfarin
    anticoagulation.
  • There is no increased serious adverse events in
    the elderly patient on warfarin vs. high dose
    aspirin.
  • However, due to co morbid conditions, dementia,
    inability to monitor INR , recurrent falls,
    warfarin is often stopped.
  • Evidence supports aspirin and clopidogrel if
    warfarin cannot be used.

30
Atrial Fibrillation
  • If the patient has no symptoms from atrial
    fibrillation, then rate control only is
    indicated.
  • If patient is symptomatic with dyspnea, weakness,
    then trial at cardioversion is indicated.

31
Summary
  • If one lives long enough, he or she will die.
  • Our jobs as physicians is to delay that death
    while life is good.
  • Choose your treatment based on your patient. Be
    aggressive with the healthy elderly save the
    inheritance of the sick.
  • Treat the patient with the care and concern you
    would treat your mother or father. Be careful,
    be correct, and be compassionate.
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