Title: Cardiovascular Disease and the Elderly
1Cardiovascular Disease and the Elderly
- Dorothy D. Sherwood, MD, FACP
2So who are you calling old?
3Introduction
- 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.
4Clinical 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.
5Myocardial 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
6Intervention 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.
7Management of Risk Factors in the Elderly
- Smoking
- Increased Bp
- Increased Heart Rate
- Increased PV resistance
- Increased catecholamines
- Increased susceptibility to clotting
- Decreased HDL
8Management 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.
9Management 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
10Management 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
11Management 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.
12Management 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.
13Management 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
14Management 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
15Management 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.
16Management 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
17Management 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 (
18Management 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.
19Management 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).
20Management 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.
21Management 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
22Management 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
23Management 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
24Management 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
25Management 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.
26Management 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.
27Management 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
28Management 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
29Atrial 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.
30Atrial 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.
31Summary
- 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.