CARDIOVASCULAR DISEASE IN THE ELDERLY

Definition of elderly
No universal definition of elderly and no accurate biomarker for aging exist. Most definitions of elderly are based on chronological age. WHO : uses 60 years of age to define elderly. Most of US classification use the age of 65 years.

Gerontologists subclassify older age groups into :

- Young old (60-74 years), Old old (75-85 years), Very old (over 85 years of age).

Clinicians often separate older patients into 2 groups :

- those 65 to 80 years and those older than 80 years.

Physiologic changes in aging heart and blood vessels

The Heart : Muscle relaxes less between beats (becomes stiffer). May not pump blood as efficiently. Is less responsive to stimulation by the nervous system. Is less able to increase strength of contractions during

exercise
Wall may thicken. The blood vessels : Wall becomes less elastic. Reflex that maintains BP upon standing up may become slower.

Cardiovascular diseases in elderly

CVD is the most frequent diagnosis in elderly people Leading cause of death in both men women >65 years. Hypertension occurs in 1/2 to 2/3 of people >65 years. Heart failure (HF) is the most frequent hospital discharge

diagnosis among older Americans.

Systolic but not diastolic BP increases with aging. Systolic hypertension : a stronger predictor of CV events. HF with preserved systolic function : more common at the older ages and more common in women than men.

Cardiovascular diseases
CAD is more likely to involve multiple vessels and left main artery disease and is equally likely in women and men >65 years. Equal numbers of older men and women present AMI until age 80. >80% all of deaths attributable to CVD occur in people >65 years, with approximately 60% of deaths in patients >75 years.

Furthermore, CVD in older people is not seen in isolation.

89% of older Americans have at least one chronic medical condition, and half have at least two.

Types of cardiovascular disease more common in elderly

Isolated systolic hypertension Orthostatic hypotension Coronary heart disease Heart failure

Aortic stenosis
Mitral annular calcification Complete heart block

Sick sinus syndrome

Atrial fibrillation Stroke

Differentiation between age-associated changes and cardiovascular disease in older people

Organ
Vasculature

Age-associated changes
Increased intimal thickness
Arterial stiffening Increased pulse pressure Increased pulse wave velocity Early central wave reflections Decreased endothelium-mediated vasodilatation

CVD
Systolic hypertension
Coronary artery obstruction Peripheral artery obstruction Carotid artery obstruction

Atria
Sinus node

Increased left atrial size

Atrial premature complexes Decreased maximal heart rate Decreased heart rate variability

Atrial fibrillation
Sinus node dysfunction, SSS

Differentiation between
Organ
Atrioventricular Node Valves Ventricle

Age-associated changes
Increased conduction time Sclerosis, calcification Increased LV wall tension Prolonged myocardial contraction Prolonged early diastolic filling rate Decreased maximal cardiac output Right bundle branch block (RBBB) Ventricular premature complexes

CVD
Type II block 3rd block Stenosis, Regurgitation LV hypertrophy Heart failure (with or without preserved systolic function) Ventricular tachycardia, V.fibrillation

Unique features of CVD in the elderly

Presentation
AMI
Atrial Fibrillation CAD
Dyspnea, CHF chest pain, nausea/vomiting, confusion.
Dyspnea, CHF rate slower than in young.

Diagnosis
ECG,serum markers or imaging.
Apical pulse, ECG

Treatment
Thrombolysis ?Revascularization
Rate control, anticoagulation

Chest discomfort or dyspnea TMT test, Nuclear test with emotion/DOE women imaging, stress echo, as well as men smoking sessation, medicine, PTCA, CABG, lipid reduction Same as young Systolic, asymptomatic Diastolic > sistolic Three readings at > 2 weeks apart Diuretics,digoxin,+B -blockers/CCB Diet, exercise, alcohol withderawal, medications.

CHF Htn

Valvular disease

Altered physical findings

Echocardiography

Critical --- surgery.

Guidelines for drug dosing in older patients

In general, loading doses should be reduced weight (or body surface
area) can be used to estimate loading dose requirements; doses in women are usually less than those in men.

Base doses of renally cleared drugs on estimates of glomerular filtration

or creatinine clearance (or if not possible, initiate with lower doses than in younger patients) ; reduce doses of hepatically cleared drugs.

Time between dosage adjustments and evaluation of dosing changes should be longer in older patients than in younger patients. Routine use of strategies to avoid drug interactions is essential. Assessment of adherence and attention to factors contributing to nonadherence should be part of the prescription process.

Drugs and the elderly

Slower metabolism and other physiologic changes in the aging body may cause drugs to act differently in elderly patients than in younger ones.

High BP medication may produce dizziness and orthostatic hypotension,

especially the vasodilators, diuretics, or some of CCB. Dizziness from anti-anginal medications (nitroglycerine) is also more common. Toxicity from digitalis (used in heart failure) may be more common. The use of antiocoagulant drugs may result in bleeding more readily and is dangerous in people who are unsteady and subjects to frequent falls. B-blockers tend to slow the heart more. Inravenous lidocaine may cause more confusion.

Approach to hypertension in older patients

Systolic as well diastolic htn should be treated : Diastolic target is <90 mmHg. Systolic target is <140 mmHg. Individualization is needed for patients older than 80 years. Initial therapy is often in low dose of a HCT or is based on concomitant diseases (cardiac and noncardiac). Drug dosing regimens should be reduced for age-and disease-related changes in drug metabolism and for drug-drug interactions. Patients should be monitored for postural hypotension. BP should be measured at least 4 hr from meals. Patients should be monitored for adverse effects and drug interactions, especially Hypovolemia with diuretics. Hyperkalemia with ACEI, ARB, aldosteron antagonists. Renal function

Approach to the older patient with CAD/CHD

Morbidity and mortality from CAD and CAD treated medically or with

revascularization increases with age and more steeply at age older than 75 years. After age 70 to 75 years, there few data to suggest clear advantages of one method of treatment of CAD over another. Anticipated procedural complication rates should reflect the age and health status of the patient, not complication rates from series of younger patients. Decisions regarding medical therapy versus revascularization or for PCI versus CABG should be based on the role of CAD in the context of the individual older patients overall health, life style, projected life span, and preferences.

Approach to anticoagulation in older patients

Obtain complete medication and nutraceutical intake data to anticipate warfarin requirements, interactions, contraindications, and necessary adjustment. Educate patient, family and/or caregivers on diet, alcohol effects and drug interactions and need for monitoring and communication. Initiate with low doses (warfarin)--- often at 2 mg/d not to exceed 5 mg/d. Monitor closely and titrate slowly. Consider warfarin effects of all medication, supplement, and diet changes. Use preventive measures for osteoporosis.

Approach to the older patient with Peripheral artery disease (PAD)

Treatment of CV risk factors, aspirin, and supervised walking-based exercise programs are first line therapy. Medications can improved symptoms (cilostazol > clopidogrel > pentoxyfilline; cilostazol should not be used in patients with HF. Estrogen and progesterone should be avoided in women with PAD. Revascularization options include PCI for iliac disease but long-term efficacy requires surgical approaches at femoropopliteal and infra popliteal level. Surgical morbidity and mortality increase with age and postoiperative recovery times can be prolonged. All are highest in the setting of surgery for critical ischemia or limb salvage.

Approach to the older patient with HF

Symptoms may be relatively nonspesific in the older patient. Diagnosis may be facilitated by use echocardiography or serum markers of heart failure. Recognize that HF may be present in the older patient with preserved systolic function, especially older women. Treat symptoms with a goal of improving quality of life as well as morbidity : Control BP ---- systolic and diastolic. Control atrial fibrillation rate. Promote physical activity. Adjust medications for age- and disease- related changes in kinetics and dynamics. Educated and involve patients, family members, or caregivers in mangement of HF : Monitor weight. Consider use of multidisciplinary team approaches.

Approach to the older patient with AF

Atrial fibrillation (AF) is frequent in elderly people and confers a risk of stroke but the patient may be unaware of its presence, suggesting that routine examinations or electrocardiographic evaluations be targeted toward detection of AF. Anticoagulant is the chief weapon against stroke : Both greater potential benefit and risk for fatal intracranial bleeding are present at ages >75 years, especially in women.

Careful attention to anticoagulant monitoring is needed.

Aspirin does not usually provide stroke risk reduction in older patients because of higher likelihood of the presence of CVD but has overall bleeding complication rates similar to those with warfarin. Rate control produces equivalent benefits with lower costs than attempts as rhythm control. Useful agents for elderly patients include digoxin, BB, nondihydropyridine CCB, and amiodarone with dose adjustment for age, weight, and cocomitant diseases.

Approach to the older patient with suspected valvular heart disease

Physical examination cannot reliably assess the severity of valvular lesions in most older patients. Doppler echocardiography is the clinical standard for diagnosis and evaluation of the severity of valve lesions : Differentiates sclerosis from stenosis. Quantitates regurgitation. Assesses calcification of valves and supporting structures. Age is a predictor of worse outcomes for the natural history of valvular lesions as well as surgical approaches. Surgery is definitive therapy for valvular lesions with age, CAD, additional diseases, projected life span, and desired life style as factors in evaluating surgical option.