cardiology in the elderly
DESCRIPTION
GeriatrieTRANSCRIPT
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Geriatric Cardiology
Adam Hajduk
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Population Projections in the U.S.: 2000-2050
0
10
20
30
40
50
2000 2010 2020 2030 2040 2050
Po
pu
lati
on
in
mil
lio
ns
Women >65
Men > 65
Women > 85
Men > 85
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Hospital Mortality for Cardiovascular Causes
Total deaths
(in thousands) Age > 65
Acute MI 78 68 (87.2%)
Arrhythmias 17 12 (70.6%)
Heart failure 42 37 (88.1%)
Cerebrovascular disease 65 49 (75.4%)
Source: National Hospital Discharge Survey, 1998.
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EFFECTS OF AGING ON THE
CARDIOVASCULAR SYSTEM
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Principal Effects of Aging on
Cardiovascular Structure and Function
Increased vascular + myocardial stiffness
Decreased -adrenergic and baroreceptor responsiveness
Impaired sinus node function
Impaired endothelial function
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CV Changes: Max Exercise - Ages 20 and 80 Years
Oxygen consumption Reduced ~ 50%
AV oxygen difference Reduced ~ 25%
Cardiac output Reduced ~ 25%
Heart rate Reduced ~ 25%
LV stroke volume Reduced ~ 15% to 25%
LV end diastolic volume No change or small
decrease
LV end systolic volume Increased ~ 150%
LV ejection fraction Reduced ~ 15%
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Age Changes in Systolic and Diastolic BP
Source: J Gerontol Med Sci 1997;52:M177-83
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Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.
Stroke Volume
Aorta
Resistance Arterioles
Pressure (Flow)
Young Artery
Systole Diastole
Elastic Vessel
Arteriosclerotic Artery
Stiff Vessel
Systole Diastole
Arterial Wall Compliance and Pulse Pressure Wave
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Clinical Implications
Increased systolic BP and pulse pressure
Increased prevalence of atrial fibrillation,
heart failure, especially heart failure with
preserved LV function
Increased prevalence of bradyarrhythmias
and sick sinus syndrome
Worse prognosis associated with all CV
diseases
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CORONARY HEART DISEASE
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Ischemic Heart Disease in the Elderly
Leading cause of death
35% of all deaths in people over age 65
Among people who die of IHD, 83% are over
age 65
CV mortality and morbidity rates increase
exponentially after age 75
6% US population over age 75
60% MI related deaths in people over age 75
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IHD characteristics in the elderly
increase in percentage of female patients
more complex and calcified coronary artery lesions
more often impairment of LV function
more often complicated myocardial infarction
coexisting diseases (HA, DM, renal function
impairment)
delayed visiting at the doctors and diagnosis
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Prevalence of Coronary Heart Disease by Age and Sex
0%
5%
10%
15%
20%
25-44 45-54 55-64 65-74 75+
Male
Female
Age, years
Source: National Health and Nutrition Examination Survey
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IHD clinical picture in the elderly
1. Stenocardia
Its frequency decreases with age (causes):
increase in threshold of pain pain-killers intake dementia acceptance of pain as inevitable in elder age limited physical activity (effort-induced angina is less
often)
well-developed collateral circulation
stenocardial pain more rare typical localization (retrosternal)
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2. Exertional dyspnea The most common symptom of myocardial ischemia in the elderly
3. Increasing symptoms of heart failure
4. Acute LV failure (pulmonary oedema)
by patients >70 years with pulmonary oedema and IHD 1-year mortality rate = 50%, 2-year = 70%
5. Fatigue or weakness during or after physical effort
6. Rhythm disturbances
7. Neurological symptoms
8. Silent ischemia
ischemia
LV compliance
LV end-diastolic
pressure
IHD clinical picture in the elderly
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1. Chest pain occurrance frequency decreases with age
< 65 years 80% of persons 6674 years 72% > 75 years 49%
2. Heart failure (dyspnea, pulmonary oedema)
< 65 years 14 % of persons 6674 years 20 % > 75 years 40 % (Gregoratos, Am. J. Ger. Cardiol. 2001)
Clinical picture of myocardial infarction
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3. Neurological symptoms (balance disturbances, vertigo, consciousness
disturbances, faintness, ischemic stroke)
4. Rhythm disturbances (esp. ventricular)
5. Abdominal symptoms (symptoms resembling peptic ulcer disease, biliary colic,
pancreatitis)
6. Acute renal failure
7. Sudden death
8. Silent infarction (up to 50% of all infarction cases in the elderly)
Some infarction cases remain unrecognised or recognised with substantial delay due to
atypical symptomatology.
(25% of ECG-recognised infarction cases were clinically undiagnosed Framingham
Study).
Clinical picture of myocardial infarction
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GUSTO-I
Delayed recognition of infarction in patients > 65 years is 2040 minutes
MITRA Register
Average delay > 75 years is 210 min. compared to 155 min. among
younger patients (Haase KK i wsp. Clin Cardiol 2000,23)
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IHD diagnostics causes of diagnostic difficulties in the elderly
atypical symptomatology
coexisting diseases (overlapping symptoms, misleading clinical picture) and polypragmasy
difficulties in carrying out and interpreting diagnostic tests
hindered cooperation with a patient
ECG changes hindering diagnosis of ischemia
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1. Resting ECG
more common abnormalities in initial ECG (non-specific changes of ST-segment, atrio- and intraventricular conduction disturbance, hypertension-
induced LV hypertrophy)
frequent intake of digitalis glycoside affecting ECG curve
2. 24-hour ECG monitoring
(useful in diagnostics of silent ischemia)
IHD diagnostics in the elderly
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3. Exercise testing
Limited diagnostic value:
age-related changes in physiological response to exertion (reduction in aerobic capacity, decrease in maximum heart rate 1/min/year, faster increase in systolic BP
value, limited increase in ejection fraction)
less intensive physical activity and bad physical condition (difficulties in reaching target rate of 85% of the maximum predicted HR)
fast reaching of the target rate at a low stage of the exercise test (initial tachycardia)
the ability to exercise is often limited by conditions unrelated to the heart (e.g. arthritis, neurologic disorders balance disturbances, vertigo; peripheral vascular disease)
elderly persons may not exercise maximally because of psychologic factors (e.g. unfamiliarity with vigorous exercise and sophisticated medical equipment, fear,
insufficient motivation).
frequent abnormalities in resting ECG (LBBB, LV hypertrophy, pacemaker, drugs)
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4. Perfusion scintigraphy
test useful in elderly population
abnormal Thallium-201 test result examined as the only parameter the most sensitive indicator of the cardiac complications risk.
limitations similar to those of the exercise test (exertion may be replaced with dipyridamole)
possibility of conducting isotopic ventriculography (evaluation of LV function)
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5. Stress echocardiography
exercise testing / pharmacologic stress testing with use of: dobutamine, adenosine, dipyridamole
diagnostic and prognostic value of the test positive results indicates significantly higher risk of major adverse cardiac events
sensitivity 79%, specificity 88%
safe and well-tolerated
technical limitations: anatomical conditions, obesity, worse chest mobility, emphysema
the most frequent adverse symptoms: decrease in BP, atrial fibrillation.
6. Coronarography
reference method (gold standard)
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Prognosis after AMI by Age
Source: Circulation 1996;94:1826-33
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Vaccarino et al Ann of Int Med 2001; 134: 173-181. Solid lines are men; dotted lines
are women.
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Who has an Acute MI? Numbers
from the ED
8% younger than 50
15% 5059
20% 6069
30% 7079
22% 8089
5 % >90
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Efficacy of Aspirin by Age: ISIS-2
0%
5%
10%
15%
20%
25%
< 60 60-69 70+
Placebo
Aspirin
Age, years
Source: Lancet 1988;II-349-60
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Long-term Benefits of Aspirin
0%
5%
10%
15%
20%
25%
< 65 65+
Aspirin
Control
Age, years Source: BMJ 1994;308:81-106
P < 0.00001
P < 0.00001
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% Eligible AMI patients given ASA in ED (Annals Emergency Medicine 2005)
0
10
20
30
40
50
60
70
80
90
100
90
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% Given Beta Blockers in ED (Annals Emergency Medicine 2005)
0
10
20
30
40
50
60
70
80
90
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% Eligible AMI patients given reperfusion (Annals Emergency Medicine 2005)
0
10
20
30
40
50
60
70
80
90
90
(n=9)
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Source: Am Heart J 2001:142:37-42
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Risk Stratification
Age is a huge risk factor for bad outcomes
Patients over age 75 are at high risk for death/recurrent MI. Patients < 65 with NSTEMI have 1% hospital
mortality.
Patients > 85 have 10% hospital mortality with NSTEMI.
Complications of recurrent MI, CHF, bleeding increase with age.
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ATRIAL FIBRILLATION
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Atrial Fibrillation and
Anticoagulation
Prevalence:
5% of people over age 65
10% of people over age 80
50% of all patients with FA are over age 80
Dreaded outcome: Stroke
Strokes with FA have higher
mortality/disability
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Age and Stroke Risk
Incidence of stroke with FA increases with age:
1.3 %/year in patients 5059
2.2 %/year in 6069
4.2 %/year in 7079
5.1 %/year in 8089
But it is much more complicated
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Predicting Risk of Stroke
CHADS2
CHF: 1 point
HA: 1 point
Age over 75: 1 point
DM: 1 point
Prior Stroke/TIA: 2 point
Score 0 = annual stroke risk
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Benefit of Warfarin
Overall decreases risk of stroke by 6070%,
ARR of 2.73 %/year
Beneficial in all age groups, even those over
age 75
?Quality of life of preventing a stroke
ARR - absolute risk reduction
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Risks of Warfarin
Risk of warfarin associated bleeding
increases with age
Risk ICH: 0.34 %/year in age less than 60,
0.76% /year in those over 80
Absolute risk of major bleeding = 2.2%
/year (increases to near 3% in those on
warfarin plus ASA)
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Warfarin Use
Older patients less likely to receive
anticoagulation
Older patients more likely to be
underanticoagulated even though data is
clear that there is no significant stroke
protection at an INR of less than 2.
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Warfarin in Older Patients
Patients under age 65 with FA and risk
factors for stroke: warfarin decreases risk of
stroke from 4.9 %/year to 1.7 %/year
In patients over 75 with risk factors (highest
risk group), warfarin reduces risk of stroke
from 12 %/year to 24 % /year.
Those at highest risk for stroke (older, prior
stroke, CHF, DM, HA) are less likely to be
given warfarin because of concerns for their
comorbidities.
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HYPERTENSION
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Hypertension - Prevalence
one of the in aging diseases
HA seen in over 60% of those over age 65
Elevations of SBP with decreases in DBP common with age due to diminished arterial compliance (increased Pulse Pressure)
SH accounts for 65-75% HA in those over 65
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Characteristics of Hypertension in the Elderly
Increased
Systolic blood pressure and pulse pressure
Left ventricular mass and wall thickness
Arterial stiffness
Calculated total peripheral resistance
Decreased
Cardiac output and heart rate
Renal blood flow, plasma renin activity, and angiotensin II levels
Arterial compliance and blood volume
Diastolic blood pressure
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18-29 30-39 40-49 50-59 60-69 70-79 80+ 0
70
80
110
130
150
18-29 30-39 40-49 50-59 60-69 70-79 80+ 0
70
80
110
130
150
0
70
80
110
130
150
0
70
80
110
130
150 D
BP
(m
m H
g)
SB
P
(mm
Hg
) D
BP
(m
m H
g)
SB
P
(mm
Hg
)
DB
P
(mm
Hg
) S
BP
(m
m H
g)
DB
P
(mm
Hg
) S
BP
(m
m H
g)
Men, Age (y) Women, Age (y)
Non-Hispanic Black
Non-Hispanic White
Mexican American
Pulse pressure Pulse pressure
Mean Systolic and Diastolic BP by Age and Race/Ethnicity for Men and Women (US Population Age 18 Years, NHANES III)
Burt VI, et al. Hypertension. 1995;25:305-313.
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Forms of hypertension in the elderly
isolated systolic hypertension (IHS):
62,867,4% caused by an age-related increase
in arterial stiffness, more common among women
systolic-diastolic hypertension:
27,630,3%
diastolic hypertension sporadically
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The Importance Of SH
SH associated with increased risks of CAD,
LVH, renal insufficiency, stroke and
cardiovascular mortality
SH and pulse pressure more closely associated
with CV risk than diastolic BP in older patients
(even in older patients with diastolic HTN)
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The aim of treatment
to maintain SBP values < 140 and DBP < 90 mmHg, by diabetic
patients < 130 and < 85 mmHg respectively
achievement of the therapy goal should be stretched over a long
period of time (longer than by younger patients), up to several
months in some cases
it is useful to set some staging posts of the therapy, e.g.
reaching the BP values of 160/90 mmHg
such symptoms as: ill-being, vertigo, balance disorders, vision
disorders (e.g. scotoma), confusion decreasing the dosage or
changing the group of antihypertensives
the higher initial BP values are, the more carefully they should
be reduced
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Treatment benefits
Isolated systolic hypertension
over 50% of cases of hypertension in the elderly (main arteries
stiffness)
SBP value and pulse pressure are crucial prognostic factors of
hypertension complications in the elderly
cardiovascular mortality rate is almost three times higher as
compared to other hypertension forms
first-line treatment Calcium antagonists and diuretics
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Meta-analysis (SHEP, Syst-Eur, Syst-China, HEP, MRC-2, EWPHE)
14 825 elderly persons with ISH
reduction in:
all-cause mortality rate by 14%
cardiovascular mortality rate by 20%
fatal and non-fatal cardiovascular events rate by 20%
stroke rate by 33%
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Hypertension is one of the primary factors leading to dementia in the
elderly (vasogenic dementia as well as Alzheimers disease)
patients with untreated hypertension may develop dementia in
advanced age
Alzheimers disease: cerebral microflow disturbance due to
persisting increased arterial blood pressure (collagen deposition
and thickening of basement membrane of capillaries slowing
down the pace of transporting nutritious substances into neurons
as well as of elimination of toxic waste products
dementia can be a common consequence of a stroke (hypertension
complications); patients with hypertension > 84 years tend to have
ten times higher incidence of stroke than patients aged 55-64
Dementia
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Dementia (cont.)
Syst-Eur Study:
4700 patients > 60 years, treated for ISH (nitrendipine)
diagnosed dementia by 50%
(Alzheimers and vasogenic types)
PROGRESS Study
6150 patients with/without hypertension, history data: ischemic stroke
or TIA (perindopril /+indapamide);
dementia rate by 34%
stroke rate by 28%
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Modification Approximate SBP
Reduction
(range)
Weight Reduction 5-10 mmHg/10kg
Adopt DASH eating plan 8-14 mmHg
Dietary sodium reduction 2-8 mmHg
Physical activity 4-9 mmHg
Moderation of alcohol
consumption 24 mmHg
Lifestyle Modifications
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Which agent is best?
Thiazide Diuretics: First Line in large trials
ACE inhibitors LIFE (Losartan Intervention for Endpoint Reduction): Losartan vs Beta
blocker Losartan decreased risk CV events
HOPE (Heart Outcomes Prevention Evaluation) Patients with DM, over 55, CVD risk
Ramipril 10/day decreased morbidity/mortality at 5 yrs
Most pronounced effect seen in those over age 65
Ca Channel Blockers SHELL (SH in Elderly: Lacidipine Long Term Study)
CCB and thiazide similar effectiveness
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Which agent?
Beta Blockers may not be first line
LIFE study (25 events/1000 patient years in those on losartan vs 35
events/1000 pt yrs on atenolol)
Meta-analysis of 10 trials, 16000 older patients with SH Diuretic better than B blocker in preventing combined endpoint
Beta blockers and diuretics decreased risk of stroke, BUT
Beta blockers were not effective at preventing CAD, CV mortality or all cause mortality
CONTRAINDICATIONS: COPD (chronic obstructive pulmonary
disease), peripheral vascular disease, bradycardia, heart blocks
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BSH (British Society of Hypertension) / NICE (National
Institutes for Health and Clinical Extension)
recommendations, 2006
1st-line Ca-blocker or diuretic
2nd-line ACEI + Ca-blocker or ACEI + diuretic
3rd-line ACEI + Ca-blocker + diuretic
4th-line -blocker
intensificaction of diuretic treatment
-blocker
consider consulting with a specialist
treatment algorithm for patients with hypertension > 55 years
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Therapy failures (reasons)
secondary hypertension
coexisting diseases
drugs (NSAID, steroids)
improper drugs intake (e.g. therapy breaks when BP returns to
normal)
polypragmasy (incl. improper combinations of antihypertensive
drugs)
white-coat hypertension
too expensive drugs
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every sixth elderly patient with hypertension
Causes
renal diseases (renal artery stenosis, a kidney disorder e.g. polycystic
kidney disease, glomerulonephritis, chronic pyelonephritis)
endocrine disorder (eg, Cushing's syndrome, hypothyreosis, primary
aldosteronism, pheochromocytoma)
drugs (steroids, NSAID, B2-agents)
alcohol abuse
Secondary hypertension should be always considered in cases of sudden
development of hypertension, drug-resistant hypertension and fast
increasing renal failure.
Secondary hypertension
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Quality of Life
Studies demonstrate no significant impact with treatment
ACE inhibitors/ARBs have better profile
CCBs well tolerated
Sexual dysfunction most commonly reported with thiazides
Nonselective Beta blockers reported to have some subjective negative effects on cognition and mood
Higher risk of Postural hypotension (30%)
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Orthostatic hypotonia
SBP by at least 20 mmHg, often along with DBP by min. 10
mmHg after postural change (from recumbent into standing).
We measure BP after a patient has been standing quietly for at
least 1 minutes (and then after 3 minutes)
particularly common in the elderly with hypertension
15 to 20% of community-dwelling and about 50% of
institutionalized elderly persons
10% of physically fit and > 50% of infirm persons > 65 years
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Pathomechanism
HR i stroke volume
(beta-adrenergic stimulation)
Postural
change lower limbs blood hold
venous return
stroke volume
carotid sinus flow
(baroreceptors stimulation)
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Orthostatic hypotonia effects
sudden cerebral circulation decline ( stroke risk)
deterioration in coronary circulation (myocardial ischaemia /
infarction)
injuries, sometimes life-threatening (as a consequence of vertigo,
balance disturbances)
psychological trauma, anxiety of physical activity, leading to
infirmness
symptoms: vertigo, balance disturbances, dizziness, faintness,
falls and trauma, vision disorders, TIA, stenocardia, nausea
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Predisposing factors
venous insuficiency (obesity, lower limbs varices, sedentary life
style, aging processes in veins walls)
disturbances of BP autonomic control (impairment of a
baroreceptor mechanism, lesser variability of HR, a reduction in
density and sensitivity of beta-receptors, peripheral neuropathy)
impaired cerebral circulation and cerebral vessels autoregulation
dehydration, low-sodium diet
drugs (diuretics, alfa-blockers, nitrates, anti-Parkinsonic,
phenothiazines, tricyclic antidepressants)
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Management
slow postural change
raised-waist clothes
pressure stockings for patients with venous insufficiency
careful implementation and dosage of drugs which can intensify
hypotonia
orthostatic hypotonia test after each change of dosage or
implementation of a new drug
alternatively consider pharmacological treatment (fludrocortisone,
caffeine, ephedrine)
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Conclusions
There is rapid global growth in the number of elderly patients with CV disease
Mortality from CV disease is high in elderly patients
Evidence-based therapy is highly effective in elderly patients
Careful selection and tailoring of such therapies is mandatory for elderly patients with CV disease
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Take Home Points
Age is only one factor; frailty and age are
not the same thing.
There need to be increased numbers of older
adults included in trials, and these patients
should be similar to older community
patients and younger trial patients.