CARDIOVASCULAR DISEASE AND THE ELDERLY

Dorothy D. Sherwood, MD, FACP

So who are you calling old?

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.

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.

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%

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.

Management of Risk Factors in the Elderly Smoking

Increased Bp Increased Heart Rate Increased PV resistance Increased catecholamines Increased susceptibility to clotting Decreased HDL

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.

Management of Risk Factors in the Elderly Hypertension

Present in >60 % 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

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 > in patients with CAD and 60mm Hg in patients without CAD

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.

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.

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

Management of Risk Factors in the Elderly/Hypertension Choosing the right drug

Start low go slow Remember their barro-receptors don’t work

so don’t drop them fast. The all get orthostatic – to what degree is

important

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.

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

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 (

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.

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).

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.

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

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

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

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 ( < 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

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.

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.

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

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:

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.

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.

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.