geriatric cardiology richard e. freeman md 2013 lock haven university

Geriatric Geriatric CardiologyCardiology

RICHARD E. FREEMAN MD RICHARD E. FREEMAN MD 20132013

LOCK HAVEN UNIVERSITYLOCK HAVEN UNIVERSITY

Geriatric CardiologyGeriatric Cardiology

OCTOGENARIANS – 80 YRS+OCTOGENARIANS – 80 YRS+ 1850 – present1850 – present

average age increased from 40 to average age increased from 40 to ~80~80

2010: 12 million age 80 2010: 12 million age 80 ““very oldvery old”” increasing by 8% per yearincreasing by 8% per year

OLD OLD: 75- 85OLD OLD: 75- 85 OLDEST OLD: >85OLDEST OLD: >85


CV DISEASE –CV DISEASE – 1/2 octogenarians - CVD1/2 octogenarians - CVD

65 % of deaths - CAD - AMI65 % of deaths - CAD - AMI

20% of hospital admissions 20% of hospital admissions

––

1/2 CHF1/2 CHF

• OCTOGENARIANS

Geriatric CardiologyGeriatric Cardiology COMMON CARDIOVASCULAR COMMON CARDIOVASCULAR

CHANGES WITH AGINGCHANGES WITH AGINGSTRUCTURAL CHANGESSTRUCTURAL CHANGESFUNCTIONAL CHANGESFUNCTIONAL CHANGESHEART RHYTHMHEART RHYTHMECG CHANGESECG CHANGES

Geriatric Geriatric CardiologyCardiology STRUCTURAL CHANGESSTRUCTURAL CHANGES

Increased intimal media Increased intimal media thicknessthickness Reduced compliance and distensibilityReduced compliance and distensibility Increased vessel stiffness and tortuosityIncreased vessel stiffness and tortuosity Reduced NITRIC OXIDE –dependent Reduced NITRIC OXIDE –dependent

vasodilationvasodilation Arterial pressure riseArterial pressure rise Widening pulse pressureWidening pulse pressure

Increased heart weightIncreased heart weight LVH: increased size but reduced number LVH: increased size but reduced number

of myocyteof myocyteFibrosis: changes in collagen fibersFibrosis: changes in collagen fibers

Geriatric Geriatric CardiologyCardiology FUNCTIONAL CHANGESFUNCTIONAL CHANGES

Systemic arterial pressureSystemic arterial pressure-RISES-RISES Diastolic pressureDiastolic pressure- DECREASES- DECREASES Pulse pressurePulse pressure- INCREASES- INCREASES CatecholamineCatecholamine- and exercise-- and exercise-

induced increases in heart rate induced increases in heart rate BLUNTEDBLUNTED Peak CO with exercise decreased by Peak CO with exercise decreased by

up to 30%up to 30% Left ventiricular- ComplianceLeft ventiricular- Compliance - -

FALLSFALLS Diastolic dysfunction Diastolic dysfunction ““STIFF wallSTIFF wall””

Early diastolic filling reducedEarly diastolic filling reduced Late diastolic filling increased (atria)Late diastolic filling increased (atria)

LAH and LAELAH and LAE

GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY HEART RHYTHMHEART RHYTHM

Parasympathetic function- Parasympathetic function- reductionreduction Reduced R to R variabilityReduced R to R variability

Linked to increased CV morbidity and mortalityLinked to increased CV morbidity and mortality

Decreased SA cellsDecreased SA cells ArrhythmiasArrhythmias

PACsPACs present in 5-10% greater than 60 present in 5-10% greater than 60 y/oy/o

PVCs: PVCs: 8.6% men over 60%,8.6% men over 60%, Atrial Fibrillation (Abnormal Rhythm)Atrial Fibrillation (Abnormal Rhythm)

most common most common rhythm disturbance: 9% of rhythm disturbance: 9% of those >80.those >80.

Geriatric CardiologyGeriatric Cardiology ECG CHANGESECG CHANGES Most common Most common ECG finding ECG finding

involves involves repolarizationrepolarization Review previous tracingsReview previous tracings Q-T intervals, T waveQ-T intervals, T wave

PR interval lengthenedPR interval lengthened 11stst degree AV block 3-4 % degree AV block 3-4 %

healthy menhealthy men LVHLVH

Left axis deviationLeft axis deviation BBBBBB

LBBB uncommon in absence of LBBB uncommon in absence of CV diseaseCV disease


SUMMARIZING SUMMARIZING MOST DRAMATIC CHANGES MOST DRAMATIC CHANGES 1.Increased intimal media thickness and 1.Increased intimal media thickness and

arterial stiffness,arterial stiffness, 2.Alterations in diastolic filling patterns, 2.Alterations in diastolic filling patterns,

3. Impaired cardiac responsiveness to 3. Impaired cardiac responsiveness to exercise and/or β-adrenergic stimuli, andexercise and/or β-adrenergic stimuli, and

4. Alterations in heart rhythm. 4. Alterations in heart rhythm.

GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY

These age-associated These age-associated changes in cardiovascular changes in cardiovascular structure and function structure and function interact with age-prevalent interact with age-prevalent risk factors such as:risk factors such as:

hypertension,hypertension, diabetes, and diabetes, and hyperlipidemia andhyperlipidemia and This helps explain the This helps explain the

markedly increased rates of markedly increased rates of coronary heart disease, heart coronary heart disease, heart failure, and atrial fibrillation failure, and atrial fibrillation seen in older adults.seen in older adults.

Geriatric CardiologyGeriatric Cardiology PREVENTION:PREVENTION:

Primary: Primary: Lifestyle - activity, diet, emotional stressLifestyle - activity, diet, emotional stress

Secondary: Secondary: Extrapolate from younger age studies - Extrapolate from younger age studies -

behavior modification –behavior modification – bp control –bp control – lipid control (statins) lipid control (statins)

GENETICS:GENETICS: MOST likely a common denominatorMOST likely a common denominator ““It’s what’s in your gene (jeans) that It’s what’s in your gene (jeans) that

count.”count.”


HYPERTENSIONHYPERTENSION

Prevalence - 80%Prevalence - 80%

GET Treatment - 75%GET Treatment - 75%

OBTAIN Adequate treatment - 29%OBTAIN Adequate treatment - 29%


HYPERTENSIVE HEARTHYPERTENSIVE HEART

MYOCYTEMYOCYTE- hypertrophy - younger - hypertrophy - younger MUSCLEMUSCLE- thickness - elderly- thickness - elderly

Interstitial collagen and fibrosisInterstitial collagen and fibrosis

Diastolic dysfunction:Diastolic dysfunction:

““A FILLING PROBLEM”A FILLING PROBLEM”

SLOER OR INCOMPLETESLOER OR INCOMPLETE

SYSTOLICSYSTOLICDIASTOLICDIASTOLIC

EMPTYING PROBLEM FILLING PROBLEMEF – LOW EF MAY BE NORMAL STILL “DEAD “WALL STIFF WALL

GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY

HYPERTENSIONHYPERTENSION TreatmentTreatment::

Rapid reduction – cautionRapid reduction – cautionNitroglycerin IVNitroglycerin IVBeta Blocker IV (short acting)Beta Blocker IV (short acting)

Gradual reduction –(long term use)Gradual reduction –(long term use)Small reductions – event Small reductions – event reductionsreductions

Multiple agents – small dosageMultiple agents – small dosage

Evidence suggests that lowering Evidence suggests that lowering SYSTOLICSYSTOLIC blood pressure in the geriatric patient is blood pressure in the geriatric patient is beneficial beneficial in lowering morbidityin lowering morbidity, but , but may not effect mortalitymay not effect mortality, , especially in the very old. It also suggests that when especially in the very old. It also suggests that when a target blood pressure cannot be achieved—for a target blood pressure cannot be achieved—for example, because of an adverse drug effect, even a example, because of an adverse drug effect, even a mild reduction mild reduction in systolic blood pressure (7 to 10 in systolic blood pressure (7 to 10 mm Hg) is still mm Hg) is still beneficialbeneficial and may be attempted and may be attempted. . DECREASE BOTH IN STROKE AND HEART DECREASE BOTH IN STROKE AND HEART EVENTSEVENTS


CORONARY ARTERY DISEASECORONARY ARTERY DISEASE INCIDENCE :INCIDENCE :

Increases with advancing ageIncreases with advancing age2/3 of all MIs and 80% of MI-2/3 of all MIs and 80% of MI-related deaths occur in those related deaths occur in those over 65over 65

CHD

MI

CHF

GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION

Presentation variable Presentation variable –– chest pain, acute dyspnea, sudden fatigue, chest pain, acute dyspnea, sudden fatigue,

confusion, or syncopeconfusion, or syncope REMEMBER : ELDERLY AND WOMEN -ATYPICALREMEMBER : ELDERLY AND WOMEN -ATYPICAL

Preventative Treatment Preventative Treatment ––

BP and Rate controlBP and Rate control Beta blocker, and ace inhibitorBeta blocker, and ace inhibitor

Nitroglycerin - BP control and vessel dilationNitroglycerin - BP control and vessel dilation

Lipid reduction Lipid reduction - extrapolation from younger - extrapolation from younger

populationpopulation


MYOCARDIAL INFARCTION (MYOCARDIAL INFARCTION (continuedcontinued))

Thrombolytic Thrombolytic therapy therapy Very elderly – higher prevalence of contraindicationsVery elderly – higher prevalence of contraindications

Anticoagulation Anticoagulation - Heparin or LMWH- Heparin or LMWH

Antiplatelet Antiplatelet - Gp IIb / IIIa ( Plavix), ASA - Gp IIb / IIIa ( Plavix), ASA

In-hospital deaths and complication rates In-hospital deaths and complication rates

increase significantly with advancing age, increase significantly with advancing age,

but those patients receiving more guideline-but those patients receiving more guideline-

based therapies had lower mortality rates. based therapies had lower mortality rates.

GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY Myocardial Infarction: PCIMyocardial Infarction: PCI

The American College of Cardiology–National The American College of Cardiology–National

Cardiovascular Data Registry has evaluated the in-Cardiovascular Data Registry has evaluated the in-

hospital outcomes of 8828 PCIs performed in hospital outcomes of 8828 PCIs performed in

octogenarians (mean age, 83.7 years, 53% female).octogenarians (mean age, 83.7 years, 53% female).

[18] PCI was angiographically successful in 93% of PCI was angiographically successful in 93% of

patients with an overall in-hospital mortality rate of patients with an overall in-hospital mortality rate of

3.77%. However, when patients with AMI in the week 3.77%. However, when patients with AMI in the week

preceding PCI were excluded from analysis, the preceding PCI were excluded from analysis, the

mortality rate decreased to 1.35%.mortality rate decreased to 1.35%.

TAKE HOME: EARLY INTERVENTION BETTER TAKE HOME: EARLY INTERVENTION BETTER

OVERALL SURVIVALOVERALL SURVIVAL

GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY MYOCARDIAL INFARCTION: MYOCARDIAL INFARCTION: CABGCABG

The older the patient the:The older the patient the: More acute need for CABGMore acute need for CABG More advanced CADMore advanced CAD Higher incidence of complicating Higher incidence of complicating

comorbiditiescomorbidities

American College of Cardiology and the American College of Cardiology and the American Heart Associationrecommended American Heart Associationrecommended that that

““age alone should not be a contraindication age alone should not be a contraindication to CABG surgery,to CABG surgery,

if it is thought that long-term benefits if it is thought that long-term benefits outweigh the procedural risk.outweigh the procedural risk.


ANGINAANGINA

VariableVariable presentation presentation

Management:Management: MedicalMedical – multiple agents – multiple agents RevascularizationRevascularization - angioplasty/stent - - angioplasty/stent -

CABGCABG External extracorporal counter pulsationExternal extracorporal counter pulsation: :

Afterload reduction Afterload reduction - endothelial - - endothelial - vascular remodelingvascular remodeling


ATRIAL FIBRILLATIONATRIAL FIBRILLATION Types:Types:

Paroxysmal - -> permanentParoxysmal - -> permanent Controlled or uncontrolled ventricular Controlled or uncontrolled ventricular

responseresponse

PathophysiologyPathophysiology Neuromuscular conduction disorderNeuromuscular conduction disorder Atrial volume disorder Atrial volume disorder (stretch)(stretch) Location: Location: atria and/or proximal pulmonary atria and/or proximal pulmonary

veinsveins

Geriatric CardiologyGeriatric Cardiology Atrial FibrillationAtrial Fibrillation

ManagementManagement Conversion Conversion Rate controlRate control NSR vs. rate controlNSR vs. rate control AblationAblation

Age ( =/< 70 )Age ( =/< 70 ) Location – pulmonary veinsLocation – pulmonary veins Success – Immediate - 90% Success – Immediate - 90%

- Long term – 70%- Long term – 70% Anticoagulation – Long termAnticoagulation – Long term STROKE RISK- 4.5 %/yr unabticoagulatedSTROKE RISK- 4.5 %/yr unabticoagulated Warfarin – 70 % reductionWarfarin – 70 % reduction


CONGESTIVE HEART FAILURECONGESTIVE HEART FAILURE

After load control After load control - BP- BP Preload control Preload control - volume (diuretic)- volume (diuretic) Rate control Rate control (Beta blocker)(Beta blocker) Energy control Energy control - creatine phospho - creatine phospho

kinase kinase

Digoxin-ACE-ARBDigoxin-ACE-ARB Revascularization/Valve Revascularization/Valve

replacement or replacement or corrective surgerycorrective surgery PacingPacing - resynchronization - resynchronization

Geriatric CardiologyGeriatric Cardiology Diastolic Heart FailureDiastolic Heart Failure


Six Minute AssessmentSix Minute AssessmentSix minute walkSix minute walk

Heart failure vs. frailty Heart failure vs. frailty Distance non-heart failureDistance non-heart failure 180180’’ (+/- (+/- 1010’’))

Frailty Frailty 150150’’ (+/- 10(+/- 10’’))Heart failure Heart failure =/< 90=/< 90’’

Geriatric CardiologyGeriatric Cardiology MANAGEMENT OF VALVULAR HEART MANAGEMENT OF VALVULAR HEART

DISEASEDISEASE Symptomatic aortic stenosis Symptomatic aortic stenosis - - surgery: surgery:

mortality = 5 - 6%, mortality = 5 - 6%, combined procedures = 10%, combined procedures = 10%, five year survival = 60%five year survival = 60%

Mitral regurgitation Mitral regurgitation ring reduction w/wo valvuloplasty, ring reduction w/wo valvuloplasty, or or mitral mitral

valve replacementvalve replacement valve replacement (limited)valve replacement (limited) 10 - 15% mortality10 - 15% mortality

Aortic valve

Mitral annular calcification


Challenges vs ChampionsChallenges vs Champions

BiasBias in applying proven therapeutic in applying proven therapeutic modalities in the elderlymodalities in the elderly

Refine and apply Refine and apply risk factor risk factor managementmanagement

Continued need to recognize theContinued need to recognize the unique unique characteristics of very elderlycharacteristics of very elderly

to better apply pharmacotherapy vs to better apply pharmacotherapy vs interventional therapyinterventional therapy

geriatric cardiology richard e. freeman md 2013 lock haven university

Documents

increased size

increased cv morbidity

common ecg

year old old

geriatric cardiology

widening pulse pressure

common rhythm disturbance

lae slide