Geriatric Cardiology – You CAN treat Angina!

April 24, 2012

• No speakers’ bureaus• No device or pharmaceutical manufacturers• General cardiologist with focus on angina,

critical care, prevention• Edgar Leifer Professor of Clinical Medicine• Chief, Allen Hospital Medical Service• Director, House Staff Training Program

Angina 2012 2

• Clinical Case – Dr. MS• Definitions• Epidemiology• Physiology• Clinical evaluation• Medical therapies• Non medical therapies• Conclusion

Angina 2012 3

• Refocus concern from angina as an entity to a symptom of ischemia

• Reinforce current concepts of pathophysiology of ischemia

• Review current therapies of ambulatory management for primary care

• No discussion of ACS (Unstable Ischemic Heart Disease)

• Emphasis on Geriatric issues

Angina 2012 4

• 10 year history of CAD– Risks: Hypertension – EKG showed RBBB

for 20 years– Murmur of AI – Symptoms of chest

pressure and DOE – LAD 90% prox, 90% mid – 4 stents

• 2 years of chest pressure– Onset with swimming– Negative stress test– Relieved with

treatment with PPI

• Current – walking induces chest pressure, relieved by rest

Angina 2012 5

• Current meds– Beta blocker

– Aspirin

– Statin

• Exam– BP 120/60 P 68

– Chest – clear

– Heart – 2/4 diastolic blow along left sternal border

– JVP normal

– EXT – no edema

• Lab studies– Hct 42 Hgb 14.2

– Creat 1.0

– CXR: Mild cardiomegaly

Angina 2012 6

Angina 2012 7

Angina 2012 8

NUCLEAR STRESS: SCAN NEGATIVE• * Symptom: Chest pain. • * HR Response: HR failed to increase

appropriately, likely due to medications. • * BP Response: Appropriate. • * ECG Abnormalities: ECG changes could not

be interpreted due to abnormal baseline ECG. • * Arrhythmia: Frequent VPDs. *• *Review of raw data shows: diaphragmatic

artifact • * The left ventricle was normal in size.

• Normal myocardial perfusion scan, with no evidence of infarction or inducible ischemia.

• * Gated wall motion analysis is performed, and shows normal wall motion with rest LVEF of 65% and post stress LVEF of 61%.

• *** Conclusions *** • The patient had a possible anginal symptom

during exercise in the absence of SPECT evidence of ischemia at a heart rate of 110/min.

Angina 2012 9

• Who was William Heberden?– English physician 1710-1801– Classic description 1768

“They who are afflicted with it, are seized while they are walking, (more especially if It be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or to continue; but the moment they stand still, all this uneasiness vanishes. “

Angina 2012 10

DEFINITIONS

• Greek : ἀγχόνη ankhone ("strangling")

• Latin: angina = “throat inflammation”

• Merriam Webster: “A disease marked by spasmodic attacks of intense suffocative pain.”

• ICD 9: 413; ICD 10: 120• Spanish: “Dolor de Pecho”

EPIDEMIOLOGY

• Only 18% of coronary attacks are preceded by longstanding angina

• New episodes increase with age and are more frequent in African Americans

• DEATH IS INFREQUENT

Angina 2012 11

Angina 2012 12

– Asymptomatic– Silent ischemia– Angina– Acute coronary syndromes

• Unstable Angina• Myocardial infarctions

– Sudden cardiac death– Congestive heart failure

Angina 2012 13

DEMAND • Heart Rate• Contractility• Wall tension

T=Pr/2h– Preload (r)– Afterload (P)– Wall thickness

(h)

SUPPLY• O2 carrying capacity

– Hemoglobin

• Coronary blood flow– Perfusion pressure

• Aortic vs. end diastolic

– Vascular resistance• Neural control

•Lesions

Angina 2012 14

Angina 2012 15

• Asymptomatic– Relaxation – S4– Contraction – S3, mitral regurgitation– Electrical – repolarization

• Symptomatic– Angina, Dyspnea, Arrhythmias

• Cellular integrity – no change, stunning, hibernation

Angina 2012 16

• Risk Factors– Framingham – Age, Gender, Family History,

Smoking, Diabetes, Hypertension, Hyperlipidemia

– ATP III – Prior CAD, Peripheral Arterial Disease = Coronary risk equivalents

– Elderly age risk factors:• Urinary albumin excretion• Pulse pressure • Arterial Stiffness

Angina 2012 17

Angina 2012 18

J Am Geriatr Soc 52:1639–1647, 2004•Prospective Population Based Study•> 65 yo, 1954 men, 2931 women, followed 7.5 years

„most lipid measures were weakly associated withcardiovascular events. The association between low HDLC

and increased MI risk was nonetheless strong and consistent.”

• History – 95% specific classically– Look for equivalents

• Dyspnea• Shoulder or back pain• Weakness, fatigue• Epigastric discomfort

– Consider physical exertion levels– Silent ischemia seen in 20-50% of patients 65 years or

older.– Adjust for population at risk (age, gender, comorbidities)– Identify stability

Angina 2012 19

• Typical Angina– Substernal chest

discomfort with characteristic quality and duration

– Provoked by exertion or emotional stress

– Relieved by rest or NTG

Angina 2012

• Dyspnea

• Indigestion

• Back, arm, neck, wrist pain

• Burning

• Pressure

• Rest, recumbency

Angina 2012

• TABLE 1. Grading of Angina of Effort by the Canadian Cardiovascular Society

I. "Ordinary physical activity does not cause ... angina," such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation.

II. "Slight limitation of ordinary activity." Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.

III. "Marked limitation of ordinary physical activity." Walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace.

IV. "Inability to carry on any physical activity without discomfort - anginal syndrome may be present at rest."

Campeau, L “Grading of Angina Pectoris” Letter to the Editor

CIRCULATION 1976: 54: 522-23

Angina 2012 22

• Determine remediable factors

• Identify patients at high risk– Anatomy – Left main > 50%; Three vessel– Physiological – Impaired LV function– Functional – unstable state

Angina 2012 23

• Physical Exam – remediable factors– VS: Heart rate, BP, T,

RR

– Chest – congestion

– Heart – enlargement, valvular disease, failure

– Vascular – obstruction, congestion

– Extremities - edema

• Lab Studies – remediable factors– CBC – anemia

– Basic metabolic panel – glucose, renal function

– Lipid Panel

– (Thyroid function)

– EKG

– Chest X Ray

– (Echocardiogram)

Angina 2012 24

• Aging increases the prevalence of CAD but is masked by the co-morbidities that reduce activity. [Schwartz,Zipes in Braunwald 9th]

Angina 2012 25

• Exercise - ?modified protocols– Treadmill

– Bicycle

• Exercise with imaging

• Pharmacologic with imaging

Angina 2012

• Hypotension with exertion• Inability to exercise beyond stage II of Bruce

protocol (6 minutes) – NOT APPLICABLE IN THE ELDERLY

• ST depression more than 2 mm• ST elevation in the absence of q waves• Ventricular arrhythmias with ischemia• Pulmonary uptake of thallium• 2 or more zones of ischemia

REFER PATIENTS WITH HIGH RISK FOR ANGIOGRAPHY

Angina 2012 27

• GI – GERD, biliary• Neuro – cervical radiculopathy• Chest wall – costochondritis, intercostal

neuralgia• Pulmonary – pleural, parenchymal• Vascular – aortic, pulmonary

Pitfalls: Placebo response, Concurrent inactive disease

Angina 2012 28

• Relieve pain, discomfort

• Improve function• Avert further

atherosclerotic complications– Sudden death– Congestive heart failure– Acute coronary

syndromes

Angina 2012 29

• 2002 guideline update for the management of patients with chronic stable angina

• www.acc.org/clinical/guidelines/stable/stable.pdf

• Diagnosis• Risk Stratification• Treatment• Follow Up• References (1052)• 2007 update: Circulation

2007; 116: 2762

Angina 2012

(From Schwartz JB: Clinical Pharmacology, ACCSAP V, 2003. As modified from Nolan L, O’Malley K: The need for a more rational approach to drug prescribing for elderly people in nursing homes. Age Aging 18:52, 1989; and Denham MJ: Adverse drug reactions. Br Med Bull 46:53, 1990.)Figure 80-6 Schwartz and Zipes, Braunwald.

Angina 2012 31

• Cost**

• Difficulty with understanding directions (hearing, sight)

• Inadequate instruction**

• Complete dosing regimens

• Packing material

• Insufficient education of patient, family, or caregiver

• Cognitive impairment**

Angina 2012 32

• Was this angina or GERD?– Known CAD, age, make for high pre test

probability?– History of GERD

• Symptom complex stable, bothersome but not debilitating

• Stress test – no high risk features• Therapeutic trials

– Nitrates– GI consult – New PPI, Decline EGD without Cath

Angina 2012 33