Heart Health in the Elderly

“Less is More”

Kevin Overbeck, DOAssistant Professor, NJISA

Learning Objectives

• Apply knowledge of Aging Physiology to the most common clinical presentations in primary care – Hypertension + Dyslipidemia

• On the basis of current evidence, evaluate therapeutic goals and intensity of treatment of Hypertension & Dyslipidemia in the elderly.

Aging Physiology:Body Composition

• Lipid Compartment Expands• Total Body Water (mainly ECF)

declines• Lean Muscle Mass Declines• Application: Implications for Drug

Prescribing

HYPERTENSION &

THE ELDERLY

Increased thickness of the intima and the media

INCREASED VASCULAR STIFFNESS

Aging Physiology

Aging Physiology

Pearson, J.D., Morrell, C.H., Brant, L.J., Landis, P.K., and Fleg, J.L. (1997). Age-associated changes in blood pressure in a longitudinal study of healthy men and women. Journal of Gerontology, 52, M177–83.

Aging Physiology

• Increased BP variability• Impaired BP homeostasis

– Hypertension– Postural (orthostatic) hypotension– Post-prandial hypotension

1. Huang CC, et al. Effect of age on adrenergic and vagal baroreflex sensitivity in normal subjects. Muscle Nerve. 2007;36(5):637-42.

2. Jansen RW, et al. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med. 1995;122(4):286

Consequences of Baroreceptor Changes1

HTN & The ElderlyOrthostatic BP Measurement

Sitting-Standing vs. Laying-StandingAfter standing wait 1 minute vs. 3

minutes vs. 5 minutes• At least a 20 mmHg fall in systolic

pressure • At least a 10 mmHg fall in diastolic

pressure • Symptoms of cerebral hypoperfusion

Parkinson’s / Lewy Body DementiaDecreased Baroreceptor Sensitivity1

Postprandial Hypotension

HTN & The ElderlyHYVET

Becket, NS, Peters, R, Fletcher, AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008; 358(18): 1887-1898.

HTN & The ElderlyHYVET

Becket, NS, Peters, R, Fletcher, AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008; 358(18): 1887-1898.

JNC 7: Clinical Practice Guidelines

• Life style Modification (LSM)

• Laboratory

The Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII), August 2004.

BP Classification

Systolic (mmHg)

Diastolic(mmHg)

Initial Therapy

Normal <120 <80 Encourage LSM

Pre-Hypertension

120-139 80-89 LSM + No Anti-Hypertensive Drug Indicated; Treat patients with CKD or DM to a goal <130/80 mmHg

Stage 1 140-159 90-99 LSM + Thiazide diuretics for most

Stage 2 > 160 >100 LSM + Two drug combination for most *

* Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.

Ambulatory BP MonitoringSelf Measuring BPAssess Risk Factors

JNC 8: Clinical Practice Guidelinesindividuals >60 years old

• Life style Modification (LSM)

• Laboratory

2014 Evidenced-Based Guideline for Management of High Blood Pressure in Adults: Reported from the Panel Members Appointed to the Eight Joint National Committee (JNC 8). JAMA FEB 2014.

BP Classification

Systolic (mmHg)

Diastolic(mmHg)

Initial Therapy

Pre-Hypertension

Deleted / Omitted

DM <140 <90 LSM + No Anti-Hypertensive Drug Indicated

CKD** (<70) <140 <90 Previous less than 130/80

Goal <150 <90 LSM + ACE or ARB or DIURETIC or Calcium Channel Blocker

** “based on evidence the committee cannot make a recommendation for individuals 70 and older”

Ambulatory BP MonitoringSelf Measuring BPAssess Risk Factors

JNC 8: Applied GeriatricsAn 78 year old female with previous CABG presents to the office for an evaluation of her chronic medical conditions including hypertension. She continues to feel well and is new to your practice as she just moved from Florida to New Jersey to be closer to her daughter.

Today her blood pressure 130/70 which is identical to her previous blood pressure last visit two months ago.

Amlodipine 2.5 mg daily Aspirin 81mg daily HCTZ 12.5mg daily KCL 10meq daily Lisinopril 10mg daily Metoprolol XL 50mg daily Omeprazole 20mg daily Atorvastatin 10mg daily

What is the next best step in the management of this patient’s condition?(A)Stop Amlodipine (Norvasc®)(B)Stop Hydrochlorothiazide (HCTZ)(C)Reduce Metoprolol XL (Lopressor XL ®)(D)Reduce Lisinopril(E)Reassurance / continue current medication regimen

MEDICATION LIST

JNC 8: Applied GeriatricsAn 85 year old female presents to your outpatient ambulatory office following a hospital evaluation (09/06/2014 – 9/10/2014) for shortness of breath. She was diagnosed and treated for an acute exacerbation of COPD. She was upgraded from an inhaler to a nebulizer.

She also reports that her blood pressure was high in the hospital with records indicating 172/92 on day 3 and they recommended that she start AMLODIPINE (NORVASC®) 5mg every AM and follow-up with you for blood pressure checks.

Today her blood pressure is 144/88. Your records indicate that her blood pressure was controlled at the time of last visit during August 2014.

DISCHARGE MED LIST:

1. Aspirin 81mg daily2. Amlodipine 5mg daily3. Prednisone Taper 4. Albuterol Nebulizer QID

PRN5. Lisinopril 10mg daily6. HCTZ 12.5mg daily7. Omeprazole 20mg daily8. KCL 10meq daily9. Vitamin D 1000 IU daily10. Alendronate 70mg qHS11. Pravastatin 40mg qHS

Medications Known To Increase BP

• Steroids• Sympathomimetic

Drugs• Decongestants• NSAIDS• Erythropoietin

JNC 8: Applied Geriatrics

A 84 year old with PARKINSON’S DISEASE

presents to the office following a 3-day hospital

admission prompted by an UNWITNESSED

FALL. He was subsequently diagnosed and

treated for CONGESTIVE HEART FAILURE.

Which of the following is the next best plan of care for this patient?

DISCHARGE RX LIST:1. Aspirin 81mg daily2. Carbidopa-Levodopa QID3. Carvedilol 6.25mg BID4. Ferrous Sulfate 325mg daily5. Finasteride 5mg daily6. Fludrocortisone 0.1mg daily7. Furosemide 40mg daily8. Lisinopril 5mg daily9. Centrum silver one tablet daily10. KCl 20meq daily11. Allopurinol 300mg daily12. Midodrine 5mg TID13. Pravastatin 80mg qHS14. Tamsulosin 0.4mg daily

JNC 8: Applied Geriatrics

A 84 year old with PARKINSON’S DISEASE

presents to the office following a 3-day hospital

admission prompted by an UNWITNESSED

FALL. He was subsequently diagnosed and

treated for CONGESTIVE HEART FAILURE.

DISCHARGE RX LIST:1. Aspirin 81mg daily2. Carbidopa-Levodopa QID3. Carvedilol 6.25mg BID4. Ferrous Sulfate 325mg daily5. Finasteride 5mg daily6. Fludrocortisone 0.1mg daily7. Furosemide 40mg daily8. Lisinopril 5mg daily9. Centrum silver one tablet daily10. KCl 20meq daily11. Allopurinol 300mg daily12. Midodrine 5mg TID13. Pravastatin 80mg qHS14. Tamsulosin 0.4mg daily

LYING 151/73SITTING 134/84STANDING 137/63RETURN TO LYING 176/89

DYSLIPIDEMIA & THE ELDERLY

Dyslipidemia

Dyslipidemia

Corti MC, et al. Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons. Ann Intern Med. 1997;126(10):753.

Dyslipidemia

The Choose Wisely® Campaign:

AMDA: “Don't routinely prescribe lipid-lowering medications in individuals with a limited life

expectancy”

AMDA Choose Wisely® Campaign – 2013 - 09SEP

eprognosis.org [select "bubbleview"]

DyslipidemiaPrimary Prevention: CARDS

Study

Neil HA, et al. Analysis of efficacy and safety in patients aged 65-75 years at randomization: Collaborative Atorvastatin Diabetes Study (CARDS). Diabetes Care. 2006;29(11):2378.

Age 45-75 yrsAtorvastatin 10mg v.

Placebo4 years

NNT Data:

Older Younger

1st major cardiovascular even

22 32

DyslipidemiaPrimary Prevention

No LDL goal is recommended when primary prevention is the treatment goal.

Atorvastatin 10mg Pravastatin 40mg Simvastatin 10mg

DyslipidemiaSecondary Prevention: The

LIPID Trial

Hunt D, et al. Benefits of pravastatin on cardiovascular events and mortality in older patients with coronary heart disease are equal to or exceed those seen in younger patients: Results from the LIPID trial. Ann Intern Med. 2001;134(10):931.

NNT Data:

Older

Younger

All Cause Mortality 22 46CAD Death 35 71Fatal / Non-Fatal MI

30 36Stroke 79 170

Age 40-75 yr olds; Pravastatin v. Placebo

The ‘Iron Nun’

• Sister Madonna Buder

• Age 79• Ironman British

Columbia• Time 16:54:30

• Autobiography “The Grace to Race”