Transcript Cardiovascular Disease and the Elderly

CARDIOVASCULAR DISEASE
AND THE ELDERLY
Dorothy D. Sherwood, MD, FACP
So who are you
calling old?
Introduction
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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
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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
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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
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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
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Smoking
 Increased
Bp
 Increased Heart Rate
 Increased PV resistance
 Increased catecholamines
 Increased susceptibility to clotting
 Decreased HDL
Management of Risk Factors in the
Elderly
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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
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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
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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
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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
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Treatment Efficacy
 Over
15,693 patients over the age of 60 with systolic
hypertension have been studied.
 Number
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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
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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
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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
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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
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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
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Choosing the right drug
 Low
 1)
dose combination therapy:
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
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Choosing the right drug
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Combination
Amolodipine/benazepril (Lotrel)
 Lisinopril/hydrocholothiazide (Zesoretic)
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Additions
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Diuretic or calcium channel blocker to above
Further addition
Aliskerin ( Tekturna)
 Beta blocker
 Central alpha agonist
 Peripheral alpha blockers.
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Management of Risk Factors in the
Elderly/Hypertension
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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
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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
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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
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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
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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
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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
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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
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Management of Risk Factors in the
Elderly/Aspirin
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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
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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
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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
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Barriers: Lack of physician Rx, economic, logistics,
cost
Management of Risk Factors in the
Elderly/Exercise
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Diagnosis that qualify for Finley Ewing Cardiac
Rehabilitation .
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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
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Briefly – elderly benefit most from warfarin
anticoagulation.
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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
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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
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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.