Transcript Atypical Presentations - Florida State University College

Due to Age Related Cardiac and Renal Changes
Three Stage Case Exemplar
John Agens MD
Copyright 2009, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds
Foundation. All rights reserved.
Case I: Baseline Heart & Kidney
 79 female non productive cough rhinorrhea for 2 days
 well controlled high blood pressure, no CHF or CAD
 independent in activities of daily living, low vision
 no chest pain, orthopnea, or palpitations
 BP 146/76 T 97.6 Pulse is 88 R 18 Weight 48kg H 63”
 Mini-Cog delayed recall 2 of 3 items, clock normal
 crackles R base only, clear with cough
 +S4 gallop, 2/6 early systolic murmur LSB, Gait normal
 Creatinine 1.2, EKG is normal, Chest X ray is normal
Case I: Aging Heart & Vessels
 Loss of myocytes, hypertrophy of remaining myocytes
 Decreased compliance of the left ventricle
 Increased relative contribution of left atrium to C.O.
 Audible s4 gallop is common in normal aging
 Increased vascular stiffness causes increased afterload
 Thickening and calcification of aortic valve common
 Early-peaking basal systolic murmur: aortic sclerosis
 Normal diastolic filling pressures at rest
 Increased end diastolic pressures with exercise/ stress
Case I: Aging Kidney
 Reduced glomerular filtration rate of 10ml/ decade
 CrCl=(140-age)(weight kg)(0.85 females) / S. Cr. x 72
 CrCl= (140-79 )(48kg)(0.85) / (1.2 X72)= 29ml/min
 Reduced renal blood flow
 Reduced concentrating and diluting ability
 Progressive reduced ability to excrete sodium load
 Decreased responsiveness to antidiuretic hormone
 Less sodium excretion on NSAIDS versus young
persons
Case I: Cold or Influenza?
Case II: Short of Breath, Fever
 Same patient has fever, chills, body aches for 3 days
 Shortness of breath for the past 24 hours
 ECHO done 3 days prior, aortic sclerosis, normal LVF
 Patient has been less active for three days
 No weight gain or loss since office visit 3 days ago
 BP 122/86, P 120 no orthostasis, T 102 orally, RR 22
 Lungs show rales ¼ up both lung bases, O2 sat 90%
 +S4, soft S3, II/VI systolic M at LSB, +1 edema +JVD
 GUAG 20 sec., EKG sinus tachy, CXR cephalization
Case II: Pneumonia or CHF
 “Among octogenarians, the predominant presentation
of heart failure is in women with systolic hypertension
and diastolic dysfunction with preserved
ventricular systolic function.”1
 How much diuretic and for how long?
 What about heart rate control?
 Does the patient have influenza, pneumonia, or both?
 If you use antimicrobials, which? What dosage?
1 Wenger NK, “Cardiovascular Disease” Geriatric
Medicine Fourth Edition, Cassel CK et. al. editor
Case III: Morning Rounds Day 2
 Low blood pressure 78 systolic after breakfast.
 Yesterday, the cardiology consultant recommended
aggressive diuresis: furosemide 40mg IV q 8 hours
 BP 82/60 supine. P 84 BPM. T 98.4 degrees F. RR 14
 Weight 45kg
 Delayed recall only 1/3 words, disorganized thinking
believes she is at home, easily distracted by noises
 Neck: no JVD, Lungs: clear,
 +S4, 2/6 early systolic murmur LSB, no edema
Objectives: 1 of 2
 Use knowledge of physiology of the normal aging
heart to recognize that +S4 is normal in the elderly.
 Recognize that reduced left ventricle compliance is
normal and common in an aging heart.
 Recognize that heart failure with normal systolic
function manifests itself during exercise, stress, or
tachycardia and is common in the elderly.
 Recognize that small changes in circulating volume
cause large changes in heart filling pressures.
Objectives: 2 of 2
 Calculate a creatinine clearance in an elderly patient
with a normal serum creatinine.
 Recognize that the elderly cannot excrete a sodium
load as well as the young, especially on ibuprofen.
 Recognize that reduced ability to concentrate urine,
reduced sensitivity to ADH, and reduced ability to
excrete sodium plus reduced left ventricular
compliance leads to both rapid increases and decreases
in left heart filling pressures even with small increases
or decreases in circulating volume.
References
 Stoelting Basics of Anesthesia, 5th ed. (Figure slide 11)
 Wenger NK “Cardiovascular Disease” Geriatric
Medicine Fourth Edition, Cassel CK et. al. editor
(Quote slide 9)
 Walsh Palliative Medicine , 1st ed. (CXR image slide 8)
 Chen MA “Heart Failure with Preserved Ejection
Fraction in Older Adults” The American Journal of
Medicne 2009 Volume 122, 712-723
 Taffet GE “Physiology of Aging” Geriatric Medicine
Fourth Edition, Cassel CK et. al. editor