Transcript figure 80-1

FIGURE 80-1 United States population estimates projected from 2000 until
2050. Dark pink bars represent numbers of women older than 65 years, and dark
blue bars represent numbers of men older than 65 years; lighter pink bars
represent numbers of women older than 85 years, and lighter blue bars represent
numbers of men older than 85 years in millions of people.
)Source: U.S. Census Bureau(.
FIGURE 80-2 Prevalence of cardiovascular and other common chronic
medical illnesses in older persons in the United States. Data are
percentages. AF = atrial fibrillation; CAD = coronary artery disease;
CVD = cardiovascular disease; HF = heart failure; high BP =
hypertension (all forms); PAD = peripheral artery disease. Blue bars
represent data for men older than 65 years, pink bars represent women
older than 65 years, and yellow bars represent men and women older
than 80 years
Table 135.1 -- Effects of aging on the cardiovascular
system .
↑Left ventricular wall thickness
↓Left ventricular cavity size
Endocardial thickening and sclerosis
Gross anatomy
↑Left atrial size
Valvular fibrosis and sclerosis
↑Epicardial fat
↑Lipid and amyloid deposition
↑Collagen degeneration and fibrosis
Calcification of fibrous skeleton, valve rings, and coronary arteries
Histology
Shrinkage of myocardial fibers with focal hypertrophy
↓Mitochondria, altered mitochondrial membranes
↓Nucleus/myofibril size ratio
↓Protein elasticity
Numerous changes in enzyme content and activity affecting most metabolic pathways, but no change in myosin ATPase
activity
Biochemical changes
↓Catecholamine synthesis, especially norepinephrine
↓Acetylcholine synthesis
↓Activity of nitric oxide synthase
Degeneration of sinus node pacemaker and transition cells
↓Number of conducting cells in the AV node and His-Purkinje system
Conduction system
↑Connective tissue, fat, and amyloid
↑Calcification around the conduction system
↓Distensibility of large and medium-sized arteries
Impaired endothelial function
Vasculature
Aorta and muscular arteries become dilated, elongated, and tortuous
↑Wall thickness
↑Connective tissue and calcification
↓Responsiveness to β-adrenergic stimulation
↑Circulating catecholamines, decreased tissue catecholamines
↓α-Adrenergic receptors in the left ventricle
Autonomic nervous system
↓Cholinergic responsiveness
Diminished response to Valsalva and baroreceptor stimulation
↓Heart rate variability
Modified from Stolker JM, Rich MW. Diagnosis and management of heart disease in the elderly. In
Arenson C, Reichel W, eds. Reichel's Care of the Elderly. 6th ed. Lippincott Williams & Wilkins, 2009.
Figure
135.1 Prevalence
of cardiac
disease by age
and gender .
Prevalence of
cardiovascular
diseases
(including
coronary heart
disease, heart
failure, stroke,
and
hypertension) by
age and gender
in the United
States, 1999 to
2002
Table 135.2 -- Effects of aging on other organ systems
Kidneys
Gradual ↓ in glomerular filtration rate
(~8cc/min/decade(
Impaired fluid and electrolyte homeostasis
↓Ventilatory capacity
Lungs
↑Ventilation/perfusion mismatching
↓Cerebral perfusion autoregulatory capacity
Neurohumoral
system
Diminished reflex responsiveness
Impaired thirst mechanism
↑Levels of coagulation factors
↑Platelet activity and aggregability
Hemostatic system
↑Inflammatory cytokines and C-reactive protein
↑Inhibitors of fibrinolysis and angiogenesis
Musculoskeletal
system
↓Muscle mass (sarcopenia(
↓Bone mass (osteopenia), especially In women
Modified from Stolker JM, Rich MW. Diagnosis and management of heart disease in the elderly. In Arenson C,
Reichel W, eds. Reichel's Care of the Elderly. 6th ed. Lippincott Williams & Wilkins, 2009.
Figure
135.2 VO 2
max as a
function of
age and
gender .Peak
treadmill
oxygen
consumption
(VO 2max) as
a function of
age and
gender in
healthy
subjects.
•
Figure 135.3 Annual rate of first heart attack. Annual rate of first heart attack by age,
gender, and race in the Atherosclerosis Risk in Communities (ARIC) study, 1987 to 2000.
Figure 135.4 Clinical
presentation of acute
myocardial infarction in
elderly patients .
Clinical presentation of
acute myocardial
infarction in patients
age 85 or older
•
Figure 135.5 Prevalence of atrial fibrillation by age and gender .Prevalence of
atrial fibrillation by age and gender in a large health maintenance organization,
1996 to 1997.
Figure 135.8 Benefits of invasive therapy for the elderly .Benefits of invasive
therapy for elderly subjects with non-ST-elevation acute coronary syndromes
enrolled in the TACTICS-TIMI 18 trial.
FIGURE 80-3 Directly measured arterial waveforms from a peripheral artery (radial) and calculated
aortic pressure waves for a young man aged 26 years in the upper panels and his 83-year-old
grandfather in the lower panels.
)Courtesy of Michael O’Rourke, MD, University of Sydney, Australia(.
TABLE 80-1
Differentiation Between Age-Associated Changes and Cardiovascular Disease in Older People
AGE-ASSOCIATED CHANGES
ORGAN
Increased intimal thickness
CARDIOVASCULAR DISEASE
Systolic hypertension
Arterial stiffening
Increased pulse pressure
Increased pulse wave velocity
Early central wave reflections
Decreased endothelium-mediated vasodilation
Vasculature
Increased left atrial size
Atria
Atrial fibrillation
Sinus node
Sinus node dysfunction, sick sinus syndrome
Increased conduction time
Atrioventricular
node
Type II block, third-degree block
Sclerosis, calcification
Valves
Stenosis, regurgitation
Coronary artery obstruction
Peripheral artery disease
Carotid artery obstruction
Atrial premature complexes
Decreased maximal heart rate
Decreased heart rate variability
Increased left ventricular wall tension
Prolonged myocardial contraction
Prolonged early diastolic filling rate
Decreased maximal cardiac output
Right bundle branch block
Ventricular premature complexes
Ventricle
Left ventricular hypertrophyHeart failure (with or
without preserved systolic function)
Ventricular tachycardia, fibrillation
TABLE 80-2 -- Guidelines for Medication Prescribing in Older Patients
In general, loading doses should be reduced. Weight (or body surface area) can be used to estimate loading
dose requirements. Weight differences between the sexes are greatest for white people.
Use estimates of glomerular filtration to guide dosing of renally cleared medications and contrast agent
administration. Reduce initial doses of metabolically or hepatically cleared drugs but titrate to effect.
Time between dosage adjustments and evaluation of dosing changes should be longer in older patients than in
younger patients.
Routine use of strategies to avoid drug interactions is essential. Incorporation of reference materials, a team
approach, and quality improvement efforts are effective strategies.
Knowledge of effects of noncardiac medications is critical.
Assessment of adherence and attention to factors contributing to nonadherence should be part of the
prescribing process.
Physicians must be familiar with the patient's source of prescription medication coverage and provide education
and assistance with obtaining critical medications.
Multidisciplinary approaches to monitoring of medication therapy may improve outcomes.
•
FIGURE 80-6 The relationship between the number of drugs consumed and
drug interactions. Current guidelines for the pharmacologic management of
patients with heart failure (HF) or myocardial infarction (post MI) place them at
high risk for drug interactions.
)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(.
TABLE 80-4 -- Considerations for Pharmacologic Therapy for Older Patients with
Hypertension and Other Disorders
HYPERTENSION+
EFFICACY CONSIDERATIONS
TOXICITY OR ADVERSE EFFECT
CONSIDERATIONS
Arthritis
—
ACE, ARB, aldosterone, and renin
antagonist interactions with NSAIDs
Recurrent
ARB, ACE*
Interactions with warfarin
Permanent
Beta blocker, calcium channel blocker (non-DHP]†[,*(
Atrial fibrillation
Beta blockers, non-DHP calcium channel
blockers
Atrioventricular block
—
Carotid disease or
stroke
Calcium channel blocker ]†[,ACE*
Constipation
—
Verapamil
Coronary artery disease
Beta blocker ]†[,*calcium channel blocker]†[,*
Nitrates and postural hypotension
Dementia
Clonidine]‡[
Depression
—
SSRIs and hyponatremia
Diabetes
ACE ]†[,*,ARB ]†[,*,CCB (non-DHP) , beta blocker
Chlorpropamide and hyponatremia
ACE or ARB + renin inhibitor and
hyperkalemia
Glaucoma
Beta blocker
Gout
Thiazide diuretics*
Heart failure
ACE ]†[,*,ARB + ]†[,*,loop diuretic ]†[,*,beta blocker ? ]†[,*,
aldosterone antagonist]?[,]†[,*
Calcium channel blockers (possible*)
ACE, ARB, aldosterone antagonist
and hyperkalemia
Hyponatremia
—
Diuretic (especially with SSRI)
Incontinence
—
Diuretic
Metabolic syndrome
ACE *,ARB *,calcium channel blocker*
Beta blockers, diuretics
Myocardial infarction
Beta blocker ? ]†[,*,ACE ? ]†[,*,aldosterone antagonist*
ACE, ARB, aldosterone antagonist and
hyperkalemia
Osteoporosis
Thiazides (beta blocker, ACE neutral or protect); potassium (K)
phosphate (versus KCl)
Furosemide (bone loss)
Peripheral artery disease
Calcium channel blocker (DHP ]†[,*,)ACE + diuretics]∥[
Beta blocker (only if severe)
Postural hypotension
Thiazide]?[
Prostatic hypertrophy
Alpha blocker]†[
Pulmonary disease
(asthma, COPD)
Alpha blocker, calcium channel blockers
(DHP)
Beta blocker
Renal failure
ACE ]†[,*,ARB ]†[,*,ACE + ARB; loop diuretic]†[,*
Aldosterone antagonists (? renin
inhibitors) and hyperkalemia
Ventricular arrhythmias
Beta blocker]†[
Thiazide, loop diuretics and hypokalemia
ACE = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; COPD = chronic obstructive
pulmonary disease; NSAIDs = nonsteroidal anti-inflammatory drugs; DHP = dihydropyridine; SSRI = selective serotonin
reuptake inhibitor.
*Recommendations for second-line agents usually added to thiazide diuretics from Chobanian AV, Bakris GL, Black HR,
et al: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure. The JNC 7 Report. JAMA 289:2560, 2003†.Mancia G, De Backer G, Dominiczak A, et al: 2007 Guidelines
for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European
Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 28:1462, 2007‡.Only
available transdermal formulation for patients unable to swallow or who refuse oral medications?.Systolic heart failure
only∥.Norgren L, Hiatt W, Dormandy J, et al: Inter-Society consensus for the management of peripheral arterial disease
(TASC II). J Vasc Surg 45:S5A, 2007?.Nursing home patients.
Table 80-5 summarizes the approach to hypertension in older patients
FIGURE 80-8 In-hospital mortality rates reported for revascularization procedures by age group. PCI
= percutaneous coronary intervention of all types; CABG = coronary artery bypass graft surgery .
(Data are from the National Cardiovascular Revascularization Network as reported by Alexander K,
Anstrom K, Muhlbaier L, et al: Outcomes of cardiac surgery in patients ≥80 years: Results from the
National Cardiovascular Network. J Am Coll Cardiol 35:731, 2000; Batchelor W, Anstrom K, Muhlbaier
L, et al: Contemporary outcome trends in the elderly undergoing percutaneous coronary
interventions: Results in 7,472 octogenarians. National Cardiovascular Network Collaboration. J Am
Coll Cardiol 36:723, 2000; and the Society of Thoracic Surgeons data base, Bridges C, Edwards F,
Peterson E, et al: Cardiac surgery in nonagenarians and centenarians. J Am Coll Cardiol 197:347,
2003 ).Data were not available for PCI in patients older than 90 years. See text for further discussion
of results for drug-eluting stents and newer surgical approaches.
FIGURE 80-5 Estimates of creatinine clearance with the Cockcroft and Gault formula( left
panel )and estimates of glomerular filtration rate with the MDRD simplified algorithm( right
panel )for men and women aged 45 to 85 years. For calculations, mean weight and height by
decade were obtained from U.S. survey data (NHANES ,http://www.cdc.gov ;) serum creatinine
is 1.0 mg/dL (average for older than 65 years in NHANES). Pink lines and circles represent
estimates for women; blue lines and diamonds are estimates for men; lighter symbols are
estimates for whites, and darker symbols represent estimates for African Americans. The
shaded areas indicate GFR estimates of 30 to 59 mL/min/m 2classified as stage 3 renal
disease or moderate GFR decrease. Cockcroft and Gault estimates show a steeper decline
with age. Both formulas estimate lower clearance in women compared with men and higher
clearances in African Americans compared with whites (based on average height and weights
and the same creatinine concentration.)
(Modified from Schwartz JB: The current state of knowledge on age, sex, and their interactions
on clinical pharmacology