Transcript Cardiovascular Disease Management in the Geriatric Patient

Heart Health in the Elderly
“Less is More”
Kevin Overbeck, DO
Assistant 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
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Lipid Compartment Expands
Total Body Water (mainly ECF) declines
Lean Muscle Mass Declines
Application: Implications for Drug Prescribing
HYPERTENSION
&
THE ELDERLY
Aging Physiology
Increased thickness of the intima and the media 
INCREASED VASCULAR STIFFNESS
Aging Physiology
Pearson, J.D., Morrell, C.H., Brant, L.J., Landis, P.K., and Fleg, J.L. (1997). Ageassociated changes in blood pressure in a longitudinal study of healthy men and
women. Journal of Gerontology, 52, M177–83.
Aging Physiology
Consequences of Baroreceptor Changes1
• 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
HTN & The Elderly
Orthostatic BP Measurement
Sitting-Standing vs. Laying-Standing
After 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 Dementia
Decreased Baroreceptor Sensitivity1
Postprandial Hypotension
HTN & The Elderly
HYVET
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 Elderly
HYVET
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
Ambulatory BP Monitoring
Self Measuring BP
Assess Risk Factors
BP Classification Systolic
(mmHg)
Diastolic Initial Therapy
(mmHg)
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.
The Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC VII), August 2004.
JNC 8: Clinical Practice Guidelines
individuals >60 years old
• Life style
Modification (LSM)
• Laboratory
BP Classification Systolic
(mmHg)
Ambulatory BP Monitoring
Self Measuring BP
Assess Risk Factors
Diastolic Initial Therapy
(mmHg)
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”
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.
JNC 8: Applied Geriatrics
An 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.
MEDICATION LIST
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
JNC 8: Applied Geriatrics
An 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:
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11.
Aspirin 81mg daily
Amlodipine 5mg daily
Prednisone Taper
Albuterol Nebulizer QID
PRN
Lisinopril 10mg daily
HCTZ 12.5mg daily
Omeprazole 20mg daily
KCL 10meq daily
Vitamin D 1000 IU daily
Alendronate 70mg qHS
Pravastatin 40mg qHS
Medications Known To Increase BP
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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.
2.
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11.
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14.
Aspirin 81mg daily
Carbidopa-Levodopa QID
Carvedilol 6.25mg BID
Ferrous Sulfate 325mg daily
Finasteride 5mg daily
Fludrocortisone 0.1mg daily
Furosemide 40mg daily
Lisinopril 5mg daily
Centrum silver one tablet daily
KCl 20meq daily
Allopurinol 300mg daily
Midodrine 5mg TID
Pravastatin 80mg qHS
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.
LYING 151/73
SITTING 134/84
STANDING 137/63
RETURN TO LYING 176/89
DISCHARGE RX LIST:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Aspirin 81mg daily
Carbidopa-Levodopa QID
Carvedilol 6.25mg BID
Ferrous Sulfate 325mg daily
Finasteride 5mg daily
Fludrocortisone 0.1mg daily
Furosemide 40mg daily
Lisinopril 5mg daily
Centrum silver one tablet daily
KCl 20meq daily
Allopurinol 300mg daily
Midodrine 5mg TID
Pravastatin 80mg qHS
Tamsulosin 0.4mg daily
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"]
Dyslipidemia
Primary Prevention: CARDS Study
NNT
Older
Younger
22
32
Data:
1st major
cardiovascular
even
Age 45-75 yrs
Atorvastatin 10mg v. Placebo
4 years
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.
Dyslipidemia
Primary Prevention
No LDL goal is recommended when primary
prevention is the treatment goal.
 Atorvastatin 10mg
 Pravastatin 40mg
 Simvastatin 10mg
Dyslipidemia
Secondary Prevention: The LIPID Trial
NNT
Older Younger
Data:
All Cause
Mortality
CAD Death
Fatal / NonFatal MI
Stroke
22
35
30
79
46
71
36
170
Age 40-75 yr olds; Pravastatin v. Placebo
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.
The ‘Iron Nun’
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Sister Madonna Buder
Age 79
Ironman British Columbia
Time 16:54:30
• Autobiography “The Grace
to Race”