Transcript 1 - RCRMC Family Medicine Residency

Problems in the Elderly
Hypertension
• hypertension accounts for 35 million office visits per
year
• slightly >33% of patients with hypertension under control
(goal for 2010, 50%)
• affects 50 million people in United States
• person 55 yr of age with normal blood pressure (BP) at
90% lifetime risk of developing hypertension
• higher BP associated with greater risk for myocardial
infarction (MI), congestive heart failure (CHF), stroke, and
kidney disease
• in persons 40 to 70 yr of age with BP of 115/75 mm Hg to
185/115 mm Hg, increase of 20 mm Hg in systolic BP (10
mm Hg in diastolic BP) doubles risk for cardiovascular
disease (even if still in normal range)
BP monitoring
• home BP monitoring helpful
• 135/85 mm Hg at home correlates with 140/90 in office
• ask patients to bring home measuring cuff to office at least
once yearly to check for accuracy and correlation with
office cuff
• Arm cuff more accurate than finger or thumb cuff
• Ambulatory BP monitoring—can be helpful for identifying
whitecoat hypertension
• normal BP, 135/85 mm Hg (120/75 mm Hg when asleep)
• results correlate better with end-organ injury, compared to
office monitoring
• may be difficult to obtain insurance coverage
Classification
• normal—<120/80 mm Hg
• prehypertension— systolic BP 120 to 139 mm Hg,
diastolic BP 80 to 89 mm Hg;
• stage 1—begin treatment; systolic BP 140 to 159 mm Hg,
diastolic BP 90 to 99 mm Hg
• stage 2—systolic BP >160 mm Hg, diastolic BP >100 mm
Hg
• isolated systolic hypertension—common; systolic BP >140
mm Hg, diastolic BP <90 mm Hg
• present in most hypertension patients, especially in elderly
• widened pulse pressure >50 mm Hg and low diastolic BP
(eg, <70 mm Hg) independent cardiovascular risk factors
Pathophysiology in elderly patients
• increase in arterial stiffness
• coincides with increased sympathetic activation (eg, increased
adrenaline, norepinephrine, and epinephrine)
• larger arteries dilate and thicken, which leads to hyperplasia of intimal
layer, increased systolic BP, widened pulse pressure, and greater
cardiovascular mortality and morbidity
• isolated systolic hypertension is a natural result of aging that causes
cardiovascular problems
• increased total peripheral vascular resistance
• Lowered cardiac output
• BP lability (due to changes in baroreceptor function and decreased
autoregulation in brain, heart, and kidneys)
• in patients 65 to 94 yr of age, average systolic BP 133 mm Hg (±19
mm Hg), diastolic BP 77 mm Hg (±11 mm Hg; prehypertension range)
Whitecoat hypertension
• occurs in nearly 50% of patients 65 yr of
age
• diagnosed in patients with hypertension in
clinic who have documented accurate BP
readings <134/84 mm Hg outside clinic
• prognosis in end-organ damage is the same
as in normotensive patients
• treat patients with other risk factors, and
watch symptoms (eg, dizziness)
Pseudohypertension
• advanced arterial stiffness prevents
compression by arm cuff
• results in higher BP reading
• Osler’s sign—after pumping arm cuff,
brachial artery palpable, but no audible
beats
• intraarterial pressure not reflected by cuff
pressure
• difficult to reproduce
• accurate diagnostic test not currently
available
Treatment goals
• reduce cardiovascular and renal morbidity and
mortality
• help prevent vascular dementia
• focus on systolic BP
• goal for patients without diabetes or renal disease, 140/90
mm Hg (130/80 mm Hg for patients with diabetes or renal
disease)
• treatment decreases risk for stroke by 35% to 40%, MI by
20% to 25%, and CHF by 50%
• 5-yr treatment of 19 elderly patients with isolated systolic
hypertension prevented 1 cardiovascular event (number
needed to treat [NNT] to prevent 1 cardiovascular death,
50
• NNT to prevent1 all-cause death, 63)
• NNT lower in all categories for older patients
Treatment goals
• how low is too low?
• trial looking at patients with mean age 61 yr found best
effect of treatment on cardiovascular events with systolic
BP 130 to 140 mm Hg and diastolic BP 80 to 85 mm Hg
• another study in older patients found lowering systolic BP
to <150 mm Hg did not provide further prevention of
stroke, and diastolic BP <55 mm Hg showed twice rate of
cardiovascular events
• systolic BP <130 mm Hg showed increase in
cardiovascular events
• suggested goals—diastolic BP 90 mm Hg; higher
systolic BP possibly acceptable for older age groups
Lifestyle modification
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initial treatment of stage 1 hypertension and diabetes
weight reduction (level C recommendation clini-cal data lacking)
reduction of BP with Dietary Approach to Stop Hypertension (DASH) eating plan
equivalent to that with monotherapy
reduce dietary sodium
increase physical activity (level A recommendation)
moderate alcohol consumption and cessation of tobacco smoking (level A
recommendations)
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7) recommends 6-mo trial of lifestyle
modification before considering medication
paced breathing—some case reports and small nonrandomized trials found deep
breathing exercises with device that helps slow breathing reduced systolic BP by 15 mm
Hg and diastolic BP by 8 mm Hg over 1 mo
one study found paced breathing no better than placebo in patients with type 2 diabetes
other studies show good reduction in BP
No outcome studies about cardiovascular disease prevention
Low risk
no side effects
expensive ($300-$500)
Pharmacologic treatment
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all effective in lowering BP and
improving cardiovascular mortality and morbidity
Thiazide diuretics—basis of most outcome trials
unsurpassed in preventing cardiovascular
complications of hypertension;
enhance efficacy of multidrug regimens
diuretics do not widen pulse pressure in elderly
patients
Affordable
Recommended by JNC 7 as first-line therapy for
uncomplicated hypertension;
Pharmacologic treatment
• can consider angiotensin-converting enzyme (ACE)
inhibitor, angiotensin receptor blocker (ARB), calcium
channel blocker, combination therapy
• Beta-blocker (in certain cases; meta-analysis showed
poorer outcomes [especially with atenolol] than with
thiazide diuretics)
• Can progress in stepwise fashion starting with thiazide
diuretic and then moving on to other medications as
needed
• Can consider starting 2 drugs initially if systolic BP 20 mm
Hg and diastolic BP 10 mm Hg above goal
• most patients eventually need 2 or more medications
Key trials
• Antihypertensive and Lipid-Lowering treatment to
prevent Heart Attack Trial (ALLHAT)—1) compared
amlodipine, lisinopril, and doxazosin to chlorthalidone in
42,000 patients with risk factors (eg, diabetes, overweight)
• 2) added either atenolol, clonidine, or reserpine
• 3) added hydralazine
• doxazosin stopped early due to higher incidence of CHF
(avoid alpha-blockers unless treating benign prostatic
hyperplasia with hypertension)
• at 5-yr follow-up, no difference in primary end point of
combined fatal coronary heart disease or nonfatal MI, but
chlorthalidone better than lisinopril or amlodipine at
preventing HF
Key trials
• Second Australian National Blood Pressure Study (ANBP2)—1) openlabel randomized controlled trial (RCT) of 6000 healthy patients
• looked at ACE inhibitor vs diuretic;
• 2) added Beta-blocker, alpha-blocker, or calcium channel blocker
• primary end point changed at midpoint of study from total
cardiovascular events (including death) to all cardiovascular events
and all-cause morbidity
• primary end point with ACE inhibitors marginally lower (56.1 events
vs 59.8 per 1000 patient-years)
• stroke rate lower with diuretic
• problems with study include change in primary end point, open-label
design (may have introduced bias), and use of diuretics in ACE
inhibitor group
• reanalysis found differences in primary end points almost exclusively
attributed to BP control
Key trials
• Anglo-Scandinavian Cardiac Outcomes Trial–Blood Pressure
Lowering Arm (ASCOT-BPLA)
• 1) open-label RCT compared amlodipine to atenolol in 20,000 patients
with 3 cardiovascular risk factors
• atenolol least beneficial Beta-blocker for BP control
• 2) added perindopril vs thiazide diuretic with potassium, then
doxazosin
• patients followed for 5.5 yr, trial stopped early
• no significant difference in end point between amlodipine and atenolol
• reduction in all-cause mortality (secondary end point) slightly better
with amlodipine
• differences between arms attributed to BP control (ie, BP control, rate
of stroke, and cardiovascular mortality better in amlodipine arm)
• validity issues include change in statistical significance, use of
lipophilic Beta-blocker
• (less effective), few patients on Beta-blocker and diuretic, and openlabel design
• shows lowering BP helpful
Chlorthalidone
• At higher doses lowers potassium
• lower doses provide good control of BP
with less effect on potassium levels
• longer acting and more potent diuretic than
hydrochlorothiazide
• (no head-to-head data [uncertain whether it
reduces cardiovascular events])
Treatment trials in elderly
• in 12 studies, average drop in systolic BP 17 mm Hg
(diastolic BP, 8 mm Hg) with 30% decrease in relative risk
for coronary artery disease (CAD), CHF, and overall total
cardiovascular diseases
• Systolic Hypertension in the Elderly Program (SHEP)
study of chlorthalidone, atenolol, and reserpine in 5000
patients (average age 72 yr) with isolated systolic
• hypertension saw BP decrease from 177/77 mm Hg to
143/68 mm Hg (NNT to prevent stroke, 50
• NNT to prevent cardiovascular event, 20)
• another trial using calcium channel blocker, ACE inhibitor,
and thiazide diuretic saw 25-mm Hg drop in systolic BP
(diastolic BP, 8 mm Hg
• NNT to prevent stroke, 100; NNT to prevent
cardiovascular event, 50)
Treatment trials in elderly
• Swedish Trial in Old Patients with
Hypertension-2 (STOP-2)—looked at
• 1) diuretics and Beta-blockers, 2) ACE
inhibitors, and 3) calcium channel blockers
• no difference between 3 arms in outcome or
lowering of BP
• Study on Cognition and Prognosis in the
Elderly (SCOPE) saw no difference in
lowering of BP with candesartan (compared
to placebo), but nonfatal stroke lower with
ARB
Treatment trials in elderly
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Hypertension in the Very Elderly Trial (HYVET)—4000
patients >80 yr of age with low prevalence of diabetes and CAD, and systolic BP >160 mm Hg
exclusion criteria included CHF, dementia, and nursing home care; target BP 150/80 mm Hg
indapamide (Lozol; nonthiazide diuretic) and perindopril compared to placebo
beneficial effects seen within 1 yr
Patients treated for 2.1 yr
BP lowered by 15 mm Hg
decrease in primary end point (stroke) not statistically significant; trial stopped due to statistically
significant decreases in stroke deaths (39%) and all-cause deaths (21%) in treatment arm
21% decrease in cardiovascular deaths not statistically significant
64% decrease in CHF highly statistically significant
fewer adverse events (ie, side effects) reported in treatment group (statistically significant)
conclusions include importance of screening for hypertension in patients >80 yr of age, systolic BP
of 160 mm Hg key point for starting treatment, and indapamide and perindopril
(ie, thiazide diuretics and ACE inhibitors) effective; other studies using perindopril may indicate
inherent quality of drug provides added benefits (eg, protection against repeat stroke)
unclear whether results due to BP lowering alone or inherent qualities of indapamide and perindopril
ideal systolic BP for patients >80 yr of age, 150 mm Hg (uncertain whether lower better)
The DASH Studies Goals (Dietary
Approaches to Stop Hypertension)
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Daily Nutrient Goals Used in
(for a 2,100 Calorie Eating Plan)
Total fat 27% of calories Sodium 2,300 mg*
Saturated fat 6% of calories Potassium 4,700 mg
Protein 18% of calories Calcium 1,250 mg
Carbohydrate 55% of calories Magnesium 500 mg
Cholesterol 150 mg Fiber 30 g
BOX2
* 1,500 mg sodium was a lower goal tested and found to be even better
for lowering blood pressure.
• It was particularly effective for middle-aged and older individuals,
• African Americans, and those who already had high blood pressure.
• g = grams; mg = milligrams
Following the
DASH Eating Plan
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Grains 6–8 /d1 slice bread1 oz, dry cereal, 1/2 cup cooked rice, pasta, or
cereal. Whole grains are recommended for most grain servings as a good
source of fiber and nutrients.
Vegetables 4–5/d 1 cup raw leafy vegetable, 1/2 cup cut-up raw or cooked
vegetable, 1/2 cup vegetable juice
Fruits 4–5 /d1 medium fruit, 1/4 cup dried fruit, 1/2 cup fresh, frozen, or
canned fruit, 1/2 cup fruit juice
Fat-free or low-fat, milk and milk products 2–3/d 1 cup milk or yogurt, 11/2
oz cheese
Lean meats, poultry, and fish 6 or less/d 1 oz cooked meats, poultry, or fish,
1 egg
Nuts, seeds, and legumes 4–5 per week 1/3 cup or 11/2 oz nuts, 2 Tbsp
peanut butter, 2 Tbsp or 1/2 oz seeds, 1/2 cup cooked legumes (dry beans and
peas)
Fats and oils 2–3/d 1 tsp soft margarine, 1 tsp vegetable oil, 1 Tbsp
mayonnaise, 2 Tbsp salad dressing
Sweets and added sugars 5 or less per week 1 Tbsp sugar, 1 Tbsp jelly or
jam, 1/2 cup sorbet, gelatin, 1 cup lemonade
How to Lower Calories on the
DASH Eating Plan
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The DASH eating plan can be adopted to promote weight loss. It is
rich in lower-calorie foods, such as fruits and vegetables. You can
make it lower in calories by replacing higher calorie foods such as
sweets with more fruits and vegetables—and that also will make it
easier for you to reach your DASH goals. Here are some examples:
To increase fruits—
● Eat a medium apple instead of four shortbread cookies. You’ll save
80 calories.
● Eat 1/4 cup of dried apricots instead of a 2-ounce bag of pork rinds.
You’ll save 230 calories.
To increase vegetables—
● Have a hamburger that’s 3 ounces of meat instead of 6 ounces.
Add a 1/2-cup serving of carrots and a 1/2-cup serving of spinach.
You’ll save more than 200 calories.
● Instead of 5 ounces of chicken, have a stir fry with 2 ounces of
chicken and 11/2 cups of raw vegetables. Use a small amount of
vegetable oil. You'll save 50 calories.
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How to Lower Calories on the
DASH Eating Plan
To increase fat-free or low-fat milk products—
● Have a 1/2-cup serving of low-fat frozen yogurt instead of a 1/2-cup
serving of full-fat ice cream. You’ll save about 70 calories.
And don’t forget these calorie-saving tips:
● Use fat-free or low-fat condiments.
● Use half as much vegetable oil, soft or liquid margarine, mayonnaise,
or salad dressing, or choose available low-fat or fat-free versions.
● Eat smaller portions—cut back gradually.
● Choose fat-free or low-fat milk and milk products.
● Check the food labels to compare fat content in packaged foods—
items marked fat-free or low-fat are not always lower in calories than
their regular versions.
● Limit foods with lots of added sugar, such as pies, flavored yogurts,
candy bars, ice cream, sherbet, regular soft drinks, and fruit drinks.
● Eat fruits canned in their own juice or in water.
● Add fruit to plain fat-free or low-fat yogurt.
● Snack on fruit, vegetable sticks, unbuttered and unsalted popcorn,
or rice cakes.
● Drink water or club soda—zest it up with a wedge of lemon or lime.
DASH Diet
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Because it is rich in fruits and vegetables, which are naturally lower
in sodium than many other foods, the DASH eating plan makes it
easier to consume less salt and sodium. Still, you may want to begin
by adopting the DASH eating plan at the level of 2,300 milligrams
of sodium per day and then further lower your sodium intake to
1,500 milligrams per day.
The DASH eating plan also emphasizes potassium from food,
especially fruits and vegetables, to help keep blood pressure levels
healthy. A potassium-rich diet may help to reduce elevated or high
blood pressure, but be sure to get your potassium from food
sources, not from supplements. Many fruits and vegetables, some
milk products, and fish are rich sources of potassium. (See box 12
on page 21.) However, fruits and vegetables are rich in the form of
potassium (potassium with bicarbonate precursors) that favorably
affects acid-base metabolism. This form of potassium may help to
reduce risk of kidney stones and bone loss.
Follow-up
• JNC 7 recommends monthly (or more
frequent) visits until good BP control
achieved, then follow up every 3 to 6 mo
• check potassium and creatinine twice per
year
• when starting low-dose aspirin, wait until
BP under control
Choice of medications
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quality of life—difficult to measure
discuss with patient
no class of medication clearly superior
ACE inhibitors and ARBs appear more helpful for dementia and
memory with less sexual dysfunction
CHF—diuretics;
Beta-blockers (eg, carvedilol, bisoprolol, metoprolol
start slowly and titrate up slowly)
ACE inhibitors and ARBs (level A recommendations)
antialdosterone agents effective in patients with metabolic syndrome,
and help with remodeling of cardiac tissue
post-MI— Beta-blockers standard of care
ACE inhibitors (if patient stable and has normal left ventricular
function) aldosterone antagonists shown helpful for remodeling after
MI
Choice of medications
• high cardiovascular risk—diuretics and Beta-blockers (level A
recommendations)
• ACE inhibitors; calcium channel blockers in diabetes—thiazide
diuretics can increase patient’s blood glucose (consider indapamide)
• Beta-blockers (level B recommendation) may mask hyperglycemia in
patients on insulin
• ACE inhibitors, ARBs, and calcium channel blockers recommended
• chronic kidney disease—combination of ACE inhibitors and ARBs
causes side effects, worsening renal function, and no significant
improvement in BP
• consider direct renin inhibitor (eg, aliskiren) in patients who do not do
well on ACE inhibitor or ARB
• recurrence of cerebrovascular accidents—prevent by lowering BP
• risk reduction with perindopril and indapamide, 43%
Improving control
• relationship with patient important
• Provide treatment and follow-up within
context of patient’s cultural beliefs
• agree on BP goal
• consider costs and complexities of care
• once-daily medications ideal for elderly
patients
• use combination therapy and low-cost
medications
• focus on widespread and cost-effective care
Resistant hypertension
• failure to reach goal despite taking 3
drugs
• look at identifiable causes
• explore reasons with patient
• consider higher medication doses or use of
loop diuretic in patients with kidney disease
• BP may increase due to renal feedback loop
(consider increasing or adding diuretic)
Pseudohypertension
• Pseudohypertension refers to falsely elevated systolic BP readings in
elderly patients with very stiff arteries.
• Pseudohypertension occurs because the BP cuff cannot completely
occlude the artery.
• Osler's sign, the ability to palpate the stiff, thickened radial artery when
the sphygmomanometric cuff is inflated to suprasystolic BP, was once
thought to suggest pseudohypertension, but more recent studies
suggest that Osler's sign is an unreliable marker for this condition.
• Alternative ways to distinguish true systolic hypertension from
pseudohypertension include arm x-rays to document extensive vascular
calcification and Doppler flow studies, but neither is routine practice.
• More commonly, pseudohypertension is diagnosed when elderly
patients do not respond to treatment, have markedly elevated systolic
BP without signs of end-organ damage, or develop signs of
hypotension (eg, fatigue, orthostasis) despite persistently elevated BP
measurements
Secondary hypertension
• Secondary hypertension should be suspected when BP is resistant to
treatment or increases rapidly over weeks to months or to very high
levels.
• An abdominal bruit over one or both of the renal arteries, especially in
a patient with other manifestations of vascular disease, suggests renal
artery stenosis.
• Hypokalemia unrelated to diuretic therapy and accompanied by
metabolic alkalosis suggests primary aldosteronism.
• Other tests for secondary causes of hypertension may include
polysomnography (for obstructive sleep apnea)
• Thyroid examination and thyroid function testing (for hyperthyroidism
or hypothyroidism), magnetic resonance angiography (for renal artery
stenosis
• Measurement of 24-h urinary cortisol (for Cushing's syndrome)
• Measurement of plasma metanephrine (for pheochromocytoma)
• Ratio of plasma aldosterone activity to plasma renin activity (for
primary aldosteronism), and abdominal CT (for adrenal tumors
associated with primary aldosteronism or pheochromocytoma).
Conclusions
• controlling systolic BP more important
than diastolic BP in patients >50 yr of age
• thiazide diuretics mainstay of treatment
• tailor treatment recommendations to
patient’s medical conditions
• lowering BP in patients and populations
more important than which agent used
Questions and answers
• thiazide diuretics and sulfonamide allergy—indapamide
recommended (cross-reactivity, 20%- 25%)
• consider ACE inhibitor, ARB, or loop diuretic
• BP measurements—repeating BP measurement at end of office visit
helpful (often 10-15 mm Hg lower)
• diuretics and swollen feet—consider chlorthalidone (more potent)
• clonidine (eg, Catapres, Duraclon)—useful for hypertensive urgency;
systolic BP >240 mm Hg—send patients to emergency department
• associated with high risk for stroke
• hyponatremia and thiazide diuretics—if mild, no action needed; if
more severe (eg, 123 mEq/L with dizziness and confusion), switch
agents or consider another class of medications
• use low-dose chlorthalidone or indapamide (associated with less
sodium loss than thiazide diuretics)
Questions and answers
• isolated systolic hypertension—ARBs, ACE inhibitors, and
thiazide diuretics effective
• key to lower BP
• small study showed slight decrease in nonfatal stroke with
ARBs
• thiazide or thiazide-like diuretic recommended (lowers BP
without widening pulse pressure)
• thiazide diuretics and urinary frequency and urgency—
lowering of BP can be obtained with doses as low as 6.25
mg to 12.50 mg with little diuresis
• recommend taking in morning
• in patients >80 yr of age start at 6.25 mg and do not exceed
25 mg
• Antialdosterone agents—can be effective in patients
without primary aldosteronism
Demographics of the elderly
• presently, 13% of population in United
States >65 yr of age
• for statistical purposes, 65 yr of age used to
define elderly
• by 2030, 20% of population >65 yr of age
• elderly divided into young old (65-75 yr of
age), middle old (75-85 yr of age), and old
old (>85 yr of age)
• old-old group fastest growing segment of
population
Emergency department (ED)
• Emergency department (ED) visits:
>15% from elderly
• Regional variations present (eg, greater
elderly population in Florida) elderly stay
20% longer and undergo more extensive
work-up (more laboratory tests and studies),
with higher rate of misdiagnosis
• poor tolerance of delays in diagnosis
• higher rates of morbidity and mortality
Coronary artery disease (CAD)
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leading cause of death in elderly in United States
age most powerful predictor
85% of deaths from cardiac disease occur in the elderly population;
30-day mortality after myocardial infarction (MI) significantly
increased as patient’s age increases (<65 yr of age, mortality 3%
young-old group, 9.5%
old-old group, 30%)
even higher mortality if MI missed in patients >65 yr of age
in elderly patients discharged from ED with MI, mortality 50% within
3 days
overall, MI leading cause of malpractice payouts in emergency
medicine (20%); major causes for missed diagnosis include
failure to consider high-risk groups
failure to recognize atypical presentations,
overreliance on negative tests
Physiologic Changes of Aging
• Heart: increased stiffness of aorta results in
increased arterial blood pressure and afterload,
and left ventricular hypertrophy
• (LVH) more common (risk factor for early MI and
worse outcome after MI)
• delayed or impaired diastolic filling produces
atrial stretch, placing elderly at higher risk for
atrial fibrillation (AF), including after MI
• higher filling pressure leads to development of
LVH
• after 35 yr of age, cardiac output reduced by 1%
per year (reversed by exercise exercise to some
extent),
Physiologic Changes of Aging
• resulting in greater risk for development of congestive heart failure
(CHF) with any medical stress
• in elderly, sepsis, and sometimes even emotional stress, can produce
heart failure (lack ability to compensate)
• decreased response to endogenous and exogenous catecholamines
• inadequate production of catecholamines, and response from
adrenoreceptors poor
• poor response to catecholamines may require maximization of dose,
with
• higher risk for tachycardia and other side effects
• most of elderly on Beta-blockers, which mitigate response to
epinephrine, norepinephrine, dopamine, and dobutamine drips
• may need to consider nonadrenergic vasopressors when elderly patient
in shock
• for CHF, consider milrinone if patient not responding
• for septic patient, add vasopressin to norepinephrine;
Physiologic Changes of Aging
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glucagon—used only in acute overdose of Beta-blockers; significant dose
required because of saturation of receptors with -blockers and chronically
downregulated adrenoreceptors; main adverse effect vomiting;
not as effective in patients with long-term Beta-blocker use
shock—develops earlier and more easily
elderly unable to compensate for reduced cardiac output (unable to increase
heart rate [HR])
instead, rely on increasing ventricular filling and stroke volume (cardiac output
equals stroke volume multiplied by HR)
most elderly patients dehydrated due to decreased thirst response and renal
vasopressin response (unable to hold water)
Consider intravenous (IV) fluid bolus in all elderly patients with systemic
illness (unless obviously fluid overloaded)
Endothelial dysfunction—one of most prominent causes of development of
atherosclerosis
irritation or dysfunction within endothelium of coronary arteries
decreased coronary vasodilatory response, angiogenesis, and collateral vessel
formation
Kidneys
• decreased renal cell mass and drug clearance result in
greater risk for drug toxicities
• serum creatinine not good marker for renal function
• use creatinine clearance instead
• elderly patient with creatinine of 1.2 mg/dL actually in
mild renal insufficiency, because renal cell mass
decreasing, so creatinine should decrease also
• normal creatinine for elderly 0.5 to 0.8 mg/dL
• creatinine clearance <30 mL/min indicates renal
insufficiency and requires reduced dose of any drug
cleared through kidneys
• drugs include enoxaparin and glycoprotein IIb/IIIa
inhibitors
Acute MI
• major high-risk groups include elderly, women, and
patients with diabetes
• OLDCARD—mnemonic for obtaining history of patient
presenting with pain
• Onset
• Location
• Duration
• Character
• what aggravates pain
• what relieves pain
• activity of patient (doing) when pain started
• associated symptoms
• whether pain radiates
Textbook presentation of unstable
angina or acute MI
• onset associated with exertion and gradual (over
10-15 min)
• location midsternum and left-sided; duration
minimum of 10 min to 2 hr
• character substernal pressure and tightness
• relieved by rest or nitroglycerin
• aggravated by exertion
• performing exertional activity when pain occurred
• associated symptoms include shortness of breath
(SOB), nausea, vomiting, and diaphoresis; pain
radiating to left side of neck, jaw, and arm
• actual presentation different
Actual presentation
• onset—70% of patients present with abrupt onset of pain
• location—chest pain absent in 20% of patients (have
abdominal pain instead)
• Obtain electrocardiography (ECG) emergently in elderly
patient who presents with upper abdominal pain (only
symptom in 6% of elderly with MI)
• always consider atypical presentations and obtain ECG
• duration—few minutes to few hours
• if pain momentary or constant for days, unlikely cardiac in
origin
• crushing pressure sensation seen in 24% of MIs and 30%
of unstable angina
• may also present as mild ache
• sharp stabbing pain also common;
Actual presentation
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burning pain or indigestion—described in 20% of Mis and 21% of unstable
angina
“indigestion” has highest predictive value for ruling in MI
reflux esophagitis or peptic ulcer disease most common misdiagnosis for
missed MI
15% of patients with MIs obtain partial relief and 7% obtain complete relief
with antacids
15% report pain as pleuritic or positional, and 15% report worsening with
palpation
7% have completely reproducible pain with palpation
study found that 6% of patients with acute costochondritis ruled in for MI
should consider MI even if pain reproducible with palpation
European study of >10,000 patients ruled in for MI found 7% associated with
emotional stress, and 8% eating meal when pain occurred
associated symptoms—SOB, nausea, vomiting and diaphoresis common
studies found diaphoresis most specific of all symptoms
patients with chest pain and diaphoresis
almost always require admission;
Actual presentation
• almost 50% of patients with MI complain of increase in belching
(probably due to diaphragmatic irritation from inferior MI)
• radiation—pain radiating to right side more specific than pain
radiating to left side (worse if pain radiates bilaterally);
• pain absent in 33% of patients, especially diabetics and elderly
• pain absent in two-thirds of patients >85 yr of age on presentation;
instead present with anginal equivalent, with SOB most common
• SOB most common chief complaint in elderly with acute MI
• neurologic presentation (eg, confusion) possible; acute weakness
common in old-old patients
• in patients >85 yr of age, generalized weakness and malaise extremely
common, and physician should obtain ECG
• also obtain ECG in patient with chronic obstructive pulmonary disease
(COPD) who presents with episode of exacerbation of COPD (may
precipitate cardiac ischemia)
Diagnosis
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Electrocardiography
more often nondiagnostic in elderly
also consider patient risk factors
other cardiac problems (eg, left bundle branch
block, LVH, Q wave from old MI) that occur more
frequently in elderly may interfere with
interpretation of ECG
elderly less capable of mounting ST elevation
non-ST segment elevation MI (non-STEMI) more
common than STEMI in elderly
computers programmed to read ischemia only if
ST elevation >1 mm
(nonspecific if <1 mm)
Premature ventricular contractions (PVCs)
• do not treat
• routine treatment increases mortality
• routine prophylaxis with lidocaine for ventricular tachycardia (VT)
decreases in-hospital incidence of ventricular fibrillation arrest but
increases in-hospital incidence of asystolic arrest, increasing overall
mortality
• sustained VT only time to treat ventricular ectopy
• sustained VT defined as wide regular QRS complexes, with rate of
>120 beats/min
• sustained VT defined as run of VT that either causes instability or lasts
>30 sec
• (if <30 sec, nonsustained VT does not warrant antiarrhythmic
treatment)
• treatment of condition other than sustained VT increases overall
mortality by increasing asystolic death
• in nonsustained VT, look for underlying cause (eg, hypoxia, ischemia,
electrolyte abnormalities)
• consider – Beta-blocker in intermittent VT
Management
• Polypharmacy
• average elderly patient in United States on 7
medications (4-5 prescription medications, 1-2
herbal medications,
• and 1-2 over-the-counter medications)
• Anticholinergic toxicity common in elderly
because of antihistaminic and anticholinergic side
effects of medications (cause mental status
changes)
• impairment of renal and hepatic function,
• decrease in lean body mass
• increase in adipose tissue seen as individual ages
Beta-blockers
• no longer recommended in current American College
of Cardiology and American Heart Association guidelines
for acute MI (also not core measure)
• routine use of early IV or oral Beta-blockers associated
with increased incidence of cardiogenic shock (specific
risk factor in patients >70 yr of age)
• not indicated in first 24 hr for elderly patients with MI
• sinus tachycardia (>110 or 120 beats/min) also risk factor
for cardiogenic shock; presence of tachycardia requires
more aggressive treatment for ischemia
• only indication in acute MI presence of tachydysrhythmia
(eg, rapid AF) or intractable hypertension
• (higher dose of nitroglycerin first choice)
Nitrates
• consider possibility of hypotension
• (elderly patient most likely hypovolemic)
• ask specifically about other drugs patient
taking
• sildenafil
Aspirin
• highly effective
• elderly patients often underdosed or not dosed
• relative benefits greater in elderly, compared to
young patients
• if patient has ulcer or history of gastrointestinal
bleeding, current guidelines still recommend
aspirin but given with proton pump inhibitor
• if patient develops rash, give diphenhydramine
(Benadryl)
• Promethazine (Phenergan) if patient develops
nausea and vomiting
Anticoagulants and
antiplatelet agents
• clopidogrel—not given with thrombolytics if patient >75 yr of age
• Current guidelines state insufficient data to suggest any difference in
treatment in elderly (also true for glycoprotein IIb/IIIa inhibitors)
• patient overdosed if given glycoprotein IIb/IIIa inhibitor without
calculating creatinine clearance
• Data show increased bleeding complications when creatinine clearance
not calculated
• enoxaparin—data show increased bleeding complications and
mortality if creatinine clearance not considered
• unfractionated heparin—data show increased bleeding and mortality if
patient not weighed before dosing
• thrombolytics—age not contraindication
• overall, greater benefit seen in elderly than in young patients
• percutaneous intervention treatment of choice and only effective
treatment for elderly patient in cardiogenic shock
Resuscitation
• give IV fluids because elderly patient usually dehydrated
• consider nonadrenergic vasopressors because of poor response to
catecholamines treat shock aggressively
• lactate rises before changes in vital signs seen in shock
• occult shock relatively common in elderly and should consider
obtaining lactate level as early indicator consider empiric magnesium
because data show elderly patients most commonly hypomagnesemic
due to dehydration, kidney dysfunction, and diabetes
• beware of postintubation hypotension
• 2 major causes include hypovolemia and tension pneumothorax due to
decreased lung compliance
• use low tidal volumes and lower ventilatory rates to avoid barotrauma
• intubation causes increased intrathoracic pressure that decreases
venous return and cardiac output
• severe hypotension right after intubation common if patient
hypovolemic
• cardiac arrest—age alone not significant determinant of survival, but
comorbidities are
Take-home message
• should not rely on presence of chest pain
for diagnosis
• obtain ECG in elderly patients presenting
with malaise or shortness of breath
• treat aggressively, except with Betablockers
• calculate creatinine clearance if giving
anticoagulants and weight if giving
unfractionated heparin
A patient with a blood pressure
(BP) reading of 127/87 mm Hg
would be classified as having:
(A) Normal BP
(B) Prehypertension
(C) Stage 1 hypertension
(D) Isolated diastolic
hypertension
Answer
• (B) Prehypertewernsion
Whitecoat hypertension is diagnosed
in patients with hypertension
measured in the clinic, and
documented accurate BP
readings of _______ outside of the
clinic.
(A) <140/90 mm Hg
(B) <134/84 mm Hg
(C) <134/80 mm Hg
(D) <130/84 mm Hg
Answer
• (B) <134/84 Hg
When managing elderly patients
with hypertension, treatment
should focus more on controlling
systolic BP than
diastolic BP.
(A) True (B) False
Answer
• (A) True
All the following lifestyle
modifications are level A
recommendations for
hypertension, except:
(A) Moderate alcohol
consumption
(B) Tobacco smoking cessation
(C) Weight reduction
(D) Increased physical activity
Answer
• (C) Weight reduction
The Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High
Blood Pressure recommends
which of the following classes of drugs as
first-line therapy for uncomplicated
hypertension?
(A) Angiotensin-converting enzyme (ACE)
inhibitors
(B) Angiotensin receptor blockers (ARBs)
(C) Calcium channel blockers
(D) Thiazide diuretics
Answer
• (D) Thiazide diuretics
The Dash Diet can Lower BP by
_______ mmHg
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•
•
•
•
A) 5 mmHg
B) 7 mmHg
C) 9 mmHg
D) 11 mmHg
E) 13 mmHg
Answer
• D) 11 mmHg
One antihypertensive Medication
can lower blood pressure by
•
•
•
•
•
A) 10 mmHg
B) 12 mmHg
C) 15 mmHg
D) 18 mmHg
E) 20 mmHg
Answer
• C) 15 mmHg
What number is the lowest risk
for MI, stroke, Heart Disease and
renal failure
•
•
•
•
•
A. 115/75
B. 120/80
C. 125/85
D. 130/80
E. 140/90
Answer
• A. 115/75
In persons 40 to 70 yr of age with BP of
115/75 mm Hg to 185/115 mm Hg, an
increase of ________in systolic BP
(________in diastolic BP) doubles your risk
for cardiovascular disease
• A. 10, 5
• B, 10, 10
• C. 15, 5
• D. 15, 10
• E. 20, 10
Answer
• E. 20, 10
A widened pulse pressure of
_______and low diastolic BP
(eg,_________) are independent
cardiovascular risk factors
• A. >40 mm Hg and low diastolic BP (eg,
<60mm Hg)
• B. >50 mm Hg and low diastolic BP (eg,
<70 mm Hg)
• C. >60 mm Hg and low diastolic BP (eg,
<70 mm Hg)
• D. >55 mm Hg and low diastolic BP (eg,
<65 mm Hg)
Answer
• B. >50 mm Hg and low diastolic BP (eg,
<70 mm Hg)
Choose the correct statement about
chlorthalidone.
(A) High doses increase potassium levels
(B) Lower doses do not provide adequate
lowering of BP
(C) Longer acting and more potent
diuretic than hydrochlorothiazide
(D) Associated with fewer
cardiovascular events than
hydrochlorothiazide
Answer
• (C) Longer acting and more potent diuretic
than hydrochlorothiazide
Antialdosterone agents
• (A) Effective in patients with metabolic
syndrome; help with remodeling of cardiac
tissue
• (B) Standard of care for treating
hypertension after myocardial infarction
• (C) Can increase blood glucose levels in
patients with diabetes
• (D) Shown to reduce relative risk for
cerebrovascular accidents by 43%
Answer
• (A) Effective in patients with metabolic
syndrome; help with remodeling of cardiac
tissue
Beta-blockers
• (A) Effective in patients with metabolic
syndrome; help with remodeling of cardiac
tissue
• (B) Standard of care for treating
hypertension after myocardial infarction
• (C) Can increase blood glucose levels in
patients with diabetes
• (D) Shown to reduce relative risk for
cerebrovascular accidents by 43%
Answer
• (B) Standard of care for treating
hypertension after myocardial infarction
Thiazide diuretics
• (A) Effective in patients with metabolic
syndrome; help with remodeling of cardiac
tissue
• (B) Standard of care for treating
hypertension after myocardial infarction
• (C) Can increase blood glucose levels in
patients with diabetes
• (D) Shown to reduce relative risk for
cerebrovascular accidents by 43%
Answer
• (C) Can increase blood glucose levels in
patients with diabetes
Perindopril and indapamide
• (A) Effective in patients with metabolic
syndrome; help with remodeling of cardiac
tissue
• (B) Standard of care for treating
hypertension after myocardial infarction
• (C) Can increase blood glucose levels in
patients with diabetes
• (D) Shown to reduce relative risk for
cerebrovascular accidents by 43%
Answer
• (D) Shown to reduce relative risk for
cerebrovascular accidents by 43%
Antialdosterone agents
can be effective for
resistant hypertension in
patients who do not
have primary
aldosteronism.
(A) True (B) False
Answer
• (A) True
Which of the following factors is
the most powerful predictor of
coronary artery disease?
(A) Sex
(B) Age
(C) Presence of comorbidities
(D) Lifestyle
Answer
• (B) Age
Which of the following is(are) the
major cause(s) for missed diagnosis
of myocardial infarction (MI)?
(A) Failure to consider high-risk
groups
(B) Failure to recognize atypical
presentations
(C) Overreliance on negative tests
(D) All the above
Answer
• (D) All the above
In individuals >35 yr of age,
cardiac output has been shown to
decrease by _______ per year.
(A) 0.25%
(B) 0.5%
(C) 1%
(D) 2%
Answer
• (C) 1%
Glucagon is used only
in _______ overdose
of Beta-blockers.
(A) Acute (B)
Chronic
Answer
• (A) Acute
Which of the following statements are true
about the presentation of MI in the elderly?
1. “Indigestion” has highest predictive value
for ruling in MI
2. Reflux esophagitis or peptic ulcer disease
most common misdiagnosis for missed MI
3. 15% of patients with MI obtain partial
relief and 7% obtain complete relief with
antacids
4. 7% of patients with MI have completely
reproducible pain on palpation
(A) 1,3 (B) 2,4 (C) 1,2,3 (D) 1,2,3,4
Answer
• 1. “Indigestion” has highest predictive value
for ruling in MI
• 2. Reflux esophagitis or peptic ulcer disease
most common misdiagnosis for missed MI
• 3. 15% of patients with MI obtain partial
relief and 7% obtain complete relief with
antacids
• 4. 7% of patients with MI have completely
reproducible pain on palpation
(D) 1,2,3,4
Of the symptoms associated with
MI, studies show that _______ is
the most specific, while _______
is the most
common.
(A) Shortness of breath;
diaphoresis
(B) Diaphoresis; shortness of
breath
Answer
• (B) Diaphoresis; shortness of breath
Electrocardiography should be
obtained in an elderly patient who
presents with which of the
following?
(A) Upper abdominal pain
(B) Generalized weakness and
malaise
(C) Episode of exacerbation of
chronic obstructive pulmonary
disease (COPD)
(D) All the above
Answer
• (D) All the above
Antiarrhythmic
treatment is indicated in
ventricular tachycardia
lasting <30 sec.
(A) True
(B) False
Answer
• (B) False
Current guidelines for acute MI still
recommend aspirin in patients with
peptic ulcer disease or history of
gastrointestinal
bleeding, but it should be given with:
(A) Histamine (H)2-receptor antagonists
(B) Antacids
(C) Proton pump inhibitors
(B) Antacids
(D) Prostaglandins
Answer
• (C) Proton pump inhibitors
Data show increased bleeding
and mortality if creatinine
clearance not calculated before
administering _______, and if
patient’s weight not determined
before administering _______.
(A) Enoxaparin; unfractionated
heparin (B) Unfractionated
heparin; enoxaparin
Answer
• (A) Enoxaparin; unfractionated heparin