Transcript Geriatric Grand Rounds

Patient-Centered Care
for the
Complex Older
Cardiology Patient
Kevin Overbeck, DO
Assistant Professor, NJISA
Learning Objectives
• Apply knowledge of Aging Physiology to JNC 8
to optimize strategy for HYPERTENSION
management
• Understand the benefits of STATINS in aging in
the context of 2013 guidelines for
HYPERLIPIDEMIA
• Apply 2014 AHA/ACC/HRS guidelines for
ATRIAL FIBRILLATION to decision-making
for ANTICOAGULATION and RATE
CONTROL in the elderly
Aging Physiology:
Body Composition
•
•
•
•
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 Gerontology
A 85 year old with community dwelling male
with previous TIA (>5 years ago) and current
CKD stage III (eGFR 55) presents to the office
for routine evaluation of his chronic medical
conditions
BP 120/80mmHg
HR 68
ACTIVE MED LIST:
1.
2.
3.
4.
5.
6.
7.
8.
Aspirin 81mg daily
Metoprolol XL 50mg daily
Amlodipine 2.5mg daily
HCTZ 12.5mg daily
KCL 10meq daily
Losartan 50mg daily
Atorvasatin 10mg daily
Tamsulosin 0.4mg 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 Losartan
(E) Continue current medication regimen
JNC 8: Applied Gerontology
An 85 year old female presents to your outpatient
ambulatory office following a hospital evaluation
(09/04/2015 – 9/08/2015) for shortness of breath.
She was diagnosed and treated for an acute
exacerbation of COPD. She was upgraded from an
inhaler to a nebulizer and prescribed
PREDNISONE with a plan to taper
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 2015.
DISCHARGE MED LIST:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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
•
•
•
•
•
Steroids
Sympathomimetic Drugs
Decongestants
NSAIDS
Erythropoietin
JNC 8: Applied Gerontology
An 80 year old male with PARKINSON’S
DISEASE presents for an evaluation of
deterioration in his GAIT evidence by FIVE FALLS
in the home WITHOUT INJURY during the past
SIX MONTHS despite strict adherence to utilization
of TWO WHEELED ROLLING WALKER in the
home
CAD with previous MI (2008), Lower Extremity
Edema, Barrett’s Esophagus
CURRENT MED LIST:
1.
2.
3.
4.
5.
6.
7.
8.
Aspirin 81mg daily
Losartan 50mg daily
Carvedilol 6.25mg BID
HCTZ 12.5mg daily
Omeprazole 20mg daily
KCL 10meq daily
Vitamin D 1000 IU daily
Pravastatin 40mg qHS
BP (sitting): 154/70
BP (standing): 120/60 [asymptomatic]
Lower Extremity 1++ bilateral edema
BUN 20 / Creat 1.2 / eGFR > 60
What is the next BEST step in the management of this patient’s condition?
STATINS, DYSLIPIDEMIA
& THE ELDERLY
Dyslipidemia
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
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
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.
ATRIAL FIBRILLATION
&
THE ELDERLY
Atrial Fibrillation
•
•
•
•
•
Patient Centered Care / Goals of Care
Incidence increases with Age
Stroke Risk
Stroke Prophylaxis
Rate Control
January CT, et al. 2014 AHA/ACC/HRS guideline for the management of
patients with atrial fibrillation: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines and
Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1-76.
Anticoagulation
HPI: An 84 year old resident of an assisted living dementia unit presents
to sub-acute rehabilitation following a hospital evaluation for a “change
in mental status” ruled to DELIRIUM due to new onset ATRIAL
FIBRILLATION with rapid ventricular response
Functional Hx: (+) ambulates with a rolling walker at baseline
PMHx: DM, HTN, Hx Recurrent Falls, Osteoporosis, Depression,
Dementia, Chronic Constipation
MMSE (8/2012): Total Score 14/30 [noted deficits in the following areas
– 1/5 with time orientation , 3/5 deficit with location orientation, 1/5
serial sevens, 0/3 recall, 2/3 three step command, 0/1 drawing pentagon,
0/1 writing sentence]
Medications
Insulin Glargine 12 units qHS
Lisinopril 20mg daily
Metoprolol XL 50mg daily
Alendronate 70mg qWeek
Calcium 500mg
Vitamin D 400IU BID
Docusate BID
Citalopram 20mg daily
Donepezil 10mg daily
Memantine10mg BID
Should WARFARIN be prescribed in this patient?
(A) YES
(B) NO
Anticoagulation
HPI: An 84 year old resident of an assisted living dementia unit
presents to sub-acute rehabilitation following a hospital
evaluation for a fall with a hip fracture requiring ORIF.
Functional Hx: (+) ambulates with a rolling walker at baseline
PMHx: DM, HTN, Hx Recurrent Falls, Osteoporosis,
Depression, Dementia, Chronic Constipation
MMSE (8/2012): Total Score 14/30 [noted deficits in the
following areas – 1/5 with time orientation , 3/5 deficit with
location orientation, 1/5 serial sevens, 0/3 recall, 2/3 three step
command, 0/1 drawing pentagon, 0/1 writing sentence]
Medications
Insulin Glargine 12 units qHS
Lisinopril 20mg daily
Metoprolol XL 50mg daily
Alendronate 70mg qWeek
Calcium 500mg
Vitamin D 400IU BID
Docusate BID
Citalopram 20mg daily
Donepezil 10mg daily
Memantine10mg BID
Should WARFARIN be prescribed in this patient?
(A) YES
(B) NO
Atrial Fibrillation
Stroke Prophylaxis
We under utilize anticoagulation in the elderly
with atrial fibrillation
Anticoagulation
Clinician Concerns
•
•
•
•
•
•
1.
2.
Compliance
Monitoring
“Fall Risk1,2”
Cognitive Impairment
Drug-Drug Interactions
Bleeding Risk
Man-Son-Hing M, Nichol G, Lau A, et al. Choosing antithrombotic therapy for elderly patients with atrial
fibrillation who are at risk for falls. Arch Intern Med 1999; 159: 677-685
Kappor J. Management of Atrial Fibrillation. The Lancet, Volume 370, Issue 9599, Page 1608, 10
November 2007
Anticoagulation
• Increased risk of ICH >
85 but not statistically
significant
• INRs less than 2.0 as
compared to INRs 2-3
were not associated with
lower risk of ICH
• INRs > 3.5 associated
with increased risk as
should be avoided
Fang MC, et al. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin
for atrial fibrillation. Ann Intern Med. 2004;141(10):745
CHA2DS2-VASc
SCORE Adjusted
Stroke Rate
(%/year)
0
0
1
1.3
2
2.2
3
3.2
4
4.0
5
6.7
6
9.8
7
9.6
8
6.7
9
15.2
With CHA2DS2- VASc = 0, it is
reasonable to omit antithrombotic
therapy
With CHA2DS2- VASc = 1, no
antithrombotic therapy or treatment
with oral anticoagulation or aspirin may
be considered
With CHA2DS2- VASc > 2, oral
anticoagulants are recommended
Warfarin vs Aspirin in the Elderly
•
973 patients > 75 years old
(mean 81.5 years old)
•
Randomly assigned to Aspirin
75mg or Warfarin INR 2-3
•
The primary endpoint was
fatal or disabling stroke
(ischemic or hemorrhagic) or
intracranial hemorrhage or
significant emboli
•
Warfarin Group – 24 events
(21 strokes, 2 ICH, 1
embolism)
Aspirin Group – 48 events
(44 strokes, 1 ICH, 3 emboli)
•
Mant J, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the
Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet.
2007;370(9586):493.
Warfarin vs Aspirin + Clopidogrel
•
CHADS2 Score of 2
•
Randomly assigned to receive
Warfarin (target INR 2.0-3.0)
or the combination of
Clopidogrel 75mg plus
Aspirin 75mg-100mg
•
Trial Terminated Early due to
WARFARIN superiority
Connolly S, et al. Clopidogrel plus Aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation
Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE-W): a randomized controlled trial. Lancet
2006; 367:1903-12.
Anticoagulation & The Elderly
Setting
% in Range
Self-Monitoring
72%
Randomized
Trials
55-66%
Anti-Coagulation
Clinics
66%
Community
Physicians
57%
* Simple Finger Stick required
1. van Walraven C, et al. Effect of study setting on anticoagulation control: a systematic review and metaregression. Chest.
2006;129(5):1155.
WARFARIN superiority
• NNT 37 PRIMARY PREVENTON1
• NNT 12 SECONDARY PREVENTION1
Q: What about new agents?
A: “… complex patients with multiple chronic
conditions were excluded from all trials …”
1. Hart RG, et al. Meta-analysis antithrombotic therapy to prevent stroke in patients
who have non-valvular atrial fibrillation. Ann Intern Med 2007; 146: 857-67
ATRIAL FIBRILLATION
RATE CONTROL
Which Patient is “more sick?”
(1)
40 Year Old Female
HR 160
3.
(2)
80 Year Old Female
HR 118
Both Equally
Aging Cardio-Physiology
• Resting HR
Unchanged With
Aging
• Maximum HR
= 220 – age
OR
• = 208 – (0.7) x age
Cardiac Ventricular Filling Rate
Recommendations for Rate Control
• Control ventricular rate with Beta-Blocker or
Non-Dihydropyridine Calcium Channel
Antagonist for AF
• A heart rate control (resting heart rate < 80 bpm)
strategy is reasonable for symptomatic
management in AF
• A lenient rate-control strategy (resting heart rate
< 110bpm) maybe reasonable when patient
asymptomatic & LV systolic function preserved
• Non-Dihydropyridine Calcium Channel
Antagonists should NOT be used in
decompensated HF
An 88 year old male with systolic cardiomyopathy
with an EF < 35% presents with complaints of
fatigue and palpitations due to ATRIAL
FIBRILLATION with HR 110-130 bpm. He is
euvolemic, BP 130/70, and presently taking
CARVEDIOLOL 25mg BID. Which of the
following strategies is the best next step in the
management of his heart rate?
(A)Prescribe Diltiazem
(B)Prescribe Verapamil
(C)Prescribe Digoxin
(D)Prescribe Amiodarone
(E)Consult Cardiology
Rate Control Medications
Beta-Blockers – Atenolol, Carvedilol,
Metoprolol, Nadolol, Propanolol
Nondihydropyridine Calcium Channel
Blockers – Diltiazem + Verapamil
Digoxin
Amiodarone
Craig T. January et al. Circulation. 2014;130:e199-e267