Transcript Cardiovascular Disease Management in the Geriatric Patient

Search for the Fountain of
Youth:
Cardiovascular Disease
Management in the
Geriatric Patient
Kevin Overbeck, DO
Assistant Professor, NJISA
Learning Objectives
• Apply knowledge of Aging Physiology to JNC 8
+ SPRINT 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
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
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.
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 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.
SPRINT
1.
Williamson JD, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease
Outcomes in Adults Aged >75 years: A Randomized Clinical Trial. JAMA 2016: 315(24):2673-2682.
SPRINT
NNT Data:
Primary
Composite
Outcome
All Cause
Mortality
1.
2.
Older
(aged>75)
Overall Study
Group
27
61
41
90
Williamson JD, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease
Outcomes in Adults Aged >75 years: A Randomized Clinical Trial. JAMA 2016: 315(24):2673-2682.
The SPRINT Research Group. A Randomized Controlled Trial of Intensive versus Standard Blood
Pressure Control. NEJM 2015: 373(22): 2103-2116.
SPRINT EXCLUSION CRITERIA
•
•
•
•
DIABETES
Previous history of STROKE
Dementia / Memory Loss or MOCA < 19
SBP < 110mmHg following 1 MINUTE of
STANDING
• Residents of a NURSING HOME / ASSISTED
LIVING
• Symptomatic HF within 6 months (or EF < 35%)
1.
Williamson JD, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults
Aged >75 years: A Randomized Clinical Trial. JAMA 2016: 315(24):2673-2682.
RECOMMENDATIONS
• ADMINISTER COGNITIVE TEST – MOCA
• ROUTINELY measure STANDING BLOOD
PRESSURE
• TARGET SBP 140mmHg – once reached could
consider 130mmHg
• If standing BP < 110mmHg at ANY TIME raise
the target from 140mmHg back to 150mmHg
MORE FREQUENT VISITS
• WOULD NOT treat to a target of 120mmHg
• AVOID DIASTOLIC below 60mmHg
Applied Geriatrics
A 85 year old with community dwelling male
with CKD stage 3 (eGFR 55) presents to the
office for routine evaluation of his chronic
medical conditions
BP [sitting + standing]: 120/80mmHg
HR 68
MOCA: 26/30
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
Atorvastatin 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
Applied Geriatrics
A 85 year old with community dwelling male
with previous TIA (>5 years ago) and CKD
stage 3(eGFR 55) presents to the office for
routine evaluation of his chronic medical
conditions
BP [sitting + standing]: 120/80mmHg
HR 68
MOCA: 26/30
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
Atorvastatin 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
Applied Geriatrics
A 85 year old with community dwelling male
with previous TIA (>5 years ago) and CKD
stage 3 (eGFR 55) presents to the office for an
evaluation of his increasing lower extremity
edema
PHYSICAL EXAM
BP [sitting + standing]: 120/80mmHg
HR: 68
CARDIO: (+) regular (+) 2+ bilateral pitting
lower extremity edema (-) S3 (-) JVD
MOCA: 26/30
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
Atorvastatin 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) Increase Hydrochlorothiazide (HCTZ)
(C) Reduce Metoprolol XL (Lopressor XL ®)
(D) Reduce Losartan
(E) Continue current medication regimen
Medications Known To Increase BP
•
•
•
•
•
•
•
Steroids
Sympathomimetic Drugs
Decongestants
NSAIDS
Erythropoietin
Venlafaxine (Effexor®)
Mirabegron (Myrbetriq®)
Applied Geriatrics
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
MOCA: 21/30
BP / HR (laying): 154/70 -- 66
BP / HR (standing): 120/60 [asymptomatic] -- 70
Lower Extremity 1++ bilateral edema
BUN 20 / Creat 1.2 / eGFR > 60
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
What is the next BEST step in the management of this patient’s condition?
STATINS, DYSLIPIDEMIA
& THE ELDERLY
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
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.
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
Atrial Fibrillation
Stroke Prophylaxis
We underutilize 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
Clinician Concerns
1. Staerk L, et al. Stroke and recurrent haemorrhage associated with antithrombotic treatment after
gastrointestinal bleeding in patients with atrial fibrillation nationwide cohort study. BMJ 2015; 351:h5876.
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
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.
NOVEL ANTICOAGULATION
1.
Shama, et al. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial
fibrillation and secondary prevention of venous thromboembolism systemic review and meta-analysis.
Circulation 2015; 132(3): 194-204.
ATRIAL FIBRILLATION
RATE CONTROL
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
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
Craig T. January et al. Circulation. 2014;130:e199-e267