Geriatric Geriatric CardiologyCardiology
RICHARD E. FREEMAN MD RICHARD E. FREEMAN MD 20132013
LOCK HAVEN UNIVERSITYLOCK HAVEN UNIVERSITY
Geriatric CardiologyGeriatric Cardiology
OCTOGENARIANS – 80 YRS+OCTOGENARIANS – 80 YRS+ 1850 – present1850 – present
average age increased from 40 to average age increased from 40 to ~80~80
2010: 12 million age 80 2010: 12 million age 80 ““very oldvery old”” increasing by 8% per yearincreasing by 8% per year
OLD OLD: 75- 85OLD OLD: 75- 85 OLDEST OLD: >85OLDEST OLD: >85
Geriatric CardiologyGeriatric Cardiology
CV DISEASE –CV DISEASE – 1/2 octogenarians - CVD1/2 octogenarians - CVD
65 % of deaths - CAD - AMI65 % of deaths - CAD - AMI
20% of hospital admissions 20% of hospital admissions
––
1/2 CHF1/2 CHF
• OCTOGENARIANS
Geriatric CardiologyGeriatric Cardiology COMMON CARDIOVASCULAR COMMON CARDIOVASCULAR
CHANGES WITH AGINGCHANGES WITH AGINGSTRUCTURAL CHANGESSTRUCTURAL CHANGESFUNCTIONAL CHANGESFUNCTIONAL CHANGESHEART RHYTHMHEART RHYTHMECG CHANGESECG CHANGES
Geriatric Geriatric CardiologyCardiology STRUCTURAL CHANGESSTRUCTURAL CHANGES
Increased intimal media Increased intimal media thicknessthickness Reduced compliance and distensibilityReduced compliance and distensibility Increased vessel stiffness and tortuosityIncreased vessel stiffness and tortuosity Reduced NITRIC OXIDE –dependent Reduced NITRIC OXIDE –dependent
vasodilationvasodilation Arterial pressure riseArterial pressure rise Widening pulse pressureWidening pulse pressure
Increased heart weightIncreased heart weight LVH: increased size but reduced number LVH: increased size but reduced number
of myocyteof myocyteFibrosis: changes in collagen fibersFibrosis: changes in collagen fibers
Geriatric Geriatric CardiologyCardiology FUNCTIONAL CHANGESFUNCTIONAL CHANGES
Systemic arterial pressureSystemic arterial pressure-RISES-RISES Diastolic pressureDiastolic pressure- DECREASES- DECREASES Pulse pressurePulse pressure- INCREASES- INCREASES CatecholamineCatecholamine- and exercise-- and exercise-
induced increases in heart rate induced increases in heart rate BLUNTEDBLUNTED Peak CO with exercise decreased by Peak CO with exercise decreased by
up to 30%up to 30% Left ventiricular- ComplianceLeft ventiricular- Compliance - -
FALLSFALLS Diastolic dysfunction Diastolic dysfunction ““STIFF wallSTIFF wall””
Early diastolic filling reducedEarly diastolic filling reduced Late diastolic filling increased (atria)Late diastolic filling increased (atria)
LAH and LAELAH and LAE
GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY HEART RHYTHMHEART RHYTHM
Parasympathetic function- Parasympathetic function- reductionreduction Reduced R to R variabilityReduced R to R variability
Linked to increased CV morbidity and mortalityLinked to increased CV morbidity and mortality
Decreased SA cellsDecreased SA cells ArrhythmiasArrhythmias
PACsPACs present in 5-10% greater than 60 present in 5-10% greater than 60 y/oy/o
PVCs: PVCs: 8.6% men over 60%,8.6% men over 60%, Atrial Fibrillation (Abnormal Rhythm)Atrial Fibrillation (Abnormal Rhythm)
most common most common rhythm disturbance: 9% of rhythm disturbance: 9% of those >80.those >80.
Geriatric CardiologyGeriatric Cardiology ECG CHANGESECG CHANGES Most common Most common ECG finding ECG finding
involves involves repolarizationrepolarization Review previous tracingsReview previous tracings Q-T intervals, T waveQ-T intervals, T wave
PR interval lengthenedPR interval lengthened 11stst degree AV block 3-4 % degree AV block 3-4 %
healthy menhealthy men LVHLVH
Left axis deviationLeft axis deviation BBBBBB
LBBB uncommon in absence of LBBB uncommon in absence of CV diseaseCV disease
Geriatric CardiologyGeriatric Cardiology
SUMMARIZING SUMMARIZING MOST DRAMATIC CHANGES MOST DRAMATIC CHANGES 1.Increased intimal media thickness and 1.Increased intimal media thickness and
arterial stiffness,arterial stiffness, 2.Alterations in diastolic filling patterns, 2.Alterations in diastolic filling patterns,
3. Impaired cardiac responsiveness to 3. Impaired cardiac responsiveness to exercise and/or β-adrenergic stimuli, andexercise and/or β-adrenergic stimuli, and
4. Alterations in heart rhythm. 4. Alterations in heart rhythm.
GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY
These age-associated These age-associated changes in cardiovascular changes in cardiovascular structure and function structure and function interact with age-prevalent interact with age-prevalent risk factors such as:risk factors such as:
hypertension,hypertension, diabetes, and diabetes, and hyperlipidemia andhyperlipidemia and This helps explain the This helps explain the
markedly increased rates of markedly increased rates of coronary heart disease, heart coronary heart disease, heart failure, and atrial fibrillation failure, and atrial fibrillation seen in older adults.seen in older adults.
Geriatric CardiologyGeriatric Cardiology PREVENTION:PREVENTION:
Primary: Primary: Lifestyle - activity, diet, emotional stressLifestyle - activity, diet, emotional stress
Secondary: Secondary: Extrapolate from younger age studies - Extrapolate from younger age studies -
behavior modification –behavior modification – bp control –bp control – lipid control (statins) lipid control (statins)
GENETICS:GENETICS: MOST likely a common denominatorMOST likely a common denominator ““It’s what’s in your gene (jeans) that It’s what’s in your gene (jeans) that
count.”count.”
Geriatric CardiologyGeriatric Cardiology
HYPERTENSIONHYPERTENSION
Prevalence - 80%Prevalence - 80%
GET Treatment - 75%GET Treatment - 75%
OBTAIN Adequate treatment - 29%OBTAIN Adequate treatment - 29%
GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY
HYPERTENSIVE HEARTHYPERTENSIVE HEART
MYOCYTEMYOCYTE- hypertrophy - younger - hypertrophy - younger MUSCLEMUSCLE- thickness - elderly- thickness - elderly
Interstitial collagen and fibrosisInterstitial collagen and fibrosis
Diastolic dysfunction:Diastolic dysfunction:
““A FILLING PROBLEM”A FILLING PROBLEM”
SLOER OR INCOMPLETESLOER OR INCOMPLETE
SYSTOLICSYSTOLICDIASTOLICDIASTOLIC
EMPTYING PROBLEM FILLING PROBLEMEF – LOW EF MAY BE NORMAL STILL “DEAD “WALL STIFF WALL
GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY
HYPERTENSIONHYPERTENSION TreatmentTreatment::
Rapid reduction – cautionRapid reduction – cautionNitroglycerin IVNitroglycerin IVBeta Blocker IV (short acting)Beta Blocker IV (short acting)
Gradual reduction –(long term use)Gradual reduction –(long term use)Small reductions – event Small reductions – event reductionsreductions
Multiple agents – small dosageMultiple agents – small dosage
Evidence suggests that lowering Evidence suggests that lowering SYSTOLICSYSTOLIC blood pressure in the geriatric patient is blood pressure in the geriatric patient is beneficial beneficial in lowering morbidityin lowering morbidity, but , but may not effect mortalitymay not effect mortality, , especially in the very old. It also suggests that when especially in the very old. It also suggests that when a target blood pressure cannot be achieved—for a target blood pressure cannot be achieved—for example, because of an adverse drug effect, even a example, because of an adverse drug effect, even a mild reduction mild reduction in systolic blood pressure (7 to 10 in systolic blood pressure (7 to 10 mm Hg) is still mm Hg) is still beneficialbeneficial and may be attempted and may be attempted. . DECREASE BOTH IN STROKE AND HEART DECREASE BOTH IN STROKE AND HEART EVENTSEVENTS
GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY
CORONARY ARTERY DISEASECORONARY ARTERY DISEASE INCIDENCE :INCIDENCE :
Increases with advancing ageIncreases with advancing age2/3 of all MIs and 80% of MI-2/3 of all MIs and 80% of MI-related deaths occur in those related deaths occur in those over 65over 65
GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION
Presentation variable Presentation variable –– chest pain, acute dyspnea, sudden fatigue, chest pain, acute dyspnea, sudden fatigue,
confusion, or syncopeconfusion, or syncope REMEMBER : ELDERLY AND WOMEN -ATYPICALREMEMBER : ELDERLY AND WOMEN -ATYPICAL
Preventative Treatment Preventative Treatment ––
BP and Rate controlBP and Rate control Beta blocker, and ace inhibitorBeta blocker, and ace inhibitor
Nitroglycerin - BP control and vessel dilationNitroglycerin - BP control and vessel dilation
Lipid reduction Lipid reduction - extrapolation from younger - extrapolation from younger
populationpopulation
GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY
MYOCARDIAL INFARCTION (MYOCARDIAL INFARCTION (continuedcontinued))
Thrombolytic Thrombolytic therapy therapy Very elderly – higher prevalence of contraindicationsVery elderly – higher prevalence of contraindications
Anticoagulation Anticoagulation - Heparin or LMWH- Heparin or LMWH
Antiplatelet Antiplatelet - Gp IIb / IIIa ( Plavix), ASA - Gp IIb / IIIa ( Plavix), ASA
In-hospital deaths and complication rates In-hospital deaths and complication rates
increase significantly with advancing age, increase significantly with advancing age,
but those patients receiving more guideline-but those patients receiving more guideline-
based therapies had lower mortality rates. based therapies had lower mortality rates.
GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY Myocardial Infarction: PCIMyocardial Infarction: PCI
The American College of Cardiology–National The American College of Cardiology–National
Cardiovascular Data Registry has evaluated the in-Cardiovascular Data Registry has evaluated the in-
hospital outcomes of 8828 PCIs performed in hospital outcomes of 8828 PCIs performed in
octogenarians (mean age, 83.7 years, 53% female).octogenarians (mean age, 83.7 years, 53% female).
[18] PCI was angiographically successful in 93% of PCI was angiographically successful in 93% of
patients with an overall in-hospital mortality rate of patients with an overall in-hospital mortality rate of
3.77%. However, when patients with AMI in the week 3.77%. However, when patients with AMI in the week
preceding PCI were excluded from analysis, the preceding PCI were excluded from analysis, the
mortality rate decreased to 1.35%.mortality rate decreased to 1.35%.
TAKE HOME: EARLY INTERVENTION BETTER TAKE HOME: EARLY INTERVENTION BETTER
OVERALL SURVIVALOVERALL SURVIVAL
GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY MYOCARDIAL INFARCTION: MYOCARDIAL INFARCTION: CABGCABG
The older the patient the:The older the patient the: More acute need for CABGMore acute need for CABG More advanced CADMore advanced CAD Higher incidence of complicating Higher incidence of complicating
comorbiditiescomorbidities
American College of Cardiology and the American College of Cardiology and the American Heart Associationrecommended American Heart Associationrecommended that that
““age alone should not be a contraindication age alone should not be a contraindication to CABG surgery,to CABG surgery,
if it is thought that long-term benefits if it is thought that long-term benefits outweigh the procedural risk.outweigh the procedural risk.
GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY
ANGINAANGINA
VariableVariable presentation presentation
Management:Management: MedicalMedical – multiple agents – multiple agents RevascularizationRevascularization - angioplasty/stent - - angioplasty/stent -
CABGCABG External extracorporal counter pulsationExternal extracorporal counter pulsation: :
Afterload reduction Afterload reduction - endothelial - - endothelial - vascular remodelingvascular remodeling
GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY
ATRIAL FIBRILLATIONATRIAL FIBRILLATION Types:Types:
Paroxysmal - -> permanentParoxysmal - -> permanent Controlled or uncontrolled ventricular Controlled or uncontrolled ventricular
responseresponse
PathophysiologyPathophysiology Neuromuscular conduction disorderNeuromuscular conduction disorder Atrial volume disorder Atrial volume disorder (stretch)(stretch) Location: Location: atria and/or proximal pulmonary atria and/or proximal pulmonary
veinsveins
Geriatric CardiologyGeriatric Cardiology Atrial FibrillationAtrial Fibrillation
ManagementManagement Conversion Conversion Rate controlRate control NSR vs. rate controlNSR vs. rate control AblationAblation
Age ( =/< 70 )Age ( =/< 70 ) Location – pulmonary veinsLocation – pulmonary veins Success – Immediate - 90% Success – Immediate - 90%
- Long term – 70%- Long term – 70% Anticoagulation – Long termAnticoagulation – Long term STROKE RISK- 4.5 %/yr unabticoagulatedSTROKE RISK- 4.5 %/yr unabticoagulated Warfarin – 70 % reductionWarfarin – 70 % reduction
GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY
CONGESTIVE HEART FAILURECONGESTIVE HEART FAILURE
After load control After load control - BP- BP Preload control Preload control - volume (diuretic)- volume (diuretic) Rate control Rate control (Beta blocker)(Beta blocker) Energy control Energy control - creatine phospho - creatine phospho
kinase kinase
Digoxin-ACE-ARBDigoxin-ACE-ARB Revascularization/Valve Revascularization/Valve
replacement or replacement or corrective surgerycorrective surgery PacingPacing - resynchronization - resynchronization
GERIATRIC CARDIOLOGYGERIATRIC CARDIOLOGY
Six Minute AssessmentSix Minute AssessmentSix minute walkSix minute walk
Heart failure vs. frailty Heart failure vs. frailty Distance non-heart failureDistance non-heart failure 180180’’ (+/- (+/- 1010’’))
Frailty Frailty 150150’’ (+/- 10(+/- 10’’))Heart failure Heart failure =/< 90=/< 90’’
Geriatric CardiologyGeriatric Cardiology MANAGEMENT OF VALVULAR HEART MANAGEMENT OF VALVULAR HEART
DISEASEDISEASE Symptomatic aortic stenosis Symptomatic aortic stenosis - - surgery: surgery:
mortality = 5 - 6%, mortality = 5 - 6%, combined procedures = 10%, combined procedures = 10%, five year survival = 60%five year survival = 60%
Mitral regurgitation Mitral regurgitation ring reduction w/wo valvuloplasty, ring reduction w/wo valvuloplasty, or or mitral mitral
valve replacementvalve replacement valve replacement (limited)valve replacement (limited) 10 - 15% mortality10 - 15% mortality
GERIATRIC GERIATRIC CARDIOLOGYCARDIOLOGY
Challenges vs ChampionsChallenges vs Champions
BiasBias in applying proven therapeutic in applying proven therapeutic modalities in the elderlymodalities in the elderly
Refine and apply Refine and apply risk factor risk factor managementmanagement
Continued need to recognize theContinued need to recognize the unique unique characteristics of very elderlycharacteristics of very elderly
to better apply pharmacotherapy vs to better apply pharmacotherapy vs interventional therapyinterventional therapy