Geriatric Cardiology

Adam Hajduk

Population Projections in the U.S.: 2000-2050

0

10

20

30

40

50

2000 2010 2020 2030 2040 2050

Po

pu

lati

on

in

mil

lio

ns

Women >65

Men > 65

Women > 85

Men > 85

Hospital Mortality for Cardiovascular Causes

Total deaths

(in thousands) Age > 65

Acute MI 78 68 (87.2%)

Arrhythmias 17 12 (70.6%)

Heart failure 42 37 (88.1%)

Cerebrovascular disease 65 49 (75.4%)

Source: National Hospital Discharge Survey, 1998.

EFFECTS OF AGING ON THE

CARDIOVASCULAR SYSTEM

Principal Effects of Aging on

Cardiovascular Structure and Function

Increased vascular + myocardial stiffness

Decreased -adrenergic and baroreceptor responsiveness

Impaired sinus node function

Impaired endothelial function

CV Changes: Max Exercise - Ages 20 and 80 Years

Oxygen consumption Reduced ~ 50%

AV oxygen difference Reduced ~ 25%

Cardiac output Reduced ~ 25%

Heart rate Reduced ~ 25%

LV stroke volume Reduced ~ 15% to 25%

LV end diastolic volume No change or small

decrease

LV end systolic volume Increased ~ 150%

LV ejection fraction Reduced ~ 15%

Age Changes in Systolic and Diastolic BP

Source: J Gerontol Med Sci 1997;52:M177-83

Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.

Stroke Volume

Aorta

Resistance Arterioles

Pressure (Flow)

Young Artery

Systole Diastole

Elastic Vessel

Arteriosclerotic Artery

Stiff Vessel

Systole Diastole

Arterial Wall Compliance and Pulse Pressure Wave

Clinical Implications

Increased systolic BP and pulse pressure

Increased prevalence of atrial fibrillation,

heart failure, especially heart failure with

preserved LV function

Increased prevalence of bradyarrhythmias

and sick sinus syndrome

Worse prognosis associated with all CV

diseases

CORONARY HEART DISEASE

Ischemic Heart Disease in the Elderly

Leading cause of death

35% of all deaths in people over age 65

Among people who die of IHD, 83% are over

age 65

CV mortality and morbidity rates increase

exponentially after age 75

6% US population over age 75

60% MI related deaths in people over age 75

IHD characteristics in the elderly

increase in percentage of female patients

more complex and calcified coronary artery lesions

more often impairment of LV function

more often complicated myocardial infarction

coexisting diseases (HA, DM, renal function

impairment)

delayed visiting at the doctors and diagnosis

Prevalence of Coronary Heart Disease by Age and Sex

0%

5%

10%

15%

20%

25-44 45-54 55-64 65-74 75+

Male

Female

Age, years

Source: National Health and Nutrition Examination Survey

IHD clinical picture in the elderly

1. Stenocardia

Its frequency decreases with age (causes):

increase in threshold of pain pain-killers intake dementia acceptance of pain as inevitable in elder age limited physical activity (effort-induced angina is less

often)

well-developed collateral circulation

stenocardial pain more rare typical localization (retrosternal)

2. Exertional dyspnea The most common symptom of myocardial ischemia in the elderly

3. Increasing symptoms of heart failure

4. Acute LV failure (pulmonary oedema)

by patients >70 years with pulmonary oedema and IHD 1-year mortality rate = 50%, 2-year = 70%

5. Fatigue or weakness during or after physical effort

6. Rhythm disturbances

7. Neurological symptoms

8. Silent ischemia

ischemia

LV compliance

LV end-diastolic

pressure

IHD clinical picture in the elderly

1. Chest pain occurrance frequency decreases with age

< 65 years 80% of persons 6674 years 72% > 75 years 49%

2. Heart failure (dyspnea, pulmonary oedema)

< 65 years 14 % of persons 6674 years 20 % > 75 years 40 % (Gregoratos, Am. J. Ger. Cardiol. 2001)

Clinical picture of myocardial infarction

3. Neurological symptoms (balance disturbances, vertigo, consciousness

disturbances, faintness, ischemic stroke)

4. Rhythm disturbances (esp. ventricular)

5. Abdominal symptoms (symptoms resembling peptic ulcer disease, biliary colic,

pancreatitis)

6. Acute renal failure

7. Sudden death

8. Silent infarction (up to 50% of all infarction cases in the elderly)

Some infarction cases remain unrecognised or recognised with substantial delay due to

atypical symptomatology.

(25% of ECG-recognised infarction cases were clinically undiagnosed Framingham

Study).

Clinical picture of myocardial infarction

GUSTO-I

Delayed recognition of infarction in patients > 65 years is 2040 minutes

MITRA Register

Average delay > 75 years is 210 min. compared to 155 min. among

younger patients (Haase KK i wsp. Clin Cardiol 2000,23)

IHD diagnostics causes of diagnostic difficulties in the elderly

atypical symptomatology

coexisting diseases (overlapping symptoms, misleading clinical picture) and polypragmasy

difficulties in carrying out and interpreting diagnostic tests

hindered cooperation with a patient

ECG changes hindering diagnosis of ischemia

1. Resting ECG

more common abnormalities in initial ECG (non-specific changes of ST-segment, atrio- and intraventricular conduction disturbance, hypertension-

induced LV hypertrophy)

frequent intake of digitalis glycoside affecting ECG curve

2. 24-hour ECG monitoring

(useful in diagnostics of silent ischemia)

IHD diagnostics in the elderly

3. Exercise testing

Limited diagnostic value:

age-related changes in physiological response to exertion (reduction in aerobic capacity, decrease in maximum heart rate 1/min/year, faster increase in systolic BP

value, limited increase in ejection fraction)

less intensive physical activity and bad physical condition (difficulties in reaching target rate of 85% of the maximum predicted HR)

fast reaching of the target rate at a low stage of the exercise test (initial tachycardia)

the ability to exercise is often limited by conditions unrelated to the heart (e.g. arthritis, neurologic disorders balance disturbances, vertigo; peripheral vascular disease)

elderly persons may not exercise maximally because of psychologic factors (e.g. unfamiliarity with vigorous exercise and sophisticated medical equipment, fear,

insufficient motivation).

frequent abnormalities in resting ECG (LBBB, LV hypertrophy, pacemaker, drugs)

4. Perfusion scintigraphy

test useful in elderly population

abnormal Thallium-201 test result examined as the only parameter the most sensitive indicator of the cardiac complications risk.

limitations similar to those of the exercise test (exertion may be replaced with dipyridamole)

possibility of conducting isotopic ventriculography (evaluation of LV function)

5. Stress echocardiography

exercise testing / pharmacologic stress testing with use of: dobutamine, adenosine, dipyridamole

diagnostic and prognostic value of the test positive results indicates significantly higher risk of major adverse cardiac events

sensitivity 79%, specificity 88%

safe and well-tolerated

technical limitations: anatomical conditions, obesity, worse chest mobility, emphysema

the most frequent adverse symptoms: decrease in BP, atrial fibrillation.

6. Coronarography

reference method (gold standard)

Prognosis after AMI by Age

Source: Circulation 1996;94:1826-33

Vaccarino et al Ann of Int Med 2001; 134: 173-181. Solid lines are men; dotted lines

are women.

Who has an Acute MI? Numbers

from the ED

8% younger than 50

15% 5059

20% 6069

30% 7079

22% 8089

5 % >90

Efficacy of Aspirin by Age: ISIS-2

0%

5%

10%

15%

20%

25%

< 60 60-69 70+

Placebo

Aspirin

Age, years

Source: Lancet 1988;II-349-60

Long-term Benefits of Aspirin

0%

5%

10%

15%

20%

25%

< 65 65+

Aspirin

Control

Age, years Source: BMJ 1994;308:81-106

P < 0.00001

P < 0.00001

% Eligible AMI patients given ASA in ED (Annals Emergency Medicine 2005)

0

10

20

30

40

50

60

70

80

90

100

90

% Given Beta Blockers in ED (Annals Emergency Medicine 2005)

0

10

20

30

40

50

60

70

80

90

% Eligible AMI patients given reperfusion (Annals Emergency Medicine 2005)

0

10

20

30

40

50

60

70

80

90

90

(n=9)

Source: Am Heart J 2001:142:37-42

Risk Stratification

Age is a huge risk factor for bad outcomes

Patients over age 75 are at high risk for death/recurrent MI. Patients < 65 with NSTEMI have 1% hospital

mortality.

Patients > 85 have 10% hospital mortality with NSTEMI.

Complications of recurrent MI, CHF, bleeding increase with age.

ATRIAL FIBRILLATION

Atrial Fibrillation and

Anticoagulation

Prevalence:

5% of people over age 65

10% of people over age 80

50% of all patients with FA are over age 80

Dreaded outcome: Stroke

Strokes with FA have higher

mortality/disability

Age and Stroke Risk

Incidence of stroke with FA increases with age:

1.3 %/year in patients 5059

2.2 %/year in 6069

4.2 %/year in 7079

5.1 %/year in 8089

But it is much more complicated

Predicting Risk of Stroke

CHADS2

CHF: 1 point

HA: 1 point

Age over 75: 1 point

DM: 1 point

Prior Stroke/TIA: 2 point

Score 0 = annual stroke risk

Benefit of Warfarin

Overall decreases risk of stroke by 6070%,

ARR of 2.73 %/year

Beneficial in all age groups, even those over

age 75

?Quality of life of preventing a stroke

ARR - absolute risk reduction

Risks of Warfarin

Risk of warfarin associated bleeding

increases with age

Risk ICH: 0.34 %/year in age less than 60,

0.76% /year in those over 80

Absolute risk of major bleeding = 2.2%

/year (increases to near 3% in those on

warfarin plus ASA)

Warfarin Use

Older patients less likely to receive

anticoagulation

Older patients more likely to be

underanticoagulated even though data is

clear that there is no significant stroke

protection at an INR of less than 2.

Warfarin in Older Patients

Patients under age 65 with FA and risk

factors for stroke: warfarin decreases risk of

stroke from 4.9 %/year to 1.7 %/year

In patients over 75 with risk factors (highest

risk group), warfarin reduces risk of stroke

from 12 %/year to 24 % /year.

Those at highest risk for stroke (older, prior

stroke, CHF, DM, HA) are less likely to be

given warfarin because of concerns for their

comorbidities.

HYPERTENSION

Hypertension - Prevalence

one of the in aging diseases

HA seen in over 60% of those over age 65

Elevations of SBP with decreases in DBP common with age due to diminished arterial compliance (increased Pulse Pressure)

SH accounts for 65-75% HA in those over 65

Characteristics of Hypertension in the Elderly

Increased

Systolic blood pressure and pulse pressure

Left ventricular mass and wall thickness

Arterial stiffness

Calculated total peripheral resistance

Decreased

Cardiac output and heart rate

Renal blood flow, plasma renin activity, and angiotensin II levels

Arterial compliance and blood volume

Diastolic blood pressure

18-29 30-39 40-49 50-59 60-69 70-79 80+ 0

70

80

110

130

150

18-29 30-39 40-49 50-59 60-69 70-79 80+ 0

70

80

110

130

150

0

70

80

110

130

150

0

70

80

110

130

150 D

BP

(m

m H

g)

SB

P

(mm

Hg

) D

BP

(m

m H

g)

SB

P

(mm

Hg

)

DB

P

(mm

Hg

) S

BP

(m

m H

g)

DB

P

(mm

Hg

) S

BP

(m

m H

g)

Men, Age (y) Women, Age (y)

Non-Hispanic Black

Non-Hispanic White

Mexican American

Pulse pressure Pulse pressure

Mean Systolic and Diastolic BP by Age and Race/Ethnicity for Men and Women (US Population Age 18 Years, NHANES III)

Burt VI, et al. Hypertension. 1995;25:305-313.

Forms of hypertension in the elderly

isolated systolic hypertension (IHS):

62,867,4% caused by an age-related increase

in arterial stiffness, more common among women

systolic-diastolic hypertension:

27,630,3%

diastolic hypertension sporadically

The Importance Of SH

SH associated with increased risks of CAD,

LVH, renal insufficiency, stroke and

cardiovascular mortality

SH and pulse pressure more closely associated

with CV risk than diastolic BP in older patients

(even in older patients with diastolic HTN)

The aim of treatment

to maintain SBP values < 140 and DBP < 90 mmHg, by diabetic

patients < 130 and < 85 mmHg respectively

achievement of the therapy goal should be stretched over a long

period of time (longer than by younger patients), up to several

months in some cases

it is useful to set some staging posts of the therapy, e.g.

reaching the BP values of 160/90 mmHg

such symptoms as: ill-being, vertigo, balance disorders, vision

disorders (e.g. scotoma), confusion decreasing the dosage or

changing the group of antihypertensives

the higher initial BP values are, the more carefully they should

be reduced

Treatment benefits

Isolated systolic hypertension

over 50% of cases of hypertension in the elderly (main arteries

stiffness)

SBP value and pulse pressure are crucial prognostic factors of

hypertension complications in the elderly

cardiovascular mortality rate is almost three times higher as

compared to other hypertension forms

first-line treatment Calcium antagonists and diuretics

Meta-analysis (SHEP, Syst-Eur, Syst-China, HEP, MRC-2, EWPHE)

14 825 elderly persons with ISH

reduction in:

all-cause mortality rate by 14%

cardiovascular mortality rate by 20%

fatal and non-fatal cardiovascular events rate by 20%

stroke rate by 33%

Hypertension is one of the primary factors leading to dementia in the

elderly (vasogenic dementia as well as Alzheimers disease)

patients with untreated hypertension may develop dementia in

advanced age

Alzheimers disease: cerebral microflow disturbance due to

persisting increased arterial blood pressure (collagen deposition

and thickening of basement membrane of capillaries slowing

down the pace of transporting nutritious substances into neurons

as well as of elimination of toxic waste products

dementia can be a common consequence of a stroke (hypertension

complications); patients with hypertension > 84 years tend to have

ten times higher incidence of stroke than patients aged 55-64

Dementia

Dementia (cont.)

Syst-Eur Study:

4700 patients > 60 years, treated for ISH (nitrendipine)

diagnosed dementia by 50%

(Alzheimers and vasogenic types)

PROGRESS Study

6150 patients with/without hypertension, history data: ischemic stroke

or TIA (perindopril /+indapamide);

dementia rate by 34%

stroke rate by 28%

Modification Approximate SBP

Reduction

(range)

Weight Reduction 5-10 mmHg/10kg

Adopt DASH eating plan 8-14 mmHg

Dietary sodium reduction 2-8 mmHg

Physical activity 4-9 mmHg

Moderation of alcohol

consumption 24 mmHg

Lifestyle Modifications

Which agent is best?

Thiazide Diuretics: First Line in large trials

ACE inhibitors LIFE (Losartan Intervention for Endpoint Reduction): Losartan vs Beta

blocker Losartan decreased risk CV events

HOPE (Heart Outcomes Prevention Evaluation) Patients with DM, over 55, CVD risk

Ramipril 10/day decreased morbidity/mortality at 5 yrs

Most pronounced effect seen in those over age 65

Ca Channel Blockers SHELL (SH in Elderly: Lacidipine Long Term Study)

CCB and thiazide similar effectiveness

Which agent?

Beta Blockers may not be first line

LIFE study (25 events/1000 patient years in those on losartan vs 35

events/1000 pt yrs on atenolol)

Meta-analysis of 10 trials, 16000 older patients with SH Diuretic better than B blocker in preventing combined endpoint

Beta blockers and diuretics decreased risk of stroke, BUT

Beta blockers were not effective at preventing CAD, CV mortality or all cause mortality

CONTRAINDICATIONS: COPD (chronic obstructive pulmonary

disease), peripheral vascular disease, bradycardia, heart blocks

BSH (British Society of Hypertension) / NICE (National

Institutes for Health and Clinical Extension)

recommendations, 2006

1st-line Ca-blocker or diuretic

2nd-line ACEI + Ca-blocker or ACEI + diuretic

3rd-line ACEI + Ca-blocker + diuretic

4th-line -blocker

intensificaction of diuretic treatment

-blocker

consider consulting with a specialist

treatment algorithm for patients with hypertension > 55 years

Therapy failures (reasons)

secondary hypertension

coexisting diseases

drugs (NSAID, steroids)

improper drugs intake (e.g. therapy breaks when BP returns to

normal)

polypragmasy (incl. improper combinations of antihypertensive

drugs)

white-coat hypertension

too expensive drugs

every sixth elderly patient with hypertension

Causes

renal diseases (renal artery stenosis, a kidney disorder e.g. polycystic

kidney disease, glomerulonephritis, chronic pyelonephritis)

endocrine disorder (eg, Cushing's syndrome, hypothyreosis, primary

aldosteronism, pheochromocytoma)

drugs (steroids, NSAID, B2-agents)

alcohol abuse

Secondary hypertension should be always considered in cases of sudden

development of hypertension, drug-resistant hypertension and fast

increasing renal failure.

Secondary hypertension

Quality of Life

Studies demonstrate no significant impact with treatment

ACE inhibitors/ARBs have better profile

CCBs well tolerated

Sexual dysfunction most commonly reported with thiazides

Nonselective Beta blockers reported to have some subjective negative effects on cognition and mood

Higher risk of Postural hypotension (30%)

Orthostatic hypotonia

SBP by at least 20 mmHg, often along with DBP by min. 10

mmHg after postural change (from recumbent into standing).

We measure BP after a patient has been standing quietly for at

least 1 minutes (and then after 3 minutes)

particularly common in the elderly with hypertension

15 to 20% of community-dwelling and about 50% of

institutionalized elderly persons

10% of physically fit and > 50% of infirm persons > 65 years

Pathomechanism

HR i stroke volume

(beta-adrenergic stimulation)

Postural

change lower limbs blood hold

venous return

stroke volume

carotid sinus flow

(baroreceptors stimulation)

Orthostatic hypotonia effects

sudden cerebral circulation decline ( stroke risk)

deterioration in coronary circulation (myocardial ischaemia /

infarction)

injuries, sometimes life-threatening (as a consequence of vertigo,

balance disturbances)

psychological trauma, anxiety of physical activity, leading to

infirmness

symptoms: vertigo, balance disturbances, dizziness, faintness,

falls and trauma, vision disorders, TIA, stenocardia, nausea

Predisposing factors

venous insuficiency (obesity, lower limbs varices, sedentary life

style, aging processes in veins walls)

disturbances of BP autonomic control (impairment of a

baroreceptor mechanism, lesser variability of HR, a reduction in

density and sensitivity of beta-receptors, peripheral neuropathy)

impaired cerebral circulation and cerebral vessels autoregulation

dehydration, low-sodium diet

drugs (diuretics, alfa-blockers, nitrates, anti-Parkinsonic,

phenothiazines, tricyclic antidepressants)

Management

slow postural change

raised-waist clothes

pressure stockings for patients with venous insufficiency

careful implementation and dosage of drugs which can intensify

hypotonia

orthostatic hypotonia test after each change of dosage or

implementation of a new drug

alternatively consider pharmacological treatment (fludrocortisone,

caffeine, ephedrine)

Conclusions

There is rapid global growth in the number of elderly patients with CV disease

Mortality from CV disease is high in elderly patients

Evidence-based therapy is highly effective in elderly patients

Careful selection and tailoring of such therapies is mandatory for elderly patients with CV disease

Take Home Points

Age is only one factor; frailty and age are

not the same thing.

There need to be increased numbers of older

adults included in trials, and these patients

should be similar to older community

patients and younger trial patients.