3- Geriatrics CV Disease

Describe the 4 major physiologic changes that occur in an aging pt?

1. Substantial anatomical and physiologic alterations to heart and vasculature with age

2. Declines in most CV function --> reduced reserve capacity

3. Age related changes may lower threshold for clinical disease

4. Age related declines in CV and exercise performance are partially preventable and reversible with exercise training

Age related declines in CV and exercise performance are partially preventable and reversible with ____________.

exercise training

Declines in most CV function lead to what?

reduced reserve capacity

List the age related changes that occur to the CV system.

- Increased vessel stiffness

- decreased vessel elasticity

- less receptive to sympathetic stimulation

- decrease in plasma renin

- atrial fibrosis

- increased myocardial stiffness

- myocyte hypertrophy & degeneration

- reduction in pacemaker cells

What does decreased vessel elasticity due to aging cause?

less compliance= variable pressure/flow

What does increased vessel stiffness due to aging cause?

increased SBP, increased afterload

What does less receptive sympathetic stimulation due to aging cause?

blunted CV response to demand/need

What does decreased plasma renin activity due to aging cause?

impaired BP control and fluid balance

What can atrial fibrosis due to aging cause?

increased risk of arrythmia

What does increased myocardial stiffness due to aging cause?

may impair diastolic filling

What does myocyte hypertrophy and degeneration due to aging cause?

larger cells- more vulnerable to stress

What does reduction in pacemaker cells (SA node) due to aging cause?

may affect depolarization and control of HR

What has the greatest impact on mortality than any other RF?

high BP

Reducing BP by ______ SBP and _______ DBP = associated reduction of MI (25%), stroke (40%), CHF (50%), mortality (10-20%).

10mmHg, 5mmHg

What are the age related physiologic changes that lead to elevated BP (HTN)?

•Arterial Stiffness

•Decreased baroreceptor sensitivity

•Increased sympathetic activity

•Decreased α and β receptor responsiveness

•Endothelial dysfunction

•Sodium sensitivity (decreased excretion)

•Low plasma renin activity

•Insulin resistance

•Central Adiposity

What does HTN cause a pt to be at increased risk for?

CVD, stroke, CKD, a. fib, CHF

What defines geriatric stage 1 HTN?

130/80

What is the MC type of HTN?

essential

What type of HTN occurs as HBP with no known cause and is the MC type?

essential

What type of HTN is less common in elderly and should be considered if a pt has a sudden rapid increase in BP or if lack of response to treatment?

secondary

(primarily diastolic HTN)

What type of HTN defines BP above goal despite use of 3+ medications at optimal dosing?

resistant

How is the diagnosis of HTN made?

MULTIPLE MEASUREMENTS

9 measurements on 3 separate visits (Txt definition)

- can use home and ambulatory measurements

What are the laboratory/ dx tests associated with HTN workup?

•CBC

•Lipid

•CMP

•TSH

•UA

•ECG

What are the pharmacologic agents used to tx HTN?

Thiazide (HCTZ, Chlorthalidone)- not widely used in the geriatric population

ACEi (-PRIL)

ARB (-ARTAN)

CCB (Diltiazem, amlodipine, nifedipine)- first line!

BB (-LOL)

Aldosterone Antagonist (Spiro, Eple)

What are the non-pharm treatments for HTN?

•Weight loss

•Physical Activity: 30 minutes a day

•Low salt diet: less than 2.4g

•Heart-Healthy Diet: DASH

•Potassium Supplementation: prefer dietary

•Smoking cessation

For patients in the 130-139 SBP range w/o diabetes, _______________ is recommended.

6-mo trial of lifestyle intervention

What is the BP goal for most older adults?

130/80

What are the HTN treatment challenges?

- medication adherence

- drug interactions

- SEs: dizziness, hypotension, fatigue, imbalance, electrolyte disturbance

- comorbid conditions: CKD, COPD, vascular disease

- monitoring- home and office

- sequelae- if untreated/undertreated can lead to LVH, CHF, stroke, etc.

What causes high morbidity/mortality in older pts but many older pts have asymptomatic, stable, or subclinical versions of the disease?

CHD/CAD

What is not a significant RF after age 80 for coronary heart/artery disease?

dyslipidemia

Are risk estimators for ASVCD applicable for pts >80yo?

no

What can be considered for effective relief of frequent angina depending on comorbidities and life expectancy?

revascularization

What are typical signs/sx of CAD?

-Chest pain

-Dyspnea on Exertion

What are the anginal equivalent sx that can present as CAD?

Dyspnea, epigastric pain, fatigue, confusion, malaise

What are the diagnostic tests for CAD?

- NEW progressive or refractory sx need expedited or inpt workup!

- Baseline ECG If RFs present

- Exercise ECG as first line stress testing (pharm if unable to exercise)

- If baseline ECG abnormal --> stress w/ imaging is needed (ECHO, nuclear)

What is needed in a pt with an abnormal ECG and likely CAD?

stress test w/ imaging (echo, nuclear)

What is the first line stress testing for suspected CAD?

exercise ECG

What should be considered if high risk for severe CAD or refractory symptoms despite maximal medical therapy?

cardiac cath

What is the management for ASYMPTOMATIC stable IHD?

· Antiplatelet: ASA 81mg/d OR Clopidogrel 75mg/d

· HMG CoA reductase inhibitor (statin)

What is the management for symptomatic stable IHD (angina)?

•Antiplatelet

•HMG CoA reductase inhibitor (statin)

•Beta-Blocker

•Calcium Channel Blocker

•Nitrates

•Ranolazine

•PCI if symptoms remain despite medical therapy

What is the management for unstable angina/NSTEMI?

•Long-acting nitrates are beneficial

•Comorbidities and rehospitalization is high

•High risk features (hemodynamic abn., ventricular arrhythmia, shock, HF) indicate need for early invasive strategies

What is the management for a STEMI?

immediate reperfusion therapy:

•Fibrinolysis (thrombolysis)

•Primary PCI (preferred)

What is included in post-STEMI care?

Antiplatelet, statin, BB, ACEI

What type of MI occurs with an imbalance between myocardial oxygen demand and supply and is often secondary to exacerbations of chronic comorbid conditions or acute medical illness?

type 2

Describe the difference in pathophys behind type 1 MI vs. type 2 MI.

Type 1:

- plaque rupture with thrombus

Type 2:

- supply-demand imbalance

What are some type 2 MI potential causes?

•Sepsis

•Acute blood loss

•Anemia (acute, chronic, worsening)

•Pneumonia

•Pulmonary Embolism

•COPD

•CHF

•Dysrhythmias

•HTN urgencies

What is the MC arrhythmia in elderly?

atrial fibrillation

What are the RFs associated with a fib?

•Age

•Male

•HTN

•DM

•Valvular disease

•OSA

•Obesity

•CHF

•CAD

•Lung Disease

•Alcohol/Tobacco

•Long-term endurance exercise

•Postop period

•PE

Hyperthyroid

How does a fib present?

•Fatigue

•Palpitations

•Shortness of Breath

•Lightheadedness

•Falls

•Delirium

•Syncope

What are the diagnostics for a fib?

ECG- Irregularly irregular with an absence of discernable P waves

Labs- CBC, CMP, TSH, +/- troponin

Other studies- ECHO, CXR, overnight oximetry, sleep study

What helps reduce stroke risk?

CHADS-VASC & anticoagulation

What is the rate management for a fib?

•Beta-Blocker: carvedilol, metoprolol

•Calcium Channel Blocker: diltiazem, verapamil

Define CHADS-VASC.

CHF= 1

HTN= 1

age >=75 = 2

DM= 1

Stroke/TIA= 2

Vascular disease =1

age 65-74= 1

sex F= 1

Low risk: M&F= 0 (none)

Moderate risk: M=1, F=2 (none or oral anticoag)

High risk: M= >=2, F= >=3 (oral anticoagulant)

What are the medication options for rhythm control in a pt with a fib?

•Amiodarone

•Flecainide

•Propafenone

•Sotalol

For valvular stroke reduction in a pt with a fib- what medication should be given?

warfarin

For NONvalvular stroke reduction in a pt with a fib- what medication/s can be given?

rivaroxaban, apixaban, dabigatran

What a fib scenarios require cardioversion?

-Persistent AF

-Paroxysmal with moderate to severe symptoms

-Hemodynamic compromise

List the timing of cardioversion when dealing with a fib?

-Immediate in hemodynamic compromise

-IF a fib present for < 48 hours cardioversion can take place

-Otherwise, must anticoagulated x 4 weeks

-TEE can be used to r/o clot in atria

What is the MCC of hospital admission and rehospitalization among Medicare pts?

heart failure

What are the RFs associated with HF?

•Ischemic heart disease

•Hypertension

•Genetic Mutations

•Alcohol/illicit drugs

•Cardiotoxic medication

•Valvular Disease

•Age

What is the pathophys behind HF?

•Myocardial remodeling

•Neurohormonal Adaptations:

-- Sympathetic Nervous System

-- Renin-angiotensin-aldosterone system

-- Antidiuretic hormone

What stage of HF:

High risk, but without structural heart disease. May have HTN, obesity, CAD

A

What stage of HF:

Structural disease without signs/symptoms. Includes patients with systolic or diastolic dysfunction and/or LVH or valvular disease

B

What stage of HF:

Structural disease with prior or current symptoms

C

What stage of HF:

Refractory heart failure

D

What Class of HF:

No limitation, no symptoms

I

What Class of HF:

Slight limitation, comfortable at rest

II

What Class of HF:

Marked limitation, Comfortable at rest

III

What Class of HF:

Unable to perform physical activity, symptoms at rest

IV

What are some sx associated with HF?

dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, fatigue, decreased exercise tolerance

What are the PE findings for a pt with HF?

· CV: S3 gallop, +/- murmur

· Elevated JVP (best assessment of volume status)

· Pulmonary rales

What are the diagnostics AND findings associated with HF?

•CXR: +/- cardiomegaly, perivascular edema, cephalization, kerley B lines, effusions

•ECG: LAE, RAE, LVH, acute ST changes

•CMP

•CBC

•BNP: if normal, essentially rules out HF

•ECHO: (Transthoracic echocardiography) -assess diastolic/systolic function and valves

What will you see on a CXR for HF?

+/- cardiomegaly, perivascular edema, cephalization, kerley B lines, effusions

What are the non-pharm interventions for HF?

LOW salt diet/fluid management: <3g sodium/d and fluid restriction

ICD- increased risk of sudden death

exercise- mild aerobic, increase QOL and functional capacity

Cardiac rehab- once acute sx controlled transition to home exercise

What medications when treating HF have mortality benefit?

ACE/ARB/ARNI

BB

MRA

What medications for HF are used for sx management?

loop diuretics

-Furosemide, torsemide, bumetanide

What group of medication should be avoided in pts with HF if Cr > 2.5 or K > 5.0?

MRA

What should be monitored in a pt with CHF on an ACE/ARB/ARNI?

•Hypotension

•Decreased Renal Function (benefit outweighs mild decreases in GFR)

•Hyperkalemia

What should be monitored in a pt with CHF on a BB?

•Hypotension

•Bradycardia

•Contraindicated: advanced lung disease and acute decompensated HF

What is BB use contraindicated in?

advanced lung disease and acute decompensated HF

What should be monitored in a pt with CHF on a MRA?

•Hypotension

•Hyperkalemia / Decreased renal function

•Gynecomastia

What should be monitored in a pt with CHF on a loop diuretic?

•Electrolyte disturbance - monitor BMP, Mg

•Okay in reduced kidney function

•Hypotension

What type of stroke:

•Episode of neurologic dysfunction caused by focal CNS infarction

•Identified on imaging or consistent with pathologic vascular distribution

•Clinical evidence > 24 hours

ischemic

What type of stroke:

•Temporary neurologic dysfunction due to ischemia without evidence of CNS infarction

•Not visible on imaging

•Clinical evidence < 24 hours

transient ischemic attack

What are the RFs associated with stroke & TIA?

Age

HTN, HLD

A. fib

OSA

Tobacco/alcohol

Sedentary

How does stroke present?

-Weakness

-Sensory Loss

-Speech difficulties

-Vision loss

-Vertigo

-Loss of Balance

-Severe Headache

What are the labs that should be done on a pt with a suspected stroke?

•Expedient Imaging: non-contrast CT

•Glucose*

•CBC, CMP, INR, troponin

•MRI / MRA

What is the preferred imaging for TIA if within 24 hrs?

MRI

What is the preferred vessel imaging for TIA?

•intracranial carotid

•MRA

•Carotid u/s

For a pt with stroke or TIA -- Goal time to imaging is within _________ of arrival.

20 min

What is the management for stroke?

Thrombolysis (IV alteplase)

•First line if no contraindications

•Earlier the better

Mechanical thrombectomy

•Large Vessel: terminal ICA or M1 occlusion

•Secondary Prevention

BP Control

•Antiplatelet

•Statin

•Anticoagulation (AFib)

What is the first line for stroke management if no contraindications?

Thrombolysis (IV alteplase)

What is the management for TIA?

•Antiplatelet- Aspirin or Clopidogrel

•Statin

•BP Control

•Treat underlying conditions

What are some complications associated with strokes?

•Decreased functional ability -> increased need for care

•Falls

•Dysphagia -> aspiration pneumonia

•Hemiosteoporosis

•Pressure Ulcers

•Depression

•Cognitive impairment -> Dementia

What are the RFs associated with carotid artery disease?

•Smoking

•Age

•Male

How does carotid artery disease present?

•Asymptomatic

•Unilateral deficit

•Sensory change

•Aphasia

•TIA

•Vision disturbance

What is NOT a sensitive exam for carotid artery disease?

carotid auscultation

What are the diagnostics for carotid artery disease?

•Best initial test: carotid u/s

•CT must be with angiography

•MRI w/o contrast in those that cannot tolerate angiography

What is the management for asymptomatic carotid artery disease?

< 50% = Medical Management w/ Aspirin + Statin + RF management

> 70-90% = surgical intervention

What is the management for carotid artery disease in a symptomatic pt?

•Carotid stenting

•Endarterectomy (gold standard)