Geriatrics Week 3 - The Aging Cardiovascular System

How does increased vessel stiffness + decreased elasticity lead to an output that is considered a predicter of heart disease?

Results in increased SBP and decreased DBP -> widened pulse pressure

Age related CV changes

Increased vessel stiffness/decreased elasticity

Less receptive to sympathetic stimulation

Decreased plasma renin activity

Atrial fibrosis

Increased myocardial stiffness

Myocyte hypertrophy & degeneration

Reduction in pacemaker cells

What is the effect of increased vessel stiffness?

increased SBP, increased afterload

Decreased vessel elasticity leads to

less compliance = variable pressure/flow

What is the result of geriatrics being less receptive to sympathetic stimulation

Blunted CV response to demand/need

Decreased plasma renin activity leads to

Impaired BP control and fluid balance

Atrial fibrosis can reslt in what?

Increased risk of arrhythmia

Increased myocardial stiffness may cause what?

Impaired diastolic filling

Myocyte hypertrophy and degeneration means what?

Larger cells -> more vulnerable to stress

Reduction in pacemaker cells may affect what?

Depolarization and control of HR

________ has the greatest impact on mortality of any risk factor

High BP

Age related physiologic affects of elevated BP

Arterial stiffness

Decreased baroreceptor sensitivity

Increased sympathetic activity

Decreased alpha and beta receptor responsiveness

Endothelial dysfunction

Sodium sensitivity

Low plasma renin activity

Insulin resistance

Central adiposity

First line pharmacologic treatments for HTN

Thiazide diuretics

ACEi

ARB

CCB

Goal BP for most older adults

130/80

**120/80 if higher stroke risk

HTN treatment challenges

Adherence, drug interactions, side effects

Common side effects associated with HTN medications

Dizziness, hypotension, fatigue, imbalance, electrolyte disturbance

Common anginal equivalent sxs

Dyspnea, epigastric pain, fatigue, confusion, malaise

When should cardiac catheterization be considered?

If high risk (EF < 35%) for severe CAD or refractory symptoms despite maximal medical therapy

Stable ischemic heart disease management if asx

Aspirin or Clopidogrel and a Statin

Stable ischemic heart disease management if symptomatic

Antiplatelet

Statin

Beta-blocker

CCB

Nitrates

Ranolazine

STEMI tx

Fibrinolysis, PCI preferred

Post STEMI care

Antiplatelet, statin, BB, ACEi

Type 2 MI pathophys

Imbalance between myocardial oxygen demand and supply

**often secondary to comorbid conditions or acute illnesses

MC arrhythmia in elderly

A-fib

Risk associated with a-fib in elderly

Stroke, cognitive decline, physical disability, falls

Clinical presentation of a-fib in the elderly

Fatigue, palpitations, SOB, lightheadedness, falls, delirium, syncope

CHADSVASC

When is a left atrial appendage closure device recommended for a-fib?

If patient is not suitable for long term oral anticoagulation, has a reasonable life expectancy, and/or has non-valvular a-fib

A-fib rate control meds for elderly patients

Carvedilol or metoprolol

Diltiazem or verapamil

A-fib rhythm control meds for elderly patients

Amiodarone

Flecainide

Propafenone

Sotalol

A-fib stroke reduction management (valvular)

Warfarin

A-fib stroke reduction management (nonvalvular)

Rivaroxaban, Apixaban, Dabigatran

Which patients need cardioversion?

Persistent A-fib

Paroxysmal with mod-severe sxs

Hemodynamic compromise

Timing of cardioversion

If a-fib for < 48 hours cardioversion can take place but if not, must anticoagulate x 4 weeks

MCC of hospital admission and rehospitalization among Medicare patients

Heart failure

Stage A Heart failure

High risk but without structural heart disease

-HTN, obesity, CAD

Stage B Heart failure

Structural disease without s/s

Stage C heart failure

Structural disease with prior or current symptoms

Stage D heart failure

Refractory HF

HF class by patient symptoms

I-no limitations

II-slight limitation, fine at rest

III-marked limitation, fine at rest

IV-Symptoms at rest

S/S of HF in elderly

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

HF PE findings

S3 gallop

Elevated JVP

Rales

CHF on CXR

Kerley B lines

Perivascular edema

HF medication management

ACEi/ARB/ARNI

Beta blocker

MRA

Loop Diuretics

Which HF medication does not provide mortality beenfit?

Loop diuretics, only for symptoms

When should you avoid Mineralocorticoid receptor antagonists?

If Cr > 2.5 or K > 5

Mechanical circulatory support devices for advanced heart failure care

Chronic resynchronization therapy

Left or right ventricular assist device

When may you do a heart transplant for advanced heart failure?

If < 70 y/o

Ischemic stroke

Episode of neurologic dysfunction caused by focal CNS infarction

Clinical evidence > 24 hours

Transient ischemic Attack

Temporary neurologic dysfunction due to ischemia without evidence of CNS infarction; not visible on imaging

Clinical evidence < 24 hours

Most significant and modifiable risk factor for stroke and TIA

HTN

S/S of stroke

Weakness, sensory loss, speech difficulties, vision loss, vertigo, loss of balance, severe headache, amaurosis fugax

What lab is required before administering IV alteplase?

Glucose

Stroke and TIA time to treatment

Time to imaging is within 20 mins of arrival

Stroke tx

IV alteplase, tPA

Mechanical thrombectomy

When is mechanical thrombectomy used?

Large vessel occlusion: terminal ICA or M1

Secondary stroke prevention

BP control

TIA treatment

Aspirin, Clopidogrel, DAPT?

Statin

BP control

Thrombolysis CI

Bleeding

Stroke within the last 3 months

Intracranial or intraspinal surgery in the last 3 months

Serious head trauma

Neoplasm, aneurysms, AVMs

Severe uncontrolled hypertension

Stroke complications

Decreased functional ability

Falls

Dysphagia

Hemiosteoporosis

Pressure ulcers

Depression

Cognitive impairment

Clinical presentation of CAD in elderly

Asx

Unilateral deficit: weakness, facial droop

Sensory change

Aphasia

TIA

Vision loss, amaurosis fugax

Best initial test for CAD

Carotid US

CAD treatment for asymptomatic pt

Aspirin + Statin + RF management

Smoking cessation

BP control (< 120/80)

CAD treatment if symptomatic

Medical management

Stent

Endarterectomy = GOLD

AAA screening recommendation

65-75 y/o males with any smoking hx

55+ if any family history

AAA dx

US or CT

AAA management

Smoking cessation, manage comorbidities, lifestyle mods

When is a vascular referral needed for AAA?

> 4.0 cm or rapid growth