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21 Cards in this Set
- Front
- Back
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Cardiovascular disease in elderly: twelve take home points
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The elderly account for the vast majority of CV events and deaths
Several key changes occur in the cardiovascular system with normal aging, including: increased stiffness of the left ventricle and arteries, and decreased maximal heart rate and cardiac output during exercise These normal age related changes reduce cardiovascular reserve capacity, and thereby lower the threshold for development of common cardiovascular diseases, and reduce the ability to adapt to them Common cardiovascular risk factors, including hypertension, diabetes, and smoking, retain and even increase in importance with advancing age and should be treated. Obesity is very common but its management is uncertain. Obesity is common among elderly in Western populations. Observational studies have paradoxical results: increased risk of developing disease; decreased risk of death. -Corollary: Observational studies sometimes produce misleading results regarding CV risk factors in older persons. Clinical management guidelines are best based on RTC’s in this specific populations. Cardiovascular risk for women rises after menopause and becomes similar to men by age by 70 Several common CV disorders are nearly unique to elderly, such as heart failure with preserved ejection fraction and calcific aortic stenosis. However, despite their importance, their pathophysicology and optimal treatment are not well understood In contrast to younger patients with cardiovascular disease, the elderly usually have multiple co-morbidities, such as pulmonary and renal disease, as well as dementia/ delirium, hearing and sight impairments. These confound diagnosis, worsen prognosis, and complicate therapy Older persons, particularly women, with new onset of MI or CHF often present with atypical symptoms Given adequate preparation and allowance for their special needs, elderly adhere and respond at least as well as younger patients to risk factor modifications, both with medications and with behavioral therapies Therapeutic interventions, both pharmacological and surgical, have greater risk of complicatons in the elderly compared to younger patients. However, due to a higher risk of adverse outcome without treatment, they receive greater absolute benefit compared to younger patients. Therefore, age alone should not be a contraindication to surgical or invasive treatment; careful patient selection and preparation are key In elderly persons, quality of life may be a more important goal than quantity of life |
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Changes in heart and aging
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LV wall thickness/mass
-increased 30% Diastolic filling -reduced 50% LA dimension -Increased 10% |
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ECG changes in elderly
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Modest increase in PR and QT intervals
Left shift in QRS axis Increased prevalence of RBBB but not LBBB No significant change in resting heart rate but marked reduction in heart rate variability Increased tendency to atrial fibrillation Increased tendency to conduction abnormalities Increased premature atrial and ventricular beats, at rest and with exercise Decreased maximal heart rate with exercise (IMPORTANT) |
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Arterial changes with aging
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↑ Calcium, collagen, and collagen cross-linking
↑ Intima-medial thickness ↑ Vessel diameter ↓ Elastin ↑ Systolic and pulse pressures ↑ Vascular stiffness indices, pulse wave velocity Altered central arterial pressure wave contour Net effect: ↑ LV pulsatile load (afterload) Marked decline in endothelium-mediated vasodilation from age 40 to 70 |
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Age changes in systolic and diastolic BP
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Systolic increases
Diastolic does not |
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Cardiovascular aging changes during exercise
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Oxygen consumption
-reduced 50% AV oxygen difference -reduced 25% Cardiac output -reduced 25% Heart rate -reduced 25% LV ejection fraction -Reduced 15% |
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Lungs, kidneys, musculoskeletal changes in aging
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Lungs
• Loss of elastic recoil • Reduced vital capacity and minute ventilation • Increased V/Q mismatching Kidneys • Decline in glomerular filtration rate ~ 8 cc/min/decade • Impaired water and electrolyte homeostasis • Reduced plasma renin and aldosterone activity • Impaired elimination of renally-excreted drugs Musculoskeletal • Sarcopenia – loss of muscle mass and strength |
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Summary: principle effects of aging on the cardiovascular system
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Increased arterial stiffness
Increased myocardial stiffness Impaired β-adrenergic responsiveness Impaired endothelial function Reduced sinus node function Net effect: Substantial reduction in CV reserve Impacts ability to respond to stresses or other diseases Lowers threshold for expression of CV diseases (heart failure) Does not impair ability to perform everyday activities |
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Management of HTN in elderly
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Lifestyle modifications
First-line therapy: thiazide diuretic Dosing: start low, titrate slowly Monitor closely for adverse effects, especially orthostatic hypotension Caution regarding pseudohypertension from stiff arteries Goal BP: same as in younger patients |
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Nonpharmacological therapy for HTN
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Dietary sodium restriction
Weight control Regular physical activity Moderation in alcohol use Smoking cessation Control of other risk factors, incl. diabetes, hyperlipidemia Elderly at least as successful as younger pts |
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Cholesterol and aging
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Rises with normal aging
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Lipids as a risk factor for CVD
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Although strength of association between lipids and cardiovascular disease declines with age, LDL and HDL levels predict CV risk at least to age 80
Although relative risk declines with age, the population attributable risk of dyslipidemias for the development of coronary artery disease may be higher in the elderly |
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Obesity and aging
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Weight, BMI, and waist circumference increase with aging
Women add average of 5 kg following menopause |
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Obesity paradox in elderly and CVD
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Obesity is one of the strongest risk factors for development of heart failure and CAD in the elderly
However, many studies have shown that older persons, including those with heart failure, have better survival than those with normal and low BMI! This has produced a conundrum for physicians: should they avoid recommending weight loss to their elderly obese patients? U-shaped curve: extremes are bad (underweight and morbid obesity. Prior data tainted by lack of ascertainment of intentional vs unintentional weight loss. The later may be a sign of underlying, occult malignancy or other terminal disease. Two recent publications from Wake Forest demonstrate for the first time that randomization to a program of intentional weight loss is associated with improved survival in the elderly. |
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Summary of risk factors in elderly and CVD
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Hypertension, dyslipidemia, smoking, and diabetes retain prognostic power even into old age
Relative risk ratio may decline or be unchanged with age, however attributable risk tends to increase due to higher prevalence Treatment of risk factors is beneficial as in young, if not more so Obesity is the new epidemic; weight loss is not harmful in well-selected elderly patients |
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Factors that may contribute to adverse outcomes in older patiets with acute coronary syndrome
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Age related changes:
-Loss of benefit from ischemic preconditioning -Myocyte apoptosis -Decreased angiogenesis Increased comorbidities Delayed presentation Atypical symptoms & non-diagnostic ECG More extensive coronary artery disease Higher prevalence of prior myocardial damage Increased risk of complications from pharmacologic and procedural interventions |
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Atypical presentation of MI in elderly
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Up to a third of MI’s in very elderly persons may present with atypical symptoms
-Confusion -Dyspnea -Lassitude -New onset CHF -New arrhythmia -Syncope -Stroke -Sudden death Increases with age and more common in women Atyipical presentation can also occur for CHF Can delay recognition and treatment |
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Treatment benefits for elderly compared with younger patients
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Thrombolytic Therapy Benefits Elderly at Least as much or more than Younger Pts Pooled Results from 5 Major Trials
PCI also just as effective in older persons Aspirin is equally effective BB save more lives than in younger patients ACEI larger absolut benefit in elderly |
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Summary: MI in elderly
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MI rate increases in women after menopause and becomes relatively similar to men by age 70
Atypical presentations are more frequent In general, interventional and pharmacological therapies are at least as beneficial in appropriately selected older patients as in younger patients |
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Heart failure with normal ejection fraction
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More common in elderly
In elderly women it makes up 2/3 of heart failure Incidence appears to be increasing Mortality is similar to reduced ejection fraction heart failure |
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Summary of heart failure in elderly
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Increases dramatically with age in men and women
Blood pressure is the major, modifiable risk factor for HF in the elderly HFPEF is nearly unique to and is the dominant form of HF in the elderly Optimal treatment for HFPEF is unknown Case management reduces rehospitalizations, improves quality of life, reduces costs Active area of research due to its disproportionate impact on health care |
