Geriatric Cardiology RICHARD E. FREEMAN MD 2013 LOCK HAVEN UNIVERSITY

Geriatric Cardiology OCTOGENARIANS – 80 YRS+ OCTOGENARIANS – 80 YRS – present 1850 – present average age increased from 40 to ~80 average age increased from 40 to ~ : 12 million age 80 “very old” 2010: 12 million age 80 “very old” increasing by 8% per year increasing by 8% per year OLD OLD: OLD OLD: OLDEST OLD: >85 OLDEST OLD: >85

Geriatric Cardiology CV DISEASE – CV DISEASE – 1/2 octogenarians - CVD 1/2 octogenarians - CVD 65 % of deaths - CAD - AMI 65 % of deaths - CAD - AMI 20% of hospital admissions – 20% of hospital admissions – 1/2 CHF 1/2 CHF OCTOGENARIANS

Geriatric Cardiology COMMON CARDIOVASCULAR CHANGES WITH AGING COMMON CARDIOVASCULAR CHANGES WITH AGING STRUCTURAL CHANGES STRUCTURAL CHANGES FUNCTIONAL CHANGES FUNCTIONAL CHANGES HEART RHYTHM HEART RHYTHM ECG CHANGES ECG CHANGES

Geriatric Cardiology STRUCTURAL CHANGES STRUCTURAL CHANGES Increased intimal media thickness Increased intimal media thickness Reduced compliance and distensibility Reduced compliance and distensibility Increased vessel stiffness and tortuosity Increased vessel stiffness and tortuosity Reduced NITRIC OXIDE –dependent vasodilation Reduced NITRIC OXIDE –dependent vasodilation Arterial pressure rise Arterial pressure rise Widening pulse pressure Widening pulse pressure Increased heart weight Increased heart weight LVH: increased size but reduced number of myocyte LVH: increased size but reduced number of myocyte Fibrosis: changes in collagen fibers

Geriatric Cardiology FUNCTIONAL CHANGES FUNCTIONAL CHANGES Systemic arterial pressure-RISES Systemic arterial pressure-RISES Diastolic pressure- DECREASES Diastolic pressure- DECREASES Pulse pressure- INCREASES Pulse pressure- INCREASES Catecholamine- and exercise-induced increases in heart rate BLUNTED Catecholamine- and exercise-induced increases in heart rate BLUNTED Peak CO with exercise decreased by up to 30% Peak CO with exercise decreased by up to 30% Left ventiricular- Compliance - FALLS Left ventiricular- Compliance - FALLS Diastolic dysfunction “STIFF wall” Diastolic dysfunction “STIFF wall” Early diastolic filling reduced Early diastolic filling reduced Late diastolic filling increased (atria) Late diastolic filling increased (atria) LAH and LAE LAH and LAE

GERIATRIC CARDIOLOGY HEART RHYTHM HEART RHYTHM Parasympathetic function- reduction Parasympathetic function- reduction Reduced R to R variability Reduced R to R variability Linked to increased CV morbidity and mortality Linked to increased CV morbidity and mortality Decreased SA cells Decreased SA cells Arrhythmias Arrhythmias PACs present in 5-10% greater than 60 y/o PACs present in 5-10% greater than 60 y/o PVCs: 8.6% men over 60%, PVCs: 8.6% men over 60%, Atrial Fibrillation (Abnormal Rhythm) Atrial Fibrillation (Abnormal Rhythm) most common rhythm disturbance: 9% of those >80. most common rhythm disturbance: 9% of those >80.

Geriatric Cardiology ECG CHANGES ECG CHANGES Most common ECG finding involves repolarization Most common ECG finding involves repolarization Review previous tracings Review previous tracings Q-T intervals, T wave Q-T intervals, T wave PR interval lengthened PR interval lengthened 1 st degree AV block 3-4 % healthy men 1 st degree AV block 3-4 % healthy men LVH LVH Left axis deviation Left axis deviation BBB BBB LBBB uncommon in absence of CV disease LBBB uncommon in absence of CV disease

Geriatric Cardiology SUMMARIZING SUMMARIZING MOST DRAMATIC CHANGES MOST DRAMATIC CHANGES 1.Increased intimal media thickness and arterial stiffness, 1.Increased intimal media thickness and arterial stiffness, 2.Alterations in diastolic filling patterns, 2.Alterations in diastolic filling patterns, 3. Impaired cardiac responsiveness to exercise and/or β -adrenergic stimuli, and 3. Impaired cardiac responsiveness to exercise and/or β -adrenergic stimuli, and 4. Alterations in heart rhythm. 4. Alterations in heart rhythm.

GERIATRIC CARDIOLOGY These age-associated changes in cardiovascular structure and function interact with age- prevalent risk factors such as: These age-associated changes in cardiovascular structure and function interact with age- prevalent risk factors such as: hypertension, hypertension, diabetes, and diabetes, and hyperlipidemia and hyperlipidemia and This helps explain the markedly increased rates of coronary heart disease, heart failure, and atrial fibrillation seen in older adults. This helps explain the markedly increased rates of coronary heart disease, heart failure, and atrial fibrillation seen in older adults.

Geriatric Cardiology

PREVENTION: PREVENTION: Primary: Primary: Lifestyle - activity, diet, emotional stress Lifestyle - activity, diet, emotional stress Secondary: Secondary: Extrapolate from younger age studies - behavior modification – Extrapolate from younger age studies - behavior modification – bp control – bp control – lipid control (statins) lipid control (statins) GENETICS: GENETICS: MOST likely a common denominator MOST likely a common denominator “It’s what’s in your gene (jeans) that count.” “It’s what’s in your gene (jeans) that count.”

Geriatric Cardiology HYPERTENSION HYPERTENSION Prevalence - 80% Prevalence - 80% GET Treatment - 75% GET Treatment - 75% OBTAIN Adequate treatment - 29% OBTAIN Adequate treatment - 29%

GERIATRIC CARDIOLOGY HYPERTENSIVE HEART HYPERTENSIVE HEART MYOCYTE- hypertrophy - younger MYOCYTE- hypertrophy - younger MUSCLE- thickness - elderly MUSCLE- thickness - elderly Interstitial collagen and fibrosis Interstitial collagen and fibrosis Diastolic dysfunction: Diastolic dysfunction: “A FILLING PROBLEM” “A FILLING PROBLEM” SLOER OR INCOMPLETE SLOER OR INCOMPLETE

SYSTOLICDIASTOLIC EMPTYING PROBLEMFILLING PROBLEM EF – LOWEF MAY BE NORMAL STILL “DEAD “WALLSTIFF WALL

GERIATRIC CARDIOLOGY HYPERTENSION HYPERTENSION Treatment: Treatment: Rapid reduction – caution Rapid reduction – caution Nitroglycerin IV Nitroglycerin IV Beta Blocker IV (short acting) Beta Blocker IV (short acting) Gradual reduction –(long term use) Gradual reduction –(long term use) Small reductions – event reductions Small reductions – event reductions Multiple agents – small dosage Multiple agents – small dosage

Evidence suggests that lowering SYSTOLIC blood pressure in the geriatric patient is beneficial in lowering morbidity, but may not effect mortality, especially in the very old. It also suggests that when a target blood pressure cannot be achieved—for example, because of an adverse drug effect, even a mild reduction in systolic blood pressure (7 to 10 mm Hg) is still beneficial and may be attempted. DECREASE BOTH IN STROKE AND HEART EVENTS Evidence suggests that lowering SYSTOLIC blood pressure in the geriatric patient is beneficial in lowering morbidity, but may not effect mortality, especially in the very old. It also suggests that when a target blood pressure cannot be achieved—for example, because of an adverse drug effect, even a mild reduction in systolic blood pressure (7 to 10 mm Hg) is still beneficial and may be attempted. DECREASE BOTH IN STROKE AND HEART EVENTS

GERIATRIC CARDIOLOGY CORONARY ARTERY DISEASE CORONARY ARTERY DISEASE INCIDENCE : INCIDENCE : Increases with advancing age Increases with advancing age 2/3 of all MIs and 80% of MI-related deaths occur in those over 65 2/3 of all MIs and 80% of MI-related deaths occur in those over 65

CHD MI CHF

GERIATRIC CARDIOLOGY  MYOCARDIAL INFARCTION Presentation variable – Presentation variable – chest pain, acute dyspnea, sudden fatigue, confusion, or syncope chest pain, acute dyspnea, sudden fatigue, confusion, or syncope REMEMBER : ELDERLY AND WOMEN -ATYPICAL REMEMBER : ELDERLY AND WOMEN -ATYPICAL Preventative Treatment – Preventative Treatment – BP and Rate control BP and Rate control  Beta blocker, and ace inhibitor  Nitroglycerin - BP control and vessel dilation  Lipid reduction - extrapolation from younger population

GERIATRIC CARDIOLOGY MYOCARDIAL INFARCTION ( continued ) MYOCARDIAL INFARCTION ( continued ) Thrombolytic therapy Thrombolytic therapy Very elderly – higher prevalence of contraindications Very elderly – higher prevalence of contraindications Anticoagulation - Heparin or LMWH Anticoagulation - Heparin or LMWH Antiplatelet - Gp IIb / IIIa ( Plavix), ASA Antiplatelet - Gp IIb / IIIa ( Plavix), ASA In-hospital deaths and complication rates increase significantly with advancing age, but those patients receiving more guideline-based therapies had lower mortality rates. In-hospital deaths and complication rates increase significantly with advancing age, but those patients receiving more guideline-based therapies had lower mortality rates.

GERIATRIC CARDIOLOGY Myocardial Infarction: PCI Myocardial Infarction: PCI The American College of Cardiology–National Cardiovascular Data Registry has evaluated the in- hospital outcomes of 8828 PCIs performed in octogenarians (mean age, 83.7 years, 53% female). The American College of Cardiology–National Cardiovascular Data Registry has evaluated the in- hospital outcomes of 8828 PCIs performed in octogenarians (mean age, 83.7 years, 53% female). [18] PCI was angiographically successful in 93% of patients with an overall in-hospital mortality rate of 3.77%. However, when patients with AMI in the week preceding PCI were excluded from analysis, the mortality rate decreased to 1.35%. [18] PCI was angiographically successful in 93% of patients with an overall in-hospital mortality rate of 3.77%. However, when patients with AMI in the week preceding PCI were excluded from analysis, the mortality rate decreased to 1.35%. [18] TAKE HOME: EARLY INTERVENTION BETTER OVERALL SURVIVAL TAKE HOME: EARLY INTERVENTION BETTER OVERALL SURVIVAL

GERIATRIC CARDIOLOGY MYOCARDIAL INFARCTION: CABG MYOCARDIAL INFARCTION: CABG The older the patient the: The older the patient the: More acute need for CABG More acute need for CABG More advanced CAD More advanced CAD Higher incidence of complicating comorbidities Higher incidence of complicating comorbidities American College of Cardiology and the American Heart Associationrecommended that American College of Cardiology and the American Heart Associationrecommended that “age alone should not be a contraindication to CABG surgery, “age alone should not be a contraindication to CABG surgery, if it is thought that long-term benefits outweigh the procedural risk. if it is thought that long-term benefits outweigh the procedural risk.

GERIATRIC CARDIOLOGY ANGINA ANGINA Variable presentation Variable presentation Management: Management: Medical – multiple agents Medical – multiple agents Revascularization - angioplasty/stent - CABG Revascularization - angioplasty/stent - CABG External extracorporal counter pulsation: Afterload reduction - endothelial - vascular remodeling External extracorporal counter pulsation: Afterload reduction - endothelial - vascular remodeling

GERIATRIC CARDIOLOGY ATRIAL FIBRILLATION ATRIAL FIBRILLATION Types: Types: Paroxysmal - -> permanent Paroxysmal - -> permanent Controlled or uncontrolled ventricular response Controlled or uncontrolled ventricular response Pathophysiology Pathophysiology Neuromuscular conduction disorder Neuromuscular conduction disorder Atrial volume disorder (stretch) Atrial volume disorder (stretch) Location: atria and/or proximal pulmonary veins Location: atria and/or proximal pulmonary veins

Geriatric Cardiology Atrial Fibrillation Atrial Fibrillation Management Management Conversion Conversion Rate control Rate control NSR vs. rate control NSR vs. rate control Ablation Ablation Age ( =/< 70 ) Age ( =/< 70 ) Location – pulmonary veins Location – pulmonary veins Success – Immediate - 90% Success – Immediate - 90% - Long term – 70% - Long term – 70% Anticoagulation – Long term Anticoagulation – Long term STROKE RISK- 4.5 %/yr unabticoagulated STROKE RISK- 4.5 %/yr unabticoagulated Warfarin – 70 % reduction Warfarin – 70 % reduction

GERIATRIC CARDIOLOGY CONGESTIVE HEART FAILURE CONGESTIVE HEART FAILURE After load control - BP After load control - BP Preload control - volume (diuretic) Preload control - volume (diuretic) Rate control (Beta blocker) Rate control (Beta blocker) Energy control - creatine phospho kinase Energy control - creatine phospho kinase Digoxin-ACE-ARB Digoxin-ACE-ARB Revascularization/Valve replacement or corrective surgery Revascularization/Valve replacement or corrective surgery Pacing - resynchronization Pacing - resynchronization

Geriatric Cardiology Diastolic Heart Failure Diastolic Heart Failure

GERIATRIC CARDIOLOGY Six Minute Assessment Six Minute Assessment Six minute walk Six minute walk Heart failure vs. frailty Heart failure vs. frailty Distance non-heart failure 180’ (+/- 10’) Distance non-heart failure 180’ (+/- 10’) Frailty 150’ (+/- 10’) Frailty 150’ (+/- 10’) Heart failure =/< 90 ’ Heart failure =/< 90 ’

Geriatric Cardiology MANAGEMENT OF VALVULAR HEART DISEASE MANAGEMENT OF VALVULAR HEART DISEASE Symptomatic aortic stenosis - surgery: Symptomatic aortic stenosis - 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, or mitral valve replacement ring reduction w/wo valvuloplasty, or mitral valve replacement valve replacement (limited) valve replacement (limited) % mortality % mortality

Aortic valve Mitral annular calcification

GERIATRIC CARDIOLOGY Challenges vs Champions Challenges vs Champions Bias in applying proven therapeutic modalities in the elderly Bias in applying proven therapeutic modalities in the elderly Refine and apply risk factor management Refine and apply risk factor management Continued need to recognize the unique characteristics of very elderly Continued need to recognize the unique characteristics of very elderly to better apply pharmacotherapy vs interventional therapy to better apply pharmacotherapy vs interventional therapy