Dr. Mehdi Reza Emadzadeh Department of cardiology Mashhad University of Medical Science

From a physiologic standpoint human aging is characterized by progressive constriction of the homeostatic reserve of every organ system HOMEOSTENOSIS

Principles of geriatric medicine Individuals become more dissimilar as they age. An abrupt decline in any system or function is always due to disease and not to “normal aging”.

Normal aging can be attenuated by modification of risk factors. Healthy old age is not an oxymoron

Other Concepts Disease presentation is of ten atypical in the elderly. Because of decreased physiologic reserve, older patients often develop symptoms at an earlier stage of their disease.

Since many homeostatic mechanisms may be compromised concurrently,there are usually multiple abnormalities amenable to treatment. Many findings that are abnormal in younger patients are relatively common in older people.

Because symptoms in older people are often due to multiple causes,the diagnostic “law of parsimony” often does not apply. Because the older patient is more likely to suffer the adverse consequences of disease, treatment __ and even prevention__ may be equally or even more effective.

EPIDEMIOLOGY The population 65 years and older has grown from 20 million in 1970 to 35 million in 2000 and there will be 69 million by 2030 At present 1 in every ten people is 60 years or older. By 2050 this is projected to become 1 in every 5. The number of 100 years and older is projected to increase from in 1999 to 2.2 million by2050

In this older population cardiovascular disease plays a significant role and is the most common cause of morbidity and mortality. The overall cost of treating cardiac disease in people older than the age of 65 years was estimated at $58 billion in 1995.

VALVULAR HEART DISEASE The most common valve disease are calcific AS and MR due to myxomatous mitral valve, MR due to ischemia or previous ML, LV failure for any reason. DIAGNOSIS - Echocardiographic - Doppler imaging

TREATMENT - Similar to that for younger patients. In elderly patients, even with mild MV disease, AF is common, and represents a markedly increased threat of systemic embolization and stroke. Anticoagulation, unless absolutely contraindicated, is essential.

VALVE SURGERY - In patients older than 75, the risk of neurological problems and stroke with cardiopulmonary bypass surgery increases. The goals of valve surgery in the elderly are somewhat different from those in younger patients. In the older patient the major goal becomes relief of symptoms, with improvement in activity and quality of life rather than prolongation of life.

CORONARY ARTERY DISEASE As the population ages, the prevalence and annual incidence of the development of overt CAD substantially with age. Almost 85 percent of people who die of CAD are age 65 or older. Elderly patients have more multivessel disease and lower EF than younger patients. Acute ischemic syndromes are common initial presentations of CAD.

ACUTE MYOCARDIAL INFARCTION In the elderly, AM1 results in an increase in mortality compared with younger patients. Eighty percent of all deaths due to AM1 occur in those 65 years of age and elder.

MANAGEMENT In the older population, attention should be paid to impaired baroreceptor reflexes, decreased beta-adrenergic responsiveness, and stiff aorta. Combinations of digoxin, amiodarone, and calcium channel blockers can also produce profound bradycardia more easily in the elderly.

CARDIAC REHABILITATION Fewer than half of eligible patients, and most elderly patients after a myocardial infarction or CABG do not participate in rehabilitation programs. Psychological depression is common after AM1 and coronary surgery, especially in the elderly.

Exercise prescriptions designed for the individual show substantial evidence for benefit of exercise in the elderly, with an increase in exercise tolerance and capacity, obesity indices, lipid profile, overall levels of physical fitness, and quality of life.

SYSTEMIC HYPERTENSION IN THE ELDERLY prevalence and incidence - BP>140/90 occurs in half to two thirds of people older than 65y and in 75% of people older than 80y. - Systolic hypertension becomes more prevalent with aging. - “Isolated” systolic hypertension, without elevation of diastolic blood pressure, is present in about 8 percent of sexagenarians and more than 25 percent of the population older than 80 years of age.

TREATMENT - The need for treatment of hypertension in the elderly. - There is cardiovascular benefit for treatment of systolic or diastolic blood pressure in the elderly. - Combination of drug regimens including a diuretic are usually required to approach blood pressure targets.

- Different combination of pharmacological agents may have advantages based on the patients, concomitant diseases, genetics, or risk factors. - Dihydropyridine calcium channel blockers  greater stroke benefit. - ACE inhibitors  cardiac benefit, primarily in men. NSAIDS, as well as cox-2 selective NSAIDS. Thiazide diuretics.

- Lower initial drug dosages and slower medication titration, as well as the need for monitor for postural hypotension. - Postural hypotension of greater than 20 mmHg or 20 percent of systolic pressure is a risk factor for falls and fractures that carries significant morbidity and mortality. - Diuretic therapy. - Postprandial decline in both systolic and diastolic blood pressure.

CURRENT CONTROVERSIES - Target blood pressure for systolic blood pressure in the very old. - Differences in central versus peripheral blood pressure. - Lifestyle modifications. Impact of blood pressure treatment on development of dementia.