1. THE ELDERLY POPULATION

2. Cardiovascular Disease in the Elderly
Coronary Artery Disease
Hypertension, HHD
Stroke
Peripheral Artery Disease
Dysrhythmias
Valvular Heart Disease
Heart Failure

3. DISEASE PREVALENCE

4. Differentiation between Age-Associated Changes and CVD in Older People

5. AGE-ASSOCIATED CHANGES CARDIOVASCULAR DISEASE
Differentiation Between Age-Associated Changes and Cardiovascular Disease in Older People
AGE-ASSOCIATED CHANGES
ORGAN
CARDIOVASCULAR DISEASE
Increased intimal thickness
Arterial stiffening
Increased pulse pressure
Increased pulse wave velocity
Early central wave reflections
Decreased endothelium-mediated vasodilation
Vasculature
Systolic hypertension
Coronary artery obstruction
Peripheral artery disease
Carotid artery obstruction
Increased left atrial sice
Atrial premature complexes
Atria
Atrial fibrillation
Decreased maximal heart rate
Decreased heart rate variability
Sinus node
Sinus node dysfunction, sick sinus syndrome
Increased conduction time
Atrioventricular node
Type II block, third-degree block
Sclerosis, calcification
Valves
Stenosis, regurgitation
Increased left ventricular wall tension
Prolonged myocardial contraction
Prolonged early diastolic filling rate
Decreased maximal cardiac output
Right bundle branch block
Ventricular premature
Ventricle
Left ventricular hypertrophyheart failure (with or without preserved systolic function)
Ventricular tachycardia, fibrillation

12. Guidelines for Medication Prescribing in Older Patients
In general, loading doses should be reduced. Weight (or body surface area) can be used to estimate loading dose requirements. Weight differences between the sexes are greatest for white people
Use estimates of glomerular filtration to guide dosing of renally cleared medications and contrast agent administration. Reduce initial doses of metabolically or hepatically cleared drugs but tutrate to effect.
Time between dosage adjustments and evaluation of dosing changes should be longer in older patients than in younger patients.
Routine use of strategies to avoid drug interactions is essential.
incorporation of reference materials, a team approach, and quality improvement efforts are effective strategies.
Knowledge of effects of noncardiac medicaions is critical.
Assessment of adherence and attention to factors contributing to nonadherence should be part of the prescribing process.
Physicians must be familiar with the patient’s source of prescription medication coverage and provide education and assistance with obtaining critical medications.
Multidisciplinary approaches to monitoring of medication therapy may improve outcomes.

13. Estimates of creatinine clearance with the Cockcroft and Gault Formula (left panels) and estimates of glomerular filtration rate with the MDRD simplifies algorithm (right panel) for men and women aged 45 – 85 years

14. The relationship between the number of drugs consumed and drug interactions

15. Approach to the Older patient with :
Hypertension
Coronary Artery Disease
Stroke
Peripheral Artery Disease
Heart Failure
Atrial Fibrillation
Valvular Disease

17. Approach to Hypertension in Older Patients
Systolic as well as diastolic hypertension should be treated; current recommendations are based on brachial artery measurement :
Diastolic target is < 90 mm Hg
Systolic target is < 140 mm Hg for most (< 150 mm Hg for patients older than 80 years).
The focus should be on achieving blood pressure control, not initial therapy
Multiple medications are usually required in older patients, and combination shoud be based on concomitant diseases.
Drug dosing regimens should be adjusted for age and disease-related changes in drug metabolism and potential drug-drug interactions.
Patients should be monitored for adverse effects and drug interactions, especially :
Postural hypotension and postprandial hypotension
Hypovolemia with diuretics
Hyperkalemia with ACE inhibitors, ARBs, aldosterone, renin antagonists

19. In-hospital mortality rates reported for revascularization procedures by age group19

21. SR SM
Risk of stroke (light blue) is compared for medical and surgical therapy for patients with hemispheric transient ischemic attack in the North American Symptomatic Carotid Endarterectomy Trial are shown on the left. On the right are more recent data comparing risk of stroke (light blue) and risk of death (dark blue) with surgical carotic endarterectomy with protected stenting (SAPPHIRE long-term follow-up) in high-risk patients. Earlier medical therapy did not include aggressive lowering of lipids or blood pressure, and the data shown differ for lower risk as well as for older patients 21

24. Incidence rates of heart failure by age in a nationally reperesentative sample of nearly 3 million Medicare beneficiaries. The incidence of heart failure increases with increasing age within the Medicare population 24

29. Estimation of 4-year mortality in the Elderly
Age
Gender
BMI
Smoking
Disease : DM,Ca,Lung, HF
Assistance needed
Difficulty

32. The End