CARDIOVASCULAR DISEASE

IN THE ELDERLY
 Definition of elderly

• No universal definition of “elderly” and no accurate

biomarker for aging exist.
• Most definitions of elderly are based on chronological age.
• WHO : uses 60 years of age to define “elderly”.
• Most of US classification use the age of 65 years.
• Gerontologists subclassify older age groups into :
- Young old (60-74 years), Old old (75-85 years), Very old (over 85
years of age).

• Clinicians often separate older patients into 2 groups :

- those 65 to 80 years and those older than 80 years.
Physiologic changes in aging heart and blood vessels
The Heart :
• Muscle relaxes less between beats (becomes stiffer).
• May not pump blood as efficiently.
• Is less responsive to stimulation by the nervous system.
• Is less able to increase strength of contractions during
exercise
• Wall may thicken.
The blood vessels :
• Wall becomes less elastic.
• Reflex that maintains BP upon standing up may become
slower.
 Cardiovascular diseases in elderly
• CVD is the most frequent diagnosis in elderly people
• Leading cause of death in both men women >65 years.
• Hypertension occurs in 1/2 to 2/3 of people >65 years.
• Heart failure (HF) is the most frequent hospital discharge
diagnosis among older Americans.
• Systolic but not diastolic BP increases with aging.
• Systolic hypertension : a stronger predictor of CV events.
• HF with preserved systolic function : more common at the
older ages and more common in women than men.
 Cardiovascular diseases …………

• CAD is more likely to involve multiple vessels and left main

artery disease and is equally likely in women and men
>65 years.
• Equal numbers of older men and women present AMI until
age 80.
• >80% all of deaths attributable to CVD occur in people >65
years, with approximately 60% of deaths in patients
>75 years.
• Furthermore, CVD in older people is not seen in isolation.
• 89% of older Americans have at least one chronic medical
condition, and half have at least two.
Types of cardiovascular disease more common in
elderly
• Isolated systolic hypertension
• Orthostatic hypotension
• Coronary heart disease
• Heart failure
• Aortic stenosis
• Mitral annular calcification
• Complete heart block
• Sick sinus syndrome
• Atrial fibrillation
• Stroke
 Differentiation between age-associated changes and
cardiovascular disease in older people

Organ Age-associated changes CVD

Vasculature Increased intimal thickness Systolic hypertension
Arterial stiffening Coronary artery obstruction
Increased pulse pressure Peripheral artery obstruction
Increased pulse wave velocity Carotid artery obstruction
Early central wave reflections
Decreased endothelium-mediated
vasodilatation

Atria Increased left atrial size Atrial fibrillation

Atrial premature complexes
Sinus node Decreased maximal heart rate Sinus node dysfunction, SSS
Decreased heart rate variability
 Differentiation between …………

Organ Age-associated changes CVD

Atrioventricular Increased conduction time Type II block
Node 3rd block

Valves Sclerosis, calcification Stenosis, Regurgitation

Ventricle Increased LV wall tension LV hypertrophy

Prolonged myocardial contraction
Prolonged early diastolic filling rate Heart failure (with or
without preserved
systolic function)
Decreased maximal cardiac output
Right bundle branch block (RBBB)
Ventricular premature complexes Ventricular tachycardia,
V.fibrillation
 Unique features of CVD in the elderly

Presentation Diagnosis Treatment

AMI Dyspnea, CHF chest pain, ECG,serum markers Thrombolysis

nausea/vomiting, confusion. or imaging. ?Revascularization
Atrial Dyspnea, CHF rate slower Apical pulse, ECG Rate control,
than in young. anticoagulation
Fibrillation
CAD Chest discomfort or dyspnea TMT test, Nuclear test
with emotion/DOE women imaging, stress echo,
as well as men smoking sessation,
medicine, PTCA,
CABG, lipid reduction
CHF Same as young Diastolic > sistolic Diuretics,digoxin,+B
-blockers/CCB
Htn Systolic, asymptomatic Three readings at > 2 Diet, exercise,
weeks apart alcohol withderawal,
medications.
Valvular Altered physical findings Echocardiography Critical --- surgery.
disease
 Guidelines for drug dosing in older patients

• In general, loading doses should be reduced – weight (or body surface

area) can be used to estimate loading dose requirements; doses in
women are usually less than those in men.

• Base doses of renally cleared drugs on estimates of glomerular filtration

or creatinine clearance (or if not possible, initiate with lower doses than
in younger patients) ; reduce doses of hepatically cleared drugs.

• 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.

• Assessment of adherence and attention to factors contributing to
nonadherence should be part of the prescription process.
 Drugs and the elderly
Slower metabolism and other physiologic changes in the aging body may
cause drugs to act differently in elderly patients than in younger ones.
• High BP medication may produce dizziness and orthostatic hypotension,
especially the vasodilators, diuretics, or some of CCB.
• Dizziness from anti-anginal medications (nitroglycerine) is also more
common.
• Toxicity from digitalis (used in heart failure) may be more common.
• The use of antiocoagulant drugs may result in bleeding more readily and
is dangerous in people who are unsteady and subjects to frequent falls.
• B-blockers tend to slow the heart more.
• Inravenous lidocaine may cause more confusion.
 Approach to hypertension in older patients

Systolic as well diastolic htn should be treated :

• Diastolic target is <90 mmHg.
• Systolic target is <140 mmHg.
• Individualization is needed for patients older than 80 years.

Initial therapy is often in low dose of a HCT or is based on concomitant

diseases (cardiac and noncardiac).

Drug dosing regimens should be reduced for age-and disease-related changes in

drug metabolism and for drug-drug interactions.

Patients should be monitored for postural hypotension.

• BP should be measured at least 4 hr from meals.
Patients sholud be monitored for adverse effects and drug interactions, especially
• Hypovolemia with diuretics.
• Hyperkalemia with ACEI, ARB, aldosteron antagonists.
• Renal function
 Approach to the older patient with CAD/CHD

• Morbidity and mortality from CAD and CAD treated medically or with
revascularization increases with age and more steeply at age older than
75 years. After age 70 to 75 years, there few data to suggest clear
advantages of one method of treatment of CAD over another.
• Anticipated procedural complication rates should reflect the age and
health status of the patient, not complication rates from series of younger
patients.
• Decisions regarding medical therapy versus revascularization or for PCI
versus CABG should be based on the role of CAD in the context of the
individual older patient’s overall health, life style, projected life span, and
preferences.
 Approach to anticoagulation in older patients

• Obtain complete medication and nutraceutical intake data to

anticipate warfarin requirements, interactions, contraindications,
and necessary adjustment.
• Educate patient, family and/or caregivers on diet, alcohol effects and
drug interactions and need for monitoring and communication.
• Initiate with low doses (warfarin)--- often at 2 mg/d not to exceed
5 mg/d.
• Monitor closely and titrate slowly.
• Consider warfarin effects of all medication, supplement, and diet
changes.
• Use preventive measures for osteoporosis.
 Approach to the older patient with
Peripheral artery disease (PAD)
• Treatment of CV risk factors, aspirin, and supervised walking-based
exercise programs are first line therapy.
• Medications can improved symptoms (cilostazol > clopidogrel >
pentoxyfilline; cilostazol should not be used in patients with HF.
• Estrogen and progesterone should be avoided in women with PAD.
• Revascularization options include PCI for iliac disease but long-term
efficacy requires surgical approaches at femoropopliteal and infra
popliteal level.
• Surgical morbidity and mortality increase with age and postoiperative
recovery times can be prolonged. All are highest in the setting of
surgery for critical ischemia or limb salvage.
 Approach to the older patient with HF
Symptoms may be relatively nonspesific in the older patient. Diagnosis may be
facilitated by use echocardiography or serum markers of heart failure.
Recognize that HF may be present in the older patient with preserved systolic
function, especially older women.
Treat symptoms with a goal of improving quality of life as well as morbidity :
• Control BP ---- systolic and diastolic.
• Control atrial fibrillation rate.
• Promote physical activity.
• Adjust medications for age- and disease- related changes in kinetics and
dynamics.
Educated and involve patients, family members, or caregivers in mangement
of HF :
• Monitor weight.
• Consider use of multidisciplinary team approaches.
 Approach to the older patient with AF
Atrial fibrillation (AF) is frequent in elderly people and confers a risk of stroke
but the patient may be unaware of its presence, suggesting that routine
examinations or electrocardiographic evaluations be targeted toward detection
of AF.
Anticoagulant is the chief weapon against stroke :
• Both greater potential benefit and risk for fatal intracranial bleeding are
present at ages >75 years, especially in women.
• Careful attention to anticoagulant monitoring is needed.
• Aspirin does not usually provide stroke risk reduction in older patients
because of higher likelihood of the presence of CVD but has overall bleeding
complication rates similar to those with warfarin.
Rate control produces equivalent benefits with lower costs than attempts as
rhythm control.
• Useful agents for elderly patients include digoxin, BB, nondihydropyridine
CCB, and amiodarone with dose adjustment for age, weight, and cocomitant
diseases.
 Approach to the older patient with
suspected valvular heart disease
Physical examination cannot reliably assess the severity of valvular
lesions in most older patients.
Doppler echocardiography is the clinical standard for diagnosis and
evaluation of the severity of valve lesions :
• Differentiates sclerosis from stenosis.
• Quantitates regurgitation.
• Assesses calcification of valves and supporting structures.
Age is a predictor of worse outcomes for the natural history of
valvular lesions as well as surgical approaches.
Surgery is definitive therapy for valvular lesions with age, CAD,
additional diseases, projected life span, and desired life style as
factors in evaluating surgical option.