CARDIOVASCULAR

IN ELDERLY
Charles Limantoro
Population Projections in the U.S.:
2000-2050
50
Population in millions

40 Women >65
Men > 65
30 Women > 85
Men > 85
20

10

0
2000 2010 2020 2030 2040 2050
 Hospital Mortality for
Cardiovascular Causes

Total deaths
(in thousands) Age > 65
Acute MI 78 68 (87.2%)
Arrhythmias 17 12 (70.6%)
Heart failure 42 37 (88.1%)
Cerebrovascular disease 65 49 (75.4%)

Source: National Hospital Discharge Survey, 1998.

EFFECTS OF AGING ON THE
CARDIOVASCULAR SYSTEM
 Principal Effects of Aging on
Cardiovascular Structure and Function

• Increased vascular + myocardial

stiffness
• Decreased -adrenergic and
baroreceptor responsiveness
• Impaired sinus node function
• Impaired endothelial function
Net effect - Large reduction in CV reserve
 CV Changes: Max Exercise - Ages 20 and
80 Years
Oxygen consumption Reduced ~ 50%
AV oxygen difference Reduced ~ 25%
Cardiac output Reduced ~ 25%
Heart rate Reduced ~ 25%
LV stroke volume Reduced ~ 15% to 25%
LV end diastolic volume No change or small
decrease
LV end systolic volume Increased ~ 150%
LV ejection fraction Reduced ~ 15%
Age Changes in Systolic and
Diastolic BP

Source: J Gerontol Med Sci 1997;52:M177-83

 Possible Mechanism Leading from
Hypertension to Atherosclerosis

Hypertension

Shear forces Endothelial injury

vessel wall thickness

Change in gene Change in lipid Change in Redox

expression, cytokines, metabolism status/
growth factors, adhesion free radicals
mollecules

Atherosclerosis
 Conduction System
• Increased elastic tissue, collagen and fat,
especially in the SA node with marked
reduction in SA node pacemaker cells
• Calcification of cardiac skeleton
• Slowed conduction throughout the heart
• Hypertension, CAD, and amyloid infiltration
amplify conduction abnormalities
 Arrhythmias
• Marked increase in frequency of supra-
ventricular and ventricular ectopic beats
• Short runs of SVT occur in 1/3 of healthy
older subjects on Holter studies
• Ventricular couplets occur in ~11% and
short runs of VT occur in ~4% of normal
persons > 60 yr
• In the absence of heart disease, none of
these arrhythmias are associated with an
adverse prognosis
Source: Am J Cardiol 1992:70:748-51
Prevalence of Nonsustained SVT
during Maximal Exercise

Source: Am J Cardiol 1995;75:788-92

 Clinical Implications
• Increased systolic BP and pulse pressure
• Increased prevalence of AF, HF, especially HF
with preserved LV function
• Increased prevalence of bradyarrhythmias
and “sick sinus syndrome”
• Worse prognosis associated with all CV
diseases
 Disease Presentation
• Atypical symptomatology
- Chest pain less frequent
- Exertional dyspnea or fatigue common
- ‘Gastrointestinal’ symptoms common
- Confusion, dizziness, other CNS sx’s
• Non-diagnostic ECG due to IVCD, LVH, paced
rhythm, electrolyte abnormalities
CORONARY HEART DISEASE
IN THE ELDERLY
Prognosis after AMI by Age

Source: Circulation 1996;94:1826-33

 Disease Presentation
• Atypical symptomatology
- Chest pain less frequent
- Exertional dyspnea or fatigue common
- ‘Gastrointestinal’ symptoms common
- Confusion, dizziness, other CNS sx’s
• Non-diagnostic ECG due to IVCD, LVH, paced
rhythm, electrolyte abnormalities
CARDIOVASCULAR DRUG THERAPY
IN THE ELDERLY
 Drug Therapy in the Elderly:
General Considerations

• Decreased volume of distribution

• Decreased renal and hepatic clearance
• Altered drug pharmacodynamics
• Increased comorbidity
• Increased risk of drug interactions
• Paucity of data from clinical trials
IN GENERAL, ELDERLY PATIENTS DO
WELL WITH EVIDENCE-BASED
MEDICAL AND INTERVENTIONAL
THERAPY ALTHOUGH MORBIDITY
AND MORTALITY ARE HIGHER
THAN IN YOUNGER PATIENTS
 Conclusions
• There is rapid global growth in the number of
elderly patients with CV disease
• Mortality from CV disease is high in elderly
patients
• Evidence-based therapy is highly effective in
elderly patients
• Careful selection and tailoring of such
therapies is mandatory for elderly patients
with CV disease