CARDIOVASCULAR

DISEASES IN GERIATRICS
dr. Jamaluddin, M.Kes, SpJP, FIHA

Faculty of medicine, Halu Oleo University

Kendari
Introduction
The leading cause of death in those older than 65
years is heart disease, presenting challenges in
diagnosis and treatment.

 The care of elderly patients with cardiac conditions

has many important differences from the care of
younger patients with the same diagnoses
AGE-RELATED CHANGES IN CARDIAC
ANATOMY AND PHYSIOLOGY
Vascular Physiology

Decreased compliance of the central arteries ---ISH

The function of the endothelium of aged vessels is

abnormal, with reduced production of nitric oxide
(NO), resulting in decreased NO dependent dilatation

increases in specific matrix metalloproteinases,

transforming growth factor-beta 1, and angiotensin II,
also lead to endothelial dysfunction
Cardiac Physiology
Heart weight increases about 1 g per year between ages
30 and 90 years
There are decreased numbers of ventricular myocytes
(due to apoptosis and necrosis), but the remaining
myocytes enlarge
Fibroblasts beneficially remodel the ventricle,
connecting the remaining myocytes to improve cardiac
output, but excess fibrosis decreases the compliance of
the ventricle and leads to dysfunction
Left ventricular ejectionfraction (LVEF) remains
unchanged
‘‘sigmoid septum’’
Aortic valve (AV) sclerosis (up to 40% of those aged 75
years)
Electrophysiology
The conduction system undergoes progressive fibrosis
as the heart ages
In a 75-year-old, an estimated 10% of the original
pacemaker cells in the sinus node remain functional
----- lower resting heart rates in the elderly, as well as
lower maximal heart rates achieved with exercise
 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
AGING AND PHARMACOLOGY
Altered pharmacokinetics and pharmacodynamics are
characteristic in older patients
Decreased volume of distribution and creatinine
clearance lead to significant changes in drug effect
profiles and drug concentration
Renal impairment is often missed on routine
laboratory studies because the decrease in muscle
mass that accompanies normal aging leads to a lower
serum creatinine level than in younger patients with
the same level of kidney function
Goals of Care in the Elderly
Maintaining independence in daily living
Ability to ambulate, decreased hospitalizations, and
decreased symptoms of illness
SPECIFIC CARDIOVASCULAR DISEASE STATES
IN THE ELDERLY
CORONARY ARTERY DISEASE
Dyspnea is a more common presenting symptom
A fourth heart sound and a soft mitral regurgitation
murmur are frequently present
The treatment of coronary artery disease in the
elderly is similar to that in younger patients
Coronary artery bypass and percutaneous coronary
intervention are both very effective in the elderly but
are associated with a somewhat higher morbidity and
mortality rate.
MYOCARDIAL INFARCTION
Myocardial infarction is associated with a higher
mortality rate, a higher incidence of congestive
cardiac failure, and a higher reinfarction rate in
the elderly patient than in the younger patient

Fewer elderly patients with myocardial infarction are

eligible for thrombolysis because of
contraindications and the higher occurrence of late
and atypical presentations of myocardial infarction
The elderly have a higher percentage of atypical chest
pain complaints as well as non chest pain
presentations (general fatigue/malaise, dyspnea,
abdominal pain, nausea and vomiting, or syncope).
The diagnosis of myocardial infarction is more
difficult in the elderly; dyspnea and pulmonary edema
are the most common presentation symptoms

Electrocardiography frequently is nondiagnostic

because of baseline electrocardiographic
abnormalities including left bundle branch block
Both primary coronary intervention (PCI) and
thrombolysis are beneficial for the treatment of acute
ST elevation myocardial infarction (STMI) in the
elderly but PCI is associated with a lower rate of
stroke compared with thrombolysis in the elderly

PCI is the treatment of choice for elderly patients with

STMI
ISOLATED SYSTOLIC HYPERTENSION
Isolated systolic hypertension is an elevated systolic
blood pressure (above 140-160 mm Hg) with a diastolic
pressure below 90 mm Hg
caused primarily by arterial stiffness and diminished
vascular compliance

Th/ with thiazide diuretic and added a β-blocker if

needed, significantly reduces morbidity and mortality
(SHEPS trial)
CONGESTIVE HEART FAILURE
Heart failure occurs in up to 10% of patients older than
80 years,
The most common cause is CAD, followed by HTN
Many cases it is due to diastolic ventricular
dysfunction with preserved systolic ventricular
function.
Factors that lead to ventricular diastolic dysfunction
and heart failure in the elderly include an impaired
ventricular relaxation and increased myocardial
stiffness
The elderly are relatively more dependent on the
Frank-Starling stretch response and less dependent
on heart rate to increase cardiac output in response
to exercise
The impaired ability of the aged kidney to excrete a
fluid challenge contributes to fluid overload
Th/:
Systolic HF : ACE-I/ARB, diuretic, Aldosterone
Antagonists, Vasodilator Therapy (Nitrates and
Hydralazine), digoxin, beta blockers, CRT
Diastolic HF : control of hypertension and
management of sodium/fluid status
VALVULAR HEART DISEASE
1. Calcific aortic stenosis

 The most common valvular heart disease in the

elderly
 Usually due to degenerative changes in a tricuspid
valve,
 The classic physical signs of aortic stenosis seen in
younger patients including the parvus and tardus
pulse waveform may be absent because of
increased arterial stiffness
Th/:
Balloon aortic valvuloplasty (BAV),
Transcatheter aortic valve implantation (TAVI),
Surgical (repair/replace)
2. Mitral Valve Disease

The next most common indication for valvular surgery

in the elderly is mitral regurgitation (MR)
Due to papillary muscle dysfunction resulting from
ischemia and myxomatous degeneration of the mitral
valve apparatus
Th/ : surgical ( repair/replace), transcatheter mitral
valve clipping
3. MITRAL STENOSIS
usually the late result of rheumatic fever.
The opening snap of mitral stenosis may be absent in
the elderly patient because of valve calcification and
rigidity.
The intensity of the first heart sound also may be
reduced for similar reasons.
Balloon mitral valvuloplaXCCsty is less successful
ATRIAL FIBRILLATION
Atrial fibrillation occurs in about 5% of subjects older
than 65 years.
Age is an independent risk factor for hemorrhagic
complications with warfarin therapy in the elderly
Warfarin reduces the stroke risk by about two-thirds.
A strategy of rhythm control in which an
antiarrhythmic drug is used to lower the risk of
recurrent atrial fibrillation does not reduce the stroke
risk compared to rate control alone
BRADYCARDIAS
Aging is associated with an increased occurrence of
conduction system fibrosis within the sinus node,
atrioventricular node, and bundle branches.
Sympathetic and parasympathetic neural influence on
the conduction system decreases.
Maximal heart rate decreases with age, and sinus
bradycardia is common in the elderly even in the absence
of cardiac disease.
The elderly are more dependent than younger patients on
atrial systole to complete late ventricular diastolic filling.
THANKS