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Geriatric Cardiology – You CAN treat Angina!

Geriatric Cardiology – You CAN treat Angina!. April 24, 2012. Joseph Tenenbaum, MD, FACC, FACP Conflicts of Interest. No speakers’ bureaus No device or pharmaceutical manufacturers General cardiologist with focus on angina, critical care, prevention

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Geriatric Cardiology – You CAN treat Angina!

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  1. Geriatric Cardiology – You CAN treat Angina! April 24, 2012

  2. Joseph Tenenbaum, MD, FACC, FACPConflicts of Interest No speakers’ bureaus No device or pharmaceutical manufacturers General cardiologist with focus on angina, critical care, prevention Edgar Leifer Professor of Clinical Medicine Chief, Allen Hospital Medical Service Director, House Staff Training Program Angina 2012 2

  3. Angina: The Agenda Clinical Case – Dr. MS Definitions Epidemiology Physiology Clinical evaluation Medical therapies Non medical therapies Conclusion Angina 2012 3

  4. Angina: Goals Refocus concern from angina as an entity to a symptom of ischemia Reinforce current concepts of pathophysiology of ischemia Review current therapies of ambulatory management for primary care No discussion of ACS (Unstable Ischemic Heart Disease) Emphasis on Geriatric issues Angina 2012 4

  5. Clinical Case: Dr. MS, M/81 • 10 year history of CAD • Risks: Hypertension • EKG showed RBBB for 20 years • Murmur of AI • Symptoms of chest pressure and DOE – LAD 90% prox, 90% mid – 4 stents • 2 years of chest pressure • Onset with swimming • Negative stress test • Relieved with treatment with PPI • Current – walking induces chest pressure, relieved by rest Angina 2012 5

  6. Clinical Evaluation • Current meds • Beta blocker • Aspirin • Statin • Exam • BP 120/60 P 68 • Chest – clear • Heart – 2/4 diastolic blow along left sternal border • JVP normal • EXT – no edema • Lab studies • Hct 42 Hgb 14.2 • Creat 1.0 • CXR: Mild cardiomegaly Angina 2012 6

  7. Electrocardiogram at RestSinus Bradycardia, Normal Axis, RBBB, LVH, No change Angina 2012 7

  8. CXR: Cardiomegaly, Aortic Dilatation Angina 2012 8

  9. Stress Test NUCLEAR STRESS: SCAN NEGATIVE * Symptom: Chest pain. * HR Response: HR failed to increase appropriately, likely due to medications. * BP Response: Appropriate. * ECG Abnormalities: ECG changes could not be interpreted due to abnormal baseline ECG. * Arrhythmia: Frequent VPDs. * *Review of raw data shows: diaphragmatic artifact * The left ventricle was normal in size. Normal myocardial perfusion scan, with no evidence of infarction or inducible ischemia. * Gated wall motion analysis is performed, and shows normal wall motion with rest LVEF of 65% and post stress LVEF of 61%. *** Conclusions *** The patient had a possible anginal symptom during exercise in the absence of SPECT evidence of ischemia at a heart rate of 110/min. Angina 2012 9

  10. Historical Points • Who was William Heberden? • English physician 1710-1801 • Classic description 1768 “They who are afflicted with it, are seized while they are walking, (more especially if It be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or to continue; but the moment they stand still, all this uneasiness vanishes. “ Angina 2012 10

  11. Angina Pectoris DEFINITIONS EPIDEMIOLOGY Greek : ἀγχόνηankhone ("strangling") Latin: angina = “throat inflammation” Merriam Webster: “A disease marked by spasmodic attacks of intense suffocative pain.” ICD 9: 413; ICD 10: 120 Spanish: “Dolor de Pecho” Only 18% of coronary attacks are preceded by longstanding angina New episodes increase with age and are more frequent in African Americans DEATH IS INFREQUENT Angina 2012 11

  12. Angina Pectoris: EpidemiologyNew Cases/1000 (NHLBI) Angina 2012 12

  13. PHYSIOLOGY: Angina is a syndrome of ischemic heart disease • Asymptomatic • Silent ischemia • Angina • Acute coronary syndromes • Unstable Angina • Myocardial infarctions • Sudden cardiac death • Congestive heart failure Angina 2012 13

  14. Ischemia: Myocardial Demand EXCEEDS Supply DEMAND • Heart Rate • Contractility • Wall tension T=Pr/2h • Preload (r) • Afterload (P) • Wall thickness (h) SUPPLY • O2 carrying capacity • Hemoglobin • Coronary blood flow • Perfusion pressure • Aortic vs. end diastolic • Vascular resistance • Neural control • Lesions Angina 2012 14

  15. Ischemia Angina 2012 15

  16. ISCHEMIA - RESPONSES • Asymptomatic • Relaxation – S4 • Contraction – S3, mitral regurgitation • Electrical – repolarization • Symptomatic • Angina, Dyspnea, Arrhythmias • Cellular integrity – no change, stunning, hibernation Angina 2012 16

  17. Clinical Case: Was this Angina? • Risk Factors • Framingham – Age, Gender, Family History, Smoking, Diabetes, Hypertension, Hyperlipidemia • ATP III – Prior CAD, Peripheral Arterial Disease = Coronary risk equivalents • Elderly age risk factors: • Urinary albumin excretion • Pulse pressure • Arterial Stiffness Angina 2012 17

  18. Cardiovascular Health Study • J Am Geriatr Soc 52:1639–1647, 2004 • Prospective Population Based Study • > 65 yo, 1954 men, 2931 women, followed 7.5 years • „most lipid measures were weakly associated with • cardiovascular events. The association between low HDLC • and increased MI risk was nonetheless strong and consistent.” Angina 2012 18

  19. Angina – Clinical Diagnosis - History • History – 95% specific classically • Look for equivalents • Dyspnea • Shoulder or back pain • Weakness, fatigue • Epigastric discomfort • Consider physical exertion levels • Silent ischemia seen in 20-50% of patients 65 years or older. • Adjust for population at risk (age, gender, comorbidities) • Identify stability Angina 2012 19

  20. Angina: Clinical History Typical Angina Substernal chest discomfort with characteristic quality and duration Provoked by exertion or emotional stress Relieved by rest or NTG Angina 2012

  21. Anginal Variants Dyspnea Indigestion Back, arm, neck, wrist pain Burning Pressure Rest, recumbency Angina 2012

  22. Angina ClassificationSTABILITY/SEVERITY Campeau, L “Grading of Angina Pectoris” Letter to the Editor CIRCULATION 1976: 54: 522-23 • TABLE 1. Grading of Angina of Effort by the Canadian Cardiovascular Society I. "Ordinary physical activity does not cause ... angina," such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation. II. "Slight limitation of ordinary activity." Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions. III. "Marked limitation of ordinary physical activity." Walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace. IV. "Inability to carry on any physical activity without discomfort - anginal syndrome may be present at rest." Angina 2012 22

  23. Goals of Angina Evaluation • Determine remediable factors • Identify patients at high risk • Anatomy – Left main > 50%; Three vessel • Physiological – Impaired LV function • Functional – unstable state Angina 2012 23

  24. Angina: Clinical Assessment • Physical Exam – remediable factors • VS: Heart rate, BP, T, RR • Chest – congestion • Heart – enlargement, valvular disease, failure • Vascular – obstruction, congestion • Extremities - edema • Lab Studies – remediable factors • CBC – anemia • Basic metabolic panel – glucose, renal function • Lipid Panel • (Thyroid function) • EKG • Chest X Ray • (Echocardiogram) Angina 2012 24

  25. Comorbidites in aging Aging increases the prevalence of CAD but is masked by the co-morbidities that reduce activity. [Schwartz,Zipes in Braunwald 9th] Angina 2012 25

  26. Stress Tests: Identify High Risk Exercise - ?modified protocols Treadmill Bicycle Exercise with imaging Pharmacologic with imaging Angina 2012

  27. STRESS TESTS – HIGH RISK FINDINGS Hypotension with exertion Inability to exercise beyond stage II of Bruce protocol (6 minutes) – NOT APPLICABLE IN THE ELDERLY ST depression more than 2 mm ST elevation in the absence of q waves Ventricular arrhythmias with ischemia Pulmonary uptake of thallium 2 or more zones of ischemia REFER PATIENTS WITH HIGH RISK FOR ANGIOGRAPHY Angina 2012 27

  28. NON-Coronary Chest Pain GI – GERD, biliary Neuro – cervical radiculopathy Chest wall – costochondritis, intercostal neuralgia Pulmonary – pleural, parenchymal Vascular – aortic, pulmonary Pitfalls: Placebo response, Concurrent inactive disease Angina 2012 28

  29. Goals of Anginal Therapy • Relieve pain, discomfort • Improve function • Avert further atherosclerotic complications • Sudden death • Congestive heart failure • Acute coronary syndromes Angina 2012 29

  30. Guidelines for the Management of Patients with Chronic Stable Angina 2002 guideline update for the management of patients with chronic stable angina www.acc.org/clinical/guidelines/stable/stable.pdf Diagnosis Risk Stratification Treatment Follow Up References (1052) 2007 update: Circulation 2007; 116: 2762 Angina 2012

  31. Drug interactions in the elderly (From Schwartz JB: Clinical Pharmacology, ACCSAP V, 2003. As modified from Nolan L, O’Malley K: The need for a more rational approach to drug prescribing for elderly people in nursing homes. Age Aging 18:52, 1989; and Denham MJ: Adverse drug reactions. Br Med Bull 46:53, 1990.)Figure 80-6 Schwartz and Zipes, Braunwald. Angina 2012 31

  32. Non – adherence (vs. noncompliance) Cost** Difficulty with understanding directions (hearing, sight) Inadequate instruction** Complete dosing regimens Packing material Insufficient education of patient, family, or caregiver Cognitive impairment** Angina 2012 32

  33. Dr. MS - Challenges • Was this angina or GERD? • Known CAD, age, make for high pre test probability? • History of GERD • Symptom complex stable, bothersome but not debilitating • Stress test – no high risk features • Therapeutic trials • Nitrates • GI consult – New PPI, Decline EGD without Cath Angina 2012 33

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