Cardiovascular Disease and the Elderly

1. Cardiovascular Disease and the Elderly Dorothy D. Sherwood, MD, FACP

2. So who are you calling old?

3. Introduction • The clinical manifestation of CHD in older patients represents the effect of the disease superimposed on the physiological effects of age. • At autopsy, 50% of elderly women and 75% of elderly men have obstructive CAD • Octogenarians comprise 5% of the US population – but 20% of the hospitalizations for MI. • Coronary arteriography- older individuals have worse disease than the younger.

4. Clinical Manifestations/Angina • Typical angina only 40% have this • Dyspnea – this is related to ischemia on a stiff hypertrophied left ventricle raising PA pressure • Nausea and vomiting, syncope • Secondary MI – post pneumonia, fractured hip. • Pulmonary Edema much more common presentation in the elderly • Lack of angina based on sedentary life style due to co-morbid conditions.

5. Myocardial Infarction in the Elderly • Increased mortality due to increase co morbid conditions, more extensive CHD, and lesser use of beneficial therapies. • When comparing treatment provided to those over 75 vs. under 75 • Thrombolysis – 5% vs. 39% • PTCA – 7% vs. 29% • CABG- 5% vs. 11% • Asa – 57% vs. 82%

6. Intervention in the Elderly • Octogenarians with unstable angina treated medically have an event-free-one- year survival of 55% • Stenting outcomes are similar in the older vs. younger group although some studies show excess non-Q wave MI and vascular complications. • CABG – 3 year survival 77% vs. 54% with medical therapy alone; 5 year survival vs. stenting – 66% vs 55% • 4.7% mortality rate in octogenarians – but hospital course is prolonged and complicated.

7. Management of Risk Factors in the Elderly • Smoking • Increased Bp • Increased Heart Rate • Increased PV resistance • Increased catecholamines • Increased susceptibility to clotting • Decreased HDL

8. Management of Risk Factors in the Elderly • Smoking continued: • Cessation reduces mortality by 25 to 50% most MI • Interventions: Strong Physician Advice, Support Groups, Pharmacological Therapies, Telephone follow up. • Nicotine replacement is safe • Cardiac Rehab Program provides the counseling.

9. Management of Risk Factors in the Elderly • Hypertension • Present in >60 % of adults over age 60. • Individuals 55 to 65 do no have htn, have a 90% lifetime risk of developing it. • Isolated systolic hypertension is the most common in this age group – 60 to 75% of the cases – primarily due to diminished arterial compliance. • Threefold increase in risk of MI, LVH, renal dysfunction, stroke and cardiovascular mortality

10. Management of Risk Factors in the Elderly • ISH • CAD risk varies directly with the systolic and pulse pressure and inversely with the diastolic pressure - i.e. worse outcomes in elderly with low diastolic pressure • Cardiovascular events can occur if the diastolic pressure is reduced below the level needed to maintain perfusion. Goal should be 65 or > in patients with CAD and 60mm Hg in patients without CAD

11. Management of Risk Factors in the Elderly/Hypertension • Treatment Efficacy • Sodium restriction to 2 grams – usual diet is 4 grams – one tsp of salt is 2 grams. • TONE trial in patients form 60 to 80 placed on weight loss diet, salt restricted diet or both – those patients dropped BP 2 to 4 mm Hg systolic and 1 to 2 mm Hg diastolic • Not much bang for the buck – and elderly do have trouble with salt restriction. None the less – worth 30 seconds of education at each visit.

12. Management of Risk Factors in the Elderly/Hypertension • Treatment Efficacy • Over 15,693 patients over the age of 60 with systolic hypertension have been studied. • Number needed to treat to prevent one major CV event • 18 men, 38 women • 19 over 70, 39 under 70 • 16 with prior CV disease, 37 without • SHEP trial – attained BP 143/68 with therapy, 155/72 with placebo – stroke 5.5 in treated, 8.2% in placebo, ¼ decrease in cardiac events, and reduced LV mass index.

13. Management of Risk Factors in the Elderly/Hypertension • Treatment efficacy • HYVET trial – all patients over 80 – 3800 patient. - placebo or indapamide ( thiazide diuretic) and perindopril ( ace inhibitor) • Fatal stroke – 6.5% vs. 10% • Death from all caused – 47.2% vs 59.6% • Goal BP in patients over 80 in this study was 150/80

14. Management of Risk Factors in the Elderly/Hypertension • Choosing the right drug • Start low go slow • Remember their barro-receptors don’t work so don’t drop them fast. • The all get orthostatic – to what degree is important

15. Management of Risk Factors in the Elderly/Hypertension • Choosing the right drug – continued • Diuretics; • Angiotensin-converting enzyme (ACE) inhibitors; • Calcium channel blockers (CCBs); • Angiotensin receptor blockers (ARBs); and • Renin Inhibitor • Central Alpha Agonist • Alpha Blocker • Beta-blockers.

16. Management of Risk Factors in the Elderly/Hypertesnion • Choosing the right drug • Most elderly will require combination therapy • Most octogenarians do not want diuretics • Avoid beta blocker for first line treatment unless otherwise indicated. • Consider cost

17. Management of Risk Factors in the Elderly/Hypertension • Choosing the right drug • Low dose combination therapy: • 1) greater efficacy; • 2) 24-hour efficacy with once-a-day dosing (if the correct combination of drugs is utilized); • 3) a greater response rate than monotherapy; • 4) fewer side effects than monotherapy; • 5) fewer metabolic side effects than monotherapy; and • 6) the possibility that the combination drugs result in a lower per patient cost than higher dose monotherapy (

18. Management of Risk Factors in the Elderly/Hypertension • Choosing the right drug • Combination • Amolodipine/benazepril (Lotrel) • Lisinopril/hydrocholothiazide (Zesoretic) • Additions • Diuretic or calcium channel blocker to above • Further addition • Aliskerin ( Tekturna) • Beta blocker • Central alpha agonist • Peripheral alpha blockers.

19. Management of Risk Factors in the Elderly/Hypertension • Summary • Among elderly less than 80, initiate therapy with systolic pressures greater than 140mm Hg and diastolic pressure greater than 90 mm Hg. • Among elderly over 80 with ISH – initiate therapy between 150 to 160 systolic and goal should be 150 systolic – avoid diastolic hypotension ( less than 60).

20. Management of Risk Factors in the Elderly/Hyperlipidemia • Total cholesterol levels increase with age primarily from an increase in the LDL-cholesterol • Multiple studies have shown that a high LDL and low HDL in the elderly is associated with significant CHD risk.

21. Management of Risk Factors in the Elderly/Hyperlipidemia • Benefits of lipid lowering drugs in the elderly • 4S trial – simvastatin trial – 1000 patients over 65 – with angina or prior MI – treatment reduced all cause mortality by 34%, mortality from MI by 43% , and revascularization by 41% • CARE trial – 1200 patients over 65 – • Treatment prevented 225 hospitalizations and 207 events in the elderly; 121 and 150 in the young • LIPID trial – treatment with pravastatin – • # needed to treat in elderly vs. young to prevent event; 20 to 30 vs. 40 to 70

22. Management of Risk Factors in the Elderly/Hyperlipidemia • Further studies • PROSPER trial – ages 70 to 82 – pravastatin 40 vs. placebo- 5000 participants – Reduction in coronary death and nonfatal MI – but not decrease in all cause mortality • SAGE trial – age 65 to 80 – 80 mg atorvastatin vs. 40 mg of pravastatin – decrease in major CV events with intensive therapy and decrease in mortality

23. Management of Risk Factors in the Elderly/Hyperlipidemia • Barriers to treatment • Misconception that benefit of treatment will take years – really is shown in 6 months – improves endothelial dysfunction in days • Fear of increased risk of side effects in the elderly ; no studies have shown this – side effects same in the elderly as the young • Cost – not issue with generics

24. Management of Risk Factors in the Elderly/Hyperlipidemia • Primary prevention – limited data on lipid lowering in the aged • Greater than 40% of those over 65 meet the NCEP guidelines for treatment • There is a 37% incidence of subclinical vascular disease in patients over 65 as measured by EKG, Echo, and AAI ( < 0.9) • Over 50% of elderly people will die from Cad • The Cardiovascular Health Study 9 patients over age 65 without known heart disease ) did suggest significant benefit from primary prevention in the older population

25. Management of Risk Factors in the Elderly/Aspirin • Aspirin therapy has been proven to be of greater benefit in the elderly with CAD than in the young. • Use it – and use it with PPI – except in the acute setting when clopidogrel is also being used. • Aspirin in primary prevention in men is proven – in women, is controversial – weigh risk benefit.

26. Management of Risk Factors in the Elderly/ACE inhibitor, Beta Blocker • ACE inhibitor and Beta Blockers are effective post MI and should be used. Start with low doses and titrate up. Be alert to side effects based on decreased creatinine clearance and reduced beta receptors.

27. Management of Risk Factors in the Elderly/Exercise • Benefits: • Improvement of exercise tolerance • Reduction of symptoms  • Reduction of cholesterol levels • Reduction of cigarette smoking • Improvement in psychosocial well-being and reduction of stress • Lowering of blood pressure • Barriers: Lack of physician Rx, economic, logistics, cost

28. Management of Risk Factors in the Elderly/Exercise • Diagnosis that qualify for Finley Ewing Cardiac Rehabilitation . • Heart attack • Atherosclerotic heart disease • Angina pectoris • Abnormal stress test • Valvular heart disease • Pacemaker or AICD • Heart failure • Angioplasty or artherectomy • Coronary artery bypass surgery • Heart transplant • Potential benefits of Cardiac Rehabilitation include:

29. Atrial Fibrillation • Briefly – elderly benefit most from warfarin anticoagulation. • There is no increased serious adverse events in the elderly patient on warfarin vs. high dose aspirin. • However, due to co morbid conditions, dementia, inability to monitor INR , recurrent falls, warfarin is often stopped. • Evidence supports aspirin and clopidogrel if warfarin cannot be used.

30. Atrial Fibrillation • If the patient has no symptoms from atrial fibrillation, then rate control only is indicated. • If patient is symptomatic with dyspnea, weakness, then trial at cardioversion is indicated.

31. Summary • If one lives long enough, he or she will die. • Our jobs as physicians is to delay that death while life is good. • Choose your treatment based on your patient. Be aggressive with the healthy elderly; save the inheritance of the sick. • Treat the patient with the care and concern you would treat your mother or father. Be careful, be correct, and be compassionate.