Geriatric hearts

1. Geriatric hearts Dave Krueger, MD Yakima Heart Center Cardiac Issues 2011

2. Summary • Similar cardiovascular fundamentals but frequent treatment differences than younger patients. Dave Krueger, MD Yakima Heart Center

3. Demographic boom and increasing longevity = more patients. • My practice: I routinely see about 1/3 of my patients in their 80’s and beyond, most fairly independent. Dave Krueger, MD Yakima Heart Center

4. If 80 and independent: averagelife expectancy is 5-10 more years. • Don’t sub optimally approach hypertension, cholesterol, and other risks. • For ex, statins have more prevention of events the older the patient. • Increasing side effects with age mandate more treatment discussions, more clinical details, including the patient’s individual goals and preferences. Dave Krueger, MD Yakima Heart Center

5. “Stiffitis” • Stiffer lipid-laden arteries beget systemic hypertension: • Which begets CAD/LVH/LAE/LV diastolic dysfunction. • Which begets elevated LV end diastolic pressure/LA/wedge pressure. • Which begets dyspnea/CHF/pulmonary hypertension • Which begets peripheral edema, and often A-fib, MI. Dave Krueger, MD Yakima Heart Center

6. Cardiovascular Stiffness • Results in quicker and higher exercise-induced hypertension • Quicker dyspnea on exertion. Dave Krueger, MD Yakima Heart Center

7. Diagnosis • Left atrial dilation is the “canary in the coal mine” • LA volume index to body size is initially more sensitive than LVH, pulmonary hypertension. Dave Krueger, MD Yakima Heart Center

8. Geriatric Hypertension • BP logs: • Truly do several times per day. • Expect increasing lability (autonomic dysfunction). • Foremost, avoid low blood pressure. • Quiz closely about light-headedness, check posturals, weights. Dave Krueger, MD Yakima Heart Center

9. Postural instability cofactors • Peripheral neuropathy • decreased eyesight • inner ear problems • posterior column degeneration of spinal cord • muscle weakness • arthritis Dave Krueger, MD Yakima Heart Center

10. Geriatric hypertension treatment • Be a LOT less aggressive because of blood pressure lability • Minimize diuretics (compression stockings) • “Head more important than feet.” • Follow creatinine (declines with muscle mass) • Uric acid equals “pre-renal clue.” Dave Krueger, MD Yakima Heart Center

11. HTN: Side Effects • Calcium blockers: constipation, edema, and negative inotropes. • Alpha blockers: postural hypotension, rebound. • Beta blockers: bradycardia, fatigue. Dave Krueger, MD Yakima Heart Center

12. Geriatric Hyperlipidemia • More near-term prevention the older the patient, so idealize lipids initially, but closely ask about tolerabilty. Dave Krueger, MD Yakima Heart Center

13. Statins • Generalized weakness or myalgias often multifactorial: • Vitamin D deficiency exacerbates, replenishment often alleviates • Some statin better than none Dave Krueger, MD Yakima Heart Center

14. Lifestyle changes • (Late calories equal fat calories) Diet, weight loss, even five pounds helps. • 30 minutes daily: walk-exercise (even in-house, walker, everything helps). • Consider water-walking, arthritis-friendly exercise equipment. • Push all activities (gardening, shopping, socializing). Dave Krueger, MD Yakima Heart Center

15. Geriatric Anticoagulation • Atrial fib incidence increases from less than 1% at age 40 to 20-30% age 80 upward. • Risk and benefit of anticoagulation both increase with age, merits careful discussions and documentation on each visit. • Consider fall history, instability, postural hypotension, ANY prior bleeding. Dave Krueger, MD Yakima Heart Center

16. Anticoagulation • Combination with antiplatelets: • Aspirin and warfarin dramatically increase bleeding risk (and clopidogrel addition even worse). • Strictly try to avoid triple therapy in elderly. • Ask about NSAIDS’s • Warfarin and antiplatelet RX decrease healing. Dave Krueger, MD Yakima Heart Center

17. Modified CHADS2 • One point now for ages 65-74, two points for 75 and above. • One point for hypertension. • Aspirin-only if zero points, warfarin if two points, consider warfarin if one point. Dave Krueger, MD Yakima Heart Center

18. Geriatric Intensity of Treatment • Code status and treatment limitations: • Hard to initiate talk, do often and sensitively, should be on EVERY CHART OF VERY OLD. • Put on home fridge their written wishes. Dave Krueger, MD Yakima Heart Center

19. Geriatric Intervention • Some not “too old” for intervention. • 1/3 of open heart valve patients typically over 80 in Yakima. • Sparkle factor and precise degree of “active.” • Beware of blob factor. • Ask “typical day” and their desires. • Primary care input critical. Dave Krueger, MD Yakima Heart Center

20. Dementia • Deal breaker for open heart surgery. • Primary care assessment helpful for intensity of treatment – consider medical treatment only for even acute MI. • Pacemakers typically an exception. Dave Krueger, MD Yakima Heart Center

21. Lifestyle Changes • Weight loss – Less strict goals for very old • Plump seems fine (weight loss often = muscle loss) • Follow girth more than weight. • Stress activity more than weight loss. Dave Krueger, MD Yakima Heart Center

22. Geriatric Exercise • Strength building, aerobic, all activities to “get moving.” • Cardiac rehab. • Water walk if balance issues/arthritis. • Walking in house/walker. Dave Krueger, MD Yakima Heart Center

23. Conclusions • Not too old for treatment • Stiff cardiovascular system = dyspnea • Increasing BP lability • Anticoagulation extremely individualized • Code status and treatment limitations Dave Krueger, MD Yakima Heart Center