Geriatric Cardiology

Geriatric Cardiology: A Global Growth Industry Joseph S. Alpert, MD Department of Medicine University of Arizona Health Sciences Center, Tucson, Arizona Editor-in-Chief, American Journal of Medicine

1. No major conflicts of interest, i.e., all honoraria <$5,000; 2. Consultations currently or previously performed: Sanofi-Aventis, Merck, Bristol-Myers-Squibb, Pfizer, Astra-Zeneca, McNeill, Organon, Berlex, Novartis, Ciba-Geigy, Roche, Exeter CME. Potential Conflicts of Interest:

DEMOGRAPHICS

Population Projections in the U.S.: 2000-2050

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

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 ventricular tachycardia 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 atrial fibrillation, heart failure, especially heart failure 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

Prevalence of AHSD by Age and Sex in the U.S. from 1988-94 Age, years Percent of Population Source: National Health and Nutrition Examination Survey

Prognosis after AMI by Age Source: Circulation 1996;94:1826-33

Vaccarino et al Ann of Int Med 2001; 134: 173-181. Solid lines are men; dotted lines are women.

Risk Stratification Post-MI
The Cooperative Cardiovascular Project risk score (age > 65 years), GISSI, GUSTO
FACTORS INCREASING MORTALITY:
Older age groups - # 1
Urinary incontinence; decreased functionality; peripheral vascular disease; low body mass index; renal insufficiency; decreased LV function
Krumholz et al JACC 2001; 38: 453. Marchioli et al Eur Heart J 2001; 22: 2085. Califf et al Circulation 2000; 101: 2231 .

Thrombolysis vs. Angioplasty in Older Patients Death Death, re-MI, Stroke RR 5.2 De Boer et al., J Am Coll Cardiol 39:1723-8, 2002 p = 0.04 p = 0.003

PCI vs. Lysis Meta-Analysis 23 Trials, 7739 Patients Death Re-MI Stroke Weaver et al., JAMA 278:2093,1997; Keeley et al., Lancet 361:13-20, 2003 p = 0.0004 p < 0.001 p = 0.002

Primary Angioplasty for AMI in the Elderly: Pooled Analysis from 3 Trials Age, years Mortality Source: J Intervent Cardiol 1998;10:4A-10A P=0.21 P=0.02

Intracranial Hemorrhage GUSTO V Treatment by Age Interaction OR 0.76 p = 0.26 OR 1.91 p = 0.065 p = 0.033

GUSTO V The Age-Intracranial Hemorrhage Interaction HIGHER RISK LOWER RISK

Source: Am Heart J 2001:142:37-42

Reasons Reperfusion Missed
30% no reperfusion: OR Age  75 2.4 No CP 3.2 Prior CHF 2.9 Prior CABG 2.3 DM 1.5
Eagle et al., GRACE Registry, Lancet 359:373–77, 2002 94 Hospitals in 14 Countries, N = 1763

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

Efficacy of Aspirin by Age: ISIS-2 Age, years Vascular Mortality at 35 Days Source: Lancet 1988;II-349-60

Long-term Benefits of Aspirin Age, years Vascular Events Source: BMJ 1994;308:81-106 P < 0.00001 P < 0.00001

Clopidogrel in Non-ST-Elevation Acute Coronary Syndromes: CURE *Primary endpoint: CV death, nonfatal MI or CVA Source: N Engl J Med 2001;345:494-502 Age, years Placebo Clopidogrel Relative Risk* Lives Saved/ 1000 < 65 7.6% 5.4% 0.71 22 > 65 15.3% 13.3% 0.87 20

Impact of Statins on Major Coronary Events Placebo Active Relative Risk Events Prevented 4S < 65 26.4% 18.1% 0.66 83 > 65 33.4% 23.6% 0.66 98 CARE < 65 25.6% 21.1% 0.81 45 > 65 28.1% 19.7% 0.68 84 LIPID < 65 13.4% 10.4% 0.77 30 > 65 19.7% 15.5% 0.79 42

VALVULAR HEART DISEASE IN THE ELDERLY

Prevalence of AS in the Elderly Source: Aronow WS et al. Am J Cardiol 2001;87:1131-3

Prevalence of AI in the Elderly Source: Aronow WS et al. Am J Cardiol 2001;87:1131-3

AV Replacement: Age > 80 Actuarial survival following AVR in 71 octogenarians Source: Circulation 1989;80(suppl I):I-49-56

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

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Geriatric Cardiology

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