CVD in 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.