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

Geriatric hearts

Dave Krueger, MDYakima Heart CenterCardiac Issues 2011

Summary

• Similar cardiovascular fundamentals but frequent treatment differences than younger patients.

Dave Krueger, MDYakima Heart Center

• 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.


• If 80 and independent: average life 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.


“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.


Cardiovascular Stiffness

• Results in quicker and higher exercise-induced hypertension

• Quicker dyspnea on exertion.


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.


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.


Postural instability cofactors

• Peripheral neuropathy

• decreased eyesight

• inner ear problems

• posterior column degeneration of spinal cord

• muscle weakness

• arthritis


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.”


HTN: Side Effects

• Calcium blockers: constipation, edema, and negative inotropes.

• Alpha blockers: postural hypotension, rebound.

• Beta blockers: bradycardia, fatigue.


Geriatric Hyperlipidemia

• More near-term prevention the older the patient, so idealize lipids initially, but closely ask about tolerabilty.


Statins

• Generalized weakness or myalgias often multifactorial:

– Vitamin D deficiency exacerbates, replenishment often alleviates

• Some statin better than none


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).


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.


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.


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.


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.


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.


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.


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.


Geriatric Exercise

• Strength building, aerobic, all activities to “get moving.”

• Cardiac rehab.

• Water walk if balance issues/arthritis.

• Walking in house/walker.


Conclusions

• Not too old for treatment

• Stiff cardiovascular system = dyspnea

• Increasing BP lability

• Anticoagulation extremely individualized

• Code status and treatment limitations


Documents

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