CV disorders

in elderly
 Geriatric Medicine
that branch of internal medicine which deals
with the prevention, diagnosis and treatment
of diseases specific to old age.
 Ageing is not a disease it is a
biological process which will affect
everyone
Ageing is a biological process which cannot be
stopped or reversed-
Proper care can lead to healthy ageing
 AGE-ASSOCIATED CHANGES

BODY COMPOSITION

Decreased lean body mass

Decreased intracellular volume
Decreased bone mass
 AGE-ASSOCIATED CHANGES

CARDIOPULMONARY
Decreased heart rate response
Decreased coronary reserve
Increased systolic blood pressure
Decreased maximal oxygen capacity
Decreased vital capacity
Decreased FEV1
Increased residual volume
Increased ventilation-perfusion mismatch
 AGE-ASSOCIATED CHANGES

ENDOCRINE
Decreased GROWTH HORMONE, INSULIN
GROWTH FACTOR, CALCITONIN, RENIN,
ALDOSTERONE, DEHYDROEPI-ANDROSTERONE
(DHEA)

Increased ARGININE VASOPRESSIN, ATRIAL

NATRIURETIC PEPTIDE, PARATHORMONE,
NOREPINEPHRINE, INSULIN AND PANCREATIC
POLYPEPTIDE
 AGE-ASSOCIATED CHANGES

RENAL
Decreased CREATININE CLEARANCE
Decreased RENAL BLOOD FLOW
Decreased Maximal urine osmolality
 AGE-ASSOCIATED CHANGES

SENSORY CHANGES

Visual impairment- presbyopia, cataracts, glaucoma,

macular degeneration
Hearing impairment
Decreased thirst sensation
Decreased smell sensation
 AGE-ASSOCIATED CHANGES

MOTOR FUNCTIONING CHANGES

Decreased muscle strength

Decreased range of motion
Decreased reaction time
Decreased propioception
 Manifestations of disease in
the elderly
Atypical presentation of disease
Multiple pathology
Chronic diseases
 Diseases that affect older people much
more than younger people.

heart diseases;hypertension
cancers;
Diabetes, metabolic syndrome
strokes that attack the brain;
dementias that affects memory and thinking;
injuries;
loss of hearing and sight;
diabetes;
joint problems caused by arthritis;
bone diseases that cause bones to break easily
mental diseases, such as depression.
 The iceberg phenomenon

Elderly people may be ill and suffer

considerable disability without seeking
medical advice for a number of reasons
including the acceptance of disabilities as
being: natural and inevitable in old age
 Epidemiology of CVD in Elderly

The worldwide population of people 65 years of age and older are

projected to increase to 973 million or 12 percent by 2030 and to 20
percent of the population by 2050.

The World Health Organization uses 60 years of age to define elderly

whereas most classifications use the age of 65 years.

Cardiovascular disease is the most important cause of death in both men

and women in this age group. More than 80 % of all deaths attributable to
CVD occur in people > 65 years with approximately 60 % of deaths in
patients > 75 years old.

The prevalence and severity of CAD increases with age in both men and women. A
significant number of people > 60 years have significant CAD with increasing
prevalence of LM or MVD.
 Age related CV disorders

I) Coronary artery disease: (5o% of all cardiac events & 85% of

deaths).
II) Heart failure: (Incidence: 6-10% in old age). It may be systolic
or diastolic.
III) Hypertension: may be essential or isolated systolic
hypertension.
IV) Arrhythmia: Lone AF: most common arrhythmia in elderly:
(1/3 of cases). Sick sinus syndrome = Brady-tachyarrhythmia: (due to
loss of pacemakers cells in SAN). R/ by pacemaker. A-V block: (due to
deposition of amyloid material in conducting system).
V) Postural hypotension: (due to: abnormal baroreceptor
response to BP. peripheral venous tone.
VI) Valvular: Calcific AS (most common). Calcification of mitral
valve.
VII) Dilated aorta with medial calcification.
I) Coronary artery
disease
 Coronary artery disease
(Risk factors)
A) Traditional risk factors:
1. DM. 2. Hypertension. 3. Physical inactivity.
4. Dyslipidemia (TG & Total cholesterol/HDL
due to HDL & not due to significant in total
cholesterol).

B) New risk factors:

1. CRP. 2. Lp (a). 3. Hemocysteine.
4. Fibrinogen.
 Coronary artery disease
(Clinical picture)
The most common symptom:
exertional dyspnea due to LVEDP by
myocardial ischemia.
Anginal pain is not the classical
symptom (due to activity + incidence of
silent ischemia.
In acute myocardial infarction
(AMI): atypical symptoms (as confusion,
syncope & dyspnea). Other uncommon
symptom is diaphoresis.
 Coronary artery disease
(Diagnosis)
Diagnosis of CAD without AMI:
1) Resting ECG: (may be normal).
2) Treadmill exercise stress test: (the standard method).
3) Exercise Thallium Scintigraphy (96% sensitivity): if
baseline ECG is abnormal due to conduction defects.
4) Spiral CT coronary angio: (99% sensitivity).
5) Coronary angiography: (the definite diagnosis).
6)24-hour Ambulatory Holter monitoring: (to diagnose
silent myocardial ischemia).

Diagnosis of CAD with AMI:

ECG changes may be masked by conduction defects.
So, Cardiac enzymes (CK-MB or Troponin): are
confirmatory.
 Coronary artery disease
(Treatment)
Treatment of CAD without AMI:
A) Non pharmacological: weight reduction. Physical activity.
Avoid stress.
B) Correct any risk factors: (Control BP & R/ of High LDL by
Statins).
C) Specific pharmacological treatment:
Nitrates: (be cautious to avoid postural hypotension).
CCB: Diltiazem is the only CCB used in angina. If Deltiazem is
used with BBs, use small dose cautiously.
Aspirin.
D) In severe angina, PCI or bypass surgery in suitable cases.
NB: Avoid the following combinations:
1) Verapamil + BBs Heart block & CHF.
2) Nitrates + Nifidipine postural hypotension.
Nitrates, beta blockers, ACE inhibitors and ARBs can exacerbate
hypotension or postural hypotension in the elderly.

Also, B-blockers may produce (CNS) effects and CCBs, especially the
dihydropyridines, can produce edema which is more frequent in older
patient.

Verapamil can exacerbate constipation. Both B-blockers and

nondihydropyridine CCBs should be avoided in the presence of sick sinus
node disease.
 Coronary artery disease
(Treatment)

Treatment of AMI:
A) Thrombolytic therapy (tPA): in 1st 3hours of AMI
(except if there are peptic ulcer, bleeding tendency, severe
hypertension, recent surgery in the last 3months).
B) Full dose of anti-coagulants (Heparin): is often given to
patients with anterior MI because of the high risk of mural
thrombi formation.
C) Clopidogril (Plavix): 4tablets in 1st day, then one tablet
/ every day.
D) R/ of risk factors and complications.
E) In severe angina, PCI or bypass surgery in suitable
cases.
In summary, what to consider when approaching to the
older patient with CAD:
1. Morbidity and mortality in the elderly with CAD and CAD treated medically or
with revascularization increases with age, especially in patients older than age
75 years.
2. Special care must be taken regarding medications, dose, collateral effects,
drug interactions and interaction with other comorbidities.
3. Clinically recognized CAD or heart failure confer the greatest risk for cardiac
death and warrant aggressive secondary prevention strategies.
4. In STEMI patients
In hospitals where direct PCI can be performed rapidly by experienced
operators, PCI has an advantage over thrombolysis.
In hospitals without PCI capability reperfusion therapy with thrombolytic
should be considered, regarding thrombolytic drugs especially in very old
patients, streptokinase should be considered.
Avoid combinations of GP IIb/IIIa inhibitors with thrombolytics. In case of
low molecular heparins and thrombolytics, lower doses as recommended can
be used.
II) Heart failure
 Heart Failure (Causes)
A) Systolic HF: B) Diastolic HF:

1) CAD: most common cause. 1) Restrictive cardiomyopathy.

2) Hypertensive heart disease.
2) Concentric LVH.
3) Valvular heart disease: Calcific AS
(commonest). Calcification of mitral 3) Calcific AS
annulus.
4) Cor-pulmonale: in Rt HF.
5) Myocarditis.
6) Thyroid disease.
Heart Failure (Diagnosis)
CP: In both types: dyspnea, orthopnea, PND,
swelling LLs, bilateral basal crepitations &
congested pulsating neck veins.

S3 gallop. S4 gallop.

Echo: EF% <40% EF% >40%

 Heart Failure (Treatment)

A) Systolic HF: B) Diastolic HF:

1. Life style modification: fluid & salt restriction. Stop smoking.
2. Diuretics: Thiazides: 25-50mg/day. Furosimide: 20-100mg/day.
Spironolactone: 25mg/day.
3. ACEIs: Captopril: 6.25 -25mg/day. Used.

4. BBs: Used if no edema LLs as Used.

carvidolol (6.25mg).
5. CCBs: better avoided. Used.

6. Digoxine: used if there is AF. -

7. Warfarin: used if there is AF.

III) Hypertension
in elderly
 Hypertension (Types)

I) Essential: (most common type in

elderly).

II) Isolated systolic hypertension

 Treatment of Isolated
systolic hypertension

I) Life style modifications.

II) Drugs:
In elderly: best drugs are:
1) Diuretics (Hydrochlorothiazides) because one of the
mechanisms of hypertension in elderly is hypervolemia due to
sensitivity to dietary Na+.
2) Long acting CCBs (especially Dihydropyridine group)
because in most cases, hypertension is associated with low
plasma rennin activity.

BBs are less effective in elderly because they are

associated with depression & postural hypotension. So, BBs
are used in combined essential & isolated systolic
hypertension.
 Why is the use of drugs in
elderly difficult?
1. They use several drugs.
2. Adverse effects & drug-drug interactions
are common.
3. Risk of cognitive impairment.
4. Adherence to prescribed drugs (due to
visual, financial & cognitive problems).
 Criteria of drug of choice
in elderly
1. Effective.
2. Affordable to patients.
3. T1/2 <24hs.
4. Elimination dose is not changed with age.
5. Used as single dose.
6. No drug-drug interaction.
 Guidelines for
pharmacotherapy in elderly
1. Avoid giving drugs before diagnosis.
2. Number of pills/day.
3. Use of one daily formulation (long acting drug).
4. Use one drug to treat 2diseases.
5. Use pill box to avoid confusion.
6. Start by small dose & titrate up gradually.
7. Never shift to another drug till reaching full
therapeutic dose of 1st drug.
8. Dont use 2drugs of similar action.
9. Avoid drugs with common side effects.
10. Always monitor renal function.
11. Avoid use of one drug to treat side effects of
another drug.
 Drugs avoided in elderly
I) 2B: Benzodiazepines, Barbiturates.
II) 6A: Analgesics (NSAIDs), Anti-depressants
(TCAs), Anti-emetics (Metoclopramide), Anti-
histamine H2 (Cemitidine), Anti-psychotics and
Anti-spasmodics (atropine, hyoscine).
III) 1 C: cardiac drugs (digoxin, Propranolol,
-methyl dopa.
Risk factors that adverse
effects of drugs in elderly
1) Age.
2) Low body weight.
3) Renal insufficiency.
4) Liver insufficiency.
5) Polypharmacy (drug-drug interaction).
6) History of adverse drug reaction.