Cardiovascular Disease in the Elderly

Question 1

What is the leading cause of death in the elderly, and the most frequent discharge diagnosis?

Answer 1

Cardiovascular disease

Discharge diagnosis - congestive heart failure

Question 2

Who is more likely to get CHF (men or women), and what type is most common in the elderly?

Answer 2

Women - most commonly heart failure with preserved ejection fraction (diastolic heart failure)

HFrEF / systolic heart failure is the more common type of CHF in the 18-65 year old population

Question 3

What is the next most common diagnosis in the elderly population behind CVD?

Answer 3

Arthritis, with hypertension close behind

Question 4

What happens to early diastolic filling of LV with age and why is this a particular problem in the elderly?

Answer 4

1 risk factor for Afib is hypertension -> Afib destroys atrial contraction

It decreases, making stroke volume more dependent on atrial contraction

Question 5

What happens to the arteries with aging and why?

Answer 5

They become dilated and stiff
->migration of smooth muscle into intima, with increases in extracellular matrix due to increases collagen cross-linking and growth factor (i.e. TGFb) upregulation

Question 6

What happens to the pulse wave velocity with age and why?

Answer 6

Propagation velocity of arterial wave increases with age -> due to stiff arteries

Question 7

What are the consequences of pulse wave velocity in young people and old people?

Answer 7

Young people - arterial wave will return more slowly, and augment coronary perfusion during diastole

Old people - arterial wave will return more rapidly, increase afterload towards the end of systole
-> increases systolic BP and makes for a **wide pulse pressure*******

Question 8

What changes in the myocardium with aging?

Answer 8

Myocardium becomes more restrictive and less responsive

1. Increased Type 1:Type 3 collagen ratio, decreased elastin
2. Myocardial death via apoptosis
3. Hypertrophy of muscle cells
4. Changes in myocardial calcium handling

Question 9

How does calcium handling of the myocardium change with age / what is the net result?

Answer 9

Delayed inactivation of L-type calcium channel, delayed SR-Ca+2 uptake, delayed repolarization via K+ channels

Result: Prolonged action potential, prolonged contraction and relaxation, leaving less time for early diastolic filling

Question 10

What happens to the sympathetic nervous system with respect to the heart with aging? What clinical implication does this have?

Answer 10

Decreased Beta-receptor number and responsiveness

Decreased PANS responsiveness as well

Decreased baroreflex function -> less ability to induce tachycardia with hypotension -> orthostatic hypotension more likely

Question 11

What type of hypertension is more common in the elderly, and what percent has it?

Answer 11

Systolic -> due to stiff arteries from increased intimal thickness

75% of people over 80 will have dis

Question 12

What increases your risk of heart attack, congestive heart failure, and major cardiac events?

Answer 12

Increases in age and with higher blood pressure

Question 13

What is the best thing to treat isolated systolic hypertension? What about if diabetes is present?

Answer 13

Isolated systolic -> diuretics

Diabetes -> ACE inhibitor - delays diabetic nephropathy

Question 14

Why are elderly patients more likely to have orthostatic hypotension besides the lack of reflex tachycardia?

Answer 14

Wide pulse pressure -> low diastolic pressure for perfusion of brain
-> be careful when using diuretics

Question 15

What causes post-prandial hypotension and when does this occur?

Answer 15

30-120 min after eating a meal, occurs due to shunting of blood to intestinal tract

Question 16

What is the most common presenting complaint of coronary artery disease in young people and the elderly respectively?

Answer 16

Young people - anginal chest pain

Elderly - still chest pain, but less likely due to decreased pain perception, dementia, and memory impairment. Many will present without symptoms “silent ischemia”, or simply dyspnea / confusion

Question 17

Is it better to use a PCI or CABG for the elderly?

Answer 17

PCI has better in-hospital mortality and lower stroke risk, but if patient survives for >6 months, CABG is better

Question 18

What is the best treatment for stable angina in elderly?

Answer 18

Medical therapy - i.e. medications

PCI / CABG show no survival benefit

Question 19

Why is influenza vaccination of the elderly so important?

Answer 19

Prevents cardiac death and hospitalizations for CHF

Question 20

Why is diastolic heart failure more common in the elderly? Is mortality better in these patients than HFrEF?

Answer 20

They are more likely to have stiff ventricles and abnormal myocardial relaxation (takes longer to repolarize)

Better in younger people, but the same mortality in elderly

Question 21

What marker is much higher in the elderly and gradually worsens with heart failure?

Answer 21

Brain natriuretic peptide (BNP)

Question 22

What are the most common symptoms of CHF?

Answer 22

Dyspnea on exertion and fatigue

Orthopnea and PND are also common

Question 23

What change in elderly patients accounts for a lower volume of distribution and a decreased loading dose needed?

Answer 23

Decreased total body water

Question 24

How are the kidney and liver affected by aging?

Answer 24

Kidney - decreased CrCl and GFR

Liver - decreased Phase I but not Phase II metabolism

Question 25

What drug needs to be very carefully dose-adjusted in the elderly due to polymorphisms in the CYP system and differences in sensitivity?

Answer 25

Warfarin!