Cardiovascular Disease in the Elderly Flashcards
What is the leading cause of death in the elderly, and the most frequent discharge diagnosis?
Cardiovascular disease
Discharge diagnosis - congestive heart failure
Who is more likely to get CHF (men or women), and what type is most common in the elderly?
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
What is the next most common diagnosis in the elderly population behind CVD?
Arthritis, with hypertension close behind
What happens to early diastolic filling of LV with age and why is this a particular problem in the elderly?
1 risk factor for Afib is hypertension -> Afib destroys atrial contraction
It decreases, making stroke volume more dependent on atrial contraction
What happens to the arteries with aging and why?
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
What happens to the pulse wave velocity with age and why?
Propagation velocity of arterial wave increases with age -> due to stiff arteries
What are the consequences of pulse wave velocity in young people and old people?
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*******
What changes in the myocardium with aging?
Myocardium becomes more restrictive and less responsive
- Increased Type 1:Type 3 collagen ratio, decreased elastin
- Myocardial death via apoptosis
- Hypertrophy of muscle cells
- Changes in myocardial calcium handling
How does calcium handling of the myocardium change with age / what is the net result?
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
What happens to the sympathetic nervous system with respect to the heart with aging? What clinical implication does this have?
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
What type of hypertension is more common in the elderly, and what percent has it?
Systolic -> due to stiff arteries from increased intimal thickness
75% of people over 80 will have dis
What increases your risk of heart attack, congestive heart failure, and major cardiac events?
Increases in age and with higher blood pressure
What is the best thing to treat isolated systolic hypertension? What about if diabetes is present?
Isolated systolic -> diuretics
Diabetes -> ACE inhibitor - delays diabetic nephropathy
Why are elderly patients more likely to have orthostatic hypotension besides the lack of reflex tachycardia?
Wide pulse pressure -> low diastolic pressure for perfusion of brain
-> be careful when using diuretics
What causes post-prandial hypotension and when does this occur?
30-120 min after eating a meal, occurs due to shunting of blood to intestinal tract
What is the most common presenting complaint of coronary artery disease in young people and the elderly respectively?
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
Is it better to use a PCI or CABG for the elderly?
PCI has better in-hospital mortality and lower stroke risk, but if patient survives for >6 months, CABG is better
What is the best treatment for stable angina in elderly?
Medical therapy - i.e. medications
PCI / CABG show no survival benefit
Why is influenza vaccination of the elderly so important?
Prevents cardiac death and hospitalizations for CHF
Why is diastolic heart failure more common in the elderly? Is mortality better in these patients than HFrEF?
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
What marker is much higher in the elderly and gradually worsens with heart failure?
Brain natriuretic peptide (BNP)
What are the most common symptoms of CHF?
Dyspnea on exertion and fatigue
Orthopnea and PND are also common
What change in elderly patients accounts for a lower volume of distribution and a decreased loading dose needed?
Decreased total body water
How are the kidney and liver affected by aging?
Kidney - decreased CrCl and GFR
Liver - decreased Phase I but not Phase II metabolism
What drug needs to be very carefully dose-adjusted in the elderly due to polymorphisms in the CYP system and differences in sensitivity?
Warfarin!
