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PHAR350 > CVD in Older Adults > Flashcards

CVD in Older Adults Flashcards

1
Q

What is the relationship between hypertension and age?

A

incidence increases with age
-Framingham study: lifetime risk of developing HTN is > 90%

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2
Q

Which type of hypertension is most common in older adults?

A

isolated systolic hypertension
-SBP more closely correlated with CV risk in pts > 50y

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3
Q

What are the physiological changes in blood pressure seen with aging?

A

decreased baroreceptor response
impaired cerebral autoregulation
= increased risk for orthostatic hypotension

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4
Q

How should anti-hypertensives be started in older adults?

A

start low, go slow
-avoid overly-aggressive BP reductions due to risk of tissue hypoperfusion and ischemia

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5
Q

What are the benefits of lowering blood pressure?

A

good evidence from multiple epidemiological studies and clinical studies that lowering high blood pressure reduces risk of:
-heart attacks
-strokes
-sudden cardiac death
-heart failure
-peripheral artery disease
-end-stage renal disease

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6
Q

What is the evidence for hypertension and dementia risk reduction?

A

epidemiological studies have shown that elevated blood pressure in middle-age increases risk for cognitive impairment later in life
short-term clinical intervention studies of treating HTN in older adults have not shown decreased dementia risk
-often stopped early due to superiority in CV-endpoint risk reduction
-SPRINT-MIND showed decreased risk of MCI with intensive (<120) vs standard (<140) BP control over 5 yrs

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7
Q

What are some health behavior interventions for hypertension in older adults?

A

reduce alcohol intake
DASH diet
smoking cessation
others may be somewhat less practical in older adults, particularly if frail
-caution when advising weight reduction
-sodium restriction may result in hyponatremia, orthostatic hypotension
physical activity should continue to be encouraged
-consideration for necessary safety modifications
-PT consultation?

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8
Q

Describe appropriate at home blood pressure monitoring.

A

sitting position
back supported
arm bare and supported
middle of the cuff at heart level
do not talk or move before or during the measurement
legs uncrossed
feet flat on the floor
should have rested for 5 minutes prior

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9
Q

Which patients were excluded from SPRINT Elders?

A

diabetes
HF
history of stroke
recent MI (past 3 months)
BP < 110 mmHg after 1 min standing
dementia
LTC resident

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10
Q

What were the results of SPRINT Elders?

A

SBP target < 120 mmHg (intensive) vs < 140 mmHg (standard)
-NNT 27 over 3 yrs to prevent one CV death, MI/ACS, stroke or acute decompensated HF
-NNT 43 over 3 yrs to prevent one death
-non-significant increase in syncope, hypotension, and AKI in intensive group

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11
Q

What are the thresholds and targets for blood pressure treatment according to Hypertension Canada?

A

Hypertension Canada high-risk patients:
-threshold: SBP > 120
-target: SBP < 120
diabetes mellitus:
-threshold: > 130
-target: < 130
moderate-to-high risk (TOD or CV risk factors):
-threshold: > 140
-target: < 140
low risk (no TOD or CV risk factors):
-threshold: > 160
-target: < 140

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12
Q

What is considered to be a Hypertension Canada high-risk patient?

A

one or more of the following:
-clinical or sub-clinical CV disease
-CKD
-FRS > 15%
-age > 75 yrs

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13
Q

What are some considerations to keep in mind when pursuing intensive blood pressure targets in older adults?

A

orthostatic hypotension
diastolic hypotension
frailty and functional status

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14
Q

What is orthostatic hypotension?

A

> 20 mmHg systolic and/or > 10 mmHg diastolic decrease in BP within 1-3 minutes of standing

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15
Q

What is orthostatic hypotension a risk factor for?

A

falls
hospitalizations
CV events
functional decline

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16
Q

What is orthostatic hypotension associated with?

A

increased age
diabetes
Parkinson’s disease
dementia
medications

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17
Q

How does frailty and functional status impact intensive blood pressure control?

A

risks and treatment burden of intensive BP control may outweigh benefits in these patients
also consider time to benefit of intensive treatment (~2.5 yrs)
-is this time frame applicable to your patient?

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18
Q

When should we reconsider intensive BP targets in older adults?

A

functional dependency, limited life expectancy, dementia
orthostatic hypotension
diastolic hypotension + CAD
SPRINT exclusion criteria: diabetes, HF, history of stroke, recent MI
patient/family preference

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19
Q

What is a major key in determining antihypertensive choice in older adults?

A

is there a compelling indication for one or more antihypertensive?
-yes: choose agent according to compelling indication
-no: choose agent for ISH

20
Q

What are the antihypertensives of choice for ISH?

A

thiazide
ARB
CCB

21
Q

What are the antihypertensives of choice for diastolic HTN with or without systolic HTN?

A

monotherapy:
-thiazide
-BB
-ACEI/ARB
single pill combo:
-ACEI/ARB with CCB
-ACEI/ARB with thiazide

22
Q

What are the antihypertensives of choice for diabetics with microalbuminuria, renal disease, or additional CV risk factors?

A

ACEI/ARB

23
Q

What are the antihypertensives of choice for diabetics without any additional risk factors?

A

ACEI/ARB
DHP CCB
thiazide

24
Q

What are the antihypertensives of choice for patients with CAD?

A

ACEI/ARB
BB or CCB for patients with stable angina

25
Q

What are the antihypertensives of choice for patients with a recent MI?

A

BB and ACEI (ARB if ACEI intolerant)

26
Q

What are the antihypertensives of choice for patients with HF?

A

ACEI (ARB if ACEI intolerant)
BB
MRA

27
Q

What are the antihypertensives of choice for patients with LVH?

A

ACEI/ARB
CCB
thiazide

28
Q

What are the antihypertensives of choice for patients with a past stroke or TIA?

A

ACEI and thiazide combination

29
Q

What are the antihypertensives of choice for patients with non-diabetic CKD with proteinuria?

A

ACEI (ARB if ACEI intolerant)
diuretics as additive therapy

30
Q

What are the antihypertensives of choice for patients with PAD?

A

does not affect initial treatment recommendation

31
Q

What are some things to evaluate in older adults with high blood pressure despite treatment?

A

adherence?
secondary causes of hypertension
-medications (NSAIDs)

32
Q

Which thiazide is most potent?

A

chlorthalidone 1.5-2 x more potent than HCTZ –> monitor electrolytes

33
Q

What are the risks associated with thiazides?

A

increased gout risk
observational studies –> possible increased risk of skin cancer
electrolyte abnormalities (K and Na)
orthostatic hypotension
worsening urinary urgency/incontinence

34
Q

What are some monitoring parameters for ACEI/ARB?

A

renal function
K

35
Q

Can ACEI and ARBs be combined?

A

not recommended

36
Q

What are some common uses of CCBs?

A

all long-acting agents can be considered for:
-uncomplicated HTN, stable angina, LVH
dihydropyridines:
-also indicated for ISH
non-dihydropyridines:
-may be useful to control HR in afib

37
Q

What are side effects of CCBs?

A

can cause or exacerbate peripheral edema, especially higher doses
-can try split dosing or hs dosing
non-DHP:
-constipating in older adults

38
Q

When should non-DHP CCBs be avoided?

A

HFrEF

39
Q

What should non-DHP CCBs not be combined with?

A

BB

40
Q

What are the uses of beta-blockers?

A

not recommended as 1st line anti-hypertensive for adults > 60 yrs
still recommended in older adults if compelling indications exist:
-post-MI
-HFrEF
-control HR in afib
also may be used as add-on therapy for HTN in older adults

41
Q

What are the side effects of beta-blockers?

A

fatigue
decreased exercise tolerance

42
Q

What is the general consensus on statin use in older adults who are secondary prevention?

A

statins should be started/continued for secondary prevention of CV events regardless of age and in mild-moderate frailty
-benefits generally outweigh risks

43
Q

What is the time to benefit of a statin for secondary prevention?

A

~ 2 years

44
Q

Describe the evidence for statin use in primary prevention after 75 yrs of age.

A

lack of evidence to support who should receive statin therapy for primary prevention of CV events
PREVENTABLE and STAREE clinical trials ongoing - will hopefully provide clarity
in the meantime, shared decision making:
-cardiovascular risk factors
-functional status
-medication/treatment burden
-statin associated AE
-desire to take more/less medications

45
Q

Which dose of statins may be preferred in older adults?

A

moderate-dose
-especially outside of the acute post-event period

46
Q

What are older adults more susceptible with statins?

A

statin adverse effects
-myalgias, GI upset, fatigue, increased risk of AKI
-rare case reports of statin associated cognitive impairment (reversible on dc)

47
Q

What is the role of other cholesterol medications in older adults?

A

limited role
PCSK-9 inhibitors –> FH
fibrates may be necessary in severe hypertriglyceridemia ( > 10 mmol/L) to prevent pancreatitis
ezetimibe has limited evidence for improving CV outcomes in combinations with statins (no evidence of decreasing CV morbidity or mortality as monotherapy)
consider deprescribing if appropriate

PHAR350 (16 decks)

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