CVD in Older Adults Flashcards
What is the relationship between hypertension and age?
incidence increases with age
-Framingham study: lifetime risk of developing HTN is > 90%
Which type of hypertension is most common in older adults?
isolated systolic hypertension
-SBP more closely correlated with CV risk in pts > 50y
What are the physiological changes in blood pressure seen with aging?
decreased baroreceptor response
impaired cerebral autoregulation
= increased risk for orthostatic hypotension
How should anti-hypertensives be started in older adults?
start low, go slow
-avoid overly-aggressive BP reductions due to risk of tissue hypoperfusion and ischemia
What are the benefits of lowering blood pressure?
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
What is the evidence for hypertension and dementia risk reduction?
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
What are some health behavior interventions for hypertension in older adults?
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?
Describe appropriate at home blood pressure monitoring.
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
Which patients were excluded from SPRINT Elders?
diabetes
HF
history of stroke
recent MI (past 3 months)
BP < 110 mmHg after 1 min standing
dementia
LTC resident
What were the results of SPRINT Elders?
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
What are the thresholds and targets for blood pressure treatment according to Hypertension Canada?
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
What is considered to be a Hypertension Canada high-risk patient?
one or more of the following:
-clinical or sub-clinical CV disease
-CKD
-FRS > 15%
-age > 75 yrs
What are some considerations to keep in mind when pursuing intensive blood pressure targets in older adults?
orthostatic hypotension
diastolic hypotension
frailty and functional status
What is orthostatic hypotension?
> 20 mmHg systolic and/or > 10 mmHg diastolic decrease in BP within 1-3 minutes of standing
What is orthostatic hypotension a risk factor for?
falls
hospitalizations
CV events
functional decline
What is orthostatic hypotension associated with?
increased age
diabetes
Parkinson’s disease
dementia
medications
How does frailty and functional status impact intensive blood pressure control?
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?
When should we reconsider intensive BP targets in older adults?
functional dependency, limited life expectancy, dementia
orthostatic hypotension
diastolic hypotension + CAD
SPRINT exclusion criteria: diabetes, HF, history of stroke, recent MI
patient/family preference
What is a major key in determining antihypertensive choice in older adults?
is there a compelling indication for one or more antihypertensive?
-yes: choose agent according to compelling indication
-no: choose agent for ISH
What are the antihypertensives of choice for ISH?
thiazide
ARB
CCB
What are the antihypertensives of choice for diastolic HTN with or without systolic HTN?
monotherapy:
-thiazide
-BB
-ACEI/ARB
single pill combo:
-ACEI/ARB with CCB
-ACEI/ARB with thiazide
What are the antihypertensives of choice for diabetics with microalbuminuria, renal disease, or additional CV risk factors?
ACEI/ARB
What are the antihypertensives of choice for diabetics without any additional risk factors?
ACEI/ARB
DHP CCB
thiazide
What are the antihypertensives of choice for patients with CAD?
ACEI/ARB
BB or CCB for patients with stable angina
What are the antihypertensives of choice for patients with a recent MI?
BB and ACEI (ARB if ACEI intolerant)
What are the antihypertensives of choice for patients with HF?
ACEI (ARB if ACEI intolerant)
BB
MRA
What are the antihypertensives of choice for patients with LVH?
ACEI/ARB
CCB
thiazide
What are the antihypertensives of choice for patients with a past stroke or TIA?
ACEI and thiazide combination
What are the antihypertensives of choice for patients with non-diabetic CKD with proteinuria?
ACEI (ARB if ACEI intolerant)
diuretics as additive therapy
What are the antihypertensives of choice for patients with PAD?
does not affect initial treatment recommendation
What are some things to evaluate in older adults with high blood pressure despite treatment?
adherence?
secondary causes of hypertension
-medications (NSAIDs)
Which thiazide is most potent?
chlorthalidone 1.5-2 x more potent than HCTZ –> monitor electrolytes
What are the risks associated with thiazides?
increased gout risk
observational studies –> possible increased risk of skin cancer
electrolyte abnormalities (K and Na)
orthostatic hypotension
worsening urinary urgency/incontinence
What are some monitoring parameters for ACEI/ARB?
renal function
K
Can ACEI and ARBs be combined?
not recommended
What are some common uses of CCBs?
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
What are side effects of CCBs?
can cause or exacerbate peripheral edema, especially higher doses
-can try split dosing or hs dosing
non-DHP:
-constipating in older adults
When should non-DHP CCBs be avoided?
HFrEF
What should non-DHP CCBs not be combined with?
BB
What are the uses of beta-blockers?
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
What are the side effects of beta-blockers?
fatigue
decreased exercise tolerance
What is the general consensus on statin use in older adults who are secondary prevention?
statins should be started/continued for secondary prevention of CV events regardless of age and in mild-moderate frailty
-benefits generally outweigh risks
What is the time to benefit of a statin for secondary prevention?
~ 2 years
Describe the evidence for statin use in primary prevention after 75 yrs of age.
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
Which dose of statins may be preferred in older adults?
moderate-dose
-especially outside of the acute post-event period
What are older adults more susceptible to with statins?
statin adverse effects
-myalgias, GI upset, fatigue, increased risk of AKI
-rare case reports of statin associated cognitive impairment (reversible on dc)
What is the role of other cholesterol medications in older adults?
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
Are stable CAD patients considered primary or secondary prevention?
secondary
What are some important considerations to keep in mind with patients with CAD?
time since event
symptom stability
activity level
patient goals and preferences
What is the medication cocktail after ACS?
beta-blocker, ACEI/ARB, statin, ASA
others as needed:
-other antihypertensives for BP
-other anti-anginals as needed: CCB, long-acting or prn nitroglycerin
What lifestyle change might decrease the medication requirements for patients who have had ACS?
as activity level decreases, medication requirements might decrease also
Describe antiplatelet use after ACS.
ASA indefinitely
-clopidogrel if contraindicated
-consider adding PPI if history of GI bleed
Describe BB use after ACS.
evidence of decreased CV risk up to 3 years post-MI
-titrate to resting HR of ~ 60 bpm
When should BB use be reconsidered after ACS?
after 3 years re-evaluate based on symptoms and comorbidities
-indicated indefinitely for HFrEF
-reasonable to continue if angina symptoms, afib needing rate control
-if poorly tolerated –> re-evaluate if > 3 y post-MI
Describe ACEI/ARB use in stable CAD.
recommended for all individuals with stable CAD and HTN, DM, HFrEF, or CKD
continue indefinitely as tolerated
Describe CCB use in stable CAD.
angina if beta-blockers CI or not tolerated
diltiazem or verapamil may also be used for rate control in afib
When are short-acting nitrates used in CAD?
rescue or prophylactically prior to activities which provoke symptoms
-ensure using properly
What are some side effects of nitrates?
dizziness
headache
hypotension
flushing
edema
When are long-acting nitrates used in CAD?
may be added when BB and/or CCB are CI, not tolerated, or not providing adequate symptom relief
What needs to be ensured is done with long-acting nitrates?
12h nitrate-free period
Which class of drugs contributes to the most ED visits for ADRs?
anticoagulants and antiplatelets
What is atrial fibrillation?
abnormal electrical conduction in the atria –> chaotic, uncoordinated contraction
What are the symptoms of atrial fibrillation?
may be asymptomatic or may experience:
-SOB, fatigue
-palpitations
-chest discomfort
-anxiety, sweating
What are the two key clinical issues with atrial fibrillation?
significant increased risk of ischemic stroke
increased heart rate –> heart failure
How is stroke risk managed in atrial fibrillation?
anticoagulation
-warfarin or DOAC
What is the dilemma with age and atrial fibrillation?
incidence of atrial fibrillation increases with age
advanced age increases the risk for both major bleeds & stroke
What often becomes a deterrent to anticoagulation from a physician perspective?
advanced age
-underestimation of benefit
What are the advantages of DOACs over warfarin?
> efficacy
less ICH
no INR monitoring
fewer drug and food interactions
What are the disadvantages of DOACs compared to warfarin?
cost, EDS
more GI bleeds (rivaroxaban, edoxaban, dabigatran)
less long-term safety data
caution in renal impairment
What are contraindications of DOACs?
severe renal impairment
not indicated with mechanical heart valves
When do we consider changing from warfarin to DOAC?
really anyone that doesnt have an indication for warfarin
-ex: significant DDI, cant get to lab, labile INRs
When is warfarin preferrable to a DOAC?
severe renal dysfunction
mechanical heart valve
Describe key factors to consider with each DOAC when determining which one to choose.
dabigatran:
-most GI upset
-most highly renally eliminated
-BEERS if 75 and older
rivaroxaban:
-once daily dosing with food
-BEERS if 75 and older
edoxaban:
-once daily dosing
-watch for DDI (decrease dose with P-gp inhibitors)
apixaban:
-best safety data (so far)
-best choice when renal function is borderline
What are some considerations to be keeping in mind for anticoagulation in atrial fibrillation?
is there an indication? (always in older adults due to age > 65)
is there a high risk of bleeding or a CI?
will the patient be able to adhere to therapy or monitoring?
patient/family preferences?
Which HAS-BLED score starts to require caution?
3 or greater
Does fall risk preclude anticoagulation for afib stroke prevention?
no
What are some important considerations to keep in mind with anticoagulants and the ability of older patients to adhere to the monitoring requirements?
warfarin:
-INR monitoring
-ability to self-manage dosage adjustments?
DOACs:
-consistent adherence is very important
-also need to check CBC, renal function q 6 months
What are some factors to consider when deciding between rate vs rhythm control?
duration of afib
bothersome afib symptoms?
comorbid HF?
Which antiarrhythmics are preferred for rhythm control if the patient has heart failure?
LVEF < 40%: amiodarone
LVEF > 40%: amiodarone, sotalol
Which antiarrhythmics are preferred for rhythm control if the patient has CAD?
amiodarone
dronedarone
sotalol
Which antiarrhythmics are preferred for rhythm control if the patient has no HF nor CAD?
amiodarone
dronedarone
flecainide
propafenone
sotalol
What occurs to the likelihood of successful rhythm control as afib duration increases?
likelihood of successful rhythm control decreases as afib duration increases
-perhaps why previous trials did not show benefit with rhythm control
What is an important monitoring parameter for antiarrhythmics in older adults?
adverse effects
What are the adverse effects of amiodarone?
optic neuropathy and neuritis
pulmonary and hepatic toxicity
hypo or hyperthyroidism
blue-grey skin discolouration
photosensitivity
What are some of the many drug interactions of amiodarone?
warfarin
digoxin
beta-blockers/non-DHP CCB
Which medications are used for rate control?
beta-blockers
non-DHP CCB
2nd line: digoxin (additive), amiodarone
When are beta-blockers preferred for rate control?
when concurrent CAD, HF
When are non-DHP CCB preferred for rate control?
severe or poorly controlled asthma/COPD
When is digoxin used for rate control?
usually used as add-on therapy
may be beneficial if concurrent symptomatic HF
Why is digoxin not preferred for rate control?
less effective - does not control HR during exercise
AFFIRM trial - increased mortality when digoxin used for afib
What is the HR target in afib?
< 100 bpm at rest
Describe digoxin monitoring in afib.
monitoring for efficacy: target HR
-serum digoxin levels are not a target to aim for but a tool to avoid toxicity
monitoring for toxicity:
-serum levels if concerned about AE/DI/renal function
-digoxin AE: NVD, decreased appetite, dizziness, confusion/delirium, “halos”
-older adults much more susceptible to digoxin toxicity
-ideally maintain trough level < 1 nmol/L
Is rate or rhythm control preferred in older adults?
rate control used to be preferred management option
-new evidence suggests benefit for rhythm control in early afib –> may start seeing this more frequently
Differentiate HFrEF and HFpEF.
HFrEF:
-LVEF < 40%
-less blood pumped out of ventricles, weakened heart muscle cant squeeze as well
HFpEF:
-LVEF > 50%
-less blood fills the ventricles, stiff heart muscle cant relax normally
What is the standard therapy for HFrEF?
ACEI/ARB/ARNI
BB
MRA
SGLT2
Which drug should be started first in HFrEF?
currently no consensus regarding which drug classes to start with when initiating treatment for HFrEF
-start with one drug class and titrate up to max tolerated dose?
-start with more than one drug class at smaller dose?
decisions should be based on clinical characteristics of the patient
-hemodynamic status
-renal function
-side effects/tolerability
-cost
-adherence
What did PARADIGM-HF show?
Entresto vs enalapril
-decrease CV mortality and HF hospitalization
What is required when switching from ACEI to ARNI?
36 hour washout
What are some monitoring parameters for ACEI/ARB/ARNI?
SCr, lytes within 1-2 weeks of initiation/titration
sitting and standing BP
-orthostatic hypotension may warrant dose decrease
-use lowest required dose of diuretic
What are frail older adults more susceptible to with ARNI compared to ACEI/ARB alone?
hypotension/orthostatic hypotension
Which beta blockers are used in HFrEF?
bisoprolol
metoprolol
carvedilol
Which MRAs are used in HFrEF?
spironolactone
eplerenone
What is a BEERS criteria for MRAs?
avoid if CrCl < 30 ml/min
What did DAPA-HF and EMPEROR REDUCED show?
benefit of dapa and empa in decreasing HF hospitalizations or CV death
-~50% of patients had T2DM
-no significant difference in AE
What are monitoring parameters for SGLT2i?
decrease in eGFR ~15% on initiation
volume status - may need to decrease diuretic dose on initiation in euvolemic patients
What are some precautions for SGLT2i?
decrease BP ~1-2 mmHg
“sick day” management
How do older adults tolerate SGLT2i?
increase risk of genital fungal infections
? increase in UTI
? increase in DKA
use with caution in older adults - BEERS 2023
What is the use of loop diuretics in HF?
symptomatic treatment
-SOB, fluid retention, increased weight
use lowest effective dose
What is the use of digoxin in HF?
add-on if symptoms despite optimized 1st and 2nd line meds
-may also help decrease resting HR in afib
What is Torsades de Pointes?
arrhythmia that may lead to sudden cardiac death
-associated with prolonged QT interval and bradycardia
-may be congenital or acquired
What are the risk factors for acquired TdP?
older age
female
elyte disturbances: hypokalemia/calcemia/magnesemia
drugs
renal or liver disease
hypertension
smoking
arrhythmia, prior MI, cardiomyopathy
What are some common medications that prolong the QT interval?
antiarrhythmics
-sotalol, amiodarone, propafenone, flecainide, etc
ADHD
-atomoxetine
antiemetics
-domperidone
antipsychotics
-aripip, haloperidol, pimozide, quet > risp, cloz
SSRIs
-sertraline, citalopram, escitalopram > others
SNRIs
-mirtazapine > venlafaxine
TCAs
-all > nortriptyline
antibiotics
-moxifloxacin > levofloxacin or ciprofloxacin
-clarithromycin, erythromycin > azithromycin
antifungals
-fluconazole > others
miscellaneous
-donepezil, hydroxyzine, methadone, tramadol
What is the RISQ-PATH score that predicts a high risk of QT prolongation?
10 or greater
