Week 2 - Respiratory and Cardiac Disorders Flashcards
Pharmacological treatment for hypertention should be started in those over 60 when BP is…
150/90 or higher
First line treatment for hypertension in those over 60
- diuretics and dihydropyridine calcium channel blockers (amlodipine) are the recommended initial choices for older adults.
- Most older adults with hypertension need two or more drugs to effectively lower their blood pressure
American Heart Association
BP Goal for adults over 65 with hypertension
less than 130 mmHg
Factors to consider when commencing hypertension medication in older adults
Factors to consider when weighing the risks and benefits of treatment for hypertension in older adults
- Clinical judgment
- patient preference
- comorbidities
- life expectancy are
- Blacks at higher risk for HTN than whites (also increased stroke risk)
People with hypertension have a higher risk for
- Stroke
- PAD
- MI
- HF
- risk of cardiovascular disease increases markedly with age
HTN risk factor for alzheimers and vascular dementia due to cumulative damaged to cerebral blood vessels of the brain
Physiological changes that cause hypertension
- increase in stiffness of vessels, waves move faster and reflect back during systole augmenting systolic BP and lowering diastolic BP
- widening the pulse pressure (this is a better predictor of heart disease rather than SBP or DBP
- Blood vessels less responsive to B-adrenergic stimulation
- Plasma renin activity declines with ages
- Decreased aldosterone leads to greater risk of hyperkalemia
Essential hypertension
raise in BP with unknown cause (likely interaction of environmental and genetic factors – usually associated with aging, obesity, physical inactivity, insulin resistance, diabetes, HLD)
Secondary hypertension
HTN caused by another condition like kidney disease. Uncommon in older adults but should be considered if there is a sudden rise in BP or lack of response to drug therapy. Other causes in older adults are obesity, thyroid disease, parathyroid disease
What medications can increase blood pressure?
NSAIDs, steroids, decongestants
Resistant hypertension
BP that remains above goal despite treatment with 3+ medications at optimal doses including a diuretic or 4 HTN meds. Commonly caused by nonadherence to medication.
Psuedohypertension
peripheral arteries so stiff and rigid that measuring BP in the arm cuff may overestimate arterial pressures due to incomplete compression of brachial artery. Consider with patients who have symptoms that don’t respond to treatment or who have postural symptoms.
Severe asymptomatic hypertension
SPB >180 and DBP >110 without symptoms of acute target injury (may have headaches, nausea, palpitations, SOB)
How to diagnose hypertension
Two different high readings on two separate occassions
Blood pressure cuff effects
Cuff too small may produce a high reading
Physical exam for people with hypertension
Eyes - evaluate the optic fundi for arteriolar narrowing, hemorrhage
Palpate thyroid gland
Neuro exam for signs of stroke
Memory testing for cognition
Heart – murmur, displaced apical impulse, arrhythmia
Auscultate the lungs
Peripheral circulation – abdominal pulsation or bruit, carotid bruit, peripheral pulses, jugular venous distention
Total cholesterol
Below 200 mg/dL
HDL
Above 60 mg/dL
LDL
Below 100 mg/dL (below 70 for diabetics)
Triglycerides
Below 150 mg/dL
Tests for end organ damage and CV risk factors
- CBC
- lipid panel
- creatinine
- sodium
- potassium
- CA
- TSH
- UA
- EKG
Which patients over 60 should be treated to attain BP <130/80?
patients with ischemic heart disease or heart failure
Lifestyle changes to improve BP
- Weight loss
- Physical activity
- Reduce salt intake
- Heart healthy diet (DASH “dietary approaches to stop hypertension” – low fat with fruits and veg, whole grains, poultry, fish, nuts. Reduce intake of fats, red meats, sweets and sweetened beverages rich in K, phos and protein, not recommended for CKD 3 or 4)
- Potassium supplementation
- Smoking cessation
- Moderation of alcohol (less than 2 per day for men and 1 per day for women)
If reducing salt intake, the effects are most pronounced in what populations?
blacks, older individuals with DM, HTN, and CKD
When to follow-up after starting BP medication?
Start medication and follow-up in 1 month. If target BP not reached then increase dosage or start a second medication
First line of treatment for HTN in individuals over 60
CCB or diuretics
What conditions have increased risk for a widened pulse pressure?
stroke, heart attack and other CV disease
What medications are most effective at reducing widened pulse pressure?
Thiazide diuretics
Resistant hypertension
most common cause of inability to control BP despite 4+ medications is noncompliance to medications
Treatments for resistant hypertension
- Focus on lifestyle factors, obesity, exercise, alcohol intake and diet
- Reduced meds that elevate BP – NSAIDS, stimulants, decongestants
- Consider secondary cause of hypertension
- Maximize diuretic therapy, add a mineralocorticoid receptor agonist, agents from class fo BP med not tried, loop diuretic
Acute coronary syndrome
Ddevelopment of plaque in the vessels which then erodes, fissures or ruptures. Vascular inflammation has been shown to have a pivotal role in the development of ACS
Percutaneous coronary intervention
stent placement
Complex atheroma
– plaques in the descending aorta if they are greater than 4mm thick or have mobile debris
Clinical risk factors for CAD
- Smoking
- HTN
- DM
- HLD
- CKD
- Family history CV disease
- PAD
CAD risk reduction strategies
- smoking cessation
- lipid management
- BP control
- diet and nutrition counseling
- diabetes management
- use of cardiac rehabilitation
- exercise instructions
ASCVD Risk estimator
10 year risk of ASCVD event (CV death, MI, stroke), not validated for patient over 80, excludes family history
How does smoking impact CAD risk?
- Lower life expectancy, more year of life lost, if they survive MI at risk for problems like stent thrombosis
- Smoking cessation is associated with a 36% reduction in risk of death
- Pharmacotherapy and behavior therapy most effective methods
Statin use reduces the risk for…
stroke, MI and death
- Works best over time, not great for those with short life expectancy
- Side effects like myopathy (injury to the spinal cord due to severe compression that may result from trauma, congenital stenosis, degenerative disease or disc herniation) may limit use in patients
Hypertension is a risk factor for…
for stroke, HF, MI, CV death
Hypertension in the Very Elderly Trial (HYVET) goal BP is…
<150/80
Systolic Blood Pressure Intervention Trial (SPRINT) – BP goal
<120
Diabetes and CAD
- Aggressive hypoglycemic control reduces CAD risk but increases risk for hypoglycemic events
- Lifestyle factors help DM and CAD
- Older adults without decompensated HF or significant renal disease metformin and lifestyle changes are recommended
- For patients with DM and CAD both empagliflozin (increased risk for infection) and Liraglutide (N/V) have been shown to reduce cardiac events
Diet and exercise for CAD
- Diet low in saturated fats, increase intake of fruits, vegetables, whole grains, nuts, legumes and non-tropical vegetable oils
- Moderate activity most days of the week
Stable ischemic heart disease
asymptomatic, diagnosed with calcium coronary artery scan or stress test
- treat with lose dose aspirin or clopidogrel and statins with lifestyle changes
Guidelines for initial management of hypertension
Lifestyle modification – weight management, dietary changes, physical activity, sodium reduction
Anti hypertensive therapy - after lifestyle modifications for BP over 140/90
Unstable ischemic heart disease
Patients have exertional symptoms – treat with antianginal medications
- Revascularization in stable ischemic heart disease – CABG (coronary artery bypass graft) for high risk/complex patients or PCI (percutaneous coronary intervention) for low risk less complex patients
Treatments for unstable angina and NSTEMI
- Aspirin
- Heparin
- Clopidogrel or ticagrelor
- DC NSAIDS
- Sublingual nitroglycerin
- Beta blocker
- Statin
- ACE inhibitor
- Supplemental oxygen if needed
Treatment for STEMI
- Immediate reperfusion therapy with thrombolysis or PCI
- Maintenance therapy
- Low dose aspirin +P2Y12 inhibitor
- High intensity statin
- Beta blocker
- Ace inhibitor
- Behavior counseling
AF symptoms
- Palpitations, dyspnea, fatigue, lightheadedness, chest pain, SOB (falls, syncope, delirium in older adults)
Risk factors for AF
- Age
- male
- hypertension
- DM2
- hx of MI
- valvular heart disease
- OSA
- obesity
- HF
- CAD
- alcohol use
- smoking
- PE
- hyperthyroidism
Physical exam findings for AF patients
- Irregularly irregular heartbeat
- Requires ECG
- Tachycardia
Diagnostic testing for new onset AF
- CBC, LFT, CMP, TSH, troponin, chest xray, ECG, stress test, sleep study
Management of AF
Assess stroke risk CHA2DS2-VASc Score and Associated Increased Annual Risk For Stroke tool
Valvular AF – patients with mechanical vales and/or moderate to severe mitral stenosis
- warfarin
Nonvalvular AF – AF not caused by a problem with the heart valve
- direct oral anticoagulant therapy (DOAC) dabigatran, rivaroxaban, apixaban, edoxiban
Manage heart rate – may be tachycardic or bradycardic
- Beta blockers
-Nondihydropiridine CCBs (diltiazem and verapamil) are most often used for long-term control
* Amiodarone and digoxin can be used but limited due to adverse effects
*- Electrocardioversion for highly symptomatic AF
- Radiofrequency or cryobaloon ablation*
Signs and symptoms of Heart Failure
- Dyspnea at rest or with exertion
- Decreased exercise tolerance
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Lower extremity edema
- Abdominal distention
- In older adults syptoms may be atypical or difficult to elicit
Worsening fatigue
Decreased functional capacity
Delirium/confusion
GI disturbances (anorexia, nausea, bloating) - Pulmonary rales (can also be caused by chronic lung disease or atelectasis)
- Lower extremity edema (also caused by CCBs, venous insufficiency or CKD)
- Cough
- Weakness
- Weight gain
Diagnosing heart failure
- History and PE
- Chest xray – may show enlarged heart (cardiomegaly), perivascular edema, engorged veins, pulmonary edema with pleural effusions
- ECG – left or right atrial enlargement, left ventricular hypertrophy, evidence of acute ischemia or previous MI
- Blood tests
BNP (will be high for HF)
NT-proBNP (will be high for HF)
Cardiac troponins - TEE – evaluate left ventricular function, wall thickness, chamber sizes, valve function, pulmonary artery pressure
- Stress test
- Cardiac MRI (evaluate for cardiac amyloid)
Goals of treatment for heart failure
alleviate symptoms, maximize functional status, improve QOL, reduce hospitalizations, prolong survival.
Treatment for HFrEF
Normal EF 50-75%
- ACES/ARBS improve survival and QOL
- Beta blockers - improve LV function, increase survival, reduce hospitalization
- Mineralcorticoid receptor agonists - spironolactone
- Loop diuretics - treat symptoms but do not improve survival
Lifestyle changes for heart failure
- <3g of sodium per day
- Avoid excessive fluid intake
- Mild aerobic exercise like walking and cycling
- Cardiac rehabilitation program
- Patient education
Four stages of heart failure
A – patients high risk but don’t have structural heart disease or symptoms
B – patients who have structural heart disease without s/s of HF (includes asymptomatic left ventricular systolic or diastolic dysfunction)
C – patients have structural heart disease with prior or current symptoms
D– refractory HF
What is the best way to determine volume status?
By estimating JVP which may suggest volume overload
o S3 gallop reflects left ventricular volume overload and almost always HF
o S4 gallop caused by increased stiffness of the left ventricle may present w/or w/o HF
Diagnostic criteria for anemia
Hemoglobin (Hb) <13 g/dL for men and <12 g/dL for women.
o If hB is 2g/dL below expected valued repeat CBC q6 months
When to evaluate for anemia?
Consider reduction of 1g/dL < 5 years, or 2g/dL over 10 years is significant to warrant evaluation
Ask about:
* bleeding
* Alcohol use
* Previous transfusion
* Chemo/radiation
* Family history of anemia
What level is iron deficiency?
Ferritin <30 to 50 ng/mL is probable iron deficiency, and ferritin <100 ng/mL is possible iron deficiency
Labs to run to check for anemia
- Complete blood count, white blood cell differential, RBC indices
- Reticulocyte count
- Iron studies: serum ferritin, serum iron, TIBC, transferrin saturation
- Serum creatinine
- Thyroid stimulating hormone
- Vitamin B12
- C-reactive protein
- Thyrotroponin levels
- RBC or serum folate (only when specific risk factors)
Management of IDA
PO– iron sulfate 325mg (65 mg of elemental iron) every other day is recommended as first-line therapy for most patients
- Continue treatment for 3 months minimum therapeutic trial
Management of pernicious anemia
Oral 1000mcg vitamin B12 per day
- Continue treatment for 3 months minimum therapeutic trial
Management of anemia of chronic disease
Erythropoiesis stimulating agents for severe anemia
- Goal >10 hb
- Give iron if iron deficient prior to ESA
Types of anemia in older adults
IDA (iron, b12, folate - micronutrient deficiency)
Anemia from Chronic inflammation (common with chronically ill and hospitalized older adults)
- DM, CHF, obesity predispose people to ACI
Anemia from CKD
- decline in GFR then decline in Hb
Unexplained anemia (diagnosis of exclusion)
Comorbidities associated with anemia
- CV disease
- CHF
- Dementia/cog impairment
- Insomnia
- Depression
- Increased falls
Signs and symptoms of lung cancer
- Coughing that gets worse or doesn’t go away.
- Chest pain.
- Shortness of breath.
- Wheezing.
- Coughing up blood.
- Feeling very tired all the time.
- Weight loss with no known cause.
Diagnostics for lung cancer
Imaging tests. An X-ray image of your lungs may reveal an abnormal mass or nodule. …
Sputum cytology. If you have a cough and are producing sputum, looking at the sputum under the microscope can sometimes reveal the presence of lung cancer cells.
Tissue sample (biopsy).
Management of lung cancer
- Consider polypharmacy, frailty and functional status
- early-stage non–small cell lung cancer, the treatment is surgical resection in those who are deemed surgical candidates
- patients who are at high risk for perioperative complications, local therapy may include both surgical resection and definitive radiation treatment
Signs and symptoms of COPD
Dyspnea, cough, sputum production, wheezing, and chest pain
Diagnostic criteria for COPD
Identified by reduction in FEV1/FVC ratio on PFTs
* Irreversible airflow obstruction
* Evidence of hyperinflation or air trapping with elevated residual volume or residual lung volume (RV)/total lung capacity (TLC) ratio
Levels of obstruction based on PFT
- Mild – FEV1 >80%
- Moderate – FEV1 50-80%
- Severe – FEV1 30-50%
- Very severe – FEV1 <30%
Management of COPD
Bronchodilators
Inhaled corticosteroids
* SABA
- Fenoterol
- Levalbuterol
- Salbutamol
- Terbutaline
LABA
- Aformoterol
- Fomorterol
- Indacaterol
- salmeterol
Smoking cessation
Supplemental oxygen – only for patients with evidence of hypoxemia
Pulmonary rehabilitation
Flu and pneumonia vaccines
Management of COPD exacerbations
Inhalers
Bronchodilators
Inhaled corticosteroids
SABA
* Fenoterol
* Levalbuterol
* Salbutamol
* Terbutaline
LABA
* Aformoterol
* Fomorterol
* Indacaterol
* salmeterol
Nebulizers
Short course oral or IV steroids
antibiotics
Asthma
inflammatory disorder characterized by reversible airflow obstruction, airway inflammation, hyperresponsiveness and bronchoconstriction.
Diagnostic criteria for asthma
Clinical symptoms
* Chest tightness
* Intermittent/nocturnal wheezing
* Dyspnea
* Cough (may be the only symptom)
Presence of reversible airway obstruction
Spirometry – improvement of FEV1 of at least 12% after inhalation treatment with a short acting bronchodilator (use age adjusted values in older adults)
Symptoms may be more severe in older adults and have irreversible component due to airway remodeling, age of onset, coexistence of COPY or pulmonary fibrosis
Management of asthma - maintenance medication
Inhaled corticosteroid
* Beclometasone
* Budesonide
* Ciclesonide
* Fluticasone
* Mometasone
* Triamcinolone
Long acting bronchodilator (do not use without ICS) - LABA
Formoterol
Olodaterol
Long-acting muscarinic antagonist (LAMA) – add on to ICS/LABA
Tiotropium
Well tolerated in older adults
Management of asthma - rescue medication
Short acting beta-adrenergic agonist (SABA) - bronchodilator
* Albuterol
Management of asthma exacerbations uncontrolled with ICS
Systemic corticosteroids
Definitions for each spirometry criteria
o FEV1 (forced expiratory volume in first second)
o FVC (forced vital capacity) – total volume a person can exhale during the forced maneuver
o MVV (maximal voluntary ventilation) – checks for respiratory muscle weakness
o MIP (maximum inspiratory pressure) – checks for respiratory muscle weakness
o MEP (maximum expiratory pressure) – checks for respiratory muscle weakness
Criteria to determine severity of pulmonary disease (FEV1)
- Group A (GOLD 1 or 2): FEV-1 is 80% or more, mild symptoms
- Group B (GOLD 1 or 2): FEV-1 between 50% and 80%. Wheezing, coughing, SOB
- Group C (GOLD 3 or 4): FEV1 - between 30-50%, 2+ flare ups in year hospitalized 1x
- Group D (GOLD 3 or 4): FEV1 less than 30%, end stage
How to determine if you are seeinng reversible or irreversible pulmonary disease
use of a short acting bronchodilator increased FEV by at least 12%
Obstructive lung disease
Difficulty expiring all air out of lungs due to narrowing and air trapping. Harder to breathe when exercising
- COPD, asthma, cystic fibrosis, bronchiectasis
Restrictive lung disease
Stiffness in the lungs themselves that affect how much the lungs can expand
- Interstitial lung disease
- Pulmonary fibrosis
- Obesity
- Muscular dystrophy
