Week 5--lecture slides Flashcards
what is pseudohypertension
seen in older patients
when blood vessel wall becomes more rigid with aging because of hyaline degeneration and endothelial hyperplasia
this increases the impedance to blood flow–> exacerbated by presence of atherosclerosis
result–> BP measures in elderly may be overestimated
what does a positive osler’s sign suggest
pseudoHTN
what is osler’s sign
suggests pseudo HTN
is a palpable brachial artery well when the BP cuff is inflated above sBP with disappearance of korotkoff-I sounds
definition of orthostatic BP
drop of sPB by at least 20 mmHg and/or dBP by at least 10 mmHg when changes from supine to standing
ddx orthostatic BP
meds
autonomic dysfunction
depleted intravascular volume
how do you make the definitive diagnosis of aortic stenosis vs sclerosis
by echo or angio
increased aorto-ventricular pressure gradient
decreased cross-sectional aortic valve area
what are some clinical findings in aortic sclerosis
narrow pulse pressure
pulsus parvus et tardus (uncommon in elderly due to rigid carotid artery wall)
*intensity and pattern of AS murmur NOT helpful
how do you manage patient with new AS murmur but otherwise no sx
watchful waiting
how do cardiac myocytes changes as we age
increased oxidative stress
decreased cell renewal capacity
accumulation of metabolic wastes in myocytes leads to increased risk of apoptosis
even in absence of disease, what % of myocytes in the aging heart are lost to apoptosis
30%
cardiac causes of palpitations
- arrhythmias
- acute CHF
- cardiomyopathy
- valvular disease
- pericarditis
- prosthetic materials
- previous MI
non cardiac causes of arrhythmias
- drugs
- aortic aneurysm
- high cardiac output states (anemia, fever)
- metabolic diseases (thyrotoxicosis, hypoglycemia)
- pheochromocytoma
- psychiatric
- lifestyle (alcohol)
what types of drugs can cause palpitations
anticholinergic drugs
adrenergic drugs
amphetamines
caffeine/theophylline
nicotine
symptoms of apathetic thyrotoxicosis
can present in older people
palpitations tremor diarrhea depression/anxiety delirium falls
*dx of biochemical hyperthyroidism with TSH is important
what impact does spironolactone have in the treatment of CHF
REDUCES MORTALITY
usual dose of spironolactone
25-50 mg daily or BID
what is the risk of spironolactone when combined with ACEi or K supplement or in renal failure
hyperkalemia
ECG changes of hyperkalemia
prolonged PR
wide QRS
tall T
sinusoidal wave
VF
describe physiological cardiac changes associated with aging
- decrease in early diastolic filling
- late diastolic filling due to atrial contraction is VITAL to maintaining normal cardiac output–> CHF in older adults is usually due to diastolic dysfunction
- decreased ventricular compliance
- left ventricular muscle hypertrophies
- increased peripheral vascular resistance –> increased incidence of systolic HTN
- baro-reflex sensitivity reduced–> increased likelihood of orthostatic hypotension
- exercise response reduced older adults less adaptive to hemodynamic stress
three common cardiac findings in the elderly patient
- orthostatic BP changes
- S4
- aortic sclerosis
sx of heart failure
elevated JVP
+ hepatojugular reflex
S3 gallop
crackles
dependent edema
- occur less frequently in older adults –> may instead have:
- tender or anorexic abdo
- confusion/lethargy, anxiety /agitation
- peripheral cyanosis
what % of people with ACS have angina
less than 50%
in older adults, what are some more common sx of ACS than what we usually learn
weakness syncope confusion abdo pain pulm edema
*therefore, investigations are important!!! i.e ecg/trop
what % of aortic sclerosis develops into aortic stenosis
15%
25% of people over 65 have aortic sclerosis–no impediment to hemodynamic flow like in stenosis
