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
what % of people over 75 have afib
10%
mnemonic for working safely in an authority gradient (i.e disagreeing or speaking up about an unsafe practice)
PACE
Probe–> I was wondering why…
Alert–> I was noticing…/I am uncomfortable with…
Challenge–> Are you sure…
Emergency–> Stop, please, to double check….
how does multi-morbidity affect risk of mobility disability
more likely to have a mobility disability if you have both heart disease AND arthritis than just one or the other (odds ratio 13.6 vs 2.3 or 4.6 for each alone)
what % of over 75 year olds have 5 or more medical conditions
25%
is palliative care all about end of life
no–it is associated with improved survival and the earlier it starts the better
in the hospital, compared to conventional care, palliative care treatments were associated with significant improvements in pain, non pain sx, patient and family satisfaction, hospital length of stay, reduction of in hospital visits
what is the palliative approach to care
focuses on symptoms rather than disease entities
focus on quality of life rather than preventing death
make medical decisions based on–medical evidence for benefit, prognostic awareness, patient preference and feasibility
what conditions must be met for the federal government to supply money to provinces for their health care systems
- public administration
- universality–> excludes WCB, armed forces, those who do not meet residency requirements
- comprehensiveness–> provincial gov only has to pat for “insured health benefits” which are “medically required services” provided by physicians
- portability
- accessibility
when can a physician charge privately for a procedure/service
if it is not medically required and they can perform it
i.e wart removals, family planning counselling, cosmetic surgery
does evidence show that denial of private health insurance ensures quality public care?
no–chaoulli vs quebec
