1 CARDIOVASCULAR DISEASES AND DISORDERSSuggestions for Lecturer 1½-hour lecture Use GNRS slides alone or to supplement your own teaching materials. Refer to GNRS for further content and for strength of evidence (SOE) levels. The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

2 How the cardiovascular system changes with normal agingOBJECTIVES Know and understand: How the cardiovascular system changes with normal aging The signs and symptoms of the most important cardiovascular diseases in older patients The appropriate diagnostic tests to identify the presence and severity of CVD Standards for treating CVD Topic

3 Effects of Aging on Cardiovascular Function TOPICS COVERED Epidemiology Effects of Aging on Cardiovascular Function Cardiovascular Risk Factors Coronary Artery Disease Acute Coronary Syndromes Chronic Coronary Artery Disease Valvular Heart Disease Cardiac Arrhythmias Peripheral Arterial Disease Venous Thromboembolic Disease Topic

4 DEATHS FROM CVD Among ~ 814,000 deaths in the US from cardiac and cerebrovascular diseases in 2007: 80% occurred in adults ≥65 yr old and 67% occurred in the 6.1% of the population ≥75 yr old With the aging of the population, the absolute number of cardiovascular deaths in older adults is expected to increase markedly over the next several decades Over the past 50 years, lifestyle changes and medical advances have led to a progressive decline in age-adjusted mortality rates from CVD. However, it remains the leading cause of death in the US, accounting for approximately one third of all deaths in 2007. Notably, cancer is the leading cause of death among adults up to age 75 years, and it is only after age 75 that CVD becomes the dominant cause of death. Topic

5 PREVALENCE OF CVD Age Cohort Men Women 20–40 years old 14.2% 9.7%39.3% 37.2% 60–80 years old 72.6% 71.9% >80 years old 80.1% 86.7% Prevalence of CVD in Americans by age and sex . Source: NHANES The annual incidence of CVD increases from 1.0% in men 45−54 years old to 7.4% in men 85−94 years old, and from 0.4% in women 45−54 years old to 6.5% in women 85−94 years old. Due to the high prevalence of CVD at older age, adults 65 years old account for 61% of hospitalizations for CVD in the United States, including more than 50% of percutaneous and surgical coronary revascularization procedures, 59% of defibrillator implantations, 73% of arterial endarterectomies, and 80% of permanent pacemaker insertions. Women comprise an increasing proportion of CV hospitalizations and procedures with increasing age. The prevalence of CVD increases progressively with age, exceeding 80% in men and 86% in women >80 years old Topic

6 PRINCIPAL EFFECTS OF AGING ON THE CARDIOVASCULAR SYSTEM (1 of 2)Age effect Clinical implication ↑ Arterial stiffness ↑ Afterload and systolic BP ↓ Myocardial relaxation & compliance ↑ Risk of diastolic heart failure and atrial fibrillation Impaired responsiveness to β-adrenergic stimulation ↓ Maximum cardiac output; impaired thermoregulation ↓ Sinus node function and conduction velocity in the atrioventricular node and infranodal conduction system ↑ Risk of sick sinus syndrome, left anterior fascicular block, and bundle branch block Normal aging is associated with diverse changes throughout the cardiovascular system, and these changes are accentuated by common comorbid conditions, particularly hypertension, diabetes, obesity, and atherosclerosis. Topic

7 PRINCIPAL EFFECTS OF AGING ON THE CARDIOVASCULAR SYSTEM (2 of 2)Age effect Clinical implication Impaired endothelium-dependent vasodilation ↑ Demand ischemia and risk of coronary artery disease and peripheral arterial disease ↓ Baroreceptor responsiveness ↑ Risk of orthostatic hypotension ↓ Exercise response (↓ maximal heart rate, maximal cardiac output, VO2 max, coronary blood flow, peripheral vasodilation) ↓ Exercise capacity and ↑ cardiac complications (ischemia, heart failure, shock, arrhythmias, death) with illness Topic

8 CLINICAL EFFECTS OF CV CHANGESIn healthy older adults, age-related changes have modest clinically relevant effects on cardiac hemodynamics and performance at rest Resting heart rate, ejection fraction, stroke volume, and cardiac output are well preserved even at very advanced age Ability to respond to increased demands associated with exercise or illness (either cardiac or noncardiac) declines progressively with advancing age Peak aerobic capacity declines inexorably with age In the Baltimore Longitudinal Study on Aging, for example, maximal oxygen consumption in healthy men and women 80 years old free of CVD was roughly equivalent to that in middle-aged people with New York Heart Association functional class II heart failure. Moreover, limited cardiovascular reserve renders older adults more vulnerable to cardiac complications, especially ischemia, heart failure, arrhythmias, shock, and death, in the context of cardiac or noncardiac stressors, such as uncontrolled hypertension, infections, surgical procedures, or anemia. Topic

9 CHANGES IN OTHER ORGAN SYSTEMS CAN AFFECT CV DISEASE (1 of 3)Age-related change Clinical impact Renal Decrease in GFR Decrease in concentrating and diluting ability Impaired electrolyte homeostasis Volume overload with increased fluid intake; dehydration with decreased fluid intake; increasing risk of electrolyte disturbances; increased risk of worse outcome in patients with CVD Pulmonary Decrease in vital capacity Increased ventilation-perfusion mismatching Decrease in pulmonary reserve; increased dyspnea on exertion and decreased exercise tolerance GFR = glomerular filtration rate Age-related changes in other organ systems have important implications for the diagnosis and treatment of cardiovascular disorders in older adults. These age-related changes in numerous organ systems intersect with the cardiovascular system to substantially alter the clinical features, response to therapy, and prognosis of older adults with prevalent CVD. Topic

10 CHANGES IN OTHER ORGAN SYSTEMS CAN AFFECT CVD (2 of 3)Age-related change Clinical impact Neurologic Decrease in autoregulatory capacity Altered reflex responsiveness Impaired thirst mechanism Impaired cerebral perfusion; increased risk of orthostatic hypotension; increased risk of falls; increased risk of dehydration Musculoskeletal Osteopenia Joint stiffness Sarcopenia Decrease in exercise capacity; increased risk of falls Topic

11 CHANGES IN OTHER ORGAN SYSTEMS CAN AFFECT CVD (3 of 3)Age-related change Clinical impact Hematologic Altered balance between thrombosis and fibrinolysis Increased risk of arterial (stroke, MI) and venous (PE, DVT) thrombosis; increased risk of hemorrhage with antiplatelet, anticoagulant, or fibrinolytic therapy GI Altered absorption and elimination of drugs Altered hepatic metabolism of drugs Increased risk of adverse drug interactions and adverse events from CV and non-CV medications PE = pulmonary embolism; DVT = deep vein thrombosis. Topic

12 CVD RISK FACTORS Four major risk factors for CVD: HypertensionDiabetes mellitus Dyslipidemia Smoking Higher rates of CVD in older people: absolute number of cases per risk factor tends to increase with age Multiple risk factors act in concert with age-related CV changes to promote the development and progression of heart and vascular disorders Topic

13 HYPERTENSION Systolic BP tends to increase gradually with age, while diastolic BP peaks and plateaus in late middle age and declines thereafter Pulse pressure (the difference between systolic and diastolic BP) increases with age, and isolated systolic hypertension becomes the dominant form of hypertension in older adults, especially women Although the prevalence of diastolic hypertension declines with age, the presence of increased diastolic BP raises CVD risk independent of systolic BP, particularly in men In the Framingham Heart Study and other epidemiologic studies, systolic blood pressure was identified as the strongest risk factor for incident CVD in older adults, including those >80 years old. In some but not all studies, pulse pressure was equivalent or stronger than systolic blood pressure as a marker for CVD risk. Topic

14 DIABETES MELLITUS Prevalence increases with age at least up to age 80Approx. 50% of pts with diabetes in the US are ≥65 yr old As in younger patients, the impact of diabetes on CVD risk is greater in older women than in older men In the Framingham Heart Study, for example: The adjusted risk for incident CHD for older patients with diabetes was 2.1 in women and 1.4 in men The excess risk associated with diabetes was greater in both men and women >65 yr old than in younger individuals Topic

15 DYSLIPIDEMIA The strength of the association between total cholesterol and LDL cholesterol levels and incident CAD ↓ with age, especially after age 80 But low HDL cholesterol levels (<40 mg/dL in men, <50 mg/dL in women) and high ratios of total cholesterol to HDL cholesterol (≥5.5 in men, ≥5 in women) remain independently associated with coronary events even among people >80 yr old Clinical trials have demonstrated benefits of statin therapy in moderate-risk and high-risk patients up to 85 yr of age LDL = low-density lipoprotein; HDL = high-density lipoprotein. Population mean total serum cholesterol levels increase in men until approximately age 70 and then level off. In women, total cholesterol levels tend to rise rapidly after menopause and average 15–20 mg/dL higher than in men after age 60. Low-density lipoprotein cholesterol levels track with total cholesterol levels in men and women, while HDL cholesterol levels average about 10 mg/dL higher in women than in men throughout adult life. The value of lipid-lowering therapy for primary prevention of CVD in older adults, especially those 80–85 years old, remains uncertain. Topic

16 SMOKING Prevalence of smoking declines with age, partly due to successful smoking cessation, partly due to premature deaths in smokers Among older smokers, smoking cessation is associated with substantial reductions in CVD risk within 2−6 years relative to continued smoking In most studies, smoking remains a strong and independent risk factor for fatal and nonfatal CV events among older adults In 2006, approximately 12.6% of men and 8.3% of women ≥65 years old in the United States were active smokers, declining to <5% among individuals >85 years old. Topic

17 ADDITIONAL RISK FACTORS?Whether the following are important risk factors for CVD among older adults is unclear: Obesity Increased levels of C-reactive protein, fibrinogen, D-dimer, and plasmin-antiplasmin complex Coronary artery calcium content on CT In the Cardiovascular Health Study, several subclinical markers of CVD identified individuals at increased risk of subsequent CV events: increased carotid artery intima-media thickness assessed by carotid ultrasonography, increased left ventricular mass by echocardiography, borderline or decreased left ventricular ejection fraction, and decreased ankle-arm index (the ratio of leg-to-arm systolic blood pressure). In patients with diabetes or multiple other risk factors, the presence of any of these markers may identify patients likely to benefit from more aggressive management. Topic

18 Mortality after acute MI increases with age EPIDEMIOLOGY OF CAD Mortality after acute MI increases with age Prevalence of clinical CAD increases with age in both men and women Incidence of angina pectoris peaks between the ages of 65 and 84 and decreases modestly thereafter Two thirds of all MIs (excluding silent MIs) occur in adults ≥65 years old Topic

19 ACUTE CORONARY SYNDROMESThe acute coronary syndromes (ACS): Unstable angina Non-ST-elevation MI (NSTEMI) ST-elevation MI (STEMI) Unstable angina and NSTEMI are often considered together because they are pathophysiologically similar and clinically difficult to distinguish at the time of presentation, pending analysis of cardiac biomarker proteins Topic

20 ACS: PRESENTATION The proportion of patients who present with chest pain declines with age, especially after age 80 Shortness of breath is the most common initial symptom in patients >80−85 years old Older ACS patients are more likely than younger patients to present with altered mental status, confusion, dizziness, or syncope Presentation delays, altered symptomatology, and nondiagnostic ECGs often delay initiation of treatment The time from onset of symptoms to initial presentation at a medical facility also tends to be longer in older patients, in part due to the decreased prevalence of chest pain, although other factors likely contribute to delays in presentation. The initial ECG is more likely to be nondiagnostic of ACS in older than in younger patients due to the higher prevalence of prior MI, conduction abnormalities (especially left bundle branch block), LV hypertrophy, and paced rhythm. In addition, the proportion of ACS associated with ST elevation declines with age, further reducing the diagnostic accuracy of the ECG. Topic

21 THERAPY OF ACS (1 of 4) All patients with suspected ACS should immediately receive aspirin 160−325 mg regardless of age Oxygen should be administered to maintain an arterial oxygen saturation of at least 92% Patients with ongoing chest discomfort should receive IV nitroglycerin, followed by IV morphine if nitroglycerin is ineffective Patients with STEMI should also receive oral metoprolol or atenolol in the absence of contraindications (ie, heart rate <45−50 beats per minute, systolic BP <100 mmHg, advanced heart block, moderate or severe heart failure, active bronchospasm). An ACE inhibitor should be administered to hemodynamically stable patients with adequate renal function (estimated creatinine clearance 30 mL/min), especially those with LV systolic dysfunction and/or clinical heart failure. An angiotensin-receptor blocker (ARB) may be substituted in patients with known intolerance to ACE inhibitors due to cough. Early administration of high-dose statin therapy (eg, atorvastatin 80 mg) has been associated with improved outcomes in some but not all studies, and some experts recommend its routine use. However, data in patients >75−80 years old are very limited. In patients with diabetes, glucose control should be optimized. Routine use of antiarrhythmic agents, including lidocaine and amiodarone, is not recommended in patients with ACS. Topic

22 THERAPY OF ACS (2 of 4) The role of adjunctive antithrombotic therapy (ie, in addition to aspirin) in ACS continues to evolve In general, LMWH (enoxaparin, dalteparin) have been associated with more favorable outcomes than intravenous UFH Appropriate dosage adjustment for renal function is essential Fondaparinux, a factor Xa inhibitor, and bivalirudin, a direct thrombin inhibitor, have been associated with improved clinical outcomes and fewer major bleeding complications than either UFH or LMWH LMWH = low-molecular-weight heparin; UFH = unfractionated heparin. Fondaparinux (off-label) is not currently approved for treatment of ACS in the US, and it is contraindicated in patients with creatinine clearance <30 mL/min and in individuals weighing <50 kg. Dosage reduction is also required in patients >75 years old because of reduced clearance. Bivalirudin is currently approved only for treatment of patients with ACS undergoing percutaneous coronary intervention (PCI). Dosage reduction is required in patients with impaired renal function. A loading dose of clopidogrel 300−600 mg should be given to patients undergoing early coronary angiography in whom PCI is anticipated, but it is prudent to withhold clopidogrel in patients who may be candidates for coronary bypass surgery rather than PCI, because perioperative bleeding risks are increased for up to 5 days after even a single dose of clopidogrel. Prasugrel at a loading dose of 60 mg is an alternative to clopidogrel in patients <75 years old. Glycoprotein IIb/IIIa inhibitors (eptifibatide, tirofiban, abciximab) reduce the risk of ischemic complications in selected patients with ACS, but the value of routine use of these agents in older adults receiving aspirin, clopidogrel (or prasugrel), and heparin is uncertain while the risk of bleeding is increased. Therefore, judicious use of these agents is warranted. Topic

23 THERAPY OF ACS (3 of 4) Reperfusion therapy with a fibrinolytic agent or PCI is indicated in patients presenting within 6−12 hours of onset of STEMI (or MI with new left bundle branch block) Risk of intracranial hemorrhage increases with age, especially after age 75, and is higher with fibrin-selective agents, such as TPA or reteplase, than with the nonselective agent streptokinase PCI has been associated with superior outcomes relative to fibrinolysis in patients up to 85 years old, provided it is performed within 90−120 minutes of the patient’s arrival at the hospital. PCI = percutaneous coronary intervention; TPA = tissue plasminogen activator. Fibrinolytic therapy reduces mortality in a broad range of STEMI patients <75 years old, as well as in carefully selected patients 75 years old. In the setting of non–ST-elevation ACS, early PCI has been associated with improved outcomes in high-risk patients, including older adults, especially those with ongoing ischemia, extensive ECG changes, decreased LV systolic function, or hemodynamic instability (hypotension, tachycardia, heart failure). In hemodynamically stable patients without active chest pain or major ECG abnormalities, an initial strategy of optimal medical therapy is appropriate. Intravenous magnesium and the combination of glucose-insulin-potassium have not been shown to be beneficial. Dihydropyridine calcium channel blockers are contraindicated in patients with acute MI, and the use of diltiazem and verapamil should be limited to the treatment of supraventricular tachyarrhythmias (including atrial fibrillation and atrial flutter) in patients unresponsive or intolerant to β-blockers. Digoxin is not indicated for patients with ACS, including those with heart failure, and it also has limited efficacy in the treatment of atrial fibrillation. Topic

24 THERAPY OF ACS (4 of 4) After documented ACS, patients should be maintained on aspirin, a β-blocker, an ACE inhibitor (or ARB), and a statin in the absence of contraindications Clopidogrel 75 mg (or prasugrel 10 mg for patients <75 years old) is recommended for at least 9−12 months for all ACS patients undergoing PCI, and for those with non-ST-elevation ACS in whom PCI is not performed Whenever feasible, refer patient to a structured cardiac rehabilitation program Patients with large anterior MIs associated with apical wall motion abnormalities should receive warfarin for 3−6 months to maintain an INR of 2−3 to reduce the risk of mural thrombus formation and embolization. In addition, aggressive interventions should be undertaken to control all treatable cardiovascular risk factors, and appropriate recommendations about diet, exercise, and sexual activity should be conveyed before hospital discharge. Structured cardiac rehabilitation programs improve functional, emotional, behavioral, and clinical outcomes, including 25%−30% reduction in mortality Topic

25 Older patients tend to have more severe and diffuse CADCHRONIC CAD Older patients are more likely than younger patients to present with exertional fatigue or shortness of breath than classical angina pectoris Older patients tend to have more severe and diffuse CAD More triple-vessel and left main CAD Higher prevalence of prior MI and associated LV dysfunction Older patients tend to present later in the course of disease, in part because more sedentary lifestyles result in delays in symptom onset or reduced symptom severity. Topic

26 DIAGNOSIS OF CHRONIC CADSimilar in older and younger adults, but … Older adults have, on average, a higher pretest likelihood of significant coronary obstructions As a result, false-positive rates on stress tests tend to be lower in older adults, while false-negative rates tend to be higher In most patients with stable symptoms likely to be due to coronary ischemia, a stress test is the initial diagnostic test of choice Diminished exercise capacity can contribute to higher false-negative rates on exercise stress tests (but not pharmacologic stress tests) in older patients. When feasible, an exercise test is preferable to a pharmacologic test because it is more physiologic and provides additional information about exercise tolerance and the hemodynamic response to exercise not afforded by pharmacologic testing. In patients unable to exercise due to poor physical conditioning or comorbid illness, pharmacologic stress tests such as dobutamine echocardiography or adenosine thallium provide equivalent diagnostic sensitivity and specificity relative to exercise tests. In patients with accelerating symptoms or a markedly abnormal stress test in whom coronary revascularization is a suitable therapeutic option, coronary angiography provides definitive information about the precise location and severity of coronary stenoses. Although the risks of coronary angiography increase slightly with age, in experienced centers the procedure can be performed with very low risk of major complications, even in patients of very advanced age (ie, nonagenarians and beyond). Investigational approaches to the diagnosis of CAD include coronary artery calcium scores, CT coronary angiography, MRI, contrast echocardiography, and ambulatory ST-segment monitors. None of these is recommended for routine use at this time. Topic

27 CONTROL RISK FACTORS TO REDUCE CAD PROGRESSIONThe target LDL cholesterol level in all patients with established CAD is <100 mg/dL <70 mg/dL is reasonable in patients at very high risk, especially those with concomitant diabetes Strongly encourage stopping the use of tobacco products Prescribe a diet low in saturated fat and cholesterol but high in fruits, vegetables, and whole-grain products Encourage at least 30 minutes of aerobic exercise, such as walking, at least 5 days/week Diabetes, hypertension, and lipid abnormalities should be treated in accordance with published guidelines. Behavioral and/or pharmacologic support should be routinely offered to all patients who indicate an interest in smoking cessation. Modest weight reduction is advisable in patients who are markedly overweight (BMI 35 kg/m2), but as noted above, the value of weight loss in older patients with lesser degrees of obesity has not been established. Topic

28 MEDICAL THERAPY FOR CAD (1 of 3)All pts with chronic CAD should get aspirin 75–325 mg/d Statin therapy is indicated for all patients with CAD, even when untreated LDL levels are within the desirable range ACE inhibitors reduce mortality and CV morbidity in patients up to 85 years old with CAD, PAD, or diabetes Recommended for most patients with established CAD in the absence of contraindications Statin labeling has been modified with regard to increased risk of diabetes and decreased memory, and possible association with fatigue, especially in women. Lower dosages of aspirin are associated with decreased incidence of GI intolerance and bleeding complications, but somewhat higher risk of aspirin resistance. Therefore, the optimal dosage of aspirin may vary, but 75–160 mg is appropriate in most patients. In the small percentage of patients with true aspirin allergy or intolerance, clopidogrel 75 mg/d is a reasonable alternative. The combination of aspirin with either clopidogrel or warfarin is somewhat more effective than aspirin alone in reducing the risk of ACS in patients with CAD, but the additional expense and higher risk of major hemorrhage makes combination therapy less desirable in the absence of specific indications (eg, clopidogrel after PCI or warfarin for atrial fibrillation). Statin doses should be sufficient to induce a 30%−40% reduction in the LDL cholesterol level and to ensure that the target LDL cholesterol level is achieved. Statins have been shown to improve clinical outcomes in trials involving patients up to 85 years old, and observational studies support their use for secondary prevention in older patients as well. Although altered hepatic metabolism and the use of multiple medications may place older patients at increased risk of statin-related adverse events, studies have not consistently shown an increased incidence of major statin toxicity in older individuals. ARBs are an acceptable alternative in patients unable to tolerate ACE inhibitors due to cough. Both classes of agents should be used cautiously, if at all, in patients with estimated creatinine clearance <30 mL/min (unless receiving dialysis). Renal function and serum potassium levels should be monitored closely when starting or titrating ACE inhibitors or ARBs. Topic

29 MEDICAL THERAPY FOR CAD (2 of 3)All patients with prior MI should be treated with a β-blocker in the absence of contraindications or limiting adverse events β-blockers are indicated for all patients with LVEF  40%, regardless of cause β-blockers are also the most effective anti-ischemic agents and should be considered the medications of first choice for treatment of angina pectoris or other ischemic symptoms The dosage of β-blocker should be titrated to maintain a resting heart rate of 50 to no more than 70 beats per minute. Up to 20%−30% of patients are unable to tolerate β-blockers because of adverse events, but there is no convincing evidence that older patients experience more adverse events than younger patients. Topic

30 MEDICAL THERAPY FOR CAD (3 of 3)Calcium channel blockers are effective anti-ischemic agents, either as first-line therapy in patients unable to take β-blockers, or in combination with β-blockers or long-acting nitrates Long-acting nitrate preparations, such as isosorbide mononitrate, are less effective as anti-ischemic agents than β-blockers or calcium channel blockers Ranolazine, alone or in combination with conventional antianginal medications, reduces angina and improves exercise tolerance in patients with symptomatic CAD Calcium channel blockers are relatively contraindicated in patients with heart failure or LVEF < 40%. Leg edema due to venodilation is a common adverse event of dihydropyridine calcium channel blockers, whereas constipation occurs more commonly with the nondihydropyridines, especially verapamil. Both types of adverse events appear to be more common in older patients. Long-acting nitrate preparations, such as isosorbide mononitrate, are less effective anti-ischemic agents than β-blockers or calcium channel blockers, in part because of the high rate of tolerance that develops during long-term use and the need for a daily nitrate-free interval of at least several hours. These agents are therefore best used as adjunctive therapy in patients with persistent symptoms despite β-blocker and/or calcium channel blocker treatment. Headache is the most common adverse event associated with nitrates, but most cases resolve with continued use. Occasionally patients develop hypotension, dizziness, falls, or syncope, most commonly on initiation of nitrate therapy. The benefits of ranolazine are similar in older and younger patients. Ranolazine is generally well tolerated, although adverse events, including constipation and dizziness, tend to be more common in patients >70 years old than in younger patients. Ranolazine increases the QT interval slightly, but a significant proarrhythmic effect has not been reported. Topic

31 CAD THERAPY: REVASCULARIZATIONIn patients with chronic CAD, the principal indication for coronary revascularization is relief of symptoms to improve quality of life Neither coronary bypass surgery nor PCI has been shown to reduce the risk of MI in patients with stable CAD Complication rates, including mortality, increase with age after both PCI and coronary bypass surgery, especially among patients >80 years old In patients <70 years old, clinical trials conducted more than 2 decades ago demonstrated that coronary bypass surgery decreased mortality relative to medical therapy in patients with stenosis of the left main coronary artery, in patients with severe multivessel CAD and LV systolic dysfunction, and in other patient subgroups. The applicability of these findings to the current population of older patients is unclear, especially in light of the availability of more effective medical treatments. However, despite the failure of revascularization procedures to reduce mortality or major coronary event rates in most patients with stable CAD, more recent trials have demonstrated improved symptoms and quality of life in older patients in whom aggressive medical therapy did not elicit an adequate response. Therefore, it is appropriate to offer revascularization on an individualized basis to older patients with persistent symptoms and impaired quality of life attributable to coronary ischemia. Topic

32 In general, long-term outcomes are similar PCI VS. BYPASS SURGERY In general, long-term outcomes are similar Short-term mortality, major complication rates (including cognitive dysfunction), hospital length of stay, and convalescence time are all increased with surgery relative to PCI Need for subsequent revascularization procedures and late mortality are higher after PCI PCI is somewhat less effective in relieving symptoms On balance, factors favoring PCI include severe CAD that is amenable to complete revascularization by PCI, increased risk of perioperative complications (eg, multiple comorbid conditions, renal insufficiency, frailty), and personal preference to avoid a major operation if possible. Factors favoring bypass surgery include more severe CAD (especially if complete revascularization by PCI is unlikely), high risk coronary anatomy (eg, left main disease or high-grade stenosis of the proximal left anterior descending artery not suitable for PCI), personal preference to minimize the need for subsequent revascularization procedures, and diabetes. In all cases, the benefits and risks of all major therapeutic options— continued medical therapy, PCI, or bypass surgery—should be discussed in detail with the patient and family as part of determining the best course of treatment. Topic

33 RISKS OF BYPASS SURGERYUp to 50% of older patients undergoing bypass surgery using extracorporeal circulation experience measurable cognitive impairment after surgery Complete recovery usually occurs in 3−6 months, but a small percentage have persistent cognitive dysfunction Functional decline is also common and can be irreversible To minimize deficits, start rehab in the hospital and refer the patient to a structured cardiac rehab program after discharge Recent data suggest that the risk of postoperative cognitive dysfunction does not differ significantly between off-pump and on-pump CABG. Topic

34 TYPES OF VALVULAR DISEASEAortic stenosis (AS) Aortic regurgitation (AR) Mitral stenosis (MS) Mitral regurgitation (MR) The prevalence of AS increases with age, approaching 15% in octogenarians, and AS is the most common valvular abnormality requiring surgery in older adults. AR may be acute or chronic. The incidence of both increases with age. It is not usually severe enough to require surgical intervention. Rheumatic MS is uncommon in older adults in the US, but occasionally patients in their 70s or 80s present with symptoms attributable to previously undiagnosed rheumatic disease. The diagnosis may be established incidentally when the patient undergoes echocardiography for another reason (eg, new-onset atrial fibrillation). More commonly, MS in older adults is due to nonrheumatic calcification of the mitral valve annulus and subvalvular apparatus, leading to a narrowed orifice and decreased excursion of the valve leaflets. MR may be acute or chronic. It is present in up to one third of older adults, but only a small proportion require surgical intervention. Topic

35 DIAGNOSIS OF VALVULAR DISEASEEchocardiogram is the procedure of choice Echocardiography with Doppler can non- invasively assess the cause and severity of most acute or chronic valvular abnormalities Also provides important information about LV size and function, left atrial size, pulmonary artery pressure, and the presence and severity of other valvular lesions For AS, echocardiography is essential for assessing disease severity, evaluating LV function, and determining the presence of associated valvular lesions. Moderate AS is indicated by an aortic jet velocity (AJV) of 3−4 meters/second or an aortic valve area (AVA) of 1−1.5 cm2; severe AS is indicated by an AJV >4 meters/second or AVA <1 cm2. Occasionally, technical considerations or the presence of severe LV dysfunction preclude accurate echocardiographic assessment of AS severity; in these cases, right and left heart catheterization is definitive. In patients with acute severe AR, echocardiography demonstrates a short duration AR jet with rapid deceleration and premature closure of the mitral valve. In patients with severe chronic AR, the AR jet is typically more prominent and of longer duration, often persisting throughout diastole. The left ventricle is usually dilated and there are signs of LV diastolic volume overload. In advanced cases, there may be evidence of LV systolic dysfunction, as evidenced by a reduced LVEF. Echocardiography is the definitive test for diagnosing MS, quantifying disease severity, and evaluating for the presence of other valvular lesions, especially MR. Severe MS is indicated by a mitral valve area <1 cm2. Topic

36 AORTIC STENOSIS Symptoms Findings TreatmentAngina; DOE; heart failure; presyncope/ syncope Physical exam: mid/late systolic ejection murmur radiating to carotids; S4 gallop; left ventricular heave ECG: LVH Medical: no known effective therapy Percutaneous: transcatheter aortic valve implantation in selected patients at high surgical risk Surgical: AVRa indicated for severe AS with symptoms, bioprosthetic valves preferred in older patients DOE = dyspnea on exertion; LVH = left ventricular hypertrophy; AVR = aortic valve replacement; AS = aortic stenosis. aOlder adults being considered for AVR and MVR should have coronary angiography first because significant CAD is present in 50% of patients. Topic

37 AORTIC REGURGITATION Symptoms Findings TreatmentCan be acute or chronic; asymptomatic or minimally symptomatic in mild/ moderate AR; DOE, heart failure, angina in severe AR Physical exam: ↑ pulse pressure; bounding/ collapsing pulses; early diastolic decrescendo murmur; systolic ejection murmur in acute severe AR ECG: LVH (severe chronic AR); tachycardia (acute AR) Chest radiograph: cardiomegaly (severe chronic AR); pulmonary congestion (acute AR) Medical (less severe cases): control hypertension and other risk factors; vasodilator therapy with nifedipine, hydralazine, or ACE inhibitor as alternative to AVR in severe chronic AR Surgical: AVRa for acute severe AR with heart failure or hemodynamic instability and for chronic AR with onset of heart failure, LVEF <50%, or LV end-systolic dimension 5.5 cm AR = atrial regurgitation; DOE = dyspnea on exertion; LVH = left ventricular hypertrophy; AVR = aortic valve replacement; LVEF = left ventricular ejection fraction. aOlder adults being considered for AVR and MVR should have coronary angiography first because significant CAD is present in 50% of patients. Topic

38 MITRAL STENOSIS Symptoms Findings TreatmentGradually worsening DOE early; orthopnea and leg edema late; progressive decline in exercise capacity Physical exam: early diastolic opening snap; low-pitched (“rumbling”) diastolic murmur at apex; pulmonary hypertension; right heart failure Medical: includes diuretics for volume overload and β-blockers for decreased exercise tolerance Percutaneous: balloon valvuloplasty safe and effective, but most older adults are not good candidates due to extensive calcification and commissural fusion or concomitant mitral regurgitation Surgical: MVRa is effective but with 5%−15% operative mortality in older patients DOE = dyspnea on exertion; MVR = mitral valve replacement. aOlder adults being considered for AVR and MVR should have coronary angiography first because significant CAD is present in 50% of patients. Topic

39 MITRAL REGURGITATION (1 of 2)Symptoms Findings Can be acute or chronic; marked shortness of breath, orthopnea in acute, severe MR; progressive DOE in chronic MR Physical exam: pulmonary rales, tachycardia, narrow pulse pressure, S3, and short harsh systolic murmur in acute MR; holosystolic murmur radiating to axilla, S3, pulmonary hypertension, right heart failure in chronic severe MR MR = mitral regurgitation; DOE = dyspnea on exertion. Topic

40 MITRAL REGURGITATION (2 of 2)Treatment Medical: afterload reduction and aggressive control of hypertension Surgical: mitral valve repair preferred over MVRa (and for MVR, bioprosthetic valvesb are preferred over mechanical in older patients); all effective but with 5%−15% operative mortality in older patients Surgical intervention is indicated: Urgently for acute severe MR with heart failure At onset of symptoms or with LVEF <60% or LV end-systolic dimension 4 cm for chronic, severe MR When mitral valve repair is deemed likely to be successful in asymptomatic patients with chronic severe MR and LVEF 60% With increased pulmonary artery pressure or new-onset atrial fibrillation in patients with chronic severe MR and LVEF 60% MVR = mitral valve replacement; MR = mitral regurgitation; LVEF = left ventricular ejection fraction. aOlder adults being considered for AVR and MVR should have coronary angiography first because significant CAD is present in >50% of patients. bAfter MVR with bioprosthetic valve, anticoagulation to maintain INR of 2−3 is recommended for 3 mo, followed by maintenance therapy with aspirin 75−100 mg/d in the absence of risk factors for thromboembolism. Topic

41 CARDIAC ARRHYTHMIAS Age-related changes in the cardiac conduction system coupled with the increasing prevalence of CVD at older age  progressive increase in the incidence and prevalence of conduction abnormalities and heart rhythm disturbances in older adults Age-related degenerative changes in and around the sinoatrial and atrioventricular nodes  increase in bradyarrhythmias with advancing age In a cohort of 1,372 healthy adults 65 years old participating in the Baltimore Longitudinal Study on Aging (BLSA), >90% of men and women demonstrated supraventricular ectopic activity and >75% demonstrated ventricular ectopic activity on 24-hour ambulatory ECG. Almost 50% of men and women exhibited short runs of supraventricular tachycardia, while 13% of men and 4% of women had 3 or more consecutive ventricular premature depolarizations. In contrast, <0.5% of men and women in this cohort had runs of 5 or more beats of ventricular tachycardia. In a related study, about 4% of women >60 years old developed supraventricular tachycardia (SVT) during an exercise test, whereas the proportion of men developing SVT with exercise continued to increase with age, approaching 15% in those 80 years old. In the absence of structural heart disease, the presence of supraventricular and ventricular arrhythmias had no effect on mortality or the incidence of cardiac events in BLSA participants, except that exercise-induced SVT was associated with an increased risk of developing atrial fibrillation during follow-up. Conversely, in patients with prevalent CVD, increased ventricular (but not supraventricular) ectopy was associated with an increased risk of CV mortality. In addition, although patients with preexisting atrial fibrillation were excluded from the BLSA ambulatory monitoring study, atrial fibrillation, whether paroxysmal or persistent, has been shown to be an independent predictor of increased mortality in both men and women. The incidence and prevalence of sinus node dysfunction (“sick sinus syndrome”) and atrioventricular nodal block increase progressively with age. As a result, >75% of permanent pacemakers are implanted in patients 65 years old, and approximately half are in patients 75 years old. The prevalence of infranodal conduction disorders, including left anterior fascicular block and left and right bundle branch block, also increase with age. Topic

42 The most common sustained arrhythmia seen in clinical practice ATRIAL FIBRILLATION The most common sustained arrhythmia seen in clinical practice Incidence and prevalence increase exponentially with age, such that the prevalence in octogenarians is approximately 10% Among older patients with valvular heart disease or HF, the prevalence is even higher, approaching 30% Currently, >50% of patients with AF are 75 years old, and it is projected that by 2050 half of all adults with AF will be 80 years old. As noted above, AF is an independent predictor of increased mortality in older adults, conferring relative risks of 1.10−1.15 in men and 1.20−1.25 in women. The proportion of strokes attributable to AF also increases exponentially with age, such that AF accounts for about 1.5% of strokes in patients 50−59 years old but 23.5% of strokes in patients 80−89 years old. In addition, women with AF are at increased risk of stroke relative to men, especially after age 75, and the relative risk for stroke in women compared with that in men is approximately 1.8 (ie, an 80% greater risk) in this age group. Topic

43 AF: CLINICAL FEATURES AND DIAGNOSISSymptoms related to AF are highly variable Most common: palpitations, shortness of breath, or impaired exercise tolerance In patients with ongoing AF, the standard 12-lead electrocardiogram is diagnostic Lab studies should include echocardiogram, serum electrolytes (especially potassium and magnesium), thyroid function Physical examination reveals an irregularly irregular rhythm with heart rates ranging from <60 beats per minute (eg, in patients with sinoatrial dysfunction and in those taking a β-blocker) to >150 beats per minute. Increased systolic blood pressure is a common but nonspecific finding. Pulmonary crackles may be present in patients with acute HF, while a heart murmur may be heard in patients with valvular heart disease. Rarely, an enlarged or nodular thyroid may be detected, or signs of deep venous thrombosis may be evident. A transthoracic echocardiogram is indicated in all patients with new- onset AF to evaluate LV size and function, left atrial size, pulmonary artery pressure, and the cardiac valves. Further evaluation in selected cases might include a chest radiograph, serial cardiac biomarker proteins to exclude acute MI, a B-type natriuretic peptide level (or nt- proBNP level), a D-dimer level, leg venous Dopplers, and an evaluation for pulmonary embolism. Topic

44 MANAGEMENT OF AF Objectives include relieving symptoms and minimizing the risk of thromboembolic events, particularly stroke Principal strategies for relieving symptoms: control of heart rate and maintenance of normal sinus rhythm Patients who experience significant shortness of breath, fatigue, or exercise intolerance attributable to AF may be best managed with antiarrhythmic drug therapy aimed at maintaining sinus rhythm Several clinical trials have compared “rate control” with “rhythm control” in patients who are asymptomatic or minimally symptomatic. The results have consistently demonstrated that rate control with AV-nodal blocking agents such as a β-blocker, diltiazem, verapamil, or digoxin, alone or in combination, is associated with fewer hospitalizations and favorable trends in stroke and mortality rates, relative to the use of antiarrhythmic medications. Based on these findings, rate control in combination with systemic anticoagulation is the preferred treatment approach for AF patients with minimal or no symptoms. Recent data indicate that lenient rate control (resting heart rate <110 bpm) is associated with similar outcomes over a 2- to 3-year follow-up period as more aggressive rate control (resting heart rate <80 bpm). Lenient rate control is also easier to achieve, generally requires fewer medications and/or lower dosages, and may be associated with fewer adverse events. For these reasons, a more lenient rate control strategy may be appropriate in older patients with persistent AF. Amiodarone is the most effective medication available, but it is associated with multiple adverse events, some potentially serious, and numerous drug interactions. Dronedarone, a newer agent, is somewhat less effective than amiodarone but has fewer adverse events. Dronedarone is contraindicated in patients with advanced heart failure or chronic AF. Sotalol is less effective than amiodarone and is contraindicated in patients with significant renal insufficiency. Flecainide and propafenone are contraindicated in patients with CAD or heart failure. Quinidine and procainamide have limited efficacy and are accompanied by relatively frequent adverse events, while disopyramide is generally contraindicated in older adults because of its anticholinergic effects. Topic

45 MANAGEMENT OF AF Alternatives to antiarrhythmic drug therapy for maintenance of sinus rhythm: Catheter ablation of the arrhythmogenic foci, usually through pulmonary vein isolation The surgical maze procedure All older patients with paroxysmal or persistent AF require stroke prophylaxis Pulmonary vein isolation has been associated with “cure” rates of >80% in younger patients with paroxysmal AF, but experience is limited with this procedure in older patients with persistent AF. The surgical maze procedure results in long-term maintenance of sinus rhythm in >90% of cases but requires an open heart procedure. Nonetheless, it is a reasonable option in older patients with AF undergoing open heart surgery for other reasons if a surgeon with expertise in performing the procedure is available. Topic

46 MANAGEMENT OF AF: STROKE RISK STRATIFICATIONCHADS2 1 point for chronic HF, HTN, age 75 yr, and diabetes, 2 points for prior stroke or TIA Score of 2: significant risk of stroke CHA2DS2-VASc Better than CHADS2 for identifying low risk of stroke 2 points for age 75 yr, 1 point for age 6574 yr, 1 point for vascular disease, 1 point for female sex Score of 2: patient is candidate for systemic anticoagulation In general, patients with CHADS2 score = 0 are at low risk of stroke, and the risks of warfarin outweigh the benefits; therefore, aspirin therapy is appropriate. For CHADS2 score of 1, either warfarin or aspirin is acceptable, but warfarin is preferred in older patients in the absence of contraindications. For CHADS2 score 2, in most cases the beneficial effects of warfarin outweigh the potential for adverse events. Topic

47 MANAGEMENT OF AF: STROKE PROPHYLAXISWarfarin titrated to maintain an INR of 2–3 Aspirin 75–325 mg/d  clopidogrel Dabigatran 150 mg q12h when creatinine clearance (CrCl) ≥ 50 mL/min (75 mg q12h when CrCl = 15–30 mL/min) Rivaroxaban 20 mg/d when CrCl ≥50 mL/min (15 mg/d when CrCl = 15–50 mL/min) Apixamab 5 mg twice daily (2.5 mg twice daily when 2 or more of the following are present: age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL) Dabigatran is more effective than warfarin for reducing stroke risk and is also associated with a lower risk of intracranial hemorrhage. Rivaroxaban and apixaban have also been compared head-to-head with warfarin in large randomized trials. Rivaroxaban was noninferior to warfarin with respect to both prevention of thromboembolic events and bleeding complications. Apixaban was superior to warfarin with respect to thromboembolic events, major bleeding complications, and mortality.  The most common adverse events with dabigatran are bleeding and dyspepsia, and recent reports have raised concern that older adults may be at increased risk of serious bleeding. The role of dabigatran in managing AF in older patients remains uncertain, and additional experience with this agent is needed, particularly in patients >75 years old. Similarly, the main adverse events associated with rivaroxaban and apixaban are bleeding complications. Other adverse events appear to be relatively infrequent, although additional experience is needed in a broader range of older patients with higher comorbidity burden than those enrolled in the clinical trials. Despite these cautions, it seems likely that newer antithrombotic agents will play an increasingly important role in the management of older patients with AF over the next several years. Topic

48 OTHER SUPRAVENTRICULAR ARRHYTHMIASAtrial flutter usually occurs in older patients with concomitant AF, and management is similar to AF Consider catheter ablation if symptomatic persistent atrial flutter does not respond to medical therapy Atrial tachycardia, AV-nodal reentrant tachycardia, accessory pathway-mediated SVT, and multifocal atrial tachycardia: treat underlying condition, provide rate- control medication In selected patients with recurrent symptomatic episodes, antiarrhythmic medications or catheter ablation may be considered Topic

49 VENTRICULAR ARRHYTHMIASFrequent ventricular premature beats, ventricular couplets, and short runs of nonsustained ventricular tachycardia: no therapy unless highly symptomatic, in which case β-blockers are the medications of first choice Longer episodes of ventricular tachycardia with dizziness or syncope: referral to a cardiologist or electrophysiologist for ICD or antiarrhythmic drug therapy Patients with NYHA class II or III heart failure, LVEF of 35%, and life expectancy  1 year: consider an ICD, even if ventricular arrhythmias are not clinically manifest Topic

50 BRADYARRHYTHMIAS Patients with mild bradycardia (resting heart rate 50−60 bpm) are often asymptomatic Patients with more marked bradycardia (resting heart rate 40−50 bpm) may experience fatigue, lightheadedness (especially on standing), or reduced exercise tolerance Presyncope or syncope may occur in patients with profound bradycardia (heart rate <40 bpm or asystolic pauses 3 seconds), whether due to sinus node dysfunction or heart block within the AV node or infranodal conduction system Age-related degenerative changes in the sinoatrial node, AV node, and infranodal conduction system result in a marked increase in bradyarrhythmias with increasing age: >75% of pacemaker recipients in the United States are 65 years old, and half are 75 years old. Mild bradyarrhythmia may protect against the development of angina pectoris in patients with coronary artery disease. Topic

51 DIAGNOSING BRADYARRHYTHMIA (1 of 2)Exclude significant electrolyte abnormalities, measure the thyrotropin level to exclude hypothyroidism, and review medications Significant orthostatic hypotension: search for potentially treatable causes, including adverse events of medication(s), dehydration, or autonomic dysfunction (eg, due to diabetes, amyloidosis, parkinsonism, or other neurologic disorders) Unexplained presyncope or syncope: carotid sinus massage to evaluate for carotid hypersensitivity The most commonly used medications associated with bradycardia in older adults include β-blockers (including eye drops), diltiazem, verapamil, clonidine, amiodarone and other antiarrhythmic agents, and cholinesterase inhibitors. In patients with orthostatic hypotension, presyncope, or syncope, blood pressure should be measured in the supine, sitting, and standing positions. An abnormal response to carotid massage is defined as unequivocal reproduction of the patient’s symptoms (eg, syncope), asystole 3 seconds, or a decrease in systolic blood pressure 50 mmHg in the absence of symptoms or 30 mmHg in association with symptoms (eg, dizziness, presyncope). In patients with intermittent symptoms, it is essential to establish a correlation between symptoms and bradyarrhythmias before considering pacemaker implantation. Topic

52 DIAGNOSING BRADYARRHYTHMIA (2 of 2)If symptoms occur daily or almost every day, a 24h−48h ambulatory monitor may be helpful for confirming or excluding bradycardia (or other heart rhythm disorder) as the proximate cause In patients whose symptoms occur at least once a month (but not daily), a 30-day event monitor may provide a definitive diagnosis In patients with rare (ie, less than monthly) but recurrent symptoms of a serious nature (eg, syncope with injury), an implantable loop recorder may be considered Implantable loop recorders, which may be left in place for a year or longer, have been shown to increase diagnostic yield in patients with infrequent syncopal events. Head-up tilt testing may be useful in diagnosing vasovagal (neurocardiogenic) syncope in younger patients, but it is of limited use in older adults because of low specificity and a high prevalence of “false-positive” tests. Invasive electrophysiologic (EP) testing is not usually indicated for the diagnosis of syncope or bradyarrhythmias. However, in patients with recurrent unexplained syncope and a nondiagnostic noninvasive evaluation, EP testing may be helpful, especially in patients with CAD, cardiomyopathy, or evidence of infranodal conduction system disease (eg, right or left bundle branch block). In such cases, EP testing may distinguish syncope due to bradycardia (eg, high-grade infranodal AV block) from that due to a tachyarrhythmia (eg, sustained monomorphic ventricular tachycardia), thus facilitating appropriate therapy. Topic

53 MANAGING BRADYARRHYTHMIACorrect any treatable causes (eg, hypothyroidism) and eliminate potentially offending medications, if possible In patients with confirmed symptomatic bradycardia not amenable to conservative management, permanent pacemaker implantation is warranted For class I indications for permanent pacing, see Table 48.4 in GNRS. In tachy-brady syndrome, a common variant of “sick sinus syndrome,” patients manifest both tachyarrhythmias (most commonly SVT or atrial fibrillation) and bradyarrhythmias, either or both of which can result in symptoms. Treatment of the tachyarrhythmias with AV-nodal blocking agents or antiarrhythmic medications often exacerbates symptoms related to bradycardia, for which pacemaker implantation may be required. Topic

54 PERIPHERAL ARTERIAL DISEASEEncompasses disorders of the: Abdominal aorta Renal and mesenteric arteries Iliofemoral-popliteal arterial tree Prevalence increases with age and is higher in men than in women Risk factors include hypertension, diabetes, cigarette smoking, and family history In one study, the prevalence of PAD increased from 5.6% in adults 38−59 years old, to 15.9% in adults 60−69 years old, and to 33.8% in adults 70−82 years old. In another study, the prevalence of symptomatic PAD in nursing-home residents with a mean age of 81 years was 32% in men and 26% in women. Abdominal aortic aneurysms (AAA) are usually asymptomatic in the early stages. As the aneurysm enlarges, patients may notice abdominal pulsations or experience back pain or abdominal discomfort. Less commonly, neurologic symptoms may be evident. Symptoms of leg PAD include claudication with exertion and skin changes related to chronically impaired circulation. In advanced cases, rest pain, ulcers, or dry gangrene may develop. Physical findings associated with PAD may include a pulsatile abdominal mass, bruits over the renal and/or femoral arteries, diminished or absent peripheral pulses, and skin changes ranging from hair loss and hyperpigmentation to ulcers and gangrene. Topic

55 PAD DIAGNOSIS At least 50% of patients with PAD are asymptomatic or attribute their symptoms to another disorder Formal history and physical exam to screen for symptoms and signs of PAD is recommended for: Patients 50−69 yr with risk factors for atherosclerosis Patients 70 yr with or without risk factors Men 60 yr with a family history of AAA and men 65 – 75 yr who have ever smoked should undergo abdominal ultrasound to screen for AAA Diagnosis of PAD requires a high index of suspicion and a proactive approach. Individuals with symptoms or physical findings suggestive of PAD should undergo assessment of the ankle-brachial index (ABI), the ratio of the systolic BP obtained at the ankle to the BP obtained over the ipsilateral brachial artery. A normal ABI is 0.9−1.3, and an ABI <0.9 has been reported to be 95% sensitive and 99% specific for leg PAD. Older patients with stiff, non-compressible arteries may have artifactually high systolic BP readings using conventional BP cuffs, thereby leading to falsely normal or even increased ABI. An ABI <0.40 is generally associated with critical PAD and severely impaired perfusion of the distal limb. Patients with moderate or severe symptoms and an abnormal ABI should undergo additional evaluation if percutaneous or surgical revascularization is being contemplated. Imaging procedures that may be useful in selected cases include Doppler flow velocity measurements, ultrasonic duplex scanning, magnetic resonance angiography, and CT angiography. If revascularization is indicated based on symptoms and the results of noninvasive testing, contrast angiography is usually required before performing the revascularization procedure. Topic

56 Patients with leg PAD should exercise regularlyPAD TREATMENT (1 of 2) Aspirin 75−325 mg Clopidogrel 75 mg is more effective than aspirin in reducing CV risk in patients with PAD, but aspirin plus clopidogrel is not superior to either agent alone Clopidogrel is recommended as a reasonable alternative to aspirin in selected patients An ACE inhibitor or ARB for prevention of CV events is reasonable in patients with symptomatic PAD Patients with leg PAD should exercise regularly PAD is considered a CAD risk-equivalent, indicating that patients with PAD have a 20% risk of experiencing a new coronary event within 10 years. In patients with comorbid diabetes or established CAD, the risk is even higher. Most deaths in patients with PAD are attributable to CAD or its complications (eg, heart failure, arrhythmias) rather than to PAD per se. The importance of PAD as a risk marker for CAD provides the rationale for the aggressive treatment of prevalent CV risk factors. Thus, the target LDL cholesterol level in patients with PAD is <100 mg/dL, and hypertension should be treated in accordance with current guidelines. Smoking cessation should be strongly encouraged, and patients who indicate an interest in quitting should be offered counseling in combination with drug therapy. Patients with leg PAD should preferably exercise under supervision, to include walking at least 30−45 minutes at least 3/week for a minimum of 12 weeks. Data from multiple randomized trials and at least one large meta-analysis indicate that the beneficial effects of exercise on maximal walking capacity exceed those of available pharmacotherapies. In addition, the greatest improvements in walking ability occur in individuals who exercise to near maximal pain threshold for a period of at least 6 months. Topic

57 PAD TREATMENT (2 of 2) Revascularization is indicated for patients with severe symptoms attributable to PAD that have not responded to aggressive risk factor modification, exercise, and pharmacotherapy Revascularization is also indicated for patients with critical-limit ischemia, defined as rest pain, ulceration, or gangrene In this context, revascularization has been shown not only to improve symptoms but also to reduce the likelihood of subsequent amputation The only drug that has been convincingly shown to improve symptoms and walking distance in patients with claudication is the phosphodiesterase inhibitor (type III) cilostazol. At dosages of 100 mg q12h, cilostazol increases maximal walking distance by 40%−60%, and a therapeutic trial of this agent is recommended for all patients with lifestyle-limiting claudication. Cilostazol is contraindicated in heart failure because of its phosphodiesterase inhibitor effects. Pentoxifylline is also approved for treatment of symptomatic PAD, but its clinical effectiveness is marginal and not well established. The choice between percutaneous transluminal angioplasty with or without stenting versus surgical revascularization depends on lesion location and severity, likelihood of success, risk of major complications, and the experience and technical expertise of the interventionalist and surgeon. Importantly, these two therapeutic approaches should be viewed as complementary rather than competing strategies, and the choice of revascularization procedure should be tailored to individual patient circumstances and preferences. Indications for AAA repair include development of symptoms, rapid aneurysmal dilatation detected during serial assessments (1 cm in 1 year), and aneurysms 5.5 cm in diameter. Patients with asymptomatic AAA 4 to 5.4 cm in diameter should undergo repeat evaluations at intervals of 6−12 months. The choice of open or endovascular surgical repair of AAA is based on location of the lesion and patient comorbidities and prognosis. Open repair is favored for suprarenal AAA and for patients with fewer comorbidities and life expectancy >10 year, because this procedure has reduced rates of long-term leakage and rupture. Endovascular repair is suitable for patients with infrarenal AAA, higher surgical risks, and lower life expectancy, because it is associated with lower perioperative complications and mortality. Topic

58 VENOUS THROMBOEMBOLIC DISEASESymptoms and signs similar in older and younger patients Most patients with DVT and/or PE are asymptomatic; maintain a high index of suspicion for these conditions, particularly in hospitalized patients and in residents of transitional-care facilities and nursing homes The utility of most routine tests for diagnosing VTED, including blood tests, arterial blood gases, chest radiograph, and ECG, is quite low “Normal” test does not exclude a dx of DVT or PE Older adults are at markedly increased risk of developing VTED, including DVT and PE, due to age-related changes in the hemostatic system that predispose to thrombosis; venous stasis related to illness, injuries (eg, hip fracture), and immobility (especially hospitalization and residence in long-term care); incompetency of the superficial and deep veins, including failure of the venous valves; and the high prevalence of systemic illnesses associated with thrombogenesis (eg, heart failure, cancer, neurologic diseases). The plasma D-dimer level, when performed using ELISA, has a high sensitivity for VTED but very low specificity in older adults. Therefore, a normal D-dimer level in an older patient with low to intermediate clinical suspicion for VTED essentially excludes the diagnosis. Noninvasive tests for DVT include leg venous Dopplers, impedance plethysmography, and CT of the legs; rarely, contrast venography may be required to establish the diagnosis. Topic

59 VTED PROPHYLAXIS Indicated for: Methods:Hospitalized older adults who are not fully ambulatory Residents of transitional care facilities and long-term-care facilities at increased risk of VTED Methods: SC unfractionated or low-molecular-weight heparin Fondaparinux Intermittent pneumatic compression of the calves In long-term-care settings, screening for VTED risk is recommended every 5–7 days. VTED risk factors include age >60 years old, active cancer, acute infection, indwelling central venous catheter, chronic lung disease, dehydration, history of VTED, having a first-degree relative with VTED, heart failure, hypercoagulable state, immobility, inflammatory bowel disease, obesity, rheumatoid arthritis, and treatment with an aromatase inhibitor, hormone therapy, megestrol acetate, selective estrogen-receptor modulator, or erythroid-stimulating agent to a hemoglobin concentration >12 g/dL. Immobility is defined as the presence of ≥1 of the following: being bedridden or bedridden except for bathroom privileges, unable to walk at least 10 feet, recent reduction in ability to walk at least 10 feet for at least 72 hours, and having a lower limb cast. For some risk factors (eg, fractures), VTED prophylaxis is recommended for 35 days. If the individual has ≥2 risk factors and is immobile, prophylaxis for 10 days or until the immobility resolves is recommended. If there is immobility but only a single risk factor, consideration should be given to pneumatic compression with ongoing risk assessment. Topic

60 TREATING ACUTE DVT OR PEIntravenous UFH to maintain the activated partial thromboplastin time in the range of 50−70 seconds (1.5−2 times the control value) Full-dose LMWH adjusted for weight and renal function SC fondaparinux adjusted for weight and renal function Warfarin should be started and heparin or fondaparinux continued until the INR is 2−3 with at least 24-hour overlap Patients who are not candidates for anticoagulation may be considered for an inferior vena caval filter. Although such devices reduce the risk of PE, the risk of recurrent DVT and postphlebitic syndrome may be increased. The duration of warfarin therapy depends on the risk of recurrent VTED. In patients with a first episode of DVT or PE due to a reversible factor (eg, immobilization in the hospital), warfarin should be continued for 3 months. In patients who develop DVT or PE in the absence of an identifiable or reversible cause, warfarin therapy should be continued for at least 6−12 months, and possibly indefinitely. Ultrasonography can be used to document recanalization of the vein after a limited course of anticoagulation. If no recanalization is observed, a longer course of anticoagulation should be strongly considered. Because the efficacy of warfarin for the prevention of recurrent VTED is reduced in patients with cancer, LMWH is recommended for the first 3−6 months of therapy, followed by warfarin indefinitely (or until the cancer is resolved). In patients with recurrent VTED, long-term treatment with warfarin is recommended, and placement of an inferior vena caval filter may be considered in patients with recurrent VTED despite therapeutic anticoagulation. In addition to the above measures, regular exercise, such as walking, is recommended to reduce the risk of recurrent DVT, and elastic compression stockings are recommended for up to 2 years after an episode of DVT to reduce the risk of the postphlebitic syndrome. Topic

61 SUMMARY (1 of 3) Aging is associated with extensive changes throughout the cardiovascular system that lead to: Progressive decline in CV reserve capacity Substantive alterations in the clinical presentation, response to therapy, and prognosis of CVD Older adults account for the majority of patients hospitalized with ACS, and >80% of deaths attributable to ACS occur in patients ≥65 years old Although older patients are at increased risk of major complications from interventions for ACS, age alone should not be considered a contraindication to aggressive therapy. Topic

62 SUMMARY (2 of 3) AF increases in prevalence with age, and 50% of all patients with AF are age 75 years or older Most older patients with AF respond to rate-control medications + antithrombotic therapy, but some require antiarrhythmic drug therapy The prevalence of PAD increases progressively with age, and PAD is a potent risk marker for concomitant CAD and cerebrovascular disease Management of PAD should include appropriate treatment of hypertension, dyslipidemia, diabetes, and tobacco abuse in accordance with existing practice guidelines Topic

63 SUMMARY (3 of 3) The prevalence of aortic stenosis (AS) increases with age, approaching 15% in octogenarians AS is the most common valvular abnormality requiring surgery in older adults The prevalence of DVT and PE increases exponentially with age, because of age-related changes in the hemostatic system that predispose to thrombosis; venous stasis related to illness, injuries, and immobility; incompetency of the superficial and deep veins; and the high prevalence of systemic illnesses associated with thrombogenesis Topic

64 CASE 1 (1 of 4) An 81-year-old man comes to the office for a routine appointment. History includes moderate aortic stenosis for the past 8 years, managed with β-blockers; chronic CAD, prostate carcinoma (stage 2), and mild COPD. He received a left anterior descending artery stent in 2001. At previous appointments, he reported that he felt well and that he was maintaining his normal, active lifestyle. At this appointment, his daughter notes that her father is much less active than in the past. Topic

65 CASE 1 (2 of 4) Echocardiography undertaken last month was limited by poor echo windows due to COPD, but Doppler imaging detected a peak aortic velocity of 6 m/sec, an increase from 3 m/sec 2 years earlier. Topic

66 CASE 1 (3 of 4) Which of the following is true regarding management of this patient? Annual echocardiography is sufficient follow-up. Given that he has no chest pain, syncope, or heart failure, current management is optimal. Addition of nitrates will alleviate the patient’s symptoms. Valve replacement should be considered in the near future. Topic

67 CASE 1 (4 of 4) Which of the following is true regarding management of this patient? Annual echocardiography is sufficient follow-up. Given that he has no chest pain, syncope, or heart failure, current management is optimal. Addition of nitrates will alleviate the patient’s symptoms. Valve replacement should be considered in the near future. ANSWER: D This patient has aortic stenosis, with Doppler echocardiography revealing an increased valvular flow gradient consistent with critical stenosis physiology. Although the patient does not report many symptoms, he has constricted his activity to accommodate the change. Whereas β-blockers are beneficial, valve replacement is indicated when stenosis is significant and there is a high transvalvular gradient. Aortic valve surgery should be considered if the patient is a good candidate. He will need evaluation of cardiac function, coronary artery disease, pulmonary arterial pressures, COPD severity, and renal function. If surgery is contraindicated, transcatheter aortic valve replacement (TAVR) may be an option. TAVR does not offer the technical advantages of surgery, namely, more surgical control and the ability to integrate valve replacement with coronary artery bypass surgery. Risk of stroke is greater with TAVR, although technology and techniques are rapidly advancing and improved outcomes are anticipated. Use of nitrates would likely be counterproductive, because nitrates diminish preload filling of the left ventricle (which is severely thickened and stiff because of aortic valve disease) and might thereby lead to reduced cardiac output. Topic

68 CASE 2 (1 of 4) An 80-year-old man comes to the office for follow-up after a recent hospitalization. Last week he had new- onset chest pain, and a non–ST-elevation myocardial infarction was diagnosed. He received drug-eluting stents to the left anterior descending artery and the first obtuse marginal branch off the circumflex artery. During hospitalization, atrial fibrillation was also diagnosed. At discharge, he was prescribed aspirin, clopidogrel, warfarin, metoprolol succinate, lisinopril, and atorvastatin. Topic

69 CASE 2 (2 of 4) Before the myocardial infarction, his health was good and he had an active lifestyle. Blood pressure and cholesterol had always been within normal range. At today’s office visit, he asks whether he can discontinue the atorvastatin. Topic

70 CASE 2 (3 of 4) Which of the following would be the most appropriate recommendation? Recheck low-density lipoprotein (LDL) cholesterol; if level is ≤70 mg/dL, discontinue atorvastatin. Continue atorvastatin for 3 months, and then recheck LDL cholesterol, because lipid levels may be misleading in the interval after myocardial infarction. Continue atorvastatin. Discontinue atorvastatin and start niacin. Topic

71 CASE 3 (4 of 4) Which of the following would be the most appropriate recommendation? Recheck low-density lipoprotein (LDL) cholesterol; if level is ≤70 mg/dL, discontinue atorvastatin. Continue atorvastatin for 3 months, and then recheck LDL cholesterol, because lipid levels may be misleading in the interval after myocardial infarction. Continue atorvastatin. Discontinue atorvastatin and start niacin. ANSWER: C Use of statins after myocardial infarction is associated with improved mortality and fewer recurrent events. The benefits of lowering cholesterol correspond to the magnitude of change in LDL level; no LDL level has been demonstrated to be the lower limit for benefit from reducing cholesterol. Whereas relatively higher levels (≥40 mg/dL) of high-density lipoprotein (HDL) cholesterol have been found to have some benefit, increasing HDL cholesterol levels after myocardial infarction is not an established clinical intervention. For this reason, substituting niacin for atorvastatin is not indicated. The association of very low cholesterol levels with increased mortality (leading to concern that aggressive therapy could yield untoward effects) may be spurious. It was based on findings from many adults with low cholesterol levels who had concomitant cancer and other chronic diseases. Among patients with coronary artery disease, lowering LDL cholesterol shows unequivocal clinical benefit. Topic

72 Copyright © 2014 American Geriatrics SocietyGNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Michael W. Rich, MD, AGSF and questions by Daniel E. Forman, MD, FACC, FAHA Managing Editor: Andrea N. Sherman, MS Copyright © 2014 American Geriatrics Society Topic