Geriatric Cardiology – You CAN treat Angina!
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Transcript of Geriatric Cardiology – You CAN treat Angina!
• No speakers’ bureaus• No device or pharmaceutical manufacturers• General cardiologist with focus on angina,
critical care, prevention• Edgar Leifer Professor of Clinical Medicine• Chief, Allen Hospital Medical Service• Director, House Staff Training Program
Angina 2012 2
• Clinical Case – Dr. MS• Definitions• Epidemiology• Physiology• Clinical evaluation• Medical therapies• Non medical therapies• Conclusion
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• Refocus concern from angina as an entity to a symptom of ischemia
• Reinforce current concepts of pathophysiology of ischemia
• Review current therapies of ambulatory management for primary care
• No discussion of ACS (Unstable Ischemic Heart Disease)
• Emphasis on Geriatric issues
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• 10 year history of CAD– Risks: Hypertension – EKG showed RBBB
for 20 years– Murmur of AI – Symptoms of chest
pressure and DOE – LAD 90% prox, 90% mid – 4 stents
• 2 years of chest pressure– Onset with swimming– Negative stress test– Relieved with
treatment with PPI
• Current – walking induces chest pressure, relieved by rest
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• Current meds– Beta blocker
– Aspirin
– Statin
• Exam– BP 120/60 P 68
– Chest – clear
– Heart – 2/4 diastolic blow along left sternal border
– JVP normal
– EXT – no edema
• Lab studies– Hct 42 Hgb 14.2
– Creat 1.0
– CXR: Mild cardiomegaly
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NUCLEAR STRESS: SCAN NEGATIVE• * Symptom: Chest pain. • * HR Response: HR failed to increase
appropriately, likely due to medications. • * BP Response: Appropriate. • * ECG Abnormalities: ECG changes could not
be interpreted due to abnormal baseline ECG. • * Arrhythmia: Frequent VPDs. *• *Review of raw data shows: diaphragmatic
artifact • * The left ventricle was normal in size.
• Normal myocardial perfusion scan, with no evidence of infarction or inducible ischemia.
• * Gated wall motion analysis is performed, and shows normal wall motion with rest LVEF of 65% and post stress LVEF of 61%.
• *** Conclusions *** • The patient had a possible anginal symptom
during exercise in the absence of SPECT evidence of ischemia at a heart rate of 110/min.
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• Who was William Heberden?– English physician 1710-1801– Classic description 1768
“They who are afflicted with it, are seized while they are walking, (more especially if It be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or to continue; but the moment they stand still, all this uneasiness vanishes. “
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DEFINITIONS
• Greek : ἀγχόνη ankhone ("strangling")
• Latin: angina = “throat inflammation”
• Merriam Webster: “A disease marked by spasmodic attacks of intense suffocative pain.”
• ICD 9: 413; ICD 10: 120• Spanish: “Dolor de Pecho”
EPIDEMIOLOGY
• Only 18% of coronary attacks are preceded by longstanding angina
• New episodes increase with age and are more frequent in African Americans
• DEATH IS INFREQUENT
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– Asymptomatic– Silent ischemia– Angina– Acute coronary syndromes
• Unstable Angina• Myocardial infarctions
– Sudden cardiac death– Congestive heart failure
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DEMAND • Heart Rate• Contractility• Wall tension
T=Pr/2h– Preload (r)– Afterload (P)– Wall thickness
(h)
SUPPLY• O2 carrying capacity
– Hemoglobin
• Coronary blood flow– Perfusion pressure
• Aortic vs. end diastolic
– Vascular resistance• Neural control
•Lesions
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• Asymptomatic– Relaxation – S4– Contraction – S3, mitral regurgitation– Electrical – repolarization
• Symptomatic– Angina, Dyspnea, Arrhythmias
• Cellular integrity – no change, stunning, hibernation
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• Risk Factors– Framingham – Age, Gender, Family History,
Smoking, Diabetes, Hypertension, Hyperlipidemia
– ATP III – Prior CAD, Peripheral Arterial Disease = Coronary risk equivalents
– Elderly age risk factors:• Urinary albumin excretion• Pulse pressure • Arterial Stiffness
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J Am Geriatr Soc 52:1639–1647, 2004•Prospective Population Based Study•> 65 yo, 1954 men, 2931 women, followed 7.5 years
„most lipid measures were weakly associated withcardiovascular events. The association between low HDLC
and increased MI risk was nonetheless strong and consistent.”
• History – 95% specific classically– Look for equivalents
• Dyspnea• Shoulder or back pain• Weakness, fatigue• Epigastric discomfort
– Consider physical exertion levels– Silent ischemia seen in 20-50% of patients 65 years or
older.– Adjust for population at risk (age, gender, comorbidities)– Identify stability
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• Typical Angina– Substernal chest
discomfort with characteristic quality and duration
– Provoked by exertion or emotional stress
– Relieved by rest or NTG
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• Dyspnea
• Indigestion
• Back, arm, neck, wrist pain
• Burning
• Pressure
• Rest, recumbency
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• TABLE 1. Grading of Angina of Effort by the Canadian Cardiovascular Society
I. "Ordinary physical activity does not cause ... angina," such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation.
II. "Slight limitation of ordinary activity." Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.
III. "Marked limitation of ordinary physical activity." Walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace.
IV. "Inability to carry on any physical activity without discomfort - anginal syndrome may be present at rest."
Campeau, L “Grading of Angina Pectoris” Letter to the Editor
CIRCULATION 1976: 54: 522-23
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• Determine remediable factors
• Identify patients at high risk– Anatomy – Left main > 50%; Three vessel– Physiological – Impaired LV function– Functional – unstable state
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• Physical Exam – remediable factors– VS: Heart rate, BP, T,
RR
– Chest – congestion
– Heart – enlargement, valvular disease, failure
– Vascular – obstruction, congestion
– Extremities - edema
• Lab Studies – remediable factors– CBC – anemia
– Basic metabolic panel – glucose, renal function
– Lipid Panel
– (Thyroid function)
– EKG
– Chest X Ray
– (Echocardiogram)
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• Aging increases the prevalence of CAD but is masked by the co-morbidities that reduce activity. [Schwartz,Zipes in Braunwald 9th]
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• Exercise - ?modified protocols– Treadmill
– Bicycle
• Exercise with imaging
• Pharmacologic with imaging
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• Hypotension with exertion• Inability to exercise beyond stage II of Bruce
protocol (6 minutes) – NOT APPLICABLE IN THE ELDERLY
• ST depression more than 2 mm• ST elevation in the absence of q waves• Ventricular arrhythmias with ischemia• Pulmonary uptake of thallium• 2 or more zones of ischemia
REFER PATIENTS WITH HIGH RISK FOR ANGIOGRAPHY
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• GI – GERD, biliary• Neuro – cervical radiculopathy• Chest wall – costochondritis, intercostal
neuralgia• Pulmonary – pleural, parenchymal• Vascular – aortic, pulmonary
Pitfalls: Placebo response, Concurrent inactive disease
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• Relieve pain, discomfort
• Improve function• Avert further
atherosclerotic complications– Sudden death– Congestive heart failure– Acute coronary
syndromes
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• 2002 guideline update for the management of patients with chronic stable angina
• www.acc.org/clinical/guidelines/stable/stable.pdf
• Diagnosis• Risk Stratification• Treatment• Follow Up• References (1052)• 2007 update: Circulation
2007; 116: 2762
Angina 2012
(From Schwartz JB: Clinical Pharmacology, ACCSAP V, 2003. As modified from Nolan L, O’Malley K: The need for a more rational approach to drug prescribing for elderly people in nursing homes. Age Aging 18:52, 1989; and Denham MJ: Adverse drug reactions. Br Med Bull 46:53, 1990.)Figure 80-6 Schwartz and Zipes, Braunwald.
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• Cost**
• Difficulty with understanding directions (hearing, sight)
• Inadequate instruction**
• Complete dosing regimens
• Packing material
• Insufficient education of patient, family, or caregiver
• Cognitive impairment**
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