Geriatric hearts Dave Krueger, MD Yakima Heart Center Cardiac Issues 2011.
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Transcript of Geriatric hearts Dave Krueger, MD Yakima Heart Center Cardiac Issues 2011.
Geriatric hearts
Dave Krueger, MDYakima Heart CenterCardiac Issues 2011
Summary
• Similar cardiovascular fundamentals but frequent treatment differences than younger patients.
Dave Krueger, MDYakima Heart Center
• Demographic boom and increasing longevity = more patients.
• My practice: I routinely see about 1/3 of my patients in their 80’s and beyond, most fairly independent.
Dave Krueger, MDYakima Heart Center
• If 80 and independent: average life expectancy is 5-10 more years.
– Don’t sub optimally approach hypertension, cholesterol, and other risks.
– For ex, statins have more prevention of events the older the patient.
– Increasing side effects with age mandate more treatment discussions, more clinical details, including the patient’s individual goals and preferences.
Dave Krueger, MDYakima Heart Center
“Stiffitis”
• Stiffer lipid-laden arteries beget systemic hypertension:
– Which begets CAD/LVH/LAE/LV diastolic dysfunction.
– Which begets elevated LV end diastolic pressure/LA/wedge pressure.
– Which begets dyspnea/CHF/pulmonary hypertension
– Which begets peripheral edema, and often A-fib, MI.
Dave Krueger, MDYakima Heart Center
Cardiovascular Stiffness
• Results in quicker and higher exercise-induced hypertension
• Quicker dyspnea on exertion.
Dave Krueger, MDYakima Heart Center
Diagnosis
• Left atrial dilation is the “canary in the coal mine”
• LA volume index to body size is initially more sensitive than LVH, pulmonary hypertension.
Dave Krueger, MDYakima Heart Center
Geriatric Hypertension
• BP logs:
– Truly do several times per day.
– Expect increasing lability (autonomic dysfunction).
– Foremost, avoid low blood pressure.
– Quiz closely about light-headedness, check posturals, weights.
Dave Krueger, MDYakima Heart Center
Postural instability cofactors
• Peripheral neuropathy
• decreased eyesight
• inner ear problems
• posterior column degeneration of spinal cord
• muscle weakness
• arthritis
Dave Krueger, MDYakima Heart Center
Geriatric hypertension treatment
• Be a LOT less aggressive because of blood pressure lability
• Minimize diuretics (compression stockings)
• “Head more important than feet.”
• Follow creatinine (declines with muscle mass)
• Uric acid equals “pre-renal clue.”
Dave Krueger, MDYakima Heart Center
HTN: Side Effects
• Calcium blockers: constipation, edema, and negative inotropes.
• Alpha blockers: postural hypotension, rebound.
• Beta blockers: bradycardia, fatigue.
Dave Krueger, MDYakima Heart Center
Geriatric Hyperlipidemia
• More near-term prevention the older the patient, so idealize lipids initially, but closely ask about tolerabilty.
Dave Krueger, MDYakima Heart Center
Statins
• Generalized weakness or myalgias often multifactorial:
– Vitamin D deficiency exacerbates, replenishment often alleviates
• Some statin better than none
Dave Krueger, MDYakima Heart Center
Lifestyle changes
• (Late calories equal fat calories) Diet, weight loss, even five pounds helps.
• 30 minutes daily: walk-exercise (even in-house, walker, everything helps).
• Consider water-walking, arthritis-friendly exercise equipment.
• Push all activities (gardening, shopping, socializing).
Dave Krueger, MDYakima Heart Center
Geriatric Anticoagulation
• Atrial fib incidence increases from less than 1% at age 40 to 20-30% age 80 upward.
• Risk and benefit of anticoagulation both increase with age, merits careful discussions and documentation on each visit.
• Consider fall history, instability, postural hypotension, ANY prior bleeding.
Dave Krueger, MDYakima Heart Center
Anticoagulation
• Combination with antiplatelets:
– Aspirin and warfarin dramatically increase bleeding risk (and clopidogrel addition even worse).
– Strictly try to avoid triple therapy in elderly.
– Ask about NSAIDS’s
– Warfarin and antiplatelet RX decrease healing.
Dave Krueger, MDYakima Heart Center
Modified CHADS2
• One point now for ages 65-74, two points for 75 and above.
• One point for hypertension.
• Aspirin-only if zero points, warfarin if two points, consider warfarin if one point.
Dave Krueger, MDYakima Heart Center
Geriatric Intensity of Treatment
• Code status and treatment limitations:
– Hard to initiate talk, do often and sensitively, should be on EVERY CHART OF VERY OLD.
– Put on home fridge their written wishes.
Dave Krueger, MDYakima Heart Center
Geriatric Intervention
• Some not “too old” for intervention.
– 1/3 of open heart valve patients typically over 80 in Yakima.
– Sparkle factor and precise degree of “active.”
– Beware of blob factor.
– Ask “typical day” and their desires.
– Primary care input critical.
Dave Krueger, MDYakima Heart Center
Dementia
• Deal breaker for open heart surgery.
• Primary care assessment helpful for intensity of treatment – consider medical treatment only for even acute MI.
• Pacemakers typically an exception.
Dave Krueger, MDYakima Heart Center
Lifestyle Changes
• Weight loss – Less strict goals for very old
– Plump seems fine (weight loss often = muscle loss)
– Follow girth more than weight.
– Stress activity more than weight loss.
Dave Krueger, MDYakima Heart Center
Geriatric Exercise
• Strength building, aerobic, all activities to “get moving.”
• Cardiac rehab.
• Water walk if balance issues/arthritis.
• Walking in house/walker.
Dave Krueger, MDYakima Heart Center
Conclusions
• Not too old for treatment
• Stiff cardiovascular system = dyspnea
• Increasing BP lability
• Anticoagulation extremely individualized
• Code status and treatment limitations
Dave Krueger, MDYakima Heart Center