Geriatric Cardiology

Adam Hajduk

Population Projections in the U.S.:

2000-2050
Population in millions

50
40

Women >65
Men > 65
Women > 85
Men > 85

30
20
10
0
2000

2010

2020

2030

2040

2050

Hospital Mortality for

Cardiovascular Causes

Acute MI
Arrhythmias
Heart failure
Cerebrovascular disease

Total deaths
(in thousands)
78
17
42
65

Age > 65
68 (87.2%)
12 (70.6%)
37 (88.1%)
49 (75.4%)

Source: National Hospital Discharge Survey, 1998.

EFFECTS OF AGING ON THE

CARDIOVASCULAR SYSTEM

Principal Effects of Aging on

Cardiovascular Structure and Function

Increased vascular + myocardial stiffness

Decreased -adrenergic and baroreceptor
responsiveness
Impaired sinus node function
Impaired endothelial function

CV Changes: Max Exercise - Ages

20 and 80 Years
Oxygen consumption

Reduced ~ 50%

AV oxygen difference

Reduced ~ 25%

Cardiac output

Reduced ~ 25%

Heart rate

Reduced ~ 25%

LV stroke volume

Reduced ~ 15% to 25%

LV end diastolic volume

No change or small
decrease

LV end systolic volume

Increased ~ 150%

LV ejection fraction

Reduced ~ 15%

Age Changes in Systolic and

Diastolic BP

Source: J Gerontol Med Sci 1997;52:M177-83

Arterial Wall Compliance and Pulse Pressure Wave

Elastic Vessel
Systole Diastole

Stiff Vessel
Systole Diastole

Stroke Volume

Aorta

Resistance
Arterioles
Pressure (Flow)
Young Artery
Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.

Arteriosclerotic Artery

Clinical Implications

Increased systolic BP and pulse pressure

Increased prevalence of atrial fibrillation,
heart failure, especially heart failure with
preserved LV function
Increased prevalence of bradyarrhythmias
and sick sinus syndrome
Worse prognosis associated with all CV
diseases

CORONARY HEART DISEASE

Ischemic Heart Disease in the Elderly

Leading cause of death

35% of all deaths in people over age 65
Among people who die of IHD, 83% are over
age 65
CV mortality and morbidity rates increase
exponentially after age 75
6% US population over age 75
60% MI related deaths in people over age 75

IHD characteristics in the elderly

increase in percentage of female patients

more complex and calcified coronary artery lesions

more often impairment of LV function

more often complicated myocardial infarction

coexisting diseases (HA, DM, renal function

impairment)

delayed visiting at the doctors and diagnosis

Prevalence of Coronary Heart Disease

by Age and Sex
20%
15%
Male

10%

Female

5%
0%
25-44

45-54

55-64 65-74
75+
Age, years
Source: National Health and Nutrition Examination Survey

IHD clinical picture in the elderly

1. Stenocardia

Its frequency decreases with age (causes):

increase in threshold of pain

pain-killers intake
dementia
acceptance of pain as inevitable in elder age
limited physical activity (effort-induced angina is less
often)
well-developed collateral circulation
stenocardial pain
more rare typical localization (retrosternal)

IHD clinical picture in the elderly

2. Exertional dyspnea
The most common symptom of myocardial ischemia in the elderly
ischemia
LV compliance

LV end-diastolic
pressure

3. Increasing symptoms of heart failure

4. Acute LV failure (pulmonary oedema)
by patients >70 years with pulmonary oedema and IHD 1-year mortality
rate = 50%, 2-year = 70%
5. Fatigue or weakness during or after physical effort
6. Rhythm disturbances
7. Neurological symptoms
8. Silent ischemia

Clinical picture of myocardial infarction

1. Chest pain occurrance frequency decreases with age

< 65 years
80% of persons
6674 years 72%
> 75 years 49%
2. Heart failure (dyspnea, pulmonary oedema)
< 65 years 14 % of persons
6674 years 20 %
> 75 years 40 %
(Gregoratos, Am. J. Ger. Cardiol. 2001)

Clinical picture of myocardial infarction

3. Neurological symptoms (balance disturbances, vertigo, consciousness
disturbances, faintness, ischemic stroke)
4. Rhythm disturbances (esp. ventricular)
5. Abdominal symptoms (symptoms resembling peptic ulcer disease, biliary colic,
pancreatitis)
6. Acute renal failure
7. Sudden death
8. Silent infarction (up to 50% of all infarction cases in the elderly)

Some infarction cases remain unrecognised or recognised with substantial delay due to
atypical symptomatology.
(25% of ECG-recognised infarction cases were clinically undiagnosed Framingham
Study).

GUSTO-I
Delayed recognition of infarction in patients > 65 years is 2040
minutes
MITRA Register
Average delay > 75 years is 210 min. compared to 155 min. among
younger patients
(Haase KK i wsp. Clin Cardiol 2000,23)

IHD diagnostics causes of diagnostic difficulties in

the elderly

atypical symptomatology
coexisting diseases (overlapping symptoms, misleading clinical
picture) and polypragmasy
difficulties in carrying out and interpreting diagnostic tests
hindered cooperation with a patient
ECG changes hindering diagnosis of ischemia

IHD diagnostics in the elderly

1. Resting ECG
more common abnormalities in initial ECG (non-specific changes of STsegment, atrio- and intraventricular conduction disturbance, hypertensioninduced LV hypertrophy)
frequent intake of digitalis glycoside affecting ECG curve
2. 24-hour ECG monitoring
(useful in diagnostics of silent ischemia)

3. Exercise testing
Limited diagnostic value:
age-related changes in physiological response to exertion (reduction in aerobic
capacity, decrease in maximum heart rate 1/min/year, faster increase in systolic BP
value, limited increase in ejection fraction)
less intensive physical activity and bad physical condition (difficulties in reaching
target rate of 85% of the maximum predicted HR)
fast reaching of the target rate at a low stage of the exercise test
(initial tachycardia)
the ability to exercise is often limited by conditions unrelated to the heart (e.g.
arthritis, neurologic disorders balance disturbances, vertigo; peripheral vascular
disease)
elderly persons may not exercise maximally because of psychologic factors (e.g.
unfamiliarity with vigorous exercise and sophisticated medical equipment, fear,
insufficient motivation).
frequent abnormalities in resting ECG (LBBB, LV hypertrophy, pacemaker, drugs)

4. Perfusion scintigraphy
test useful in elderly population
abnormal Thallium-201 test result examined as the only parameter the
most sensitive indicator of the cardiac complications risk.
limitations similar to those of the exercise test (exertion may be replaced
with dipyridamole)
possibility of conducting isotopic ventriculography
(evaluation of LV function)

5. Stress echocardiography
exercise testing / pharmacologic stress testing with use of:
dobutamine, adenosine, dipyridamole

diagnostic and prognostic value of the test positive results indicates

significantly higher risk of major adverse cardiac events
sensitivity 79%, specificity 88%
safe and well-tolerated
technical limitations: anatomical conditions, obesity,
worse chest mobility, emphysema
the most frequent adverse symptoms: decrease in BP, atrial fibrillation.

6. Coronarography
reference method (gold standard)

Prognosis after AMI by Age

Source: Circulation 1996;94:1826-33

Vaccarino et al Ann of Int Med 2001; 134: 173-181. Solid lines are men; dotted lines
are women.

Who has an Acute MI? Numbers

from the ED

8%
15%
20%
30%
22%
5%

younger than 50
5059
6069
7079
8089
>90

Efficacy of Aspirin by Age: ISIS-2

25%
20%

Placebo

15%

Aspirin

10%
5%
0%

< 60

60-69
Age, years

70+

Source: Lancet 1988;II-349-60

Long-term Benefits of Aspirin

25%
20%

P < 0.00001
P < 0.00001

15%

Aspirin

10%

Control

5%
0%
< 65
65+
Age, years
Source: BMJ 1994;308:81-106

% Eligible AMI patients given ASA in ED

(Annals Emergency Medicine 2005)
100
90
80
70
60
50
40
30
20
10
0
<50
(n=169)

50-59

60-69

70-79

80-89
(n=461)

>90

% Given Beta Blockers in ED

(Annals Emergency Medicine 2005)

80
70
60
50
40
30
20
10
0
<50

50-59

60-69

70-79

80-89

>90

% Eligible AMI patients given reperfusion

(Annals Emergency Medicine 2005)

90
80
70
60
50
40
30
20
10
0
<50
(n=62)

50-59
(n=96)

60-69
(n=107)

70-79
(n=117)

80-89
(n=69)

>90
(n=9)

Source: Am Heart J 2001:142:37-42

Risk Stratification

Age is a huge risk factor for bad outcomes

Patients over age 75 are at high risk for
death/recurrent MI.

Patients < 65 with NSTEMI have 1% hospital

mortality.
Patients > 85 have 10% hospital mortality with
NSTEMI.

Complications of recurrent MI, CHF,

bleeding increase with age.

ATRIAL FIBRILLATION

Atrial Fibrillation and

Anticoagulation

Prevalence:
5% of people over age 65
10% of people over age 80

50% of all patients with FA are over age 80

Dreaded outcome: Stroke

Strokes with FA have higher

mortality/disability

Age and Stroke Risk

Incidence of stroke with FA increases with age:

1.3 %/year in patients 5059

2.2 %/year in 6069
4.2 %/year in 7079
5.1 %/year in 8089

But it is much more complicated

Predicting Risk of Stroke

CHADS2

CHF: 1 point
HA: 1 point
Age over 75: 1 point
DM: 1 point
Prior Stroke/TIA: 2 point

Score 0 = annual stroke risk <1% (ASA alone)

Score 1= individualized treatment decision
2 or more: annual stroke risk over 4%: warfarin

Score 5 = over 10%/year stroke rate

Score 6 = over 15%/year stroke rate

Benefit of Warfarin

Overall decreases risk of stroke by 6070%,

ARR of 2.73 %/year
Beneficial in all age groups, even those over
age 75
?Quality of life of preventing a stroke

ARR - absolute risk reduction

Risks of Warfarin

Risk of warfarin associated bleeding

increases with age
Risk ICH: 0.34 %/year in age less than 60,
0.76% /year in those over 80
Absolute risk of major bleeding = 2.2%
/year (increases to near 3% in those on
warfarin plus ASA)

Warfarin Use

Older patients less likely to receive

anticoagulation
Older patients more likely to be
underanticoagulated even though data is
clear that there is no significant stroke
protection at an INR of less than 2.

Warfarin in Older Patients

Patients under age 65 with FA and risk

factors for stroke: warfarin decreases risk of
stroke from 4.9 %/year to 1.7 %/year
In patients over 75 with risk factors (highest
risk group), warfarin reduces risk of stroke
from 12 %/year to 24 % /year.
Those at highest risk for stroke (older, prior
stroke, CHF, DM, HA) are less likely to be
given warfarin because of concerns for their
comorbidities.

HYPERTENSION

Hypertension - Prevalence
one of the in aging diseases

HA seen in over 60% of those over age 65

Elevations of SBP with decreases in DBP common with age due

to diminished arterial compliance (increased Pulse Pressure)

SH accounts for 65-75% HA in those over 65

Characteristics of Hypertension in the Elderly

Increased
Systolic blood pressure and pulse pressure
Left ventricular mass and wall thickness
Arterial stiffness

Calculated total peripheral resistance

Decreased

Cardiac output and heart rate

Renal blood flow, plasma renin activity, and angiotensin II levels
Arterial compliance and blood volume
Diastolic blood pressure

Mean Systolic and Diastolic BP by Age and Race/Ethnicity for Men and
Women (US Population Age 18 Years, NHANES III)
150

130
110

Non-Hispanic Black
Non-Hispanic White
Mexican American

SBP
(mm Hg)

SBP
(mm Hg)

150

110

DBP
(mm Hg)

80

70

70
0

150

150

SBP
(mm Hg)

130
110

130
110

Pulse pressure

80

Pulse pressure

80

DBP
(mm Hg)

SBP
(mm Hg)

DBP
(mm Hg)

80

DBP
(mm Hg)

130

70
0

18-29 30-39 40-49 50-59 60-69 70-79

Men, Age (y)

Burt VI, et al. Hypertension. 1995;25:305-313.

80+

70
0

18-29 30-39 40-49 50-59 60-69 70-79

Women, Age (y)

80+

Forms of hypertension in the elderly

isolated systolic hypertension (IHS):

62,867,4% caused by an age-related increase
in arterial stiffness, more common among women

systolic-diastolic hypertension:
27,630,3%

diastolic hypertension sporadically

The Importance Of SH

SH associated with increased risks of CAD,

LVH, renal insufficiency, stroke and
cardiovascular mortality

SH and pulse pressure more closely associated

with CV risk than diastolic BP in older patients
(even in older patients with diastolic HTN)

The aim of treatment

to maintain SBP values < 140 and DBP < 90 mmHg, by diabetic
patients < 130 and < 85 mmHg respectively

achievement of the therapy goal should be stretched over a long

period of time (longer than by younger patients), up to several
months in some cases

it is useful to set some staging posts of the therapy, e.g.

reaching the BP values of 160/90 mmHg

such symptoms as: ill-being, vertigo, balance disorders, vision

disorders (e.g. scotoma), confusion decreasing the dosage or
changing the group of antihypertensives

the higher initial BP values are, the more carefully they should
be reduced

Treatment benefits

Isolated systolic hypertension

over 50% of cases of hypertension in the elderly (main arteries

stiffness)

SBP value and pulse pressure are crucial prognostic factors of

hypertension complications in the elderly

cardiovascular mortality rate is almost three times higher as

compared to other hypertension forms

first-line treatment Calcium antagonists and diuretics

Meta-analysis (SHEP, Syst-Eur, Syst-China, HEP, MRC-2, EWPHE)

14 825 elderly persons with ISH

reduction in:

all-cause mortality rate by 14%

cardiovascular mortality rate by 20%

fatal and non-fatal cardiovascular events rate by 20%

stroke rate by 33%

Dementia

Hypertension is one of the primary factors leading to dementia in the

elderly (vasogenic dementia as well as Alzheimers disease)
patients with untreated hypertension may develop dementia in
advanced age
Alzheimers disease: cerebral microflow disturbance due to
persisting increased arterial blood pressure (collagen deposition
and thickening of basement membrane of capillaries slowing
down the pace of transporting nutritious substances into neurons
as well as of elimination of toxic waste products
dementia can be a common consequence of a stroke (hypertension
complications); patients with hypertension > 84 years tend to have
ten times higher incidence of stroke than patients aged 55-64

Dementia (cont.)

Syst-Eur Study:
4700 patients > 60 years, treated for ISH (nitrendipine)
diagnosed dementia by 50%
(Alzheimers and vasogenic types)
PROGRESS Study
6150 patients with/without hypertension, history data: ischemic stroke
or TIA (perindopril /+indapamide);
dementia rate by 34%
stroke rate by 28%

Lifestyle Modifications
Modification

Approximate SBP
Reduction
(range)

Weight Reduction

5-10 mmHg/10kg

Adopt DASH eating plan

8-14 mmHg

Dietary sodium reduction

2-8 mmHg

Physical activity

4-9 mmHg

Moderation of alcohol
consumption

24 mmHg

Which agent is best?

Thiazide Diuretics: First Line in large trials

ACE inhibitors

LIFE (Losartan Intervention for Endpoint Reduction): Losartan vs Beta

blocker

HOPE (Heart Outcomes Prevention Evaluation)

Losartan decreased risk CV events

Patients with DM, over 55, CVD risk

Ramipril 10/day decreased morbidity/mortality at 5 yrs
Most pronounced effect seen in those over age 65

Ca Channel Blockers

SHELL (SH in Elderly: Lacidipine Long Term Study)

CCB and thiazide similar effectiveness

Which agent?

Beta Blockers may not be first line

LIFE study (25 events/1000 patient years in those on losartan vs 35

events/1000 pt yrs on atenolol)

Meta-analysis of 10 trials, 16000 older patients with SH

Diuretic better than B blocker in preventing combined endpoint

Beta blockers and diuretics decreased risk of stroke, BUT
Beta blockers were not effective at preventing CAD, CV mortality or all cause
mortality

CONTRAINDICATIONS: COPD (chronic obstructive pulmonary

disease), peripheral vascular disease, bradycardia, heart blocks

BSH (British Society of Hypertension) / NICE (National

Institutes for Health and Clinical Extension)
recommendations, 2006
treatment algorithm for patients with hypertension > 55 years
1st-line Ca-blocker or diuretic
2nd-line ACEI + Ca-blocker or ACEI + diuretic

3rd-line ACEI + Ca-blocker + diuretic

4th-line -blocker
intensificaction of diuretic treatment

-blocker
consider consulting with a specialist

Therapy failures (reasons)

secondary hypertension

coexisting diseases

drugs (NSAID, steroids)

improper drugs intake (e.g. therapy breaks when BP returns to

normal)

polypragmasy (incl. improper combinations of antihypertensive

drugs)

white-coat hypertension

too expensive drugs

Secondary hypertension
every sixth elderly patient with hypertension
Causes

renal diseases (renal artery stenosis, a kidney disorder e.g. polycystic

kidney disease, glomerulonephritis, chronic pyelonephritis)

endocrine disorder (eg, Cushing's syndrome, hypothyreosis, primary

aldosteronism, pheochromocytoma)

drugs (steroids, NSAID, B2-agents)

alcohol abuse

Secondary hypertension should be always considered in cases of sudden

development of hypertension, drug-resistant hypertension and fast
increasing renal failure.

Quality of Life

Studies demonstrate no significant impact with treatment

ACE inhibitors/ARBs have better profile

CCBs well tolerated

Sexual dysfunction most commonly reported with thiazides

Nonselective Beta blockers reported to have some subjective negative effects

on cognition and mood

Higher risk of Postural hypotension (30%)

Orthostatic hypotonia

SBP by at least 20 mmHg, often along with DBP by min. 10

mmHg after postural change (from recumbent into standing).
We measure BP after a patient has been standing quietly for at
least 1 minutes (and then after 3 minutes)

particularly common in the elderly with hypertension

15 to 20% of community-dwelling and about 50% of

institutionalized elderly persons

10% of physically fit and > 50% of infirm persons > 65 years

Pathomechanism
Postural
change

lower limbs blood hold

venous return

stroke volume

carotid sinus flow

(baroreceptors stimulation)
HR i stroke volume
(beta-adrenergic stimulation)

Orthostatic hypotonia effects

sudden cerebral circulation decline ( stroke risk)

deterioration in coronary circulation (myocardial ischaemia /

infarction)

injuries, sometimes life-threatening (as a consequence of vertigo,

balance disturbances)

psychological trauma, anxiety of physical activity, leading to

infirmness

symptoms: vertigo, balance disturbances, dizziness, faintness,

falls and trauma, vision disorders, TIA, stenocardia, nausea

Predisposing factors

venous insuficiency (obesity, lower limbs varices, sedentary life

style, aging processes in veins walls)

disturbances of BP autonomic control (impairment of a

baroreceptor mechanism, lesser variability of HR, a reduction in
density and sensitivity of beta-receptors, peripheral neuropathy)

impaired cerebral circulation and cerebral vessels autoregulation

dehydration, low-sodium diet

drugs (diuretics, alfa-blockers, nitrates, anti-Parkinsonic,

phenothiazines, tricyclic antidepressants)

Management

slow postural change

raised-waist clothes

pressure stockings for patients with venous insufficiency

careful implementation and dosage of drugs which can intensify

hypotonia

orthostatic hypotonia test after each change of dosage or

implementation of a new drug

alternatively consider pharmacological treatment (fludrocortisone,

caffeine, ephedrine)

Conclusions

There is rapid global growth in the number

of elderly patients with CV disease
Mortality from CV disease is high in elderly
patients
Evidence-based therapy is highly effective in
elderly patients
Careful selection and tailoring of such
therapies is mandatory for elderly patients
with CV disease

Take Home Points

Age is only one factor; frailty and age are

not the same thing.
There need to be increased numbers of older
adults included in trials, and these patients
should be similar to older community
patients and younger trial patients.