1. Geriatric hearts Dave Krueger, MD Yakima Heart Center Cardiac Issues 2011

2. Summary Similar cardiovascular fundamentals butfrequent treatment differences than youngerpatients. Dave Krueger, MD Yakima Heart Center

3. Demographic boom and increasing longevity =more patients. My practice: I routinely see about 1/3 of mypatients in their 80’s and beyond, most fairlyindependent. Dave Krueger, MD Yakima Heart Center

4. If 80 and independent: average life expectancy is5-10 more years. – Don’t sub optimally approach hypertension,cholesterol, and other risks. – For ex, statins have more prevention of events theolder the patient. – Increasing side effects with age mandate moretreatment discussions, more clinical details, includingthe patient’s individual goals and preferences. Dave Krueger, MD Yakima Heart Center

5. “Stiffitis” Stiffer lipid-laden arteries beget systemichypertension: – Which begets CAD/LVH/LAE/LV diastolic dysfunction. – Which begets elevated LV end diastolicpressure/LA/wedge pressure. – Which begets dyspnea/CHF/pulmonary hypertension – Which begets peripheral edema, and often A-fib, MI. Dave Krueger, MD Yakima Heart Center

6. Cardiovascular Stiffness Results in quicker and higher exercise-inducedhypertension Quicker dyspnea on exertion. Dave Krueger, MD Yakima Heart Center

7. Diagnosis Left atrial dilation is the “canary in the coalmine” LA volume index to body size is initially moresensitive than LVH, pulmonary hypertension. Dave Krueger, MD Yakima Heart Center

8. 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, checkposturals, weights. Dave Krueger, MD Yakima Heart Center

9. Postural instability cofactors Peripheral neuropathy decreased eyesight inner ear problems posterior column degeneration of spinal cord muscle weakness arthritis Dave Krueger, MD Yakima Heart Center

10. Geriatric hypertension treatment Be a LOT less aggressive because of bloodpressure lability Minimize diuretics (compression stockings) “Head more important than feet.” Follow creatinine (declines with muscle mass) Uric acid equals “pre-renal clue.” Dave Krueger, MD Yakima Heart Center

11. HTN: Side Effects Calcium blockers: constipation, edema, andnegative inotropes. Alpha blockers: postural hypotension,rebound. Beta blockers: bradycardia, fatigue. Dave Krueger, MD Yakima Heart Center

12. Geriatric Hyperlipidemia More near-term prevention the older thepatient, so idealize lipids initially, but closelyask about tolerabilty. Dave Krueger, MD Yakima Heart Center

13. Statins Generalized weakness or myalgias oftenmultifactorial: – Vitamin D deficiency exacerbates, replenishmentoften alleviates Some statin better than none Dave Krueger, MD Yakima Heart Center

14. Lifestyle changes (Late calories equal fat calories) Diet, weightloss, even five pounds helps. 30 minutes daily: walk-exercise (even in-house,walker, everything helps). Consider water-walking, arthritis-friendlyexercise equipment. Push all activities (gardening, shopping,socializing). Dave Krueger, MD Yakima Heart Center

15. Geriatric Anticoagulation Atrial fib incidence increases from less than 1%at age 40 to 20-30% age 80 upward. Risk and benefit of anticoagulation bothincrease with age, merits careful discussionsand documentation on each visit. Consider fall history, instability, posturalhypotension, ANY prior bleeding. Dave Krueger, MD Yakima Heart Center

16. Anticoagulation Combination with antiplatelets: – Aspirin and warfarin dramatically increase bleedingrisk (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, MD Yakima Heart Center

17. Modified CHADS2 One point now for ages 65-74, two points for75 and above. One point for hypertension. Aspirin-only if zero points, warfarin if twopoints, consider warfarin if one point. Dave Krueger, MD Yakima Heart Center

18. 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, MD Yakima Heart Center

19. Geriatric Intervention Some not “too old” for intervention. – 1/3 of open heart valve patients typically over 80in Yakima. – Sparkle factor and precise degree of “active.” – Beware of blob factor. – Ask “typical day” and their desires. – Primary care input critical. Dave Krueger, MD Yakima Heart Center

20. Dementia Deal breaker for open heart surgery. Primary care assessment helpful for intensityof treatment – consider medical treatmentonly for even acute MI. Pacemakers typically an exception. Dave Krueger, MD Yakima Heart Center

21. 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, MD Yakima Heart Center

22. Geriatric Exercise Strength building, aerobic, all activities to “getmoving.” Cardiac rehab. Water walk if balance issues/arthritis. Walking in house/walker. Dave Krueger, MD Yakima Heart Center

23. Conclusions Not too old for treatment Stiff cardiovascular system = dyspnea Increasing BP lability Anticoagulation extremely individualized Code status and treatment limitations Dave Krueger, MD Yakima Heart Center