2. Due to Age Related Cardiac and Renal Changes Three Stage Case Exemplar John Agens MD Copyright 2009, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved.

3. Case I: Baseline Heart & Kidney  79 female non productive cough rhinorrhea for 2 days  well controlled high blood pressure, no CHF or CAD  independent in activities of daily living, low vision  no chest pain, orthopnea, or palpitations  BP 146/76 T 97.6 Pulse is 88 R 18 Weight 48kg H 63”  Mini-Cog delayed recall 2 of 3 items, clock normal  crackles R base only, clear with cough  +S4 gallop, 2/6 early systolic murmur LSB, Gait normal  Creatinine 1.2, EKG is normal, Chest X ray is normal

5. Case I: Aging Heart & Vessels Loss of myocytes, hypertrophy of remaining myocytes Decreased compliance of the left ventricle Increased relative contribution of left atrium to C.O. Audible s4 gallop is common in normal aging Increased vascular stiffness causes increased afterload Thickening and calcification of aortic valve common Early-peaking basal systolic murmur: aortic sclerosis Normal diastolic filling pressures at rest Increased end diastolic pressures with exercise/ stress

6. Case I: Aging Kidney Reduced glomerular filtration rate of 10ml/ decade CrCl=(140-age)(weight kg)(0.85 females) / S. Cr. x 72 CrCl= (140-79 )(48kg)(0.85) / (1.2 X72)= 29ml/min Reduced renal blood flow Reduced concentrating and diluting ability Progressive reduced ability to excrete sodium load Decreased responsiveness to antidiuretic hormone Less sodium excretion on NSAIDS versus young persons

7. Case I: Cold or Influenza?

8. Case II: Short of Breath, Fever Same patient has fever, chills, body aches for 3 days Shortness of breath for the past 24 hours ECHO done 3 days prior, aortic sclerosis, normal LVF Patient has been less active for three days No weight gain or loss since office visit 3 days ago BP 122/86, P 120 no orthostasis, T 102 orally, RR 22 Lungs show rales ¼ up both lung bases, O2 sat 90% +S4, soft S3, II/VI systolic M at LSB, +1 edema +JVD GUAG 20 sec., EKG sinus tachy, CXR cephalization

10. Case II: Pneumonia or CHF “Among octogenarians, the predominant presentation of heart failure is in women with systolic hypertension and diastolic dysfunction with preserved ventricular systolic function.”1 How much diuretic and for how long? What about heart rate control? Does the patient have influenza, pneumonia, or both? If you use antimicrobials, which? What dosage? 1 Wenger NK, “Cardiovascular Disease” Geriatric Medicine Fourth Edition, Cassel CK et. al. editor

11. Case III: Morning Rounds Day 2 Low blood pressure 78 systolic after breakfast. Yesterday, the cardiology consultant recommended aggressive diuresis: furosemide 40mg IV q 8 hours BP 82/60 supine. P 84 BPM. T 98.4 degrees F. RR 14 Weight 45kg Delayed recall only 1/3 words, disorganized thinking believes she is at home, easily distracted by noises Neck: no JVD, Lungs: clear, +S4, 2/6 early systolic murmur LSB, no edema

13. Objectives: 1 of 2 Use knowledge of physiology of the normal aging heart to recognize that +S4 is normal in the elderly. Recognize that reduced left ventricle compliance is normal and common in an aging heart. Recognize that heart failure with normal systolic function manifests itself during exercise, stress, or tachycardia and is common in the elderly. Recognize that small changes in circulating volume cause large changes in heart filling pressures.

14. Objectives: 2 of 2 Calculate a creatinine clearance in an elderly patient with a normal serum creatinine. Recognize that the elderly cannot excrete a sodium load as well as the young, especially on ibuprofen. Recognize that reduced ability to concentrate urine, reduced sensitivity to ADH, and reduced ability to excrete sodium plus reduced left ventricular compliance leads to both rapid increases and decreases in left heart filling pressures even with small increases or decreases in circulating volume.

15. References Stoelting Basics of Anesthesia, 5th ed. (Figure slide 11) Wenger NK “Cardiovascular Disease” Geriatric Medicine Fourth Edition, Cassel CK et. al. editor (Quote slide 9) Walsh Palliative Medicine, 1st ed. (CXR image slide 8) Chen MA “Heart Failure with Preserved Ejection Fraction in Older Adults” The American Journal of Medicne 2009 Volume 122, 712-723 Taffet GE “Physiology of Aging” Geriatric Medicine Fourth Edition, Cassel CK et. al. editor