1. Heart Health in the Elderly “Less is More” Kevin Overbeck, DO Assistant Professor, NJISA

2. Learning Objectives Apply knowledge of Aging Physiology to the most common clinical presentations in primary care – Hypertension + Dyslipidemia On the basis of current evidence, evaluate therapeutic goals and intensity of treatment of Hypertension & Dyslipidemia in the elderly.

3. Aging Physiology: Body Composition Lipid Compartment Expands Total Body Water (mainly ECF) declines Lean Muscle Mass Declines Application: Implications for Drug Prescribing

4. HYPERTENSION & THE ELDERLY

5. Increased thickness of the intima and the media  INCREASED VASCULAR STIFFNESS Aging Physiology

6. Pearson, J.D., Morrell, C.H., Brant, L.J., Landis, P.K., and Fleg, J.L. (1997). Age- associated changes in blood pressure in a longitudinal study of healthy men and women. Journal of Gerontology, 52, M177–83.

7. Aging Physiology Increased BP variability Impaired BP homeostasis –Hypertension –Postural (orthostatic) hypotension –Post-prandial hypotension 1.Huang CC, et al. Effect of age on adrenergic and vagal baroreflex sensitivity in normal subjects. Muscle Nerve. 2007;36(5):637-42. 2.Jansen RW, et al. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med. 1995;122(4):286 Consequences of Baroreceptor Changes 1

8. HTN & The Elderly Orthostatic BP Measurement Sitting-Standing vs. Laying-Standing After standing wait 1 minute vs. 3 minutes vs. 5 minutes At least a 20 mmHg fall in systolic pressure At least a 10 mmHg fall in diastolic pressure Symptoms of cerebral hypoperfusion Parkinson’s / Lewy Body Dementia Decreased Baroreceptor Sensitivity 1 Postprandial Hypotension

9. HTN & The Elderly HYVET Becket, NS, Peters, R, Fletcher, AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008; 358(18): 1887-1898.

10. HTN & The Elderly HYVET Becket, NS, Peters, R, Fletcher, AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008; 358(18): 1887-1898.

11. JNC 7: Clinical Practice Guidelines Life style Modification (LSM) Laboratory The Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII), August 2004. BP ClassificationSystolic (mmHg) Diastolic (mmHg) Initial Therapy Normal<120<80Encourage LSM Pre-Hypertension120-13980-89LSM + No Anti-Hypertensive Drug Indicated; Treat patients with CKD or DM to a goal <130/80 mmHg Stage 1140-15990-99LSM + Thiazide diuretics for most Stage 2> 160>100LSM + Two drug combination for most * * Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Ambulatory BP Monitoring Self Measuring BP Assess Risk Factors

12. JNC 8: Clinical Practice Guidelines individuals >60 years old Life style Modification (LSM) Laboratory 2014 Evidenced-Based Guideline for Management of High Blood Pressure in Adults: Reported from the Panel Members Appointed to the Eight Joint National Committee (JNC 8). JAMA FEB 2014. BP ClassificationSystolic (mmHg) Diastolic (mmHg) Initial Therapy Pre-HypertensionDeleted / Omitted DM<140<90LSM + No Anti-Hypertensive Drug Indicated CKD** (<70)<140<90Previous less than 130/80 Goal<150<90LSM + ACE or ARB or DIURETIC or Calcium Channel Blocker ** “based on evidence the committee cannot make a recommendation for individuals 70 and older” Ambulatory BP Monitoring Self Measuring BP Assess Risk Factors

13. JNC 8: Applied Geriatrics An 78 year old female with previous CABG presents to the office for an evaluation of her chronic medical conditions including hypertension. She continues to feel well and is new to your practice as she just moved from Florida to New Jersey to be closer to her daughter. Today her blood pressure 130/70 which is identical to her previous blood pressure last visit two months ago. Amlodipine 2.5 mg daily Aspirin 81mg daily HCTZ 12.5mg daily KCL 10meq daily Lisinopril 10mg daily Metoprolol XL 50mg daily Omeprazole 20mg daily Atorvastatin 10mg daily What is the next best step in the management of this patient’s condition? (A)Stop Amlodipine (Norvasc®) (B)Stop Hydrochlorothiazide (HCTZ) (C)Reduce Metoprolol XL (Lopressor XL ®) (D)Reduce Lisinopril (E)Reassurance / continue current medication regimen MEDICATION LIST

14. JNC 8: Applied Geriatrics An 85 year old female presents to your outpatient ambulatory office following a hospital evaluation (09/06/2014 – 9/10/2014) for shortness of breath. She was diagnosed and treated for an acute exacerbation of COPD. She was upgraded from an inhaler to a nebulizer. She also reports that her blood pressure was high in the hospital with records indicating 172/92 on day 3 and they recommended that she start AMLODIPINE (NORVASC®) 5mg every AM and follow-up with you for blood pressure checks. Today her blood pressure is 144/88. Your records indicate that her blood pressure was controlled at the time of last visit during August 2014. DISCHARGE MED LIST: 1.Aspirin 81mg daily 2.Amlodipine 5mg daily 3.Prednisone Taper 4.Albuterol Nebulizer QID PRN 5.Lisinopril 10mg daily 6.HCTZ 12.5mg daily 7.Omeprazole 20mg daily 8.KCL 10meq daily 9.Vitamin D 1000 IU daily 10.Alendronate 70mg qHS 11.Pravastatin 40mg qHS

15. Medications Known To Increase BP Steroids Sympathomimetic Drugs Decongestants NSAIDS Erythropoietin

16. JNC 8: Applied Geriatrics A 84 year old with PARKINSON’S DISEASE presents to the office following a 3-day hospital admission prompted by an UNWITNESSED FALL. He was subsequently diagnosed and treated for CONGESTIVE HEART FAILURE. Which of the following is the next best plan of care for this patient? DISCHARGE RX LIST: 1.Aspirin 81mg daily 2.Carbidopa-Levodopa QID 3.Carvedilol 6.25mg BID 4.Ferrous Sulfate 325mg daily 5.Finasteride 5mg daily 6.Fludrocortisone 0.1mg daily 7.Furosemide 40mg daily 8.Lisinopril 5mg daily 9.Centrum silver one tablet daily 10.KCl 20meq daily 11.Allopurinol 300mg daily 12.Midodrine 5mg TID 13.Pravastatin 80mg qHS 14.Tamsulosin 0.4mg daily

17. JNC 8: Applied Geriatrics A 84 year old with PARKINSON’S DISEASE presents to the office following a 3-day hospital admission prompted by an UNWITNESSED FALL. He was subsequently diagnosed and treated for CONGESTIVE HEART FAILURE. DISCHARGE RX LIST: 1.Aspirin 81mg daily 2.Carbidopa-Levodopa QID 3.Carvedilol 6.25mg BID 4.Ferrous Sulfate 325mg daily 5.Finasteride 5mg daily 6.Fludrocortisone 0.1mg daily 7.Furosemide 40mg daily 8.Lisinopril 5mg daily 9.Centrum silver one tablet daily 10.KCl 20meq daily 11.Allopurinol 300mg daily 12.Midodrine 5mg TID 13.Pravastatin 80mg qHS 14.Tamsulosin 0.4mg daily LYING 151/73 SITTING 134/84 STANDING 137/63 RETURN TO LYING 176/89

18. DYSLIPIDEMIA & THE ELDERLY

19. Dyslipidemia

20. Corti MC, et al. Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons. Ann Intern Med. 1997;126(10):753.

21. Dyslipidemia The Choose Wisely® Campaign: AMDA: “Don't routinely prescribe lipid-lowering medications in individuals with a limited life expectancy” AMDA Choose Wisely® Campaign – 2013 - 09SEP

22. eprognosis.org [select "bubbleview"]

23. Dyslipidemia Primary Prevention: CARDS Study Neil HA, et al. Analysis of efficacy and safety in patients aged 65-75 years at randomization: Collaborative Atorvastatin Diabetes Study (CARDS). Diabetes Care. 2006;29(11):2378. Age 45-75 yrs Atorvastatin 10mg v. Placebo 4 years NNT Data: OlderYounger 1 st major cardiovascular even 2232

24. Dyslipidemia Primary Prevention No LDL goal is recommended when primary prevention is the treatment goal.  Atorvastatin 10mg  Pravastatin 40mg  Simvastatin 10mg

25. Dyslipidemia Secondary Prevention: The LIPID Trial Hunt D, et al. Benefits of pravastatin on cardiovascular events and mortality in older patients with coronary heart disease are equal to or exceed those seen in younger patients: Results from the LIPID trial. Ann Intern Med. 2001;134(10):931. NNT Data: OlderYounger All Cause Mortality 2246 CAD Death 3571 Fatal / Non- Fatal MI 3036 Stroke 79170 Age 40-75 yr olds; Pravastatin v. Placebo

26. The ‘Iron Nun’ Sister Madonna Buder Age 79 Ironman British Columbia Time 16:54:30 Autobiography “The Grace to Race”