1. Patient-Centered Care for the Complex Older Cardiology Patient Kevin Overbeck, DO Assistant Professor, NJISA

2. Learning Objectives Apply knowledge of Aging Physiology to JNC 8 to optimize strategy for HYPERTENSION management Understand the benefits of STATINS in aging in the context of 2013 guidelines for HYPERLIPIDEMIA Apply 2014 AHA/ACC/HRS guidelines for ATRIAL FIBRILLATION to decision-making for ANTICOAGULATION and RATE CONTROL 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 Gerontology A 85 year old with community dwelling male with previous TIA (>5 years ago) and current CKD stage III (eGFR 55) presents to the office for routine evaluation of his chronic medical conditions ACTIVE MED LIST: 1.Aspirin 81mg daily 2.Metoprolol XL 50mg daily 3.Amlodipine 2.5mg daily 4.HCTZ 12.5mg daily 5.KCL 10meq daily 6.Losartan 50mg daily 7.Atorvasatin 10mg daily 8.Tamsulosin 0.4mg daily BP 120/80mmHg HR 68 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 Losartan (E)Continue current medication regimen

14. JNC 8: Applied Gerontology An 85 year old female presents to your outpatient ambulatory office following a hospital evaluation (09/04/2015 – 9/08/2015) for shortness of breath. She was diagnosed and treated for an acute exacerbation of COPD. She was upgraded from an inhaler to a nebulizer and prescribed PREDNISONE with a plan to taper 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 2015. 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 Gerontology An 80 year old male with PARKINSON’S DISEASE presents for an evaluation of deterioration in his GAIT evidence by FIVE FALLS in the home WITHOUT INJURY during the past SIX MONTHS despite strict adherence to utilization of TWO WHEELED ROLLING WALKER in the home CAD with previous MI (2008), Lower Extremity Edema, Barrett’s Esophagus BP (sitting): 154/70 BP (standing): 120/60 [asymptomatic] Lower Extremity 1++ bilateral edema BUN 20 / Creat 1.2 / eGFR > 60 CURRENT MED LIST: 1.Aspirin 81mg daily 2.Losartan 50mg daily 3.Carvedilol 6.25mg BID 4.HCTZ 12.5mg daily 5.Omeprazole 20mg daily 6.KCL 10meq daily 7.Vitamin D 1000 IU daily 8.Pravastatin 40mg qHS What is the next BEST step in the management of this patient’s condition?

17. STATINS, DYSLIPIDEMIA & THE ELDERLY

18. Dyslipidemia

19. 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

20. 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

21. 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

22. ATRIAL FIBRILLATION & THE ELDERLY

24. Atrial Fibrillation Patient Centered Care / Goals of Care Incidence increases with Age Stroke Risk Stroke Prophylaxis Rate Control January CT, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1-76.

25. Anticoagulation HPI: An 84 year old resident of an assisted living dementia unit presents to sub-acute rehabilitation following a hospital evaluation for a “change in mental status” ruled to DELIRIUM due to new onset ATRIAL FIBRILLATION with rapid ventricular response Functional Hx: (+) ambulates with a rolling walker at baseline PMHx: DM, HTN, Hx Recurrent Falls, Osteoporosis, Depression, Dementia, Chronic Constipation MMSE (8/2012): Total Score 14/30 [noted deficits in the following areas – 1/5 with time orientation, 3/5 deficit with location orientation, 1/5 serial sevens, 0/3 recall, 2/3 three step command, 0/1 drawing pentagon, 0/1 writing sentence] Medications Insulin Glargine 12 units qHS Lisinopril 20mg daily Metoprolol XL 50mg daily Alendronate 70mg qWeek Calcium 500mg Vitamin D 400IU BID Docusate BID Citalopram 20mg daily Donepezil 10mg daily Memantine10mg BID Should WARFARIN be prescribed in this patient? (A) YES (B) NO

26. Anticoagulation HPI: An 84 year old resident of an assisted living dementia unit presents to sub-acute rehabilitation following a hospital evaluation for a fall with a hip fracture requiring ORIF. Functional Hx: (+) ambulates with a rolling walker at baseline PMHx: DM, HTN, Hx Recurrent Falls, Osteoporosis, Depression, Dementia, Chronic Constipation MMSE (8/2012): Total Score 14/30 [noted deficits in the following areas – 1/5 with time orientation, 3/5 deficit with location orientation, 1/5 serial sevens, 0/3 recall, 2/3 three step command, 0/1 drawing pentagon, 0/1 writing sentence] Medications Insulin Glargine 12 units qHS Lisinopril 20mg daily Metoprolol XL 50mg daily Alendronate 70mg qWeek Calcium 500mg Vitamin D 400IU BID Docusate BID Citalopram 20mg daily Donepezil 10mg daily Memantine10mg BID Should WARFARIN be prescribed in this patient? (A) YES (B) NO

27. Atrial Fibrillation Stroke Prophylaxis We under utilize anticoagulation in the elderly with atrial fibrillation

28. Anticoagulation Clinician Concerns Compliance Monitoring “Fall Risk 1,2 ” Cognitive Impairment Drug-Drug Interactions Bleeding Risk 1. Man-Son-Hing M, Nichol G, Lau A, et al. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med 1999; 159: 677-685 2. Kappor J. Management of Atrial Fibrillation. The Lancet, Volume 370, Issue 9599, Page 1608, 10 November 2007

29. Anticoagulation Increased risk of ICH > 85 but not statistically significant INRs less than 2.0 as compared to INRs 2-3 were not associated with lower risk of ICH INRs > 3.5 associated with increased risk as should be avoided Fang MC, et al. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med. 2004;141(10):745

30. CHA 2 DS 2 -VASc SCOREAdjusted Stroke Rate (%/year) 00 11.3 22.2 33.2 44.0 56.7 69.8 79.6 86.7 915.2 With CHA2DS2- VASc > 2, oral anticoagulants are recommended With CHA2DS2- VASc = 0, it is reasonable to omit antithrombotic therapy With CHA2DS2- VASc = 1, no antithrombotic therapy or treatment with oral anticoagulation or aspirin may be considered

31. Warfarin vs Aspirin in the Elderly 973 patients > 75 years old (mean 81.5 years old) Randomly assigned to Aspirin 75mg or Warfarin INR 2-3 The primary endpoint was fatal or disabling stroke (ischemic or hemorrhagic) or intracranial hemorrhage or significant emboli Warfarin Group – 24 events (21 strokes, 2 ICH, 1 embolism) Aspirin Group – 48 events (44 strokes, 1 ICH, 3 emboli) Mant J, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007;370(9586):493.

32. Warfarin vs Aspirin + Clopidogrel CHADS2 Score of 2 Randomly assigned to receive Warfarin (target INR 2.0-3.0) or the combination of Clopidogrel 75mg plus Aspirin 75mg-100mg Trial Terminated Early due to WARFARIN superiority Connolly S, et al. Clopidogrel plus Aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE-W): a randomized controlled trial. Lancet 2006; 367:1903-12.

33. Anticoagulation & The Elderly Setting% in Range Self-Monitoring72% Randomized Trials 55-66% Anti-Coagulation Clinics 66% Community Physicians 57% 1. van Walraven C, et al. Effect of study setting on anticoagulation control: a systematic review and metaregression. Chest. 2006;129(5):1155. * Simple Finger Stick required

34. WARFARIN superiority NNT 37 PRIMARY PREVENTON 1 NNT 12 SECONDARY PREVENTION 1 Q: What about new agents? A: “… complex patients with multiple chronic conditions were excluded from all trials …” 1. Hart RG, et al. Meta-analysis antithrombotic therapy to prevent stroke in patients who have non-valvular atrial fibrillation. Ann Intern Med 2007; 146: 857-67

35. ATRIAL FIBRILLATION RATE CONTROL

36. Which Patient is “more sick?” (1) (2) 3. 40 Year Old Female HR 160 80 Year Old Female HR 118 Both Equally

37. Aging Cardio-Physiology Resting HR Unchanged With Aging Maximum HR = 220 – age OR = 208 – (0.7) x age

38. Cardiac Ventricular Filling Rate

39. Recommendations for Rate Control Control ventricular rate with Beta-Blocker or Non-Dihydropyridine Calcium Channel Antagonist for AF A heart rate control (resting heart rate < 80 bpm) strategy is reasonable for symptomatic management in AF A lenient rate-control strategy (resting heart rate < 110bpm) maybe reasonable when patient asymptomatic & LV systolic function preserved Non-Dihydropyridine Calcium Channel Antagonists should NOT be used in decompensated HF

40. An 88 year old male with systolic cardiomyopathy with an EF < 35% presents with complaints of fatigue and palpitations due to ATRIAL FIBRILLATION with HR 110-130 bpm. He is euvolemic, BP 130/70, and presently taking CARVEDIOLOL 25mg BID. Which of the following strategies is the best next step in the management of his heart rate? (A)Prescribe Diltiazem (B)Prescribe Verapamil (C)Prescribe Digoxin (D)Prescribe Amiodarone (E)Consult Cardiology

41. Rate Control Medications Beta-Blockers – Atenolol, Carvedilol, Metoprolol, Nadolol, Propanolol Nondihydropyridine Calcium Channel Blockers – Diltiazem + Verapamil Digoxin Amiodarone

42. Craig T. January et al. Circulation. 2014;130:e199-e267