Geriatric Cardiology: Challenges and Strategies

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1 Geriatric Cardiology: Challenges and Strategies

2 No financial disclosures

3 Geriatrics -- No Specific Age 'you know it when you see it' Functional Status Polypharmacy Impaired Renal Function Diagnostic Testing: How Much Do You Want to Know? Therapeutics: Balancing risk benefit vs. life expectancy and comorbidities

4 Geriatric Cardiology -- Common Dilemmas 1. AFib and anti-coagulation: does age play a role in choice of anti-coagulant? 2. Hypertension: what are the targets, and how far do you push? 3. Is diastole dysfunctional, or normal for age? 4. Statin therapy still beneficial? 5. When is Hospice appropriate (before it is completely obvious)?

5 Case 1: GB with AFib Mr. GB is an 88 yo man with no prior history of cardiac disease who presents for follow-up of a recent diagnosis of AFib. He has been quite active since retiring in even sky diving - but is starting to show his age. He was recently admitted to the hospital with pneumonia. On admission, AFib was documented and persistent in outpatient follow-up. He has no symptoms related to AFib. His EF is normal with a severely dilated left atrium. Mrs. BB is asking about all these new meds, and if he should be anti-coagulated. His creatinine is 1.3 and GFR is 45. CHADS2 score = 1 with age (CHADS -VASc = 2). She also wants to share to google responses to "Pradaxa."

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9 Pradaxa, Bleeding Risk, and the Elderly 2010 FDA Approved Pradaxa 12/2011 FDA starts investigating post-marketing reports of excess bleeding from Pradaxa. Reviews insurance claims and administrative data 12/2012 FDA concludes bleeding risk is consistent with reported rates in RE-LY Trial

10 Pradaxa Bleeding Risks and Age (RE-LY) Warfarin < 75 3% > % Pradaxa 150 bid < % > % (trend for increased rate vs. warfarin) Pradaxa 110 bid < % > % Similar stepwise increases for bleeding at decreasing renal function. Trend for increased bleeding at higher dose of Pradaxa, but not significant and not for ICH

11 Anti-Coagulation, why we defer in elderly Cognitive impairment fall risk, fall risk, fall risk!? Polypharmacy Aspirin perceived as 'safe' alternative Prior GI bleeding or hemorrhage Cost Challenge in monitoring

12 Anti-Coagulation -- Fall Risk Subdural Hematoma is the primary concern Falls are common and certainly memorable Generally agreed we overestimate risk of falls and confirmed with several studies One study suggested it would take 300 falls per YEAR to have risk of anti-coagulation outweigh benefits

13 Aspirin Instead? -CHADS2 score of 1: greatest risk is score of one from age -Birmingham AFib Treatment of Aged (BAFTA): compared warfarin to Asa 75 mg/day in age > 75 yo. Thrombotic rates lower with warfarin, 1.8% vs. 3.8%. Equivalent bleeding -WASPO Trial: Asa 300 mg vs. warfarin in octogenarians. Warfarin better tolerated and fewer adverse events. Healthy study group.

14 Rivoroxaban and Apixaban, the 'new' new ones Rivoraxaban (Xarelto): No increased risk of bleeding, 'noninferior' to warfarin. Again, less ICH. -Dosing easier, 20 mg qday if GFR > 50, 15 mg GFR Apixaban (Eliquis): superior to warfarin for stroke reduction, less bleeding, lower mortality. 5 bid. 2.5 bid you have 2 of following: if > 80 yo, cr >1.5, < 60 kg.

15 Key Points -- AFib 1. We generally overestimate risk of falls 2. Age is strongest individual CHADS2 predictor of ischemic CVA 3. Trend for increased bleeding with Dabigatran (Pradaxa) 150 mg bid if > 75 yo, not significant (FDA reviewed), not for ICH 4. Apixaban (Eliquis)- decrease dose at >80 if Cr 1.5 or < 60 kg. 5. Rivoraxaban (Xarelto) adjust by GFR Using any anti-coagulant will make bigger impact than differences between agents

16 Diastolic (dys) function Ms. BB is an 87 year old with hypothyroidism (history of Grave's disease) who presents for an evaluation of hypertension. She recently had an echo which showed a normal EF, mild LVH, and diastolic dysfunction stage 1. She has mild dyspnea walking up stairs and wonders if she has 'diastolic heart failure.' Also, what should be done for her?

17 Diastolic Alphabet Soup Heart failure with Preserved EF (HFPEF) is the broader term for patient's with heart failure with a normal EF. LV size generally normal / increased. Diastolic dysfunction refers to an abnormality of diastolic filling, regardless of EF or symptoms, most commonly assessed on echo The real challenge is separating HFPEF from other common causes of dyspnea. BNP can help, but increases with age and declining renal function.

18 Prevalence of Diastolic dysfunction (mild or stage 1) Age 50: 25% Age 70: 50% Not a great test to see if HFPEF present given prevalence

19 ACC / AHA Class 1 Guidelines for HFPEF 1. Control HTN per guidelines 2. Control AFib rates 3. Treat pulmonary congestion Simple because evidence limited

20 Key Points -- Diastolic Dysfunction 1. Diastolic dysfunction is common on echo 2. Guidelines for treating HFPEF easy because limited data 3. Treat common concurrent underlying conditions

21 Hypertension Mrs. T is an 84 yo with a history of an LAD stent and moderate RCA disease presents for BP follow-up. Her BP was 138/58 last month, but you stopped her amlodipine for dizziness and edema. She now feels great, enjoying her grand kids and knitting. She has not tolerated HCTZ in the past because of hyponatremia leading to an admission for mental status changes, and Beta blockers make her tired. She is on lisinopril monotherapy with a BP of 149/63, pulse 65 bpm. She has mild CRI with a GFR of 55. BP confirmed in both arms and consistent with home readings. What should you do for BP?

22 Systolic HTN of the Elderly Diastolic pressure peaks at about age 60 and starts trending down. Systolic continues to trend up (and pulse pressure). Arteries are stiff (rarer causes would be severe AI).

23 The J Curve in Hypertension: Risk of adverse events at various blood pressures

24 Trials in the elderly Several trials for anti-hypertensives in 'elderly ' patients All patients started with systolic pressures > 160 mm Hg Trial patients probably more robust patients than average Patients mostly < 80 years HYVET: RCT had only patients > 80. Starting BP average 170 mm Hg Treated BP with ACE and diuretic got to an average of 143 mm Hg Morbidity and mortality decreased

25 Key Points -- Hypertension JNC 7 recommends <140 / 90 for all patients, although keep diastolic > 60 mm Hg. < 150 mm Hg not unreasonable for those > 80 years. Goal of <140 / 90 based on observational data, not RCT in > 80 years Frailty and symptoms can limit therapy in elderly Clear graded relationship between systolic BP and cardiovascular risk

26 Is a statin worth it? 82 yo man with no overt vascular disease wants to know if he should be on a statin. Line between primary and secondary prevention blurs a bit in elderly patients. Elderly will frequently fall in 'high' risk category based on Framingham since age is such a potent risk factor

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28 Time Course: Benefit Starts Early (Primary Prevention) Pravastatin Multinational Study Group

29 Age: Benefit of Statin Similar Above or Below 65 CARE Trial (secondary prevention)

30 Statin Issues in Brief Pravastatin, rosuvastatin, and fluvastatin are NOT Metabolized by P450 3A4: less interactions and grapefruit okay Mild memory loss case reports, no consistent effect.? Lowers risk of dementia. Cancer: unlikely any affect Probable slight increase risk of diabetes

31 Key Points -- Statins 1. Similar benefits for elderly as younger patients, although 'elderly' often defined as > 65 years 2. Consider physiologic age. Benefits may occur in the first few months to 2 years in primary and secondary prevention 3. Calculating 10 year risk based on Framingham will nearly always place 80 year olds in 'high risk' over 10 years

32 Cardiac Hospice: Underutilized? Hospice cares for about 33% of dying patients, but only 3-4% dying of non-acute cardiac causes. Barriers: historical patterns of care, uncertain prognostic indicators, costs, pursuit of advanced therapies

33 Multiple therapies with a goal to 'fix' Standard Medical Therapy Revascularization Bi V ICD Percutaneous aortic valve replacement LVAD Home ('palliative') Inotrope therapy... We can get into a routine of diuretics, follow up labs, hospitalizations, repeat imaging...

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35 Heart Failure Prognosis -- Predictive Models EFFECT: hospital based, relatively easy Heart Failure Survival Score: uses peak VO2, +/- PCWP (not always readily available) Seattle Heart Failure Score: inpatient and outpatient, easy phone APP HFPEF less well defined

36 Heart Failure: predictors of mortality Age Increased BUN / Cr Elevated heart rate Hypotension Hyponatremia Lack of Beta Blocker Class 4 Symptoms

37 4 Point Risk Score (Huynh et al) BUN > 30 mg/dl BP < 120 mm Hg Peripheral arterial disease Serum sodium < 135 meq / L

38 Key Points -- Hospice Cardiology is a field of fixable and acute problems We have a number of expensive and invasive procedures for prolonging life. Interventions can lead to living with debility. At some point, co-morbidities outweigh any benefit from cardiac intervention We sometimes only bring up Hospice when it is so obvious, the family is relieved to not undergo any more tests

39 101 and finishing a marathon

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