Download Geriatric Cardiology – You CAN treat Angina! Part 1

Geriatric Cardiology – You
CAN treat Angina!
April 24, 2012
• No speakers’ bureaus
• No device or pharmaceutical
manufacturers
• General cardiologist with focus on angina,
critical care, prevention
• Edgar Leifer Professor of Clinical
Medicine
• Chief, Allen Hospital Medical Service
• Director, House Staff Training Program
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Clinical Case – Dr. MS
Definitions
Epidemiology
Physiology
Clinical evaluation
Medical therapies
Non medical therapies
Conclusion
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• Refocus concern from angina as an entity
to a symptom of ischemia
• Reinforce current concepts of
pathophysiology of ischemia
• Review current therapies of ambulatory
management for primary care
• No discussion of ACS (Unstable Ischemic
Heart Disease)
• Emphasis on Geriatric issues
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• 10 year history of
CAD
– Risks: Hypertension
– EKG showed RBBB
for 20 years
– Murmur of AI
– Symptoms of chest
pressure and DOE –
LAD 90% prox, 90%
mid – 4 stents
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• 2 years of chest
pressure
– Onset with swimming
– Negative stress test
– Relieved with
treatment with PPI
• Current – walking
induces chest
pressure, relieved by
rest
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• Current meds
– Beta blocker
– Aspirin
– Statin
• Lab studies
– Hct 42 Hgb 14.2
– Creat 1.0
– CXR: Mild cardiomegaly
• Exam
– BP 120/60 P 68
– Chest – clear
– Heart – 2/4 diastolic blow
along left sternal border
– JVP normal
– EXT – no edema
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NUCLEAR STRESS: SCAN
NEGATIVE
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* Symptom: Chest pain.
* HR Response: HR failed to increase
appropriately, likely due to medications.
* BP Response: Appropriate.
* ECG Abnormalities: ECG changes could not
be interpreted due to abnormal baseline ECG.
* Arrhythmia: Frequent VPDs. *
*Review of raw data shows: diaphragmatic
artifact
* The left ventricle was normal in size.
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Normal myocardial perfusion
scan, with no evidence of
infarction or inducible
ischemia.
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* Gated wall motion analysis is performed,
and shows normal wall motion with rest LVEF
of 65% and post stress LVEF of 61%.
*** Conclusions ***
The patient had a possible anginal symptom
during exercise in the absence of SPECT
evidence of ischemia at a heart rate of
110/min.
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• Who was William Heberden?
– English physician 1710-1801
– Classic description 1768
“They who are afflicted with it,
are seized while they are
walking, (more especially if
It be up hill, and soon after
eating) with a painful and
most disagreeable
sensation in the breast,
which seems as if it would
extinguish life, if it were to
increase or to continue; but
the moment they stand still,
all this uneasiness
vanishes. “
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DEFINITIONS
EPIDEMIOLOGY
• Greek : ἀγχόνη ankhone
("strangling")
• Latin: angina = “throat
inflammation”
• Merriam Webster: “A
disease marked by
spasmodic attacks of
intense suffocative pain.”
• ICD 9: 413; ICD 10:
120
• Spanish: “Dolor
de
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• Only 18% of coronary
attacks are preceded by
longstanding angina
• New episodes increase
with age and are more
frequent in African
Americans
• DEATH IS INFREQUENT
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– Asymptomatic
– Silent ischemia
– Angina
– Acute coronary syndromes
• Unstable Angina
• Myocardial infarctions
– Sudden cardiac death
– Congestive heart failure
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DEMAND
• Heart Rate
• Contractility
• Wall tension
T=Pr/2h
– Preload (r)
– Afterload (P)
– Wall thickness
(h)
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SUPPLY
• O2 carrying capacity
– Hemoglobin
• Coronary blood flow
– Perfusion pressure
• Aortic vs. end diastolic
– Vascular resistance
• Neural control
•Lesions
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• Asymptomatic
– Relaxation – S4
– Contraction – S3, mitral regurgitation
– Electrical – repolarization
• Symptomatic
– Angina, Dyspnea, Arrhythmias
• Cellular integrity – no change, stunning,
hibernation
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• Risk Factors
– Framingham – Age, Gender, Family History,
Smoking, Diabetes, Hypertension,
Hyperlipidemia
– ATP III – Prior CAD, Peripheral Arterial
Disease = Coronary risk equivalents
– Elderly age risk factors:
• Urinary albumin excretion
• Pulse pressure
• Arterial Stiffness
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J Am Geriatr Soc 52:1639–1647, 2004
• Prospective Population Based Study
• > 65 yo, 1954 men, 2931 women, followed 7.5 years
„most lipid measures were weakly associated with
cardiovascular events. The association between low HDLC
and increased MI risk was nonetheless strong and consistent.”
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• History – 95% specific classically
– Look for equivalents
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Dyspnea
Shoulder or back pain
Weakness, fatigue
Epigastric discomfort
– Consider physical exertion levels
– Silent ischemia seen in 20-50% of patients 65 years
or older.
– Adjust for population at risk (age, gender,
comorbidities)
– Identify stability
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• Typical Angina
– Substernal chest
discomfort with
characteristic
quality and
duration
– Provoked by
exertion or
emotional stress
– Relieved by rest or
NTG
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• Dyspnea
• Indigestion
• Back, arm,
neck, wrist pain
• Burning
• Pressure
• Rest,
recumbency
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Angina Classification
STABILITY/SEVERI
TY
Campeau, L “Grading of
Angina Pectoris” Letter to the
Editor
CIRCULATION 1976: 54:
522-23
• TABLE 1. Grading of Angina of Effort by the
Canadian Cardiovascular Society
I. "Ordinary physical activity does not cause ...
angina," such as walking and climbing stairs. Angina
with strenuous or rapid or prolonged exertion at work
or recreation.
II. "Slight limitation of ordinary activity." Walking or
climbing stairs rapidly, walking uphill, walking or stair
climbing after meals, or in cold, or in wind, or under
emotional stress, or only during the few hours after
awakening. Walking more than 2 blocks on the level
and climbing more than one flight of ordinary stairs
at a normal pace and in normal conditions.
III. "Marked limitation of ordinary physical activity."
Walking one to two blocks on the level and climbing
one flight of stairs in normal conditions and at
normal pace.
IV. "Inability to carry on any physical activity without
discomfort - anginal syndrome may be present at
rest."
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• Determine remediable factors
• Identify patients at high risk
– Anatomy – Left main > 50%; Three vessel
– Physiological – Impaired LV function
– Functional – unstable state
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• Physical Exam –
remediable factors
– VS: Heart rate, BP, T,
RR
– Chest – congestion
– Heart – enlargement,
valvular disease, failure
– Vascular – obstruction,
congestion
– Extremities - edema
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• Lab Studies –
remediable factors
– CBC – anemia
– Basic metabolic panel –
glucose, renal function
– Lipid Panel
– (Thyroid function)
– EKG
– Chest X Ray
– (Echocardiogram)
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• Aging increases the prevalence of CAD but is masked by the comorbidities that reduce activity. [Schwartz,Zipes in Braunwald 9th]
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• Exercise - ?modified
protocols
– Treadmill
– Bicycle
• Exercise with
imaging
• Pharmacologic with
imaging
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• Hypotension with exertion
• Inability to exercise beyond stage II of Bruce
protocol (6 minutes) – NOT APPLICABLE IN
THE ELDERLY
• ST depression more than 2 mm
• ST elevation in the absence of q waves
• Ventricular arrhythmias with ischemia
• Pulmonary uptake of thallium
• 2 or more zones of ischemia
REFER PATIENTS WITH HIGH RISK FOR
ANGIOGRAPHY
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• GI – GERD, biliary
• Neuro – cervical radiculopathy
• Chest wall – costochondritis, intercostal
neuralgia
• Pulmonary – pleural, parenchymal
• Vascular – aortic, pulmonary
Pitfalls: Placebo response, Concurrent
inactive disease
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• Relieve pain,
discomfort
• Improve function
• Avert further
atherosclerotic
complications
– Sudden death
– Congestive heart
failure
– Acute coronary
syndromes
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• 2002 guideline update
for the management of
patients with chronic
stable angina
• www.acc.org/clinical/gui
delines/stable/stable.pdf
• Diagnosis
• Risk Stratification
• Treatment
• Follow Up
• References (1052)
• 2007 update:
Circulation 2007; 116:
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(From Schwartz JB: Clinical Pharmacology, ACCSAP V, 2003. As modified from Nolan L, O’Malley K:
The need for a more rational approach to drug prescribing for elderly people in nursing homes. Age
Aging 18:52, 1989; and Denham MJ: Adverse drug reactions. Br Med Bull 46:53, 1990.)
Figure 80-6 Schwartz and Zipes, Braunwald.
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• Cost**
• Difficulty with understanding directions
(hearing, sight)
• Inadequate instruction**
• Complete dosing regimens
• Packing material
• Insufficient education of patient, family, or
caregiver
• Cognitive impairment**
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• Was this angina or GERD?
– Known CAD, age, make for high pre test
probability?
– History of GERD
• Symptom complex stable, bothersome but
not debilitating
• Stress test – no high risk features
• Therapeutic trials
– Nitrates
– GI consult – New PPI, Decline EGD without
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