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1 CARDIOLOGY Part 2 2 OBJECTIVES Know and understand: • How the cardiovascular system changes with normal aging • The signs and symptoms of the most important cardiovascular diseases in older patients • The appropriate diagnostic tests to identify the presence and severity of CVD • Standards for treating CVD 3 TO P I C S C O V E R E D Part 1 • Epidemiology • Effects of Aging on Cardiovascular Function • Cardiovascular Risk Factors • Coronary Artery Disease • Acute Coronary Syndromes • Chronic Coronary Artery Disease Part 2 • Valvular Heart Disease • Cardiac Arrhythmias • Peripheral Arterial Disease Note: Heart Failure is covered in a separate Teaching Slide set. 4 T Y P E S O F VA LV U L A R D I S E A S E • Aortic stenosis (AS) • Aortic regurgitation (AR) • Mitral stenosis (MS) • Mitral regurgitation (MR) 5 D I A G N O S I S O F VA LV U L A R D I S E A S E • Echocardiogram is the procedure of choice • Echocardiography with Doppler can noninvasively assess the cause and severity of most acute or chronic valvular abnormalities • Also provides important information about LV size and function, left atrial size, pulmonary artery pressure, and the presence and severity of other valvular lesions 6 AORTIC STENOSIS Symptoms Angina; DOE; heart failure; lightheadedness; presyncope/ syncope Findings Treatment Physical exam: mid/late systolic ejection murmur radiating to carotids; S4 gallop; left ventricular heave • Medical: no effective therapy ECG: LVH • Surgical: AVR indicated for severe AS with symptoms, bioprosthetic valves preferred in older patients • Percutaneous: transcatheter aortic valve replacement in selected patients at intermediate to high surgical risk 7 AORTIC REGURGITATION Symptoms Can be acute or chronic; asymptomatic or minimally symptomatic in mild/ moderate AR; DOE, heart failure, angina in severe AR Findings Treatment Physical exam: ↑ pulse pressure; bounding/ collapsing pulses; diastolic decrescendo murmur; systolic ejection murmur • Medical (less severe cases): control hypertension, preferably with a dihydropyridine ECG: LVH (severe chronic AR); tachycardia (acute AR) Chest radiograph: cardiomegaly (severe chronic AR); pulmonary congestion (acute AR) calcium channel blocker, ACE inhibitor, or angiotensin receptor blocker; β-blocker in patients with symptoms or LV systolic dysfunction • Surgical: AVR indicated for acute severe AR, symptomatic severe chronic AR, asymptomatic severe chronic AR with LVEF <50% or left ventricular end-systolic dimension 5 cm 8 MITRAL STENOSIS Symptoms Gradually worsening DOE early; orthopnea and leg edema late; progressive decline in exercise capacity Findings Treatment Physical exam: early diastolic opening snap; low-pitched (“rumbling”) diastolic murmur at apex; pulmonary hypertension; right heart failure • Medical: diuretics for volume overload and β-blockers for decreased exercise tolerance associated with tachycardia • Percutaneous: balloon valvuloplasty safe and effective, but most older adults are not good candidates due to extensive calcification and commissural fusion or concomitant mitral regurgitation • Surgical: MVR is effective but with 5%−15% operative mortality in older patients 9 MITRAL REGURGITATION (1 of 3) Symptoms Can be acute or chronic; marked shortness of breath, orthopnea in acute, severe MR; progressive DOE in chronic MR Findings Physical exam: pulmonary rales, tachycardia, narrow pulse pressure, S3, and short harsh systolic murmur in acute MR; holosystolic murmur radiating to axilla, S3, pulmonary hypertension, right heart failure in chronic severe MR 10 MITRAL REGURGITATION (2 of 3) Treatment • Medical: medical therapy as for heart failure with systolic dysfunction in patients with symptomatic chronic MR and LVEF <60% who are not candidates for intervention • Percutaneous: transcatheter mitral valve repair in selected patients • Surgical: mitral valve repair preferred over MVR; bioprosthetic valves preferred over mechanical in older patients; all effective with 5%−15% operative mortality in older patients. Operative mortality is lower for repair than replacement 11 MITRAL REGURGITATION (3 of 3) Treatment Surgical intervention is indicated: • Urgently for acute severe MR with heart failure • Symptomatic patients with severe chronic MR and LVEF >30% • Asymptomatic patients with severe chronic MR and LVEF 30%–60% and/or left ventricular end-systolic dimension 4 cm • When mitral valve repair is deemed likely to be successful in asymptomatic patients with severe chronic MR and an LVEF 60% • In patients with severe chronic MR and pulmonary artery systolic pressure >50 mmHg or new-onset atrial fibrillation with high likelihood of successful MV repair T R A N S C AT H E T E R A O R T I C VA LV E R E P L A C E M E N T ( TAV R ) • TAVR with a bioprosthesis is associated with improved outcomes relative to medical therapy in older adults who are not candidates for surgical AV replacement (SAVR) • Shorter hospital lengths of stay and faster functional recovery with TAVR • Vascular complications and stroke are more common after TAVR, but major bleeding and atrial fibrillation are less common • One year outcomes, including survival and quality of life, are similar after TAVR or SAVR, and benefits are maintained at least 3-5 years 12 13 INFECTIVE ENDOCARDITIS (1 of 2) • Native valve endocarditis is most commonly caused by Streptococcus viridans or Staphylococcus aureus Enterococcal species and gram-negative bacilli are also common causes in older adults • Endocarditis is often difficult to diagnose in older adults Fever and leukocytosis are less common TTE sensitivity is reduced due to increased calcific disease and prosthetic valves TEE improves diagnostic yield for infective endocarditis 14 INFECTIVE ENDOCARDITIS (2 of 2) • Treatment: IV antibiotic therapy for 2-6 weeks • Surgical therapy should be considered: In the presence of severe valvular dysfunction, recurrent emboli, marked heart failure, myocardial abscess formation, vegetations >1cm in diameter, or fungal endocarditis When appropriate antibiotic treatment does not yield negative blood cultures • Recommendations for preventing endocarditis after dental procedures focus on providing prophylaxis only in the highest-risk patients Those with a prosthetic valve, prior endocarditis, certain congenital heart diseases, or cardiac transplantation with valve disease Recent guidelines have eliminated recommendations for prophylaxis for those undergoing GI or GU procedures 15 CARDIAC ARRHYTHMIAS • Age-related changes in the cardiac conduction system coupled with the increasing prevalence of CVD at older age progressive increase in the incidence and prevalence of conduction abnormalities and heart rhythm disturbances in older adults • Age-related degenerative changes in and around the sinoatrial and atrioventricular nodes increase in bradyarrhythmias with advancing age 16 AT R I A L F I B R I L L AT I O N • The most common sustained arrhythmia seen in clinical practice • Incidence and prevalence increase exponentially with age, such that the prevalence in octogenarians is approximately 10% Among older patients with valvular heart disease or HF, the prevalence is even higher, approaching 30% A F : C L I N I C A L F E AT U R E S AND DIAGNOSIS • Symptoms related to AF are highly variable Most common: palpitations, shortness of breath, or impaired exercise tolerance • In patients with ongoing AF, the standard 12-lead electrocardiogram is diagnostic Other studies should include echocardiogram, serum electrolytes (especially potassium and magnesium), thyroid function Further evaluation in selected cases may include a chest radiograph, serial cardiac biomarker proteins, a brain natriuretic peptide level, a D-dimer level, lower-extremity venous Dopplers, and an evaluation for pulmonary embolism 17 18 MANAGEMENT OF AF (1 of 2) • Objectives include relieving symptoms and minimizing the risk of thromboembolic events, particularly stroke Principal strategies for relieving symptoms: control of heart rate and maintenance of normal sinus rhythm • Patients who experience significant shortness of breath, fatigue, or exercise intolerance attributable to AF may be best managed with antiarrhythmic drug therapy aimed at maintaining sinus rhythm 19 MANAGEMENT OF AF (2 of 2) • Alternatives to antiarrhythmic drug therapy for maintenance of sinus rhythm: Catheter ablation of the arrhythmogenic foci, usually through pulmonary vein isolation The surgical maze procedure • All older patients with paroxysmal or persistent AF require stroke prophylaxis MANAGEMENT OF AF: S T R O K E R I S K S T R AT I F I C AT I O N • CHADS2 1 point for chronic HF, HTN, age 75 yr, and diabetes, 2 points for prior stroke or TIA Annual stroke risk increases from about 2% for score of 0 to about 18% for score of 6 • CHA2DS2-VASc More accurate than CHADS2 for identifying low risk of stroke 2 points for age 75 yr, 1 point for age 6574 yr, 1 point for vascular disease, 1 point for female sex Score of 2: patient is candidate for systemic anticoagulation 20 MANAGEMENT OF AF: STROKE PROPHYLAXIS • Warfarin titrated to maintain an INR of 2–3 • Aspirin 75–325 mg/d clopidogrel • Novel Oral Anticoagulants (NOACs): Dabigatran: 150 mg q12h when creatinine clearance (CrCl) ≥ 30 mL/min (75 mg q12h when CrCl = 15–30 mL/min) Rivaroxaban: 20 mg/d when CrCl ≥50 mL/min (15 mg/d when CrCl = 15–50 mL/min) Apixaban: 5 mg twice daily (2.5 mg twice daily when 2 or more of the following are present: age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL) Edoxaban: 60 mg/d when CrCl 50-95 mL/min, 30 mg/d when CrCl 15-50 mL/min 21 O T H E R S U P R AV E N T R I C U L A R ARRHYTHMIAS • Atrial flutter usually occurs in older patients with concomitant AF, and management is similar to AF Consider catheter ablation if symptomatic persistent atrial flutter does not respond to medical therapy • Atrial tachycardia, AV-nodal reentrant tachycardia, accessory pathway-mediated SVT, and multifocal atrial tachycardia: treat underlying condition, provide pharmacotherapy aimed at rate-control or arrythmia suppression In selected patients with recurrent symptomatic episodes, antiarrhythmic medications or catheter ablation may be considered 22 23 VENTRICULAR ARRHYTHMIAS • Frequent ventricular premature beats, ventricular couplets, and short runs of nonsustained ventricular tachycardia: no therapy unless highly symptomatic, in which case β-blockers are the medications of first choice • Longer episodes of ventricular tachycardia with dizziness or syncope: referral to a cardiologist or electrophysiologist for ICD or antiarrhythmic drug therapy • Patients with NYHA class II or III heart failure, LVEF of ≤35%, and life expectancy 1 year: consider an ICD, even if ventricular arrhythmias are not clinically manifest 24 B R A D YA R R H Y T H M I A S • Patients with mild bradycardia (resting heart rate 50−60 bpm) are often asymptomatic • Patients with more marked bradycardia (resting heart rate 40−50 bpm) may experience fatigue, lightheadedness (especially on standing), or reduced exercise tolerance • Presyncope or syncope may occur in patients with profound bradycardia (heart rate <40 bpm or asystolic pauses 3 seconds), whether due to sinus node dysfunction or heart block within the AV node or infranodal conduction system 25 D I A G N O S I N G B R A D YA R R H Y T H M I A (1 of 2) • Exclude significant electrolyte abnormalities, measure the thyrotropin level to exclude hypothyroidism, and review medications • Significant orthostatic hypotension: search for potentially treatable causes, including adverse effects of medication(s), dehydration, or autonomic dysfunction (eg, due to diabetes, amyloidosis, parkinsonism, or other neurologic disorders) • Unexplained presyncope or syncope: carotid sinus massage to evaluate for carotid hypersensitivity D I A G N O S I N G B R A D YA R R H Y T H M I A (2 of 2) • If symptoms occur daily or almost every day, a 24h−48h ambulatory monitor may be helpful for confirming or excluding bradycardia (or other heart rhythm disorder) as the proximate cause • In patients whose symptoms occur at least once a month (but not daily), a 30-day event monitor may provide a definitive diagnosis • In patients with rare (ie, less than monthly) but recurrent symptoms of a serious nature (eg, syncope with injury), an implantable loop recorder may be considered 26 27 M A N A G I N G B R A D YA R R H Y T H M I A • Correct any treatable causes (eg, hypothyroidism) and eliminate potentially offending medications, if possible • In patients with confirmed symptomatic bradycardia not amenable to conservative management, permanent pacemaker implantation is warranted 28 PERIPHERAL ARTERIAL DISEASE • Encompasses disorders of the: Abdominal aorta Renal and mesenteric arteries Iliofemoral-popliteal arterial tree • Prevalence increases with age and is higher in men than in women • Risk factors include hypertension, diabetes, cigarette smoking, and, to a lesser extent in older adults, family history 29 PA D D I A G N O S I S • At least 50% of patients with PAD are asymptomatic or attribute their symptoms to another disorder • Formal history and physical exam to screen for symptoms and signs of PAD is recommended for: Patients 50−69 yr with risk factors for atherosclerosis Patients 70 yr with or without risk factors • Men 60 yr with a family history of AAA and men 65 – 75 yr who have ever smoked should undergo abdominal ultrasound to screen for AAA 30 PA D T R E AT M E N T ( 1 o f 2 ) • Aspirin 75−325 mg Clopidogrel is recommended as a reasonable alternative to aspirin in selected patients Combination of aspirin and clopidogrel may be considered in patients at high risk of vascular events and acceptably low risk of bleeding • An ACE inhibitor or ARB for prevention of CV events is reasonable in patients with symptomatic PAD • Patients with leg PAD should exercise regularly 31 PA D T R E AT M E N T ( 2 o f 2 ) • Revascularization is indicated for patients with severe symptoms attributable to PAD that have not responded to aggressive risk factor modification, exercise, and pharmacotherapy • Revascularization is also indicated for patients with critical-limb ischemia, defined as rest pain, ulceration, or gangrene In this context, revascularization has been shown not only to improve symptoms but also to reduce the likelihood of subsequent amputation 32 MANAGEMENT OF AAA • Indications for AAA repair: Development of symptoms, rapid aneurysmal dilatation detected during serial assessments (≥1 cm in 1 year), and aneurysms ≥5.5 cm in diameter • Patients with asymptomatic AAAs 4-5.4 cm in diameter should undergo repeat evaluations at intervals of 6-12 months • Choice of open or endovascular surgical repair of AAAs is based on location of the lesion and patient comorbidities and prognosis 33 S U M M A RY ( 1 o f 2 ) • Calcific AS is the most common valvular abnormality requiring intervention in older adults SAVR is the standard treatment for AS in healthier older adults, while TAVR is an effective alternative in older adults at moderate to high risk of surgery due to comorbidity, frailty, or other factors. • AF increases in prevalence with age, and >50% of all patients with AF are age 75 years or older Most older patients with AF respond to rate-control medications + antithrombotic therapy, but some require antiarrhythmic drug therapy or other interventions 34 S U M M A RY ( 2 o f 2 ) • The prevalence of PAD increases progressively with age, and PAD is a potent risk marker for concomitant CAD and cerebrovascular disease Management of PAD should include appropriate treatment of hypertension, dyslipidemia, diabetes, and tobacco abuse in accordance with existing practice guidelines 35 CASE 1 (1 of 3) • An 86-year-old woman is in the emergency department because she has arm pain. The pain began when she lifted her granddaughter. • History: Amaurosis fugax in left eye 1 year ago Completely resolved No history of hypertension, heart failure, diabetes, or arrhythmia • Physical examination Blood pressure 130/82 mmHg, heart rate 62–102 bpm (average, 82 bpm) No heart murmur, jugular venous distention, rales, or peripheral edema • ECG: new atrial fibrillation, no evidence of ischemia • Echocardiography: normal left ventricular systolic function, no significant valve abnormalities 36 CASE 1 (2 of 3) Which one of the following is the next step in this patient’s management? A. Electrical cardioversion B. Heart rate control C. Anticoagulation D. Pharmacologic cardioversion 37 CASE 1 (3 of 3) Which one of the following is the next step in this patient’s management? A. Electrical cardioversion B. Heart rate control C. Anticoagulation D. Pharmacologic cardioversion 38 CASE 2 (1 of 4) • An 81-year-old woman has an ulcer on her lower left lateral ankle. She thinks the ulcer developed after she scraped the ankle 2 months ago. Antibiotic creams and leg elevation have not healed the ulcer. There is no pain in lower extremities at rest or with exertion, before or since injuring ankle. • Since ankle injury, walking is more difficult. She now uses a cane, but still has general sense of instability. • She has become less active over the last year. She now goes out only to be driven to her daughter’s home and to a local senior center. 39 CASE 2 (2 of 4) • History: distant MI (no residual symptoms), diabetes (well controlled with metformin and diet) No history of vascular problems • Examination Blood pressure 150/88 mmHg, heart rate 58 bpm and regular Cardiac findings unremarkable Bilaterally, reduced but palpable pulses in lower distal extremities 4 cm × 3 cm ankle ulcer, with sharp border and dry, pale base; no surrounding rubor or erythema Right and left ankle–brachial indexes (ABIs) at rest are 1.4 and 1.42, respectively. Glomerular filtration rate: 50 mL/min/1.73 m2 40 CASE 2 (3 of 4) Which of the following is the correct diagnosis? A. Arterial ulcer B. Pressure ulcer C. Squamous cell carcinoma D. Cellulitis 41 CASE 2 (4 of 4) Which of the following is the correct diagnosis? A. Arterial ulcer B. Pressure ulcer C. Squamous cell carcinoma D. Cellulitis 42 GNRS5 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS5 Teaching Slides modified from GRS9 Teaching Slides based on chapter by Michael W. Rich, MD, AGSF and questions by Daniel E. Forman, MD, FACC, FAHA Managing Editor: Andrea N. Sherman, MS Copyright © 2016 American Geriatrics Society