Download Cardiology.Part2.GNRS5

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CARDIOLOGY
Part 2
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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
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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.
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 6574 yr,
1 point for vascular disease, 1 point for female sex
 Score of 2: patient is candidate for systemic
anticoagulation
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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