Patient-Centered Care for the

Complex Older Cardiology Patient

Kevin Overbeck, DOAssistant Professor, NJISA

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

Aging Physiology:Body Composition

• Lipid Compartment Expands• Total Body Water (mainly ECF)

declines• Lean Muscle Mass Declines• Application: Implications for Drug

Prescribing

HYPERTENSION &

THE ELDERLY

Increased thickness of the intima and the media

INCREASED VASCULAR STIFFNESS

Aging Physiology

Aging Physiology

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.

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 Changes1

HTN & The ElderlyOrthostatic BP Measurement

Sitting-Standing vs. Laying-StandingAfter 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 DementiaDecreased Baroreceptor Sensitivity1

Postprandial Hypotension

HTN & The ElderlyHYVET

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.

HTN & The ElderlyHYVET

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.

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 Classification

Systolic (mmHg)

Diastolic(mmHg)

Initial Therapy

Normal <120 <80 Encourage LSM

Pre-Hypertension

120-139 80-89 LSM + No Anti-Hypertensive Drug Indicated; Treat patients with CKD or DM to a goal <130/80 mmHg

Stage 1 140-159 90-99 LSM + Thiazide diuretics for most

Stage 2 > 160 >100 LSM + Two drug combination for most *

* Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.

Ambulatory BP MonitoringSelf Measuring BPAssess Risk Factors

JNC 8: Clinical Practice Guidelinesindividuals >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 Classification

Systolic (mmHg)

Diastolic(mmHg)

Initial Therapy

Pre-Hypertension

Deleted / Omitted

DM <140 <90 LSM + No Anti-Hypertensive Drug Indicated

CKD** (<70) <140 <90 Previous less than 130/80

Goal <150 <90 LSM + 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 MonitoringSelf Measuring BPAssess Risk Factors

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 daily2. Metoprolol XL 50mg daily3. Amlodipine 2.5mg daily4. HCTZ 12.5mg daily5. KCL 10meq daily 6. Losartan 50mg daily7. Atorvasatin 10mg daily8. Tamsulosin 0.4mg daily

BP 120/80mmHgHR 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

JNC 8: Applied GerontologyAn 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 daily2. Amlodipine 5mg daily3. Prednisone Taper 4. Albuterol Nebulizer QID

PRN5. Lisinopril 10mg daily6. HCTZ 12.5mg daily7. Omeprazole 20mg daily8. KCL 10meq daily9. Vitamin D 1000 IU daily10. Alendronate 70mg qHS11. Pravastatin 40mg qHS

Medications Known To Increase BP

• Steroids• Sympathomimetic

Drugs• Decongestants• NSAIDS• Erythropoietin

JNC 8: Applied GerontologyAn 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): 154/70BP (standing): 120/60 [asymptomatic]Lower Extremity 1++ bilateral edemaBUN 20 / Creat 1.2 / eGFR > 60

CURRENT MED LIST:

1. Aspirin 81mg daily2. Losartan 50mg daily3. Carvedilol 6.25mg BID4. HCTZ 12.5mg daily5. Omeprazole 20mg daily6. KCL 10meq daily7. Vitamin D 1000 IU daily8. Pravastatin 40mg qHS

What is the next BEST step in the management of this patient’s condition?

STATINS, DYSLIPIDEMIA& THE ELDERLY

Dyslipidemia

Dyslipidemia

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

DyslipidemiaPrimary 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 yrsAtorvastatin 10mg v.

Placebo4 years

NNT Data:

Older Younger

1st major cardiovascular even

22 32

DyslipidemiaSecondary 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:

Older

Younger

All Cause Mortality 22 46CAD Death 35 71Fatal / Non-Fatal MI

30 36Stroke 79 170

Age 40-75 yr olds; Pravastatin v. Placebo

ATRIAL FIBRILLATION&

THE ELDERLY

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.

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 responseFunctional Hx: (+) ambulates with a rolling walker at baseline

PMHx: DM, HTN, Hx Recurrent Falls, Osteoporosis, Depression, Dementia, Chronic ConstipationMMSE (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]

MedicationsInsulin Glargine 12 units qHSLisinopril 20mg dailyMetoprolol XL 50mg dailyAlendronate 70mg qWeekCalcium 500mgVitamin D 400IU BIDDocusate BIDCitalopram 20mg dailyDonepezil 10mg dailyMemantine10mg BID

Should WARFARIN be prescribed in this patient?

(A) YES(B) NO

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 ConstipationMMSE (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]

MedicationsInsulin Glargine 12 units qHSLisinopril 20mg dailyMetoprolol XL 50mg dailyAlendronate 70mg qWeekCalcium 500mgVitamin D 400IU BIDDocusate BIDCitalopram 20mg dailyDonepezil 10mg dailyMemantine10mg BID

Should WARFARIN be prescribed in this patient?

(A) YES(B) NO

Atrial FibrillationStroke Prophylaxis

We under utilize anticoagulation in the elderly with atrial fibrillation

AnticoagulationClinician Concerns

• Compliance• Monitoring• “Fall Risk1,2”• 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

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

CHA2DS2-VASc

SCORE

AdjustedStroke Rate(%/year)

0 0

1 1.3

2 2.23 3.2

4 4.0

5 6.7

6 9.8

7 9.6

8 6.7

9 15.2

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

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.

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.

Anticoagulation & The Elderly

Setting % in Range

Self-Monitoring

72%

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

WARFARIN superiority

• NNT 37 PRIMARY PREVENTON1

• NNT 12 SECONDARY PREVENTION1

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

ATRIAL FIBRILLATIONRATE CONTROL

Which Patient is “more sick?”

1. A2. B3. c

(1)(2)

3.

40 Year Old FemaleHR 160

80 Year Old Female HR 118

Both Equally

Aging Cardio-Physiology

• Resting HR Unchanged With Aging

• Maximum HR = 220 – age

OR• = 208 – (0.7) x

age

Cardiac Ventricular Filling Rate

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

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

Rate Control Medications

Beta-Blockers – Atenolol, Carvedilol, Metoprolol, Nadolol, Propanolol

Nondihydropyridine Calcium Channel Blockers – Diltiazem + Verapamil

Digoxin

Amiodarone

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