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PHAR350 > CVD in Older Adults > Flashcards

CVD in Older Adults Flashcards

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1
Q

What is the relationship between hypertension and age?

A

incidence increases with age
-Framingham study: lifetime risk of developing HTN is > 90%

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2
Q

Which type of hypertension is most common in older adults?

A

isolated systolic hypertension
-SBP more closely correlated with CV risk in pts > 50y

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3
Q

What are the physiological changes in blood pressure seen with aging?

A

decreased baroreceptor response
impaired cerebral autoregulation
= increased risk for orthostatic hypotension

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4
Q

How should anti-hypertensives be started in older adults?

A

start low, go slow
-avoid overly-aggressive BP reductions due to risk of tissue hypoperfusion and ischemia

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5
Q

What are the benefits of lowering blood pressure?

A

good evidence from multiple epidemiological studies and clinical studies that lowering high blood pressure reduces risk of:
-heart attacks
-strokes
-sudden cardiac death
-heart failure
-peripheral artery disease
-end-stage renal disease

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6
Q

What is the evidence for hypertension and dementia risk reduction?

A

epidemiological studies have shown that elevated blood pressure in middle-age increases risk for cognitive impairment later in life
short-term clinical intervention studies of treating HTN in older adults have not shown decreased dementia risk
-often stopped early due to superiority in CV-endpoint risk reduction
-SPRINT-MIND showed decreased risk of MCI with intensive (<120) vs standard (<140) BP control over 5 yrs

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7
Q

What are some health behavior interventions for hypertension in older adults?

A

reduce alcohol intake
DASH diet
smoking cessation
others may be somewhat less practical in older adults, particularly if frail
-caution when advising weight reduction
-sodium restriction may result in hyponatremia, orthostatic hypotension
physical activity should continue to be encouraged
-consideration for necessary safety modifications
-PT consultation?

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8
Q

Describe appropriate at home blood pressure monitoring.

A

sitting position
back supported
arm bare and supported
middle of the cuff at heart level
do not talk or move before or during the measurement
legs uncrossed
feet flat on the floor
should have rested for 5 minutes prior

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9
Q

Which patients were excluded from SPRINT Elders?

A

diabetes
HF
history of stroke
recent MI (past 3 months)
BP < 110 mmHg after 1 min standing
dementia
LTC resident

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10
Q

What were the results of SPRINT Elders?

A

SBP target < 120 mmHg (intensive) vs < 140 mmHg (standard)
-NNT 27 over 3 yrs to prevent one CV death, MI/ACS, stroke or acute decompensated HF
-NNT 43 over 3 yrs to prevent one death
-non-significant increase in syncope, hypotension, and AKI in intensive group

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11
Q

What are the thresholds and targets for blood pressure treatment according to Hypertension Canada?

A

Hypertension Canada high-risk patients:
-threshold: SBP > 120
-target: SBP < 120
diabetes mellitus:
-threshold: > 130
-target: < 130
moderate-to-high risk (TOD or CV risk factors):
-threshold: > 140
-target: < 140
low risk (no TOD or CV risk factors):
-threshold: > 160
-target: < 140

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12
Q

What is considered to be a Hypertension Canada high-risk patient?

A

one or more of the following:
-clinical or sub-clinical CV disease
-CKD
-FRS > 15%
-age > 75 yrs

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13
Q

What are some considerations to keep in mind when pursuing intensive blood pressure targets in older adults?

A

orthostatic hypotension
diastolic hypotension
frailty and functional status

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14
Q

What is orthostatic hypotension?

A

> 20 mmHg systolic and/or > 10 mmHg diastolic decrease in BP within 1-3 minutes of standing

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15
Q

What is orthostatic hypotension a risk factor for?

A

falls
hospitalizations
CV events
functional decline

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16
Q

What is orthostatic hypotension associated with?

A

increased age
diabetes
Parkinson’s disease
dementia
medications

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17
Q

How does frailty and functional status impact intensive blood pressure control?

A

risks and treatment burden of intensive BP control may outweigh benefits in these patients
also consider time to benefit of intensive treatment (~2.5 yrs)
-is this time frame applicable to your patient?

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18
Q

When should we reconsider intensive BP targets in older adults?

A

functional dependency, limited life expectancy, dementia
orthostatic hypotension
diastolic hypotension + CAD
SPRINT exclusion criteria: diabetes, HF, history of stroke, recent MI
patient/family preference

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19
Q

What is a major key in determining antihypertensive choice in older adults?

A

is there a compelling indication for one or more antihypertensive?
-yes: choose agent according to compelling indication
-no: choose agent for ISH

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20
Q

What are the antihypertensives of choice for ISH?

A

thiazide
ARB
CCB

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21
Q

What are the antihypertensives of choice for diastolic HTN with or without systolic HTN?

A

monotherapy:
-thiazide
-BB
-ACEI/ARB
single pill combo:
-ACEI/ARB with CCB
-ACEI/ARB with thiazide

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22
Q

What are the antihypertensives of choice for diabetics with microalbuminuria, renal disease, or additional CV risk factors?

A

ACEI/ARB

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23
Q

What are the antihypertensives of choice for diabetics without any additional risk factors?

A

ACEI/ARB
DHP CCB
thiazide

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24
Q

What are the antihypertensives of choice for patients with CAD?

A

ACEI/ARB
BB or CCB for patients with stable angina

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25
What are the antihypertensives of choice for patients with a recent MI?
BB and ACEI (ARB if ACEI intolerant)
26
What are the antihypertensives of choice for patients with HF?
ACEI (ARB if ACEI intolerant) BB MRA
27
What are the antihypertensives of choice for patients with LVH?
ACEI/ARB CCB thiazide
28
What are the antihypertensives of choice for patients with a past stroke or TIA?
ACEI and thiazide combination
29
What are the antihypertensives of choice for patients with non-diabetic CKD with proteinuria?
ACEI (ARB if ACEI intolerant) diuretics as additive therapy
30
What are the antihypertensives of choice for patients with PAD?
does not affect initial treatment recommendation
31
What are some things to evaluate in older adults with high blood pressure despite treatment?
adherence? secondary causes of hypertension -medications (NSAIDs)
32
Which thiazide is most potent?
chlorthalidone 1.5-2 x more potent than HCTZ --> monitor electrolytes
33
What are the risks associated with thiazides?
increased gout risk observational studies --> possible increased risk of skin cancer electrolyte abnormalities (K and Na) orthostatic hypotension worsening urinary urgency/incontinence
34
What are some monitoring parameters for ACEI/ARB?
renal function K
35
Can ACEI and ARBs be combined?
not recommended
36
What are some common uses of CCBs?
all long-acting agents can be considered for: -uncomplicated HTN, stable angina, LVH dihydropyridines: -also indicated for ISH non-dihydropyridines: -may be useful to control HR in afib
37
What are side effects of CCBs?
can cause or exacerbate peripheral edema, especially higher doses -can try split dosing or hs dosing non-DHP: -constipating in older adults
38
When should non-DHP CCBs be avoided?
HFrEF
39
What should non-DHP CCBs not be combined with?
BB
40
What are the uses of beta-blockers?
not recommended as 1st line anti-hypertensive for adults > 60 yrs still recommended in older adults if compelling indications exist: -post-MI -HFrEF -control HR in afib also may be used as add-on therapy for HTN in older adults
41
What are the side effects of beta-blockers?
fatigue decreased exercise tolerance
42
What is the general consensus on statin use in older adults who are secondary prevention?
statins should be started/continued for secondary prevention of CV events regardless of age and in mild-moderate frailty -benefits generally outweigh risks
43
What is the time to benefit of a statin for secondary prevention?
~ 2 years
44
Describe the evidence for statin use in primary prevention after 75 yrs of age.
lack of evidence to support who should receive statin therapy for primary prevention of CV events PREVENTABLE and STAREE clinical trials ongoing - will hopefully provide clarity in the meantime, shared decision making: -cardiovascular risk factors -functional status -medication/treatment burden -statin associated AE -desire to take more/less medications
45
Which dose of statins may be preferred in older adults?
moderate-dose -especially outside of the acute post-event period
46
What are older adults more susceptible to with statins?
statin adverse effects -myalgias, GI upset, fatigue, increased risk of AKI -rare case reports of statin associated cognitive impairment (reversible on dc)
47
What is the role of other cholesterol medications in older adults?
limited role PCSK-9 inhibitors --> FH fibrates may be necessary in severe hypertriglyceridemia ( > 10 mmol/L) to prevent pancreatitis ezetimibe has limited evidence for improving CV outcomes in combinations with statins (no evidence of decreasing CV morbidity or mortality as monotherapy) *consider deprescribing if appropriate*
48
Are stable CAD patients considered primary or secondary prevention?
secondary
49
What are some important considerations to keep in mind with patients with CAD?
time since event symptom stability activity level patient goals and preferences
50
What is the medication cocktail after ACS?
beta-blocker, ACEI/ARB, statin, ASA others as needed: -other antihypertensives for BP -other anti-anginals as needed: CCB, long-acting or prn nitroglycerin
51
What lifestyle change might decrease the medication requirements for patients who have had ACS?
as activity level decreases, medication requirements might decrease also
52
Describe antiplatelet use after ACS.
ASA indefinitely -clopidogrel if contraindicated -consider adding PPI if history of GI bleed
53
Describe BB use after ACS.
evidence of decreased CV risk up to 3 years post-MI -titrate to resting HR of ~ 60 bpm
54
When should BB use be reconsidered after ACS?
after 3 years re-evaluate based on symptoms and comorbidities -indicated indefinitely for HFrEF -reasonable to continue if angina symptoms, afib needing rate control -if poorly tolerated --> re-evaluate if > 3 y post-MI
55
Describe ACEI/ARB use in stable CAD.
recommended for all individuals with stable CAD and HTN, DM, HFrEF, or CKD continue indefinitely as tolerated
56
Describe CCB use in stable CAD.
angina if beta-blockers CI or not tolerated diltiazem or verapamil may also be used for rate control in afib
57
When are short-acting nitrates used in CAD?
rescue or prophylactically prior to activities which provoke symptoms -ensure using properly
58
What are some side effects of nitrates?
dizziness headache hypotension flushing edema
59
When are long-acting nitrates used in CAD?
may be added when BB and/or CCB are CI, not tolerated, or not providing adequate symptom relief
60
What needs to be ensured is done with long-acting nitrates?
12h nitrate-free period
61
Which class of drugs contributes to the most ED visits for ADRs?
anticoagulants and antiplatelets
62
What is atrial fibrillation?
abnormal electrical conduction in the atria --> chaotic, uncoordinated contraction
63
What are the symptoms of atrial fibrillation?
may be asymptomatic or may experience: -SOB, fatigue -palpitations -chest discomfort -anxiety, sweating
64
What are the two key clinical issues with atrial fibrillation?
significant increased risk of ischemic stroke increased heart rate --> heart failure
65
How is stroke risk managed in atrial fibrillation?
anticoagulation -warfarin or DOAC
66
What is the dilemma with age and atrial fibrillation?
incidence of atrial fibrillation increases with age advanced age increases the risk for both major bleeds & stroke
67
What often becomes a deterrent to anticoagulation from a physician perspective?
advanced age -underestimation of benefit
68
What are the advantages of DOACs over warfarin?
> efficacy less ICH no INR monitoring fewer drug and food interactions
69
What are the disadvantages of DOACs compared to warfarin?
cost, EDS more GI bleeds (rivaroxaban, edoxaban, dabigatran) less long-term safety data caution in renal impairment
70
What are contraindications of DOACs?
severe renal impairment not indicated with mechanical heart valves
71
When do we consider changing from warfarin to DOAC?
really anyone that doesnt have an indication for warfarin -ex: significant DDI, cant get to lab, labile INRs
72
When is warfarin preferrable to a DOAC?
severe renal dysfunction mechanical heart valve
73
Describe key factors to consider with each DOAC when determining which one to choose.
dabigatran: -most GI upset -most highly renally eliminated -BEERS if 75 and older rivaroxaban: -once daily dosing with food -BEERS if 75 and older edoxaban: -once daily dosing -watch for DDI (decrease dose with P-gp inhibitors) apixaban: -best safety data (so far) -best choice when renal function is borderline
74
What are some considerations to be keeping in mind for anticoagulation in atrial fibrillation?
is there an indication? (always in older adults due to age > 65) is there a high risk of bleeding or a CI? will the patient be able to adhere to therapy or monitoring? patient/family preferences?
75
Which HAS-BLED score starts to require caution?
3 or greater
76
Does fall risk preclude anticoagulation for afib stroke prevention?
no
77
What are some important considerations to keep in mind with anticoagulants and the ability of older patients to adhere to the monitoring requirements?
warfarin: -INR monitoring -ability to self-manage dosage adjustments? DOACs: -consistent adherence is very important -also need to check CBC, renal function q 6 months
78
What are some factors to consider when deciding between rate vs rhythm control?
duration of afib bothersome afib symptoms? comorbid HF?
79
Which antiarrhythmics are preferred for rhythm control if the patient has heart failure?
LVEF < 40%: amiodarone LVEF > 40%: amiodarone, sotalol
80
Which antiarrhythmics are preferred for rhythm control if the patient has CAD?
amiodarone dronedarone sotalol
81
Which antiarrhythmics are preferred for rhythm control if the patient has no HF nor CAD?
amiodarone dronedarone flecainide propafenone sotalol
82
What occurs to the likelihood of successful rhythm control as afib duration increases?
likelihood of successful rhythm control decreases as afib duration increases -perhaps why previous trials did not show benefit with rhythm control
83
What is an important monitoring parameter for antiarrhythmics in older adults?
adverse effects
84
What are the adverse effects of amiodarone?
optic neuropathy and neuritis pulmonary and hepatic toxicity hypo or hyperthyroidism blue-grey skin discolouration photosensitivity
85
What are some of the many drug interactions of amiodarone?
warfarin digoxin beta-blockers/non-DHP CCB
86
Which medications are used for rate control?
beta-blockers non-DHP CCB 2nd line: digoxin (additive), amiodarone
87
When are beta-blockers preferred for rate control?
when concurrent CAD, HF
88
When are non-DHP CCB preferred for rate control?
severe or poorly controlled asthma/COPD
89
When is digoxin used for rate control?
usually used as add-on therapy may be beneficial if concurrent symptomatic HF
90
Why is digoxin not preferred for rate control?
less effective - does not control HR during exercise AFFIRM trial - increased mortality when digoxin used for afib
91
What is the HR target in afib?
< 100 bpm at rest
92
Describe digoxin monitoring in afib.
monitoring for efficacy: target HR -serum digoxin levels are not a target to aim for but a tool to avoid toxicity monitoring for toxicity: -serum levels if concerned about AE/DI/renal function -digoxin AE: NVD, decreased appetite, dizziness, confusion/delirium, "halos" -older adults much more susceptible to digoxin toxicity -ideally maintain trough level < 1 nmol/L
93
Is rate or rhythm control preferred in older adults?
rate control used to be preferred management option -new evidence suggests benefit for rhythm control in early afib --> may start seeing this more frequently
94
Differentiate HFrEF and HFpEF.
HFrEF: -LVEF < 40% -less blood pumped out of ventricles, weakened heart muscle cant squeeze as well HFpEF: -LVEF > 50% -less blood fills the ventricles, stiff heart muscle cant relax normally
95
What is the standard therapy for HFrEF?
ACEI/ARB/ARNI BB MRA SGLT2
96
Which drug should be started first in HFrEF?
currently no consensus regarding which drug classes to start with when initiating treatment for HFrEF -start with one drug class and titrate up to max tolerated dose? -start with more than one drug class at smaller dose? decisions should be based on clinical characteristics of the patient -hemodynamic status -renal function -side effects/tolerability -cost -adherence
97
What did PARADIGM-HF show?
Entresto vs enalapril -decrease CV mortality and HF hospitalization
98
What is required when switching from ACEI to ARNI?
36 hour washout
99
What are some monitoring parameters for ACEI/ARB/ARNI?
SCr, lytes within 1-2 weeks of initiation/titration sitting and standing BP -orthostatic hypotension may warrant dose decrease -use lowest required dose of diuretic
100
What are frail older adults more susceptible to with ARNI compared to ACEI/ARB alone?
hypotension/orthostatic hypotension
101
Which beta blockers are used in HFrEF?
bisoprolol metoprolol carvedilol
102
Which MRAs are used in HFrEF?
spironolactone eplerenone
103
What is a BEERS criteria for MRAs?
avoid if CrCl < 30 ml/min
104
What did DAPA-HF and EMPEROR REDUCED show?
benefit of dapa and empa in decreasing HF hospitalizations or CV death -~50% of patients had T2DM -no significant difference in AE
105
What are monitoring parameters for SGLT2i?
decrease in eGFR ~15% on initiation volume status - may need to decrease diuretic dose on initiation in euvolemic patients
106
What are some precautions for SGLT2i?
decrease BP ~1-2 mmHg "sick day" management
107
How do older adults tolerate SGLT2i?
increase risk of genital fungal infections ? increase in UTI ? increase in DKA *use with caution in older adults - BEERS 2023*
108
What is the use of loop diuretics in HF?
symptomatic treatment -SOB, fluid retention, increased weight *use lowest effective dose*
109
What is the use of digoxin in HF?
add-on if symptoms despite optimized 1st and 2nd line meds -may also help decrease resting HR in afib
110
What is Torsades de Pointes?
arrhythmia that may lead to sudden cardiac death -associated with prolonged QT interval and bradycardia -may be congenital or acquired
111
What are the risk factors for acquired TdP?
older age female elyte disturbances: hypokalemia/calcemia/magnesemia drugs renal or liver disease hypertension smoking arrhythmia, prior MI, cardiomyopathy
112
What are some common medications that prolong the QT interval?
antiarrhythmics -sotalol, amiodarone, propafenone, flecainide, etc ADHD -atomoxetine antiemetics -domperidone antipsychotics -aripip, haloperidol, pimozide, quet > risp, cloz SSRIs -sertraline, citalopram, escitalopram > others SNRIs -mirtazapine > venlafaxine TCAs -all > nortriptyline antibiotics -moxifloxacin > levofloxacin or ciprofloxacin -clarithromycin, erythromycin > azithromycin antifungals -fluconazole > others miscellaneous -donepezil, hydroxyzine, methadone, tramadol
113
What is the RISQ-PATH score that predicts a high risk of QT prolongation?
10 or greater

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