Basics
Description
- Advanced age has strong associations with diseases such as HTN, coronary atherosclerotic heart disease, CHF, valvular disease, and conduction system abnormalities.
- Age-related changes in cardiac structure and function play an important role in several of these conditions.
Epidemiology
- Current estimates suggest >39 million people ≥65 in the U.S.; it is expected this number will surpass 80 million by the year 2030.
- 35% of all deaths in patients >65 are due to acute coronary syndrome.
- Heart failure is the leading cause for hospital admission for patients >65.
General Prevention
- Primary prevention includes treatment of HTN, diabetes, and dyslipidemia
- Smoking cessation
- Dietary modification, weight management, and regular exercise
- High benefit from preventive measures at older age due to high incidence of disease
Pathophysiology
- Remodeling of cardiac structures:
- Increased LV wall thickness:
- Greater reliance on atrial systole for cardiac output
- Increased incidence of diastolic heart failure
- Increased intracardiac filling pressures
- LV hypertrophy
- Increased left atrial size:
- Increased likelihood for atrial fibrillation
- Valvular structural changes:
- Aortic sclerosis and stenosis
- Mitral annulus thickening and calcification
- Conduction system degeneration:
- Sinus bradycardia, sinoatrial nodal block, sinoatrial arrest, sick sinus syndrome, PR prolongation, atrioventricular (AV) block
- Coronary atherosclerotic heart disease:
- Stable angina, unstable angina, MI
- Development of ischemic cardiomyopathy
- Alteration in cardiac function:
- Decreased cardiac reserve:
- Lowers threshold and increases severity for heart failure development
- Leads to inability to tolerate changes in systemic processes that have secondary effects on the cardiovascular system (ie, sepsis, hypovolemia, hypervolemia)
- Diminished threshold for cellular calcium overload:
- Increased susceptibility for atrial and ventricular arrhythmias
- Increased myocardial fibrosis and necrosis
- Diminished systolic and diastolic function
Etiology
- Remodeling of cardiac structures:
- Increased LV wall thickness:
- Possible mechanisms include increase in LV myocyte size, decrease in myocyte number via necrosis and apoptosis, altered regulation of growth factors, and focal collagen deposition
- Increased left atrial size:
- Possible mechanisms include increased left atrial pressure and volume
- Valvular structural changes:
- Thickening and calcification of valve leaflets
- Conduction system degeneration:
- Decrease in the number of sinus node cells by 50-75% in the aged heart. The number of atrioventricular node cells remains fairly well preserved
- Fibrosis of the conduction system
- Coronary atherosclerotic heart disease:
- Development of both stable and unstable atherosclerotic plaques, with the latter more prone to cause an acute coronary syndrome due to its large thrombogenic lipid core
- Injury to the endothelium by chemical, mechanical, or inflammatory events incites the process of atherosclerosis. Oxidation of LDL cholesterol propagates an inflammatory state in the endothelial lining of the vessel after deposition, causing development of atherosclerotic plaques.
- Commonly, in the aging heart, there is a greater degree of subcritical stenoses spanning the length of the vessel. This diffuse disease limits blood flow to the distal vascular bed.
- Alteration in cardiac function:
- Decreased cardiac reserve:
- Possible mechanisms include decreased intrinsic myocardial contractility, increased vascular load, increased plasma catecholamine levels, and altered β-adrenergic modulation of heart rate and myocardial contractility
- Diminished threshold for cellular calcium overload:
- Possible mechanisms include altered gene expression that regulates calcium handling, increased polyunsaturated fatty acid ratios in cardiac membranes
Associated Conditions
- Aortic sclerosis is associated with atherosclerotic disease, especially coronary atherosclerotic heart disease.
- Peripheral vascular disease and cerebrovascular disease are associated with coronary atherosclerotic heart disease
Diagnosis
History
Fatigue, confusion, lethargy, weight gain, reduced exertional tolerance, presyncope, syncope, visual disturbances, headaches, cough, shortness of breath, orthopnea, chest discomfort, and palpitations.
Physical Exam
HTN, tachycardia, bradycardia, irregular rhythm, elevated jugular venous pressure, displaced and/or sustained apical impulse, 3rd heart sound (S3), 4th heart sound (S4), regurgitant or stenotic valvular murmurs, pulmonary rales or wheezing, lower extremity edema, cool extremities, poor capillary refill
Tests
Lab
Lipid panel, fasting glucose to guide preventive therapy.
Lab
- EKG: Rhythm abnormalities, LV hypertrophy, and left atrial abnormality, old Q-waves, ST-segment and T wave abnormalities
- CXR: Cardiomegaly, LV chamber enlargement, left atrial enlargement, enlarged central pulmonary arteries, pulmonary edema
- Echo with Doppler: Enlarged left atrium/LV, LV hypertrophy, abnormal mitral valve inflow velocities, impaired relaxation, diastolic dysfunction, systolic dysfunction, wall motion abnormalities, valvular regurgitation, stenosis, or calcification
- Stress testing: Formal assessment of exercise capacity and ischemic burden of the LV myocardium-noninvasive cardiac risk assessment:
- Exercise EKG stress testing: Exercise tolerance, ST-segment depression suggestive of myocardial ischemia
- Stress echo: Stress-induced wall motion abnormalities, decrease in LV ejection fraction
- Nuclear stress: Perfusion defects, transient ischemic dilation.
- Cardiac PET imaging: Perfusion defects, cardiac viability
- Cardiac MRI: Perfusion defects, viability, valvular heart disease and structural defects, imaging of infiltrative processes
- Cardiac catheterization: Identification of angiographically significant coronary obstruction, leading to percutaneous coronary intervention (PCI) with stent or CABG (coronary artery bypass graft) surgery. Gold standard of coronary disease assessment.
Treatment
Medication
Depending on the disease, medications prescribed for younger patients should be also offered to elderly patients. Initiation of medications should be closely monitored and started at lower doses, as elderly more prone to side effects such as bradycardia, hypotension, conduction system disturbances, and hepatic or renal toxicity.
Surgery
Although increased periprocedural complications are directly associated with age, surgical intervention should not be withheld from the elderly. Careful consideration of overall clinical status of patient must be taken into consideration prior to intervention. Some data suggest the increased periprocedural complication rate for CABG in elderly patients may be offset by higher intermediate range survival benefit.
In-Patient Considerations
- Older age increases mortality and morbidity from MI or CHF during inpatient admission.
- Older patients often have atypical presentations for myocardial ischemia.
- High prevalence of diastolic dysfunction in the elderly; take care in administration of IV fluids.
Ongoing Care
Patient Education
- Patients should be carefully counseled regarding drug-drug interactions, as well as side-effect profiles of their medications.
- Patients with HTN or heart failure (systolic or diastolic) will need nutritional counseling regarding salt restriction.
- Patients should be advised regarding the symptoms of myocardial ischemia and cerebrovascular accident.
Additional Reading
1Alexander KP, Newby K, Armstrong PW. Acute Coronary Care in the Elderly, Part II: ST-segment-elevation myocardial infarction. A Scientific Statement for Healthcare Professionals from the American Heart Association Council on Clinical Cardiology: In collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115:2570-2589. [View Abstract]2Alexander KP, Newby K, Cannon CP. Acute Coronary Care in the Eldery, Part I: Non-ST Segment Elevation Acute Coronary Syndromes. Circulation. 2007;115:2549-2569. [View Abstract]3Lakatta EG, Levy D. Arterial and cardiac aging: Major Shareholders in Cardiovascular Disease Enterprises. Part II: The Aging Heart in Health: Links to Heart Disease. Circulation. 2003;107:346-354. [View Abstract]4Schwartz J MD, Zipes DP. Cardiovascular disease in the elderly. In Libby P, Bonow R Heart Disease, 8th ed. Philadelphia: WB Saunders, 2007; 1923.5Varagic J, Susic D, Frohlich ED. Heart, aging, and hypertension. Curr Opin Cardiol. 2001;16:336-341. [View Abstract]6Wei JY. Advanced aging and the cardiovascular system. In Wenger NK (ed): Cardiovascular Disease in the Octogenarian and Beyond. London, Martin Dunitz, 1999:9-19.
Codes
ICD9
- 414.00 Coronary atherosclerosis of unspecified type of vessel, native or graft
- 426.9 Conduction disorder, unspecified
- 428.0 Congestive heart failure, unspecified
SNOMED
- 443502000 atherosclerosis of coronary artery (disorder)
- 42343007 congestive heart failure (disorder)
- 44808001 conduction disorder of the heart (disorder)
Clinical Pearls
- High prevalence of cardiac disease, especially CHF and coronary disease in elderly population; leading cause of mortality and hospital admissions in elderly
- Remodeling of LV with age makes diastolic heart failure very common
- Elderly patients have higher rate of side effects with antihypertensive drugs as well as drugs that affect cardiac conduction system.