Post on 18-Oct-2020
39ο ΠΑΝΕΛΛΗΝΙΟ ΚΑΡΔΙΟΛΟΓΙΚΟ ΣΥΝΕΔΡΙΟ
Αθήνα 2018
Βασιλική Ν. Γιαννακοπούλου MD, Phds, FESC, FEASΔιευθ. ΜΕΚ Τζάνειο Νοσοκομείο Πειραιά
Πρόεδρος ΟΕ Επιδημιολογίας ΕΚΕ –Γραμμ. ΕΚΘΑ
Δεν υπάρχει σύγκρουση συμφερόντων
Disease /total death rates for the most common diseases of old age
Current Biology 2012
The impact of the aging population on CHD in the USA
Odden MC et alAm J Med. 2011
Relationship Between Hard & Fatal ASCVD Events
Martin Bødtker Mortensen JACC January 2018
BioMed Res. Intern. June 2018
Aging processes, prevalence of aging-related diseases, & some selected CVDs
BioMed Res. Intern. June 2018
The complex alterations
in aging-induced CVDs
Role of ageing pathways in CVD
◼ Insulin resistance is associated with DM and cardiac
dysfunction
◼ Defective mitochondria lead to cardiomyocyte
apoptosis, and cell loss in the heart
◼ High DNA damage and telomere shortening increase
endothelial senescence leading to atherosclerosis
CHD, HF. Could also contribute to cell loss in the
heart
◼ During ageing, autophagic flux is slowed, leading to
accumulation of damaged and toxic organelles and
proteins, which can lead to cardiac dysfunction
cardiomyopathy, cardiac hypertrophy and HFCurrent Biology 2012
Clinical Manifestations/Angina
◼ Typical angina only 40% have this
◼ Dyspnea – is related to ischemia on a stiff LVH raising PA pressure
◼ Nausea, vomiting, syncope
◼ Secondary MI – post pneumonia, fractured hip
◼ PE much more common presentation in the elderly
◼ Lack of angina based on sedentary life style due to co-morbid conditions
Geriatric Cardiovascular Syndromes
◼ Systolic Hypertension
◼ 70% NHANES1, 90%
Liftetime
◼ Load lability – Hypertensive
urgency and orthostasis
◼ Trigger: salt, NSAIDs, stress,
etc
◼ HFPEF
◼ >Half of all heart failure
◼ APE/AHDF/CHF -
presentations
◼ Multiple mechanisms
◼ Syncope/Falls
◼ 33-50% fall/year,
syncope ↑ with age
◼ Multiple triggers
◼ AF
◼ >10% of octogenarians
◼ PAF leads to chronic
afib
◼ ↑ risk for
stroke/disabilityCirculation 2011
N Engl J Med. 1997
HFPEF: Embrace
Complexity
HFPEF
Anemia ArterialStiffening
Sarcopenia
Chronotropic Incompetence
Pulmonary HTNDiastolic
DysfunctionVolume
Overload
Endothelial Dysfunction
Salt Sensitivity
Atrial Fibrillation
Outcomes in CVD
Heart failure
46%
STEMI17%
Non-STEMI19%
Arrhythmia
11%
Syncope5%
Other 2%
Diagnosis At Admission
n=211
82±5 yearsRange 75-95 years
LOS 7±4 days
Heart. 2011 Oct;97(19):1602-6
Co-Morbidities in Older Adults
◼ Renal Dysfunction:16%- GFR < 30--40% - GFR 30-59mL/min
◼ Chronic Lung Disease: 20-32%
◼ Cognitive Impairment (Mild 28%, Mod/Severe19%)
◼ Dementia 8.5%
◼ Delirium: 30-50% of hospitalized pts--36.8% in post-op pts-- >70% in ICU
◼ Depression 8-25%
◼ DM 30-50%
◼ Falls, Mobility Difficulties 30-50%
◼ Postural/Postprandial Hypotension 10-30 & 10-20%
◼ Anemia: (Inpatient: 70%--Outpatient: 10-20%)
◼ Urinary Incontinence (♀ 35%--♂ 22%)
◼ Sensory Impairments
◼ Anergia/Fatigue (Mild/mode 70%--Severe 20%)
◼ Polypharmacy: Almost all
◼ 1st describe in 1970s
◼ The term was selected to focus attention on a group of elderly with physical debilities, emotional impairments, debilitating
social & physical environments
Frailty syndrome(an inevitable consequence of aging)• Outcomes Prolonged/repeatedhospitalizations
• Proximate causesMultiple co-morbid conditions
• Intermediate causesLoss of organ system reserve
• Polypharmacy
• Initial causes Changes in endocrine function
Prolonged/limited Recoveries
Fails/fracturesProlonged reaction timeLoss of strengthPoor vision
Osteoporosis
A New Model of Care for Older Adults with CVD
Traditional Cardiology Geriatric Cardiology
Treatment focused on the heart Treatment considers the host
Few comorbidities Multiple comorbidities
Treatment yields expected outcomes
Treatment may result in complex effects
Large simple trials apply Large simple trials have limited generalizability
Evidence-based medicine Patient-centered evidence-based medicine
Cardiovascular reserve usually preserved
Cardiovascular reserve usually compromised
Outcomes: death, MI, revascularization
Outcomes: morbidity, function, independence, cognition
JACC 2011;57(18):1801-10.
Polypharmacy
Consequences of polypharmacy
➢ Greater health care costs
➢↑ risk of adverse drug events & drug-interactions
➢ Medication non-adherence
➢↓functional capacity and multiple geriatric sdrs
Factors that contribute to polypharmacy
➢ Multiple diseases states
➢ Time constraints on health professionals
➢ Multiple health care providers
➢ Use of non-prescription medications
➢ Patient-driven prescribing
Multiple Diseases & Polypharmacy in the Elderly CVD pts
Indo American J. of Pharm.Recearch 2016
Drug-Drug Interaction type in cardiac patients.
Horizontal axis represents the Drug Interaction type/ vertical
axis represents percentage of interaction
182 cardiac patients 72% ♂
J. of Applied Pharmaceutical Science 2012
Severe drug-drug interactions. Horizontal axis represents
percentage of DDIs & vertical axis represents the IDs
J. of Applied Pharmaceutical Science 2012
The prevalence and determinants of polypharmacy at
age 69: a British birth cohort study
➢ 1 medication was taken by 37.8%
➢2--4 medications by 23.8%
>5 medications by 8.1%
5362 individuals (2547♀) aged 68–69 yrs
Rawle et al. BMC Geriatrics 2018
The impact caused by polypharmacy
Asian J Pharm Clin Res 2017
Exclusion of Older Adults from Clinical Trials
◼ 1/3 of all major, original research papers in 1997 and 15% in 2004 excluded older people without justification
◼ Potential concerns:
◼ More comorbid illnesses, more difficulty to follow, higher drop out
◼ Increased risks with treatment
◼ Polypharmacy
◼ Protocol restrictions on comorbidities
◼ Older population as “vulnerable” study group
◼ Barriers with transportation and mobility
◼ Age is only one factor; frailty and age are not the
same thing
◼ Care of complicated older patients with multiple
chronic comorbidities must be individualized and
cannot be totally driven by standard guidelines
◼ But guidelines and standards of care should not be
ignored in patients just because they are older
◼ Polypharmacy is often difficult to avoid because it is associated
with a number of diseases suffered by the elderly. Therefore,
inappropriate prescribing is an important concern of health
workers to avoid unwanted drug effects
◼ Administration of drugs should pay attention to the
pharmacokinetics and pharmacodynamics of drugs especially
the adjustment of drug dose to avoid drug side effects and DIs.
Elderly patients were given >5 medications, need to be closely
monitored because they are four times higher risk of undesired
effects due to DIs
◼ Collaboration between the medical profession needs to be done
to evaluate the best treatment outcomes
◼ Elderly patients with multiple diseases, it may get more types of
drugs in polypharmacy, and potentially increase the
inappropriate prescription drugs, and contributes to ADEs,
ADRs, and duration of hospitalization
◼ Benjamin Franklin:
◼ “All would live long, but none would be
old.”
◼ Abraham Lincoln:
◼ “And in the end, it’s not the years in your
life that count. It’s the life in your years.”