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.”