CARDIOVASCULAR DISEASES IN ELDERLY

Learning objectives the students will be able to:

1. Describe the age-related physiologic changes in the cardiovascular system
2. Explain and identify clinical features of cardiovascular diseases in the older adult
3. Recognize and be familiar with a variety of testing modalities used in the workup of
cardiovascular diseases
4. Identify and describe the treatments for cardiovascular diseases
CARDIOVASCULAR DISEASE: GENERAL CONSIDERATIONS
Cardiovascular disease increases dramatically with aging and is the major cause of mortality and
disability in elderly persons; 83% of all cardiovascular deaths in the United States occur in patients
older than 65 years. Base on survey of health in 1995 coronary arterial disease is the first etiology
of death cause by non infectious diseases in Indonesia. Cardiovascular disease is also a major
contributor to the need for hospital, ambulatory, and custodial care. Coronary heart disease is the
most prevalent cardiac problem, followed by hypertensive cardiovascular disease, with valvular and
pulmonary heart disease other important etiologies. Despite these statistics, the scarcity
of
scientific studies involving very elderly patients is striking. Age-based exclusions from most
clinical trials limit the generalize ability of data to the characteristically high-risk geriatric
population.
AGE-ASSOCIATED CHANGES RELATED TO THE CARDIOVASCULAR SYSTEM
The presentation of cardiovascular disease in elderly patients is complicated by its superimposition
on the physiologic and structural cardiovascular changes of aging. These variables influence the
response of elderly patients both to specific cardiac illnesses and to their therapies. Both the
physiologic and the structural changes that occur in the cardiovascular system with aging decrease
cardiac functional capacity, limit the performance of physical activity, and lessen the ability to
tolerate a variety of stresses, including cardiovascular disease.
Maximal heart rate and maximal aerobic capacity decrease progressively with age, independent of
habitual physical activity status,owing in part to decreased catecholamine responsiveness.
Nonetheless, the maximal oxygen uptake of sedentary elderly individuals is 10% to 20% less than
of their physically active counterparts, with maximal work capacity comparably decreased. Peak
exercise cardiac output and peak exercise ejection fraction also decreased at elderly ages. Cardiac
dilation, enabling an increase in stroke volume, compensates for the diminished heart rate response
to maintain the increase in cardiac output required for exercise. Aortic and large artery thickness
and vascular stiffness increase with aging, with a resultant increase in arterial systolic pressure and
impedance to left ventricular ejection. This increased afterload of aging is likely the stimulus for left
ventricular hypertrophy, even in normotensive elderly persons. Both systolic blood pressure and
mean blood pressure increase with aging with widening of the pulse pressure.
Aging changes in the heart also include the following features: an altered geometric contour; a
decrease in ventricular compliance, with substantial reduction in the early diastolic filling rate; the
diastolic dysfunction of aging, with increase dependence on th contribution of atrial contraction to
late left ventricular filling to maintain cardiac output; a prolonged duration of myocardial
contraction and relaxation times; and lessened chronotropic and inotropic responses to sympathetic
(catecholamine) stimulation.

Baroreceptor responsiveness decreases with aging, due in part to loss of vascular distensibility. The
number of pacemaker cells in the sinoatrial (SA) node and number of bundle branch fibers decrease
with age, with the loss of SA pacemaker cells more pronounced. The sick sinus syndrome is due to
loss of sinus node pacemaker cells and fatty infiltration around the SA node with aging.
Atrioventricular block, intraventricular conduction delay, and bundle branch blocks may be caused
by fibrosis and calcium deposition in the cardiac skeleton. The combination of atrial dilation and
atrial fibrosis may underlie the increased prevalence of atrial arrhythmias.
Thickening of the aortic and mitral valve leaflets and the circumference of all four cardiac valves
increase at elderly age. Collagen degeneration and secondary calcium deposition are common at
elderly age; one third of patients aged 70 and older have calcium deposition in either the aortic or
mitral valve. Calcific degeneration is the major cause of aortic valve disease in elderly patients.
DIAGNOSTIC EVALUATIONS
A. SYMPTOMS and SIGNS
The coexistence of multiple diseases hinders the accurate evaluation of symptoms and may obscure
or complicate the patient's clinical history. Habitual activity levels differ substantially but often
decrease with progressive aging, so that many symptoms do not retain their activity-precipitated
characteristics.
Because orthostatic hypotension is common in elderly persons, it is essential to document the effect
of postural change when measuring blood pressure. Disease and medications, rather than aging per
se, account for the preponderance of postural hypotension. However, in frail elderly nursing-home
residents, orthostatic hypotension is often encountered postprandially and when first arising in the
morning.
Frequent findings in elderly individuals include the early-peaking basal systolic murmur of aortic
sclerosis, typically accompanied by a fourth heart sound at the cardiac apex as evidence of reduced
ventricular compliance. Neither the S4 nor the increased ventricular filling pressure reflects
ventricular systolic dysfunction, whose counterpart is an S3. S2 may be single at elderly age or the
inspiratory splitting may be less prominent. A combination of dorsal kyphosis, emphysema, or chest
wall alterations may limit palpation of the apical impulse, even when left ventricular hypertrophy is
present. Data from the Cardiovascular Health Study suggest the important of the ankle-arm index, a
noninvasive assessment for peripheral arterial disease; a normal values is inversely related to the
risk of cardiovascular disease.
B. NON-INVASIVE DIAGNOSTIC TESTS
Because of difficulties in obtaining a clinical history and in interpreting findings at physical
examination, diagnostic test assume greater importance. Non invasive methods should initially be
selected since elderly patients are at increased risk for complications of most diagnostic procedures.
However, many noninvasive tests have limitations unique to an elderly population.
Resting Electrocardiogram
About 50% non of elderly individuals have abnormalities of the resting electrocardiogram (ECG).
Aging changes in the cardiac conduction system and the age-related increase in the left ventricular
mass underlie the ECG changes, most commonly PR and QT interval prolongation, intraventricular
conduction abnormalities, reduction in QRS complex and T-wave voltage, nonspecific ST-segment
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and T-wave changes, and leftward shift of the frontal plane QRS axis. QT prolongation is more
common in elderly women than in elderly men. Both lung hyperinflation and dorsal kyphosis
accentuate the diminution in QRS voltage, despite the increase in left ventricular mass.
Electrocardiographic evidence of myocardial infarction occurs far more frequently than reported in
the clinical history.
Long-Term (24-Hour) Ambulatory Electrocardiogram
The 24-hour ambulatory electrocardiogram or use of event recorder is the most useful diagnostic
technique to identify symptomatic arrhythmias, particularly when diary evidence is available to
correlate symptoms with these spontaneously occurring arrhythmias. The test is indicated to
identify cardiac rhythm disturbances as etiologic of otherwise unexplained lightheadedness,
dizziness, falls, frank syncope, or uncomfortable palpitations. The limitation of utility of this study
is the high prevalence of both supraventricular and ventricular arrhythmias in the absence of cardiac
disease or cardiac symptoms, even arrhythmias as potentially serious as nonsustained ventricular
tachycardia. The increase in both of supraventricular and ventricular ectopic beats with aging is
more likely a consequence of aging changes in the aorta and ventricles than of intrinsic
abnormalities of the conduction system. Most asymptomatic arrhythmias in the absence of cardiac
disease do not warrant therapy.
Echocardiogram
The echocardiogram is far more accurate than the chest roentgenogram in the assessment of cardiac
chamber size because the kyphoscoliotic chest deformity and sternal depression common in elderly
persons may cause a factitious increase in heart size on the chest roentgenogram. The
echocardiogram is also more accurate for the determination of left ventricular hypertrophy, a
powerful marker for coronary risk, than is the ECG; in addition to identifying left ventricular wall
thickness and mass, cardiac chamber size, and valvular abnormalities, wall motion abnormalities
and ventricular ejection fraction can be determined, as can pericardial effusion. Doppler
echocardiography is reliable for determining the aortic valve area and estimating the pressure
gradient in elderly patients with significant aortic stenosis.
Exercise Tests and Exercise Radionuclide Studies
Among elderly patients able to perform an adequate treadmill test, exercise testing can be
undetaken with comparable safety and efficacy as in younger patients. The exercise test can help
determine if the chest discomfort represents myocardial ischemia, can characterize risk status in the
patient with angina pectoris or following myocardial infarction, can guide recommendations for a
physical activity regimen, and can assess the suitability for return to work when appropriate. A
normal response to exercise testing has the same favorable prognosis as in a younger population,
and an abnormal response to exercise imparts. comparable risk as in younger individuals. Few data
however, are available regarding exercise testing in patients older than 75 years of age. The
Naughton protocol or a modification of the standard Bruce protocol is preferable for treadmill
exercise testing of elderly patients with limited exercise capability.
Exercise thallium scintigraphy is helpful when conduction abnormalities or repolarization changes
on the resting ECG limit the interpretation of the exercise ECG. The presence and extent of
exercise-induced reversible abnormalities permit effective risk stratification in elderly patients.
Myocardial perfusion scintigraphy after intravenous administration of dipyridamole is well tolerated
by older patients and may help identify myocardial ischemia in elderly patients who are unable to
exercise. The sensitivity, specificity, and safety appear comparable in populations older and
younger than 70 years of age. Ventricular function can be assessed by radionuclide
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ventriculography; although it is more expensive than echocardiography, it is applicable to elderly

patients in whom adequate echocardiographic images cannot be obtained.
C. INVASIVE DIAGNOSTIC TESTS
Transesophageal echocardiography (TEE), used to evaluate for aortic dissection, infective
endocarditis, and valvular heart disease, among others, appears to be well tolerated in the elderly, as
arecardiovascular catheterization and coronary arteriography. Precise diagnosis may enable more
successful medical and surgical therapies. Procedure-related morbidity and mortality , although
relatively infrequent, are increased two-to three- fold in the elderly.
MANIFESTATIONS OF CARDIOVASCULAR DISEASE
A. HEART FAILURE
Most of the 5 million patients with heart failure in the US are elderly, and heart failure is the most
frequent hospital discharge diagnosis for patients older than 65 years of age. Heart failure is more
common in men than women until about age 80. The prevalence of heart failure increases with
increasing age and is estimated to involve 5% of the population aged 65 to 74 years and 10% of
those older than 75 years.
Heart failure tends to be both underdiagnosed and overdiagnosed in elderly patients. Many elderly
patients fail to report progressive easy fatigability, dyspnea, cough, and ankle edema. Considering
these a consequence of aging. Early manifestations of heart failure may be masked by the sedentary
lifestyle of many elderly patients, whereas exertional dyspnea may reflect another common
problem, chronic pulmonary disease, rather than cardiac failure. Owing to activity limitations,
profound fatigeu rather than exertional dyspnea may be presenting the feature. On occasion, only
anorexia, insomnia, nocturnal cough, or frequent nocturnal urination may herald heart failure.
Many elderly patients with heart failure may have disordered mental function and behavior
consequent to diminished cerebral blood flow.
Coronary atherosclerotic heart disease, hypertensive cardiovascular disease, and hemodinamically
significant calcific aortic stenosisare the most prevalent causes. Mitral regurgitation is also
contributory. Heart failure is more frequently precipitated or exacerbated by associated medical
problems than in younger patients. These include atrial fibrillation and other arrhythmias, acute
myocardial infarction, uncontrolled hypertension, intercurrent infections and fever, fluid overload,
acute blood loss, pulmonary embolism, anemia, occult thyrotoxicosis, renal insufficiency, acute
lower urinary tract obstruction in men, and major dietary indiscretions. Drugs causing myocardial
depression (beta-blocking drugs, calcium-blocking drugs, and number of antiarrhythmic agents) or
poor compliance with the medical regiments also contributory. Frequent use of nonsteroidal
inflammatory agents by elderly patients, often as nonprescription drugs, can precipitate heart
failure by a combination of sodium and water retention and the induction of renal dysfunction.
Echocardiography has substantially improved the recognition of heart failure in elderly patients and
is the most useful noninvasive test to differentiate systolic and diastolic ventricular dysfunction.
MANAGEMENT OF HEART FAILURE
Vasodilator therapy, beta-blockade, and spironolactone have improved the outlook for elderly
patients with ventricular systolic dysfunction, even when sinus rhythm is present. The combined
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end point of heart failure death or hospitalization was reduced in patients treated with digitalis.
Lower doses are appropriate for elderly patients because of the reduced glomerular filtration rate at
elderly age, which lessen drug elimination rate. Digitalis toxicity should be suspected when altered
mental status, fatigue, or anorexia occur, in addition to the usual nausea and vomiting.
Elderly patient nwith severe systolic dysfunction, particularly in association with atrial fibrillation,
are candidates for oral anticoagulant therapy to limit thromboembolic complications.
Reversion of atrial fibrillation or atrial flutter to sinus rhythm can substantially augment the cardiac
output and improve heart failure because of the importance of the atrial contribution to ventricular
filling in the poorly compliant aged ventricle.
Sodium restriction improves diuresis and limits the resultant hypokalemia, however, major dietary
alterations require assistance and encouragement i elderly patients. Difficulties with food
purchasing and preparation, lack of interest in meals when eating alone, dental problems that impair
chewing, and financial constraints often hamper dietary alterations. Although physical activity
limitation is advisable when heart failure is decompensated, protracted immobilization predisposes
to deep vein thrombosis and pulmonary embolism. Resumption of a regular physical activity
regimen is recommended once compensation is achieved.
An intensive multidisciplinary treatment strategy for heart failure involving specialized education,
assessment, and management in a randomized clinical trial decreased readmissions and improved
medication compliance. This approach has proved cost-effective in elderly populations by limiting
rehospitalizations. Intensive home care surveillance resulted in improved functional status.
B. ARRHYTHMIAS AND CONDUCTION ABNORMALITIES
Both arrhythmias and conduction abnormalities increase in prevalence with increasing age,
reflecting age-related changes in specialized conducting tissue and in atrial and ventricular
myocardium. The prevalence of single supraventricular premature beats increases with aging. They
are present in virtually all individuals older than 80 years of age, even in the absence of heart
disease, are typically asymptomatic, and do not require treatment.
Although arrhythmias may present as syncope or altered consciousness, many elderly patients have
significant arrhythmias in the absence of these symptoms or of palpitations. Syncope may result
from either tachyarrhythmias or bradiarrhythmias.
Atrial fibrillation increases in prevalence with increasing age. It is a major contributor to stroke in
elderly patients, even in the absence of valvular disease. Chronic atrial fibrillation is associated with
an increased incidence of stroke that accelerates with age. Anticoagulant can reduce stroke risk by
almost 70%. Reduction of stroke and stroke mortality has been documented with warfarin
treatment, even in patients older than 75 years so treated. However, elderly patients remain
undertreated with warfarin based on clinical practice guidelines for atrial fibrillation.
Elderly persons with cardiac arrhythmias should perform ambulatory electrocardiography and
electrophysiologic testing.
Symptomatic bradyarrhythmias are the major indications for pacemaker implantation.

C. ATHEROSCLEROTIC CORONARY HEART DISEASE

Atherosclerotic coronary heart disease is the most prevalent cardiac disease at elderly age and
responsible for more than two thirds of all cardiac deaths. It could be present as angina pectoris, and
myocardial infarction. Drug management of acute myocardial infarction includes aspirin, nitrates,
beta-blockage, and thrombolytic therapy. Myocardial revascularization includes percutaneous
transluminal coronary angiography, and coronary artery bypass grafting.
PREVENTIVE AND REHABILITATIVE APPROACHES TO CARE
Preventive approach include control of hypertension, weight reduction or control, dietary sodium
and fat restriction, physical activity, management of dyslipidemia, and smoking cessation.

1. Loengard AU. Cardiovascular and peripheral arterial diseases. In Soriano RP, Fernandez
HM, Cassel CK, Leipzig RM eds, Fundamentals of Geriatric Medicine, a case-based
approach. Springer science + business media LLC, New York 2007, pp. 403-436
2. Schulman SP. Normal aging changes of the cardiovascular system. In Tresch DD and
Aronow WS eds, Cardiovascular disease in the elderly patient. Marcell Dekker Inc New
York Basel 2nd ed, 1999, pp. 1-16
3. Schwartz JB, Zipes DP. Cardiovascular disease in the elderly. In Libby et al eds,
Braunwald's heart disease : A textbook of cardiovascular medicine 8 th ed, 2007 Saunders pp.
1923-1949