Cardiovascular Disease in the Elderly

Preface
Contents
Contributors
Atherosclerotic Cardiovascular Disease Prevention in the Older Adult: Part 1
1 Introduction
2 Assessment
2.1 Risk Scores in Older Adults
2.2 Risk Modifiers for More Accurate Risk Assessment
2.3 Frailty as Part of the Assessment
2.4 Life Expectancy, Competing Risk, and Time to Benefit
3 Antiplatelets
3.1 Antiplatelets in Primary Prevention
3.1.1 The Aspirin Debate
3.1.2 Putting It All Together: Meta-analyses
3.1.3 Additional Considerations
Minimising the Bleeding Risk
Drug Interactions
Areas of Uncertainty
3.1.4 Guideline Recommendations for Aspirin in Primary Prevention
3.2 Antiplatelets in Secondary Prevention
3.2.1 Antiplatelets in Patients with Recent Percutaneous Coronary Intervention (PCI)
Duration of Therapy
Choice of Antiplatelet Agent
Triple Therapy: When Less Is More
3.2.2 Antiplatelets in Secondary Prevention of TIA/Stroke
3.2.3 Antiplatelets in Peripheral Arterial Disease
4 Blood Pressure
4.1 Measuring Blood Pressure in Older Adults
4.2 Benefits of Treating Hypertension in Older Adults
4.3 Target BP: The Debate
4.3.1 The J-Shaped Curve and Potential Risks with Treatment
4.3.2 Targets in Those Aged 60–79 Years
4.3.3 Targets in Those Over 80 Years
The Impact of Frailty on Setting a Blood Pressure Target
Blood Pressure Targets in Nursing Home Residents and Those with Dementia
4.4 Choice of Antihypertensive Therapy: Practical Considerations
4.5 Current Guideline Recommendations
4.6 Practical Tips and Take-Home Points
References
Atherosclerotic Cardiovascular Disease Prevention in the Older Adult: Part 2
1 Cholesterol
1.1 Cholesterol and ASCVD in Older Adults
1.2 Elevated Cholesterol and All-Cause Mortality
1.3 Laboratory Measurement of Cholesterol
1.4 Primary Prevention Lipid-Lowering Therapy
1.4.1 Primary Prevention Lipid-Lowering Therapy in Those Aged 40–65
1.4.2 Primary Prevention Lipid-Lowering Therapy in Those Aged 65–75
1.4.3 Primary Prevention Lipid-Lowering Therapy in Those Over 75 Years
Guideline Recommendations
1.5 Secondary Prevention Lipid-Lowering Therapy
1.5.1 Statins in Secondary Prevention
1.5.2 Non-statin Therapy in Secondary Prevention
1.5.3 Guideline Lipid Lowering Therapy in Secondary Prevention
1.6 Special Considerations in Older Adults
1.6.1 Adverse Events of Statins
1.6.2 Statins in Frail Older Adults
1.6.3 Role for Deprescribing Statins
2 Cigarette Smoking
2.1 Benefits of Cessation in the Older Adult
2.2 Smoking Cessation Interventions
3 Diabetes
3.1 Diagnosis and Screening of Diabetes in Older Adults
3.2 Glycaemic Targets in Older Adults: The Background
3.3 Glycaemic Targets in Older Adults: Guideline Recommendations
3.4 Antihyperglycemic Therapies
3.4.1 Sodium Glucose Co-transporter 2 (SGLT-2) Inhibitors
3.4.2 Glucagon-Like Peptide 1 (GLP-1) Agonists
3.4.3 DPP-4 Inhibitors
3.4.4 Thiazolidinediones
3.4.5 Insulin and Others
4 Diet
4.1 Benefits of Maintaining a Healthy Diet in Older Adults
4.2 Components of a Healthy Diet
5 Exercise
5.1 Recommended Exercise Prescription
5.2 Identifying Barriers and Motivators to Exercise in Older Adults
5.3 Cardiac Rehabilitation in Secondary Prevention
6 Conclusion
References
Cardiovascular Pharmacology of the Older Patient
1 Concentration of Medication in Our Bodies: Pharmacokinetics
2 Physiology of Aging
2.1 Reduction of Kidney Function
2.2 Reduction of Liver Function
2.3 Gastrointestinal Absorption
3 Effects of Medication on Our Bodies: Pharmacodynamics
4 Polypharmacy
5 Drug Interactions
6 Interventions
6.1 Avoidance
6.2 Therapeutic Drug Monitoring
6.3 Proper Medication Use [16]
6.3.1 Evidence for Efficacy
6.3.2 Safety
6.3.3 Cost
6.3.4 Patient Preferences and Values
6.3.5 Medication Reconciliation
References
Aging of the Vasculature
1 Introduction
2 Molecular and Cellular Mechanisms of Vascular Aging
2.1 Role of Oxidative and Nitrative Stress
2.2 Mitochondrial Function
2.3 Vascular Inflammation
2.4 Genomic Instability
2.5 Epigenetic Alterations
2.6 Vascular Cell Senescence
2.7 The Renin–Angiotensin–Aldosterone System (RAAS)
2.8 Extracellular Matrix (ECM) Remodeling in Vascular Aging
2.9 Progenitor Cell Exhaustion
3 Structural Changes Accompanying Age-Associated Increased Stiffness
3.1 Measures of Aortic Stiffness
3.2 Consequences of Increased Stiffness
3.2.1 Cardiovascular Performance
3.2.2 Clinical Outcomes
3.3 Intervention Strategies
3.3.1 Drug Effects on Vascular Stiffness
3.3.2 The Impact of Urban Environments on Age-Associated Vascular Properties
4 Vascular Endothelial Cell Function Testing
4.1 Invasive Coronary Endothelial Function Assessment
4.2 Non-invasive Coronary Artery and Peripheral Arterial Endothelial Function Assessment
4.2.1 Non-invasive Evaluation of Epicardial Coronary Endothelial Function and Microvascular Function Testing: MRI
4.2.2 Peripheral Endothelial Function Assessment: Brachial Artery Flow Mediated Dilatation and Peripheral Artery Tonometry
4.3 Endothelial Function in the Coronary and Peripheral Vasculature
References
Peripheral Artery Disease (PAD)
1 Introduction
2 Clinical Manifestations
3 Diagnosis
4 Management
4.1 Lifestyle Modifications
4.2 Medical Management
5 Revascularization
5.1 Surgical Management
5.2 Endovascular Management
6 Conclusions
References
Arrhythmia Management in the Elderly
1 Introduction
1.1 Aging and the Conduction System
1.2 Electrocardiographic Changes in the Elderly
2 Bradyarrhythmias
2.1 Sick Sinus Syndrome
2.2 Atrioventricular Block
2.3 Bundle Branch Disease
3 Tachyarrhythmias
3.1 Supraventricular Arrhythmias
3.1.1 Paroxysmal Supraventricular Tachycardia
3.2 AV Nodal Reentrant Tachycardia
3.3 Accessory Pathway Tachycardias
3.4 Sinus Tachycardia
3.5 Multifocal Atrial Tachycardia
3.6 Atrial Flutter
3.7 Atrial Fibrillation
4 Ventricular Arrhythmias
4.1 Monomorphic Ventricular Tachycardia
4.2 Polymorphic Ventricular Tachycardia
4.3 Ventricular Fibrillation
4.4 Evaluation of Ventricular Arrhythmias in the Elderly
4.5 Management of Ventricular Arrhythmias
4.6 Secondary Prevention of Sudden Cardiac Death
4.7 Primary Prevention of Sudden Cardiac Death
5 Syncope
5.1 Orthostatic Syncope
5.2 Reflex-Mediated Syncope
5.3 Cardiac Syncope
5.4 Neurologic Causes of Syncope
5.4.1 Metabolic/Miscellaneous Causes of Nonsyncope
5.4.2 Prognosis in Syncope
5.5 Diagnostic Testing
5.5.1 Electrophysiology Testing
5.6 Management of the Syncope Patient
6 Special Issues in Management
6.1 AF Screening in the Elderly
6.2 Anticoagulation in the Elderly
6.3 Left Atrial Appendage Occlusion Devices
6.4 Anti-arrhythmics in the Elderly
6.5 Radiofrequency and Cryoablation
6.6 Device Therapy in the Elderly
7 Conclusion
References
Percutaneous Interventions for Structural Heart Disease in the Elderly
1 Introduction
2 Aortic Stenosis
2.1 Balloon Aortic Valvuloplasty
2.2 Transcatheter Aortic Valve Replacement
3 Mitral Valve Regurgitation
3.1 Transcatheter Mitral Valve Repair
3.2 Transcatheter Mitral Valve Replacement
4 Mitral Stenosis
4.1 Balloon Mitral Valvotomy
4.2 Transcatheter Mitral Valve Replacement
5 Tricuspid Regurgitation
6 Paravalvular Leak
7 Left Atrial Appendage Closure for Atrial Fibrillation
8 Conclusion
References
Cardiovascular Surgery in the Elderly
1 Background
2 Evaluation of the Elderly Patient for Cardiac Surgery
2.1 Operation Complexity
3 Suitability for Operation
3.1 Emergency Operation
3.2 Severe Respiratory Insufficiency
3.3 Renal Failure
3.4 Neurological/Physical Disability
4 Perioperative Considerations
4.1 Preoperative Evaluation
4.2 Intraoperative Considerations
4.3 Postoperative Considerations
5 Postoperative Complications
5.1 Delirium
5.2 Neurological Injury
5.3 Renal Failure
5.4 Late Neurocognitive and Physical Functional Impairment
6 Future Directions
6.1 The Relationship Between Frailty and Cardiac Surgery
6.2 Minimally Invasive Cardiac Surgery
7 Summary
References
Valvular Heart Disease in the Elderly: Clinical and Multi-Modality Imaging Perspectives
1 Aortic Stenosis
1.1 Etiologies and Epidemiology
1.2 Clinical Presentation
1.3 Echocardiography
1.4 Cardiac Computed Tomography
1.5 Magnetic Resonance Imaging
2 Aortic Regurgitation
2.1 Etiologies and Epidemiology
2.2 Clinical Evaluation
2.3 Echocardiography
2.4 Magnetic Resonance Imaging
3 Mitral Regurgitation
3.1 Etiologies and Epidemiology
3.2 Clinical Evaluation
3.3 Echocardiography
3.4 Magnetic Resonance Imaging
3.5 Computed Tomography
4 Tricuspid Regurgitation
4.1 Etiologies and Epidemiology
4.2 Clinical Evaluation
4.3 Echocardiography
4.4 Magnetic Resonance Imaging
4.5 Computed Tomography
5 Conclusion
References
Acute Coronary Syndrome in the Older Adult Populations
1 Introduction
2 The Aging Process and the Pathophysiology of ACS
3 Epidemiology of ACS in Older Adults
4 Geriatric Syndromes and ACS
4.1 Multimorbidity
4.2 Polypharmacy and Deprescribing
4.3 Cognitive Impairment
4.4 Delirium
4.5 Frailty
4.6 Disability
4.7 Functional Decline
5 Management Strategy of ACS in Older Adults
5.1 Presentation and Diagnostic Approach
6 Pharmacotherapy in ACS
6.1 Antiplatelet Therapy
6.2 Parenteral Anticoagulation Therapy
6.3 Oral Anticoagulation Therapy
6.4 Oral Anticoagulant Therapy in Patients with Atrial Fibrillation and ACS
7 Revascularization for STEMI
7.1 Role of Fibrinolysis
7.2 Role of Percutaneous Intervention
7.3 Revascularization for NSTE-ACS/NSTEMI
7.4 Role of Coronary Artery Bypass Grafting
8 Conclusion
References
Index