·:{iC0Fp'16ACOFP 53rd Annual Convention & Scientific Seminars

Geriatric Medicine: Optimal Heart Health Amid Changing Guidelines

(and the Evidence for When to Stray)

Kevin Overbeck, DO

3/22/2016

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Optimal Heart Health for the

Elderly Amid Changing

Guidelines (and the Evidence

for When to Stray)

Kevin Overbeck, DO

Assistant Professor, NJISA

Learning Objectives

• Understand the benefits of STATINS in aging in

the context of 2013 guidelines for

HYPERLIPIDEMIA

• Apply 2014 AHA/ACC/HRS guidelines for

ATRIAL FIBRILLATION to decision-making

for ANTICOAGULATION and RATE

CONTROL in the elderly

Aging Physiology:

Body Composition

• Lipid Compartment Expands

• Total Body Water (mainly ECF) declines

• Lean Muscle Mass Declines

• Application: Implications for Drug Prescribing

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STATINS, DYSLIPIDEMIA

& THE ELDERLY

Dyslipidemia

Dyslipidemia

The Choose Wisely® Campaign:

AMDA: “Don't routinely prescribe lipid-lowering

medications in individuals with a limited life

expectancy”

AMDA Choose Wisely® Campaign – 2013 - 09SEP

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Dyslipidemia

Primary Prevention: CARDS Study

Neil HA, et al. Analysis of efficacy and safety in patients aged 65-75 years at

randomization: Collaborative Atorvastatin Diabetes Study (CARDS). Diabetes Care.

2006;29(11):2378.

Age 45-75 yrs

Atorvastatin 10mg v. Placebo

4 years

NNTData:

Older Younger

1st major

cardiovascular

even22 32

Dyslipidemia

Secondary Prevention: The LIPID Trial

Hunt D, et al. Benefits of pravastatin on cardiovascular events and mortality in older

patients with coronary heart disease are equal to or exceed those seen in younger patients:

Results from the LIPID trial. Ann Intern Med. 2001;134(10):931.

NNTData:

Older Younger

All Cause

Mortality 22 46CAD Death

35 71Fatal / Non-

Fatal MI 30 36Stroke

79 170

Age 40-75 yr olds; Pravastatin v. Placebo

ATRIAL FIBRILLATION

&

THE ELDERLY

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Atrial Fibrillation

• Patient Centered Care / Goals of Care

• Incidence increases with Age

• Stroke Risk

• Stroke Prophylaxis

• Rate Control

January CT, et al. 2014 AHA/ACC/HRS guideline for the management of

patients with atrial fibrillation: a report of the American College of

Cardiology/American Heart Association Task Force on Practice Guidelines and

Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1-76.

Anticoagulation

HPI: An 84 year old resident of an assisted living dementia unit presents

to sub-acute rehabilitation following a hospital evaluation for a “change

in mental status” ruled to DELIRIUM due to new onset ATRIAL

FIBRILLATION with rapid ventricular response

Functional Hx: (+) ambulates with a rolling walker at baseline

PMHx: DM, HTN, Hx Recurrent Falls, Osteoporosis, Depression,

Dementia, Chronic Constipation

MMSE (8/2012): Total Score 14/30 [noted deficits in the following areas

– 1/5 with time orientation , 3/5 deficit with location orientation, 1/5

serial sevens, 0/3 recall, 2/3 three step command, 0/1 drawing pentagon,

0/1 writing sentence]

Medications

Insulin Glargine 12 units qHS

Lisinopril 20mg daily

Metoprolol XL 50mg daily

Alendronate 70mg qWeek

Calcium 500mg

Vitamin D 400IU BID

Docusate BID

Citalopram 20mg daily

Donepezil 10mg daily

Memantine10mg BID

Should WARFARIN be prescribed in this patient?

(A) YES

(B) NO

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Anticoagulation

HPI: An 84 year old resident of an assisted living dementia unit

presents to sub-acute rehabilitation following a hospital

evaluation for a fall with a hip fracture requiring ORIF.

Functional Hx: (+) ambulates with a rolling walker at baseline

PMHx: DM, HTN, Hx Recurrent Falls, Osteoporosis,

Depression, Dementia, Chronic Constipation

MMSE (8/2012): Total Score 14/30 [noted deficits in the

following areas – 1/5 with time orientation , 3/5 deficit with

location orientation, 1/5 serial sevens, 0/3 recall, 2/3 three step

command, 0/1 drawing pentagon, 0/1 writing sentence]

Medications

Insulin Glargine 12 units qHS

Lisinopril 20mg daily

Metoprolol XL 50mg daily

Alendronate 70mg qWeek

Calcium 500mg

Vitamin D 400IU BID

Docusate BID

Citalopram 20mg daily

Donepezil 10mg daily

Memantine10mg BID

Should WARFARIN be prescribed in this patient?

(A) YES

(B) NO

Atrial Fibrillation

Stroke Prophylaxis

We under utilize anticoagulation in the elderly

with atrial fibrillation

Anticoagulation

Clinician Concerns

• Compliance

• Monitoring

• “Fall Risk1,2”

• Cognitive Impairment

• Drug-Drug Interactions

• Bleeding Risk

1. Man-Son-Hing M, Nichol G, Lau A, et al. Choosing antithrombotic therapy for elderly patients with atrial

fibrillation who are at risk for falls. Arch Intern Med 1999; 159: 677-685

2. Kappor J. Management of Atrial Fibrillation. The Lancet, Volume 370, Issue 9599, Page 1608, 10

November 2007

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Anticoagulation

Clinician Concerns

1. Staerk L, et al. Stroke and recurrent haemorrhage associated with antithrombotic treatment after

gastrointestinal bleeding in patients with atrial fibrillation nationwide cohort study. BMJ 2015; 351:h5876.

Anticoagulation

• Increased risk of ICH >

85 but not statistically

significant

• INRs less than 2.0 as

compared to INRs 2-3

were not associated with

lower risk of ICH

• INRs > 3.5 associated

with increased risk as

should be avoided

Fang MC, et al. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin

for atrial fibrillation. Ann Intern Med. 2004;141(10):745

CHA2DS2-VASc

SCORE Adjusted

Stroke Rate

(%/year)

0 0

1 1.3

2 2.2

3 3.2

4 4.0

5 6.7

6 9.8

7 9.6

8 6.7

9 15.2

With CHA2DS2- VASc > 2, oral

anticoagulants are recommended

With CHA2DS2- VASc = 0, it is

reasonable to omit antithrombotic

therapy

With CHA2DS2- VASc = 1, no

antithrombotic therapy or treatment

with oral anticoagulation or aspirin may

be considered

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Warfarin vs Aspirin in the Elderly

• 973 patients > 75 years old

(mean 81.5 years old)

• Randomly assigned to Aspirin

75mg or Warfarin INR 2-3

• The primary endpoint was

fatal or disabling stroke

(ischemic or hemorrhagic) or

intracranial hemorrhage or

significant emboli

• Warfarin Group – 24 events

(21 strokes, 2 ICH, 1

embolism)

• Aspirin Group – 48 events

(44 strokes, 1 ICH, 3 emboli)

Mant J, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the

Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet.

2007;370(9586):493.

Warfarin vs Aspirin + Clopidogrel

• CHADS2 Score of 2

• Randomly assigned to receive

Warfarin (target INR 2.0-3.0)

or the combination of

Clopidogrel 75mg plus

Aspirin 75mg-100mg

• Trial Terminated Early due to

WARFARIN superiority

Connolly S, et al. Clopidogrel plus Aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation

Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE-W): a randomized controlled trial. Lancet

2006; 367:1903-12.

Anticoagulation & The Elderly

Setting % in Range

Self-Monitoring 72%

Randomized

Trials

55-66%

Anti-Coagulation

Clinics

66%

Community

Physicians

57%

1. van Walraven C, et al. Effect of study setting on anticoagulation control: a systematic review and

metaregression. Chest. 2006;129(5):1155.

2. Connolly SJ, et al. Dabigatran versus Warfarin in patients with atrial fibrillation. N Engl J Med 2009;

361:1139-51.

3. Patel MR, et al. Rivaroxaban versus Wafarin in patients with non-valvular atrial fibrillation. N Engl J Med

2011; 365: 883-91.

* Simple Finger Stick required

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WARFARIN superiority

• NNT 37 PRIMARY PREVENTON1

• NNT 12 SECONDARY PREVENTION1

Q: What about new agents?

A: “… complex patients with multiple chronic

conditions were excluded from all trials …”

1. Hart RG, et al. Meta-analysis antithrombotic therapy to prevent stroke in patients

who have non-valvular atrial fibrillation. Ann Intern Med 2007; 146: 857-67

NOVEL ANTICOAGULATION

1. Shama, et al. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial

fibrillation and secondary prevention of venous thromboembolism systemic review and meta-analysis.

Circulation 2015; 132(3): 194-204.

ATRIAL FIBRILLATION

RATE CONTROL

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Which Patient is “more sick?”

(1)(2)

3.

40 Year Old Female

HR 160

80 Year Old Female

HR 118

Both Equally

Aging Cardio-Physiology

• Resting HR

Unchanged With

Aging

• Maximum HR

= 220 – age

OR

• = 208 – (0.7) x age

Cardiac Ventricular Filling Rate

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Recommendations for Rate Control• Control ventricular rate with Beta-Blocker or

Non-Dihydropyridine Calcium Channel

Antagonist for AF

• A heart rate control (resting heart rate < 80 bpm)

strategy is reasonable for symptomatic

management in AF

• A lenient rate-control strategy (resting heart rate

< 110bpm) maybe reasonable when patient

asymptomatic & LV systolic function preserved

• Non-Dihydropyridine Calcium Channel

Antagonists should NOT be used in

decompensated HF

An 88 year old male with systolic cardiomyopathy

with an EF < 35% presents with complaints of

fatigue and palpitations due to ATRIAL

FIBRILLATION with HR 110-130 bpm. He is

euvolemic, BP 130/70, and presently taking

CARVEDIOLOL 25mg BID. Which of the

following strategies is the best next step in the

management of his heart rate?

(A)Prescribe Diltiazem

(B)Prescribe Verapamil

(C)Prescribe Digoxin

(D)Prescribe Amiodarone

(E)Consult Cardiology

Rate Control Medications

Beta-Blockers – Atenolol, Carvedilol,

Metoprolol, Nadolol, Propanolol

Nondihydropyridine Calcium Channel

Blockers – Diltiazem + Verapamil

Digoxin

Amiodarone

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Craig T. January et al. Circulation. 2014;130:e199-e267