Heart failure and hypertension in the elderly DR. D. Greyling.

Heart failure and hypertension in the elderly

DR. D. Greyling

Definition Heart Failure

• Heart failure results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood ( systolic heart failure ) or to fill with blood ( diastolic heart failure )

Itamine deficiencies

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Risk factors for developing heart failure

• Hypertension and coronary artery disease are the two main primary risk factors

• Age• Diabetes mellitus• Obesity• Smoking• Valvular heart disease• Vitamin deficiencies: Thiamine

Heart Replacement Valves

Stented tissue valve Mechanical valve Caged ball valve

Three different types of mechanical valves used to replace the valves of the heart.

LifeART Collection Images Copyright © 1989-2001 by Lippincott Williams & Wilkins, Baltimore, MD



Subgroup risk factors

• Systolic heart failure : Asymptomatic left ventricular dysfunction

• Diastolic heart failure: echocardiogram diagnosis .Prevalence increases with age , hypertension and female sex.

Evaluation of heart failure

• The goal is to identify the nature and cause of heart failure

• Exclude anemia, obesity, metabolic disorders, deconditioning and pulmonary disease.

Diagnosis

• History :- Shortness of breath• - Orthopnea• - Paroxysmal nocturnal dyspnea• - Edema• - Tiredness• - Altered consciousness

Clinical signs

• Elevated jugular venous pressure• Crackles on pulmonary auscultation• Hepatomegaly• Peripheral edema• Third heart sound• Frequent tricuspid and mitral incompetence

murmurs• Primary aortic stenosis possible



Precordial Examination

Examiner performing precordial examination on male patient in forwardsitting position.




Precordial Examination

Examiner performing precordial examination on male patient in left lateral decubitus position.




Diagnostic testing

• Electrocardiogram: Look for signs of myocardial infarction, ventricular hypertrophy and or conduction abnormalities

• A chest X – ray: Pulmonary edema• Cardiomegaly• Kerly B lines • B type natriuretic peptide ( pro – BNP)• Echocardiogram: Evaluate cardiac structure and

function

BNP

• Help in the emergency care setting distinguishing dyspnea of respiratory causes from heart failure

• Always intrepid Pro – BNP in the clinical setting• BNP < 100 pg/ml = unlikely to have acute heart

failure• BNP > 500 pg/ml = likely to have heart failure• Other causes of elevated BNP :Renal failure, acute

coronary syndrome • BNP is higher in women, renal failure , Acute MI

Diastolic heart failure

• 40 – 60 % of patients with heart failure

• Signs and symptoms of systolic heart failure but the echocardiogram reveals normal left ventricular ejection fraction and the absence of significant valve abnormalities.

Diagnosis diastolic heart failure

• Echocardiogram:• Normal left ventricular ejection fraction ( LVEF)

and normal left ventricular volume.• If impaired relaxation of the ventricle on echo –

Asses the mitral inflow velocity ( E –wave ) and the increased late diastolic filling ( A –wave )

• E : A ratio < 1 is normal• Another method of diagnosing diastolic heart

failure is with cardiac catheterization.

Ischemic heart disease and heart failure

• Ischemic heart disease is a major cause of ventricular dysfunction

• Chest pain suggestive of angina may warrant referral to a cardiologist for coronary angiography.

Angina

Illustration of a man suffering from angina




Functional limitation:NYHA Functional Class Estimated 1 year mortality

1- Asymptomatic 5 – 10 %

11 – Symptoms , slight limitation of physical activity

15 – 30%

111 - Symptoms marked limitation of physical activity

15 – 30 %

IV – Inability to perform any physical activity without symptoms

50 – 60%

Interventions for heart failure

• 1. Limiting fluid and sodium intake.

• 2. Avoiding toxins such as alcohol and nicotine.

• 3. Regular aerobic exercise.

• 4. Monitoring weight daily as a measure of volume status or alternatively monitor fluid intake and output.

Treatment of heart failure

• Treat conditions predisposing to the development of heart failure:

• 1. Hypertension• 2. Coronary artery disease• 3. Associated risk factors : Lipids, Diabetes ,

smoking and inactivity.• 4. ACE inhibitors for every patient if tolerated

for atherosclerotic disease, diabetes , hypertension and cardiovascular risk factors

Medical therapy

• 1. Asymptomatic • Left ventricular dysfunction / NYHA class I :• - ACE inhibitor• - β - Blocker• - Diuretic as needed

Mild heart failure treatment/ NYHA class II

• The above medical treatment plus consider the following:

• 1. Diuretic likely needed• 2. Digoxin if symptomatic• 3. Consider amilodipine if additional

vasodilatation needed

Moderate heart failure / NYHA class III

• Above treatment:• 1. Spirinolactone ( Be aware of hyperkalemia if

combining ACE inhibitors and spironolactone – 25 mg/d spironolactone beneficial )

• 2. If interventricular conduction delay on ECG consider biventricular pacemaker

Severe heart failure / Class IV NYHA

• Above and following:• Consider chronic inotrope infusion, ventricular

assist device , cardiac transplantation .• If persistent failure consider palliative care

and hospice care.

The role of Digoxin and anticoagulants

• The role of digoxin in heart failure in sinus rhythm is primarily for symptom control rather than improving survival.

• No current data support anticoagulation or anti-platelet therapy solely for the treatment of low ejection fraction. Individualize anticoagulation treatment in every patient to decide risk benefit ratio.

Indications for Device Therapy

• Biventricular pacemaker criteria :• 1. NYHA class III-IV on optimal medical therapy• 2. ORS duration> 130 msec if left bundle

branch block• 3.Left ventricular dimension > 55 mm on

echocardiogram• 4. Left ventricular ejection fraction < 35%

Indications for Device therapy

• Implantable cardioverter:• 1. Any hemodynamically significant or symptomatic

arrhythmia , including resuscitated cardiac arrest or syncope/ near syncope due to severe heart failure

• 2. Ischemic cardiomyopathy with previous myocardial infarction ( > 30 days in the past ) and left ventricular ejection fraction < 30 %

• 3.Nonischemic cardiomyopathy in absence of criteria 1. and left ventricular ejection fraction < 35 %

cardiac

Right Atrium

Right Ventricle

Implantable cardioverterdefibrillator inserted underskin

Electrodes

Electrodes insertedinto vein leading toheart

Implantable Cardioverter Defibrillator (ICD)

An ICD is surgically implantedunder the skin. It continuallymonitors the heartbeat anddelivers a shock to the heartwhen it detects a dangerousrhythm. The shocks can bepainful, like a kick in the chest.Medicines can be given to tryto reduce how often theperson experiences theirregular heartbeats thattrigger the device to deliver ashock.

Source: National Heart Lung and Blood Institute, U.S. Department of Health and Human Services, National Institute of Health. nhlbi.nih.govLifeART Collection Images Copyright © 1989-2001 by Lippincott Williams & Wilkins, Baltimore, MD



Cardiac transplant

• Cardiac transplantation is last resort and potential life saving option for refractory heart failure to optimal medical and mechanical circulatory support.

Treatment of diastolic heart failure

• 1. Treat the underlying cause• 2. Optimize diastolic filling:• - Cardio version and rate control for atrial

fibrillation• - Diuretics for pulmonary congestion while

avoiding hypovolemia and tachycardia

Cardiogenic shock

• Definition: Severe acute heart failure causing hypotension and systemic hypo perfusion

• Causes : 1. Acute myocardial infarction – requires revascularization either with thrombolytic therapy or angioplasty/stents or surgery

• 2. Acute mitral incompetence – valve replacement or valve stent placement.

• 3. Ventricle rupture requires corrective surgery• 4. Pericardial tamponade requires peri-

cardiocentesis

Medical treatment cardiogenic shock

• 1. If hypovolemic volume replacement with intravenous fluids• 2. If volume overload intravenous diuretics • 3. Monitoring intracardiac filling pressures with a Schwan – Ganz

catheter . If elevated :improves with diuretics and after load reduction

• 4. Low cardiac output requires inotropic agents: Dobutamine, or dopamine, or adrenaline IVI in the intensive care setting.

• 5. If pressures remain low an intra –aortic balloon pump that inflates during diastole and deflates during systole improves coronary perfusion and reduces after load

• 6. Failure to the above – Ventricular automatic cardioverter implantation or cardiac transplant.

Intra-Aortic Balloon Pump

Location in body, and diagrams of systole and diastolic states.




Hypertension

• The elderly may present with special problems.

• Measurement of blood pressure may have considerable variability ( occurs particularly in hot weather)

• The most common form of hypertension in the elderly is isolated hypertension, due to the stiffening of the large arteries that occur with ageing.

Measurement of blood pressure

• Advisable to check BP standing in the elderly , in particular in Diabetes to exclude postural hypotension( Complains of dizziness or if dehydrated patient more prone to have orthostatic hypotension)

• Management of Hypertension in the elderly : Aim for BP < 140/90

• Important with measurement of BP : Correct method , blood pressure cuff size , apparatus

Blood pressure control in the elderly

• The reduction of BP in the elderly should be achieved gradually over 6 months.

• Stricter BP control is required for patients with end organ damage and co-morbid conditions like DM - BP < 130/80 ( Target to be reached in 3 months)

• Co –existent risk factors like smoking should be controlled .

• Lifestyle modification and education is still the cornerstone of management of every patient

Causes secondary hypertension

• Recognize:• > 55 years ; < 35 years age• Hypertension that do not control on

treatment• Fast progression• Pregnancy hypertension: always consider

hyperthyroidism and pheochromocytoma

Treatment of hypertension

• South African Hypertension Guidelines 2006

Guidelines for uncomplicated hypertension

• First line treatment :• Low dose thiazide or thiazide like diuretic• Second line: Either an angiotensin – converting

inhibitor or a calcium channel blocker( CCB) • Third line : Add another second line drug not already

used. If resistant hypertension , add a fourth drug: a central acting drug , a vasodilator, alpha-blocker or a beta – blocker

• Drug choice may be changed with indications for a particular drug class

Management of specific situations

• The South African guidelines include management of specific situations:

• 1. Hypertensive emergency• 2. Severe hypertension with target – organ

damage • 3. Hypertension in diabetes mellitus

Hypertensive urgency treatment

• No life threatening neurological, renal , eye or cardiac complications present.

• Commence with 2 oral drugs and aim to lower Diastolic BP to 100mmHg over 48 – 72 hours

• Use furosemide if signs of renal insufficiency or pulmonary congestion.

Hypertensive emergency

• A hypertensive emergency exists when acute elevation of BP is associated with acute and ongoing damage to organs like the kidneys, brain, heart , eyes or vascular system.

• If confirmed hypertensive emergency : Intensive care management is ideally.

• Intravenous antihypertensive treatment - beware not to reduce BP >20 % in the first 24 hours

• Common among blacks and the elderly

Mean arterial blood pressure

• Diastolic blood pressure + 1/3 of the pulse pressure )

Resistant /refractory hypertension

• Blood pressure remains > 140/90 despite the use of 3 drugs including a diuretic.

• Commonest causes:• 1. Non adherence ( compliance ) to lifestyle and

medication• 2. Unavailability of medication• 3. Drug related causes and unwanted effects• Management: Fourth line drug added : ( vasodilator

, α – blocker, β – blocker or aldosterone antagonist.

Summary hypertension in the elderly

• Hypertension is not a normal aspect of ageing• The elderly develop primarily systolic hypertension• Greater blood pressure variability• Therapy should focus on lowering the systolic blood

pressure to targets• Monitor throughout for side effects ,especially

postural hypotension• Monitor for end organ damage: Urea and

electrolytes , ECG , LV hypertrophy , fundoscopy , urine micro-albuminuria

Bibliography

• Geriatric secrets , 3 rd edition• Harrisons , 17 th edition• Hazzard’s geriatric medicine and gerontology• South African Hypertension guidelines 2006

Heart failure and hypertension in the elderly DR. D. Greyling.

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