Heart failure and hypertension in the elderly

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

2. 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 )

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4. 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

6. Subgroup risk factors • Systolic heart failure : Asymptomatic left ventricular dysfunction • Diastolic heart failure: echocardiogram diagnosis .Prevalence increases with age , hypertension and female sex.

7. 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.

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

9. 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

13. 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

16. 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

17. 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.

18. 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.

19. 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.

21. Functional limitation:

22. 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.

23. 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

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

25. 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

26. 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

27. 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.

28. 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.

29. 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%

30. 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 %

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

33. 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

34. 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

35. 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.

37. 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.

38. 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

39. 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

40. Causes secondary hypertension • Recognize: • > 55 years ; < 35years age • Hypertension that do not control on treatment • Fast progression • Pregnancy hypertension: always consider hyperthyroidism and pheochromocytoma

41. Treatment of hypertension • South African Hypertension Guidelines 2006

42. 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

43. 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

44. 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.

45. 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

46. Mean arterial blood pressure • Diastolic blood pressure + 1/3 of the pulse pressure )

47. 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.

48. 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

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