Maximum heart rate falls by 10 % at rest and 25 % during stress A degree of cardiac enlargement seen on CXR is normal. Worse with hypertension, so always c heck BP and treat as needed Increases cardiac \201 lling pressures and allows compensation for drop in heart rate Left ventricular wall thickens as myocyte size increases Predisposes to AF Left atrial size increases due to alterations in cardiac \201 lling Decreased cardiac reserve to stress \200\224 may become haemodynamically compromised in re sponse to acute illness earlier than younger patients Contractility preserved at low stimulation, but with stress cannot increase meaning (along with heart rate factors) that cardiac output cannot be increased Myocardial contractility impaired at high demand Increased circulating catecholamines with down regulated receptors (especially B adrenergic ) Impairs ability to mount a stress response As above, this table \200\224 decreased cardiac reserve to stress More prone to heart failure Contributes to reduced cardiovascular reserve to stress Varies considerably between individual older patients \200\224 unchanged in those used to exercise, up to 60 % reduction in un \201 t Impaired oxygen consumption on exercise 258 CHAPTER 10 Cardiovascular Chest pain A common complaint in all settings. May be primary symptom (presenting to GPs an d general medical take) or mentioned only in response to direct questioning. Also occurs du ring inpatient stays for other reasons. There are very many causes, the majority of which become more common with age. Many are ben ign, but some are serious and even life threatening, so a thorough and sensible approach is needed. Common conditions not to be missed include: cardiac pain; pleuritic pain due to pulmonary i nfarction or infection; peptic pain (including bleeding ulcers); pain from dissecting aorti c aneurysm and pneumothorax (especially in COPD). Other possibilities include: muscular pain (eg after unaccustomed exertion); costochondriti s (local tenderness at sternal joint); pain from injury (eg after a fall); referred pain fr om the back and neck (eg osteoarthritis) and referred pain from the abdomen. Differentiating these depends on accurate history taking and careful examination, both of w hich can be more of a challenge in older patients. Presentation may be atypical, and the pa tient may have many other problems so teasing out which are the important symptoms can be d if \201 cult (experience improves the ability to \200\230feel \200\231 your way around th e history). 2It may be the last symptom mentioned in a long list, however, mention of chest pain should always trigger a careful assessment. History \200 Is this a new symptom? (may suffer from chronic angina) \200 If not, is it any different from the usual pain? (intensity, pattern) \200 What is the nature of the p ain? (pleuritic, heavy, tight. This is often hard to do, and hand gestures can help \200 \224 a clenched \201 st for a heavy pain, a stabbing action for a sharp pleuritic pain) \200 Where is it located? (including radiation) \200 How acute is the onset and what is the duration? \200 Are there any associated symptoms? Patients with cognitive impairment can be particularly dif \201 cult to assess, but allowing free conversation may reveal sym ptoms, followed by closed questions that may prompt appropriate answers. Family members may have noted signs or symptoms and are an invaluable aid to assessment, eg clutching the che st after walking. Remember that cardiac symptoms may differ for each patient and they will describe the pain in their own terms. Many older adults with ischaemia will deny \200\230pain \200\231 and i nstead describe \200\230discomfort \200\231. Some will just experience weakness, dyspnoea, or nausea. Examination \200 How does the patient look? A sweaty, clammy patient needs urgent and exhaustive assessment, whereas a patient drinking tea and chatting is less likely to ha ve a devastating condition What are the basic observations? CHEST PAIN 259 Signs of shock alert to a serious condition \200\224 IHD, pulmonary infarction, dissection, sepsis, blood loss \200\224 but remember these may be late signs and are less useful in older patients. The patient may usually be hypertensive, so a BP of 120/80 may be very low for them; they may be on a B -blocker, so unable to mount a tachycardia, etc. Temperature may be raised in sepsis \200 Low oxygen saturation always needs explaining (u nless chronic) and may indicate an intrapulmonary problem Is the jugular venous pressure (JVP) elevated? (heart failure) \200 Look at the chest wal l for shingles, bruising and localized tenderness \200 Different blood pressures in the a rms may indicate dissection (but may also occur with atheroma) Listen to the heart \200\224 are there any new murmurs (dissection or infarction) or a rub (pericarditis)? Listen to the lungs \200\224 is there consolidation (sepsis) or a rub (consolidation or infarction)? Look at the legs \200\224 is there any clinical DVT? Investigations Some tests can be less useful in older patients, and should be individually tailored to the patient. Sending off every single test on all patients with chest pain will only lead to confusion. \200 ECG \200\224 should be done on the majority of patients wi th chest pain. Remember the baseline ECG may well be abnormal in an elderly person, and com parison with old traces is extremely useful. If your patient has a very abnormal ECG (eg le ft bundle branch block (LBBB)) it is useful to give them a copy to carry with them CXR \200\224 looking for lung abnormalities and widening of the mediastinum. Remember that the aorta often \200\230unfolds \200\231, so a careful look at the contours of the aortic arch and/or comparison with old \201 lms is needed to assess possible disse ction. Remember that a patient can look fairly well in the early stages of aortic dissectio n Blood tests \200\224 basic hematology, biochemistry, and in \202 ammatory markers are oft en useful. Remember that in acute blood loss, the hemoglobin may not drop immediately, and that an elderly septic patient may take a day or two to develop an elevated white cell coun t and CRP Troponin \200\224 useful in a patient with suspected cardiac chest pain (for risk strati \201 cation). It is NOT a useful test if you do not think this is cardiac pain \200\224 th ere are many false positives that will only cause confusion D-dimer \200\224 only useful if negative in cases of suspected thromboembolism. There are a huge number of causes of a positive d-dimer (including old age itself); a positive result does not imply the diagnosis of PE Further tests (eg CT thorax for suspected dissection, exercise testing for angina, lung perfusion scans for thromboembolism, etc.) depend on clinical factors 2Always attempt to explain a chest pain \200\224 both for the patient and future clinician s. A \200\230diagnosis \200\231 of non-cardiac chest pain is rarely helpful. 260 CHAPTER 10 Cardiovascular Stable angina Coronary artery disease is clinically evident in 20 % of those > 80 years. Ma nagement is often suboptimal. It is unacceptable to leave a patient with symptoms, however frail, until all available options have been looked at, and it has been proven (by trying i t) that a certain treatment cannot be tolerated. A stepwise, slow introduction of tablets a llows insight into adverse effects and may require multiple clinic visits. Symptom diaries can assist with this process. Stable angina Risk factor reduction \200 Cholesterol and BP less likely to be lowered in older patients, but the risk reduction is equal if not greater than for younger subjects \200 Diabetic control is less likely to be tight, in part due to justi \201 able concerns about the dangers of hypoglycaemia Lifestyle advice (exercise, smoking and diet) should be given Aggravating conditions Such a s heart failure, anemia, thyroid disease, arrhythmias, valvular heart disease. More common in older people and should be corrected. Medication \200 Under utilized, particularly aspirin (concerns about bleeding) and B -blockade but there is evidence that they are both equally useful in reducing risk A trial and error approach to treatment is needed \200\224 add one or two treatments at a time to minimize the risk of side effects (most commonly orthostatic hy potension) and stop if there are problems, trying something else instead Start on low doses, and titrate upwards (eg atenolol 25mg) \200 Long-acting agents (eg di ltiazem MR) reduce compliance problems \200 Nicorandil (10 \200\22320 mg bd) is often bet ter tolerated than other anti-anginals in this age group. Choice of medication should be pragmatic \200\224 if a patient has a bradycardia for example, a negatively chronotropic drug is usually inappropriate (consider using amlodipine 5 \200\22310mg). If a patient has heart failure, a cardio selective B -blo cker (eg carvedilol, metoprolol, bisoprolol) is a better choice than a \202 uid-retaining calcium channel blocker GTN can cause considerable problems with hypotension, and instruction on correct use is essential. Tablets can be spat out once the pain starts to se ttle, so (in theory) the dose can be titrated to symptoms. In practice, the spray is often easier to use. It should be used sitting down if possible and prophylactically before signi \201 cant exertion Revascularization Should be considered (ideally after risk strati \201 cation by stress te sting), as for younger patients, if symptoms persist despite maximal medical therapy ( see b \200\230Revascularization procedures \200\231, p.264). STABLE ANGINA 261 Palliation Consider if diffuse disease, not amenable to revascularization with ongoing symp toms (eg home oxygen therapy, opiates to allow sleep). HOW TO Rationalize antianginals in older patients When? \200 With advancing age and frailty, mobility may reduce and so angina symptoms may become less frequent, or even stop It is not uncommon to \201 nd an octogenarian on four antianginals, who has not had angina for many years Use a low pulse or BP reading as a trigger to review the medication \200 Do not hesitate to rationalize this \200\224 there are many pitfalls from polypharmacy, and requirements will change with time How? \200 If cognitive impairment, con \201 rm with carers that they are genuinely asymptomatic from angina Review observations \200\224 if bradycardic, stop B -blockade \201 rst; if hypotensive, start with the symptomatic medications \201 rst (eg nitrates) before those with disease-m odifying properties \200 Select one drug to modify, then reduce in a stepwise fashion (eg reducing dose and/or frequency) Patients and family may be resistant to medication changes after years of healthcare professionals emphasizing the importance of their tablets. Some are fri ghtened of a recurrence of disabling symptoms so explain to the patient, carers and GP what you are doing Clarify contingency plan: \200\230This is a trial, and if it does not suit you, you may get angina pains again. If that happens, please just start taking your old doses ag ain \200\231 Ensure there is back-up if there are concerns (eg telephone number) Review \200 Set a dat e for review of impact \200 Assess whether there have been any symptoms, and reassess the pulse and BP If all is well, continue with careful reduction in medication Goal \200 Aim to use as few medications as possible, while maintaining control of symptoms If the BP allows, continue those with disease-modifying properties ( B -blockade, ACE inhib itors), but in frail older people it is more important to avoid orthostatic hypotension and falls Once the medication has been titrated down to an optimum level (balancing pulse, BP, symptoms, and disease modi \201 cation) communicate the \201 nal list to the GP 262 CHAPTER 10 Cardiovascular Acute coronary syndromes CHD incidence rises with increasing age. An acute coronary syndrom e describes a scenario in which the myocardial cells are not receiving enough blood and oxy gen to meet their demands. There is a range of syndromes from unstable angina to non-ST ele vation MI (NSTEMI) to ST elevation MI (STEMI). Management in general is as for younger pati ents, but there are some points relating to older patients in particular. Atypical presentation \200 More likely to present with atypical or vague symptoms (eg int ense dyspnoea, syncope, weakness, abdominal pain) Symptoms may be obscured by comorbidity \200 ECG changes may not be present in up to a fo urth of acute MI with the full diagnostic triad (chest pain, ECG changes, and biochemical c hanges) present in under a third of those > 85 years ECG may be dif \201 cult to interpret because of pre-existing abnormalities (LBBB, pacing) Vital signs or symptoms may be obscured by medication ( B -blockade, pain medication) Different pathology \200 More pre-existing coronary artery disease with more multivessel disease NSTEMI more likely than an STEMI \200 More likely to develop heart failure, AV block, AF, and cardiogenic shock after a coronary event Later presentation \200 Increased prevalence of angina so less alarmed by chest pains \200 May modify lifestyle to avoid symptoms (if climbing a hill gives them chest pain, they may just stop doing it) Increased occurrence of \200\230silent ischaemia \200\231 (especially in people with diabetes) Increased social/attitudinal factors (I didn \200\231t want to bother the doctor \200\231) \200 A third of patients > 65 with MI will present later than 6hr after symptom onset Increased comorbidity \200 Making diagnosis dif \201 cult (eg a patient with COPD who ha s exertional breathlessness) and therapy less well tolerated (eg B -blockers with periphera l vascular disease) Also as comorbidities add up, so frailty increases and medications are generally less well tolerated Older patients with acute coronary syndromes have a higher inpatient mortality so should be prioritized for specialist monitoring where there are limited resources; however, it is kn own that they are: \200 Less likely to receive aggressive acute therapy (eg less thrombol ysis, angiography and angioplasty, coronary artery bypass grafting (CABG), and maximal medi cal treatment) Less likely to have full secondary prevention measures implemented ACUTE CORONARY SYNDROMES 263 Management of the older cardiac patient is therefore more dif \201 cult and more likely to result in death than in younger patients. Sometimes there are good reasons for withholding therapy (eg patients presenting later are less often eligible for thrombolysis, side effec ts may restrict secondary pre- vention) but often the justi \201 cation is less robust. La ck of evidence in older people does not mean that there is no bene \201 t \200\224 rather that it has not been proven, as is the case with many commonly used therapies (eg loop diu retics in pulmonary oedema). Common sense dictates when to use an aggressive approach, consid- ering the patient as a whole including: \200 Patient preference where possible \200 Com orbidities (alter risk pro \201 le) \200 Current medication \200 Frailty and likely li fe expectancy \200 Apparent biological age rather than chronological age There are many w ell-de \201 ned treatment algorithms, and older patients should be included at every step unless there are good reasons not to. If you plan to exclude a patient from treatment, you should clearly docu- ment your rationale. 264 CHAPTER 10 Cardiovascular Revascularization procedures Includes percutaneous coronary angiography and intervention (PCI) and CABG. When? \200 Used when stable symptoms persist despite maximal medical therapy, when unstab le symptoms fail to settle, or for acute myocardial infarction (primary PCI) Risk stratify with exercise testing and troponin measurements. Older patients may be unable to exercise, but consider bicycle exercise, stress echocardiography or an isotope myocardi al perfusion scan to look for evidence of reversible ischaemia What are the risks? \200 PCI \200\224 higher risk of death, renal failure and infarction in elderly. Age is an independent predictor of increased complication, but so too are diabetes, heart failu re and chronic renal impairment, all of which are more common in older patients. CABG \200\224 increased early mortality and stroke in older patients What are the bene \201 ts? \200 PCI \200\224 may be only way to control intrusive symptoms in stable angin a, and the only way to settle an acute coronary syndrome. Variable evidence from studies \200\224 all agree increased early complications, but longer-term bene \201 ts in older pa tients are reported as equivalent or even better CABG \200\224 probably better with triple vessel disease, poor exercise tolerance, poor le ft ventricular function and diabetes. Generally well tolerated in elderly, with similar lon g-term improvements in symptoms and quality of life to younger patients. New minimally inva sive techniques, that do not require bypass, are likely to reduce the early complications w ithout impairing outcome Overall recommendations Consider all patients who fail medical treatment for revascularizat ion procedures, regardless of age. The early complication rate is higher in older patients, but the eventual bene \201 t is equal if not better than for younger patients. Approach a cardiologist with a record of treating older patients. Crucial to include the pa tient in the decision, with a frank and individu- alised discussion about risks and bene \201 ts. This page intentionally left blank 266 CHAPTER 10 Cardiovascular Myocardial infarction This includes both NSTEMI and STEMI. Around two-thirds of all myocar- dial infarctions occur in patients > 65 and a third in patients > 75. Overall, the inciden ce of MI has decreased, but this is not the case for older patients. Despite this, evidence regarding optimal management is lacking, as older patients tend to be underrepresented in clinical trials. Table 10.2 summarizes what is known. As a general rule, all appropriate therapies should be considered in all patients post-MI, regardless of age. While evidence is lacking in older patients, it is more reasonable to ex trapolate from a younger population than to deny treatment. This approach must of course be tempered with common sense and individually tailored decision making. Prior to discharge Medication \200 May include aspirin clopidogrel, statin, B -blockad e, ACE inhibitor, and GTN spray Use medications unless they are contraindicated, or the risk > bene \201 t \200 Be alert for common side effects (more likely with advancing age), eg orthostatic hypotension, gastrointestinal bleeding Education \200 Diet, nutrition, cholesterol control \200 Smoking cessation \200 Activ ity restrictions and graded reintroduction \200 Recurrent symptoms and what to do \200 Routine follow up after stents Cardiac rehabilitation \200 Used after acute coronary syndromes and multiple presentation s of congestive heart failure Involves structured exercise program \200 Proven to improve exercise tolerance and decrea se readmission \200 Under used for older cardiac patients \200\224 less referral, and so metimes there are upper age limits in place Bene \201 t seen in older patients is equivalent to that in younger patients, although they start from a less \201 t baseline Older people adhere well to programs and seem to suffer no complications Some adaptations are needed (more time to warm up and cool down, longer breaks, avoidance o f high impact activity, lower intensity for a longer time) Bene \201 ts include improved \201 tness, increased bone mineral density, improved mood and fewer falls as well as improved cardiovascular \201 tness MYOCARDIAL INFARCTION 267 Table 10.2 The current evidence base regarding various treatments for MI Therapy Evidence Aspirin Equivalent risk reduction in elderly population Primary PCI This is usually the strategy of choice where presentation is early. It reduces death and re current MI compared with a conservative strategy. Procedural risks are greater with frail p atients and the role for PCI in those > 80 with multiple comorbidities has not been well st udied. Resource limitations may impact Thrombolysis Not indicated for unstable angina or NSTEMI Has a role in STEMI regardless of age Must be administered <12hr after onset (ideally <3hr) and is used where PCI is not availabl e or feasible Increased risk of complications, eg cerebral bleeding (but can predict those at higher risk if hypertensive, low body weight, previous stroke or on warfarin) Contradictory evidence regarding mortality \200\224 large RCTs suggest increased absolute risk reduction of mortality in elderly patients (eg ISIS-2) but these are selected, probabl y \201 tter patients, and do not include the very old. Observational trials of actual pra ctice suggest equivalent bene \201 t in older patients, or possibly even a survival disadv antage. Probable equivalent proportional mortality reduction, so absolute reduction greates t in elderly who have the highest mortality Overall, consensus is that thrombolysis can be used in older patients, with rare exceptions for the very frail or where individual risk seems to outweigh bene \201 t Low molecular weight heparin Full dose is effective in NSTEMI, and possibly more effective in older patients GP IIb/IIIa inhibitors Trials using this therapy in unstable angina and NSTEMI show bene \201 t that is equal in the older patients 268 CHAPTER 10 Cardiovascular Hypertension Hypertension is an important risk factor for vascular disease. Historically un derdiagnosed and undertreated, especially in older patients, although this is improving in the UK as GPs now have \201 nancial incentives to treat hypertension. The incidence of hypertension overall rises with age, reaching a prevalence of 60 \200\2238 0 % beyond 65. After this age, systolic BP (SBP) rises linearly while diastolic BP (DBP) fa lls, leading to widening of the pulse pressure and relative frequency of isolated systolic hypertension (Table 10.3 ). Isolated systolic hypertension re \202 ects reduced arterial c ompliance which is disease related and not a part of \200\230normal \200\231 ageing per se . Hypertension is an independent risk factor for stroke, IHD, peripheral vascular disease, co ngestive heart failure, renal failure, and dementia in all age groups, but in older patient s it is SBP and widened pulse pressure that are the strongest predictors of adverse cardiov ascular outcome. Assessment \200 Ask about symptoms (including hypotensive), comorbidity, smoking \200 M easure with a well-maintained, calibrated device, with an appropriate sized cuff: \200 Check supine and standing BP (orthostatic hypotension can cause symptoms when treatment initiated) Take at least two measurements in a single consultation \200 Never initiate treatment bas ed on a single reading \200 Consider ambulatory measurements if drug resistance, variable BP, white coat hypertension, or postural symptoms Examine for evidence of target organ damage (stroke, dementia, carotid bruits, cardiac enlargement, IHD, peripheral vascular disease, renal disease, retin al changes) Consider secondary hypertension \200\224 Rare in older patients, but consider if drug resi stant, severe hypertension or with suggestive examination or laboratory \201 ndings. Cons ider medications (NSAIDs, steroids, SSRIs), Cushing \200\231s syndrome, sleep apnoea, prima ry aldosteronism, phaeochromocytoma, or renal artery stenosis Investigations to look at target organs (urinalysis, blood urea, and electrolytes, ECG) and for risk factor analysis (glucose, lipids) HYPERTENSION 269 Treatment thresholds and goals \200 Depends on individual \200 In active elderly popula tion with reasonable life expectancy treat as for younger patients \200\224 ie > 160/100mmHg Use lower threshold ( > 140mmHg) in high-risk patients (eg smokers, diabetics, evidence of target organ damage, high estimated 10-year risk) \200 No clear ev idence for optimal target. Probably the lower the better as long as tolerated The usual limit to treatment is symptomatic postural hypotension; consider using alternative agents which may cause less orthostatic drop (eg ARBs, calcium c hannel blockers) Caution in isolated systolic hypertension \200\224 try not to lower DBP <65mmHg There are even fewer data for very elderly ( > 85) people and a pragmatic approach based on apparent biological age is appropriate Table 10.3 British Hypertension Society de \201 nitions of high BP (2004) Grade Systolic BP (mmHg) Diastolic BP (mmHg) Mild 1 140 \200\223159 90 \200\22399 Moderate 2 160 \200\223179 100 \200\223109 Severe 3 > 180 > 110 Isolated systolic hypertension 1 140 \200\223159 <90 Isolated systolic hypertension 2 > 160 <90 270 CHAPTER 10 Cardiovascular Hypertension: treatment Similar approach to that used in younger patients, but it is import ant to bear the following in mind: \200 Side effects are more common and more debilitatin g in older patients (due to more sluggish baroreceptors and reduced cerebral autoregulation) There is a greater risk of drug interactions as older patients are more often victims of polypharmacy Comorbidity is common and should direct the choice of antihypertensive agents (see b \200\230HOW TO Use antihypertensives in a patient wit h comorbid conditions \200\231, p.271) Hypertension should be seen as a risk factor and the decision to treat should be weighed along with other risk factors. In a very frail elderly person with a limited life expectancy, the side effects might far outweigh any future bene \201 ts fro m risk factor modi \201 cation. This, however, should be an active decision reached if pos sible with the patient, and not a simple omission Begin with lower doses and titrate up slowly ( \200\230start low and go slow \200\231) to m inimize adverse reactions. It is better to be on something at a low dose than nothing at al l Non-pharmacological measures Lifestyle modi \201 cations are as important and effective in reducing BP in older patients as in the young. Salt restriction, weight reduction, and reg ular exercise are particularly effective. Moderate or absent alcohol intake is advised. Smo king cessation and decreasing saturated fat intake helps with overall risk reduction. Choice of medication Many large trials have compared the different classes of antihypertens ive but with little consistency in results. Overall, it seems that it is lowering the BP pe r se that is the important factor, and this bene \201 t continues up until at least 84 yea rs (possibly beyond \200\224 evidence pending). In older patients, with much comorbidity, there may be compelling reasons for using, or not using certain agents ( see b \200\230HOW TO Use antihypertensives in a patient with comorbid conditions \200\231, p.271). Try to use a drug that will treat both BP and a coexisting disease to limit polypharmacy. If n ot, then the British Hypertension Society recommends using the A/CD approach: \200 A ACE inhibitors and angiotensin receptor blockers \200 C Calcium channel blockers \200 D Diu retics In younger (<55), white patients, begin with A. In older patients and all black pati ents begin with C or D. If inadequate control: 1. Try A + C or A + D 2. Then A + C + D 3. Finally, consider adding an A -blocker, spironol actone, or B -blocker Further reading NICE . Hypertension: management of hypertension in adults in primary care ( 2006 ) online: M www.nice.org.uk/cg/34 . HYPERTENSION: TREATMENT 271 HOW TO Use antihypertensives in a patient with comorbid conditions Calcium channel blockers \200 Use rate-limiting options (eg diltiazem) to slow heart rate in AF or reduce angina with normal LV function May make heart failure worse or cause constipation \200 Dihydropyridine calcium channel b lockers (eg amlodipine, felodipine) are excellent in isolated systolic hypertension Thiazide diuretics For example: bendro \202 umethiazide 2.5mg \200 Useful \201 rst-lin e therapy in most older patients \200\224 may help with ankle swelling and heart failure symptoms Avoid if severe gout, urinary incontinence or profound dyslipidaemia \200 May worsen urin ary incontinence \200 Need to monitor for hyponatraemia B -blockers For example: atenolol 25mg \200 Useful with angina, AF, and stable heart failure (cardioselective better) \200 Avoid with peripheral vascular disease, asthma, heart block ACE inhibitors For exampl e: ramipril 2.5 \200\22310mg \200 Use for secondary prevention after vascular event (stro ke, TIA, heart attack), in diabetes, heart failure and chronic renal impairment Avoid in renal artery stenosis and aortic stenosis \200 Monitor potassium and renal funct ion ARBs For example: losartan 50mg \200 Use when ACE intolerant (usually cough) where an ACE is indicated \200 May cause less orthostatic symptoms than ACE inhibitors \200 Monitor potassium and renal function A -blockers For example: doxazosin 1mg \200 Excellent for r esistant hypertension in older patients \200 Use if prostatic hypertrophy \200 Commonly cause orthostatic symptoms \200 May exacerbate stress incontinence Further reading NICE . Hypertension: management of hypertension in adults in primary care ( 2006 ) online: M www.nice.org.uk/cg/34 . Cooperative Research Group . ( 2000 ). SHEP (Systolic Hypertension in the Elderly Program) . JAMA 284 (4) : 465 \200\223 71 . Dahlof B , Lindholm LH , Hansson L , et al . ( 2000 ). STOP hypertension 1 and 2 (1st and 2 nd Swedish trial in old people with hypertension) . Heart 84 Suppl I : i2 \200\223 i4 . 272 CHAPTER 10 Cardiovascular Arrhythmia: presentation Arrhythmias are very common in older people, but are not so common as a presenting complaint. A patient with recurrent presyncope preceded by palpitations pr esents very little diagnostic challenge. What is much more common is for an arrhythmia to b e the explanation for a rather more vague presentation such as: \200 Recurrent falls \200 Patient covered in bruises who has been explaining them away as clumsiness \200 General fatigue \200 Dizzy spells \200 Light-headedness \200 \200 \230Collapse query cause \200\231 \200 Blackouts \200 Worsening/new angina or heart fai lure History It is important to ask about palpitations with any of these problems, (indeed it sh ould form part of the systems review in all older people) but be aware of the following poi nts: \200 Clarify carefully what you mean \200\224 many people do not understand what we mean by \200\230palpitations \200\231 and may be describing an ectopic heart beat followe d by a compensatory pause, or even just an awareness of the normal heart beat, eg when lyin g in bed at night. Getting the patient to tap out what they feel can be very revealing Do not exclude the possibility of an arrhythmia just because the patient does not complain of palpitations \200\224 especially with confused patients Where there are palpitations/light-headedness, establish an order wherever possible. Postur al hypotension (see b \200\230Orthostatic (postural) hypotension \200\231, p.118) is very common in older patients, and can produce a similar set of symptoms (falling BP causing lig ht-headedness, then a compensatory tachycardia) \200\224 in theory the palpitations should come \201 rst in an arrhythmia Are there any constant features ? For example \200\224 dizziness occurring: on standing is more likely to be postural hypotension \200 on exertion may have an ischae mic component \200 on turning the head may be due to vestibular problems, or carotid sinu s hypersensitivity (see b \200\230Carotid sinus syndrome \200\231, p.122) \200 in any si tuation or at any time is much more likely to be due to an arrhythmia A history of signi \201 cant injury (especially facial bruising) with a blackout increases the chances of \201 nding an arrhythmia, particularly a bradycardia re quiring pacing Always take a full drug history \200\224 antiarrhythmics can be pro- arrhythmogenic, drugs that cause bradyarrhythmias (commonly B -blockers, digoxin or rate li miting calcium channel blockers such as diltiazem), and antidepressants (especially the tri cyclics) that can predispose to arrhythmias. Medications containing ephedrine, thyroxine, c affeine and B -agonists can cause tachyarrhythmias ARRHYTHMIA: PRESENTATION 273 Examination \200 Should always include lying and standing BP, assessment of the baseline pulse character, rate and rhythm, full cardiovascular examination to look for evidence of s tructural cardiac disease (eg cardiomyopathy, heart failure, valvular lesions) all of which may predispose to arrhythmias General problems require a full general examination \200\224 it is rarely appropriate to e xamine a single system only in an elderly patient. A rectal examination, eg, may reveal a r ectal tumor causing anemia and hence palpitations It may also be appropriate to examine the vestibular system (see b \200\230HOW TO Examine the vestibular system \200\231, p.561) and central ner vous system Investigations \200 Blood tests \200\224 including FBC (anemia), UC + E (low potassium predisposes to arrhythmias), thyroid function, digoxin levels where relevant ECG \200\224 look for baseline rhythm and any evidence of conducting system disease (eg a bundle branch block, or any heart block). Measure the P-R and the Q-T interval. Also look f or LV hypertrophy (arrhythmias more likely) or ischaemia. A totally normal ECG diminishes t he possibility of clinically signi \201 cant arrhythmia CXR \200\224 look at cardiac size \200 Holter monitoring \200\224 a prolonged ECG recor ding. Usually a 24-hr period initially. Remember this is a very small snapshot, and of limited value especially i f symptoms are infrequent. Can be useful if the symptoms are experienced while the monitor is on, and the ECG trace shows normal sinus rhythm. If the suspicion of arrhythmias is high , then repeat the test, or arrange for trans-telephonic event recording or even an implanta ble loop recorder where the symptoms are severe enough (eg sudden syncope) 274 CHAPTER 10 Cardiovascular Arrhythmias: management Management of arrhythmias in older patients does not differ signi \201 cantly from management in other age groups, but consider the following. Precipitants \200 Always check for common precipitants in older patients: Electrolyte abnormalities (especially hypo or hyperkalaemia and hypocalcaemia) Anemia \200 MI \200 Antiarrhythmic toxicity (especially digoxin) \200 Sepsis \200 H ypothermia \200 Any other acute illness If the precipitant cannot be reversed quickly (eg sepsis) then the arrhythmia is likely to be recurrent. Consider cardiac monitoring if cardiovascular comprom ise or if arrhythmia recurrence is likely Effect of arrhythmia \200 Tachycardia may be less well tolerated than in younger patients causing signi \201 cant hypotension, angina, or heart failure Hypotension itself may be less well tolerated than in younger patients (risk of cerebral injury) and so prompt action is required Where there is heart failure because of an arrhythmia, \202 uids cannot be used for resus citation and so de \201 nitive action is required sooner rather than later. Begin by using standard treatment for acute heart failure (oxygen, intravenous diuretics, and opiates, et c.) while organizing cardioversion (usually electrical for speed) or rate limitation (appro priate for AF) Diagnosis \200 There is more likely to be underlying cardiac pathology \200\224 always c heck for ischaemia and structural heart disease even for apparently benign arrhythmias (eg SVT) Bundle branch block is common, and so there may be confusion between supraventricular and v entricular arrhythmias. There are numerous subtle ways of distinguishing between these but in an emergency: \200 If the patient is compromised, electrical cardioversion will treat both effectively If the patient is unwell, but stable, an amiodarone infusion will treat both effectively, a nd has the advantage of causing little myocardial depression ARRHYTHMIAS: MANAGEMENT 275 Treatment \200 Elderly patients are much more likely to be on an antiarrhythmic drug already. 2Check the medication carefully before administering any therapy. See Box 10.1 for common p itfalls. \200 Electrical cardioversion is well tolerated by most older patients, usually effective and less likely to cause side effects than many medications. It should be conside red early where there is signi \201 cant compromise. Anesthetic support is required, which can take some time to arrange, so prompt referral is recommended. It is less useful in acu te sepsis where the arrhythmia is likely to recur, and it is hard to establish whether comp romise is caused by the sepsis or the arrhythmia. \200 Implantable cardiovertor de \201 brillators are life-saving for malignant ventricular arrhythmias (VT and VF) in patients wi th low ejection fractions. However they are very expensive, can cause debility and pain and do not allow a natural death (they must be turned off during palliative care). There is re luctance to use them in older, frail patients in whom non-arrhythmic deaths are common. Box 10.1 Common pitfalls with anti-arrhythmic medication Adenosine \200 Its action is prolonged by dipyridamole (commonly prescribed with aspirin in stroke), so avoid using together Exacerbates asthma and is antagonized by theophylline, so avoid in asthmatic people Amiodarone \200 Risk of ventricular arrhythmias when used with disopyramide, procainamide and quinidine, so avoid concomitant use \200 Increases plasma half-life of \202 ecainide, so reduce dose Atropine \200 Can precipitate glaucoma, so avoid in patien ts with this condition Flecainide \200 Contraindicated when there is IHD, heart failure a nd haemodynamic compromise Probably best avoided in most older patients, who may well have occult cardiac disease Verapamil \200 Do not use intravenously in a patient already on a B -blocker (high risk of asystole and hypotension) General guidance Most antiarrhythmic medication used concomitantly increases the risk of my ocardial depression and arrhythmias. This effect is more pronounced in older patients. Caut ion when using more than one, and consider using sequentially rather than additively if one alone is ineffective. 276 CHAPTER 10 Cardiovascular Atrial \201 brillation Common arrhythmia, becoming more common with age (risk doubles wit h each additional decade of age, rising to 7 % in > 85 year olds). Often associated with ot her disease (eg hypertension, coronary artery disease, mitral valve disease, thyrotoxicosis ) but also occurs in 1 \200\2232 % of otherwise healthy elderly people. Unlike other arrhyt hmias, it is often chronic. Disorganized atrial activity with variable conduction to the ventricles leads to an irregul arly irregular pulse rate and volume. Up to a third of older patients with AF will have AV nodal disease that limits the rate to less than 100bpm, often making it asymptomatic. It is therefore often noted incidentally during routine examination \200\224 but should never b e ignored.