:{ic0fp'16. Geriatric Medicine: Optimal Heart Health Amid Changing Guidelines. (and the Evidence for When to Stray) Kevin Overbeck, DO

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1 :{ic0fp'16 ACOFP 53 rd Annual Convention & Scientific Seminars Geriatric Medicine: Optimal Heart Health Amid Changing Guidelines (and the Evidence for When to Stray) Kevin Overbeck, DO

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3 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 1

4 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 SEP 2

5 Dyslipidemia Primary Prevention: CARDS Study NNT Data: 1 st major cardiovascular even Older Younger Age yrs Atorvastatin 10mg v. Placebo 4 years Neil HA, et al. Analysis of efficacy and safety in patients aged years at randomization: Collaborative Atorvastatin Diabetes Study (CARDS). Diabetes Care. 2006;29(11):2378. Dyslipidemia Secondary Prevention: The LIPID Trial NNT Data: Older Younger All Cause Mortality CAD Death Fatal / Non- Fatal MI Stroke Age yr olds; Pravastatin v. Placebo 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. ATRIAL FIBRILLATION & THE ELDERLY 3

6 Atrial Fibrillation Patient Centered Care / Goals of Care Incidence increases with Age Stroke Risk Stroke Prophylaxis Rate Control January CT, et al 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 4

7 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 Risk 1,2 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: Kappor J. Management of Atrial Fibrillation. The Lancet, Volume 370, Issue 9599, Page 1608, 10 November

8 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 CHA 2 DS 2 -VASc SCORE Adjusted Stroke Rate (%/year) 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 With CHA2DS2- VASc > 2, oral anticoagulants are recommended 6

9 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 ) 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: Anticoagulation & The Elderly Setting Self-Monitoring 72% % in Range Randomized Trials Anti-Coagulation Clinics Community Physicians 55-66% 66% 57% * Simple Finger Stick required 1. van Walraven C, et al. Effect of study setting on anticoagulation control: a systematic review and metaregression. Chest. 2006;129(5): Connolly SJ, et al. Dabigatran versus Warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: Patel MR, et al. Rivaroxaban versus Wafarin in patients with non-valvular atrial fibrillation. N Engl J Med 2011; 365:

10 WARFARIN superiority NNT 37 PRIMARY PREVENTON 1 NNT 12 SECONDARY PREVENTION 1 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: 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): ATRIAL FIBRILLATION RATE CONTROL 8

11 (1) Which Patient is more sick? (2) 40 Year Old Female HR 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 9

12 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 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 10

13 Craig T. January et al. Circulation. 2014;130:e199-e267 11