Globally the population is ageing and we in the Kashmir valley are no exception. More than 12% of our population is more than 60 years of age.
The chances of acquiring heart disease increases with age beyond 40 years. There is an increasing possibility of getting problems like atherosclerotic heart and vascular diseases (angina, heart attacks, strokes etc), heart failure.
This is linked to phenomena like inflammation, oxidative stress, cell death and deterioration of heart function. In addition, other morbid conditions like, frailty, obesity and diabetes are common in the elderly.
It is customary to measure age in chronology as a number but this does not take into consideration the functional capacity, productivity and the general health of the individual. The categorization of age in clinical trials is often arbitrary and elderly population cut offs have varied from 65, 70 and 75 years.
It is necessary to emphasize that prevention needs to start at young ages to get the maximum benefit when the individual reaches old age. The vascular events would therefore have been lower and for those who had it, secondary preventive measures could be started.
A person reaching old age with already a history of heart attack, stroke or heart failure has a much poorer prognosis than a person who has been free of these problems.
The relative benefits of treating elderly people to targets for high blood pressure (hypertension), high cholesterol levels (Dyslipidemia) and blood sugar levels have been proven in the elderly and must be kept in mind when treating.
(Adapted from European Society of Cardiology document “cardiovascular diseases in the elderly”)
Hypertension:
The maximum benefit of treating comes in the ages of 70 to 80 years of age. However, while initiating treatment in the elderly, one has to keep in mind the possibility of orthostatic hypotension (postural drop of BP), which can lead to a fall and fractures, incapacitating the person while reducing the chance of a stroke and a heart attack. Therefore, care has to be taken to start with lower doses and more frequent monitoring. Treatment therefore needs to be individualised and keeping in consideration the frailty and possibility of producing a harm.
Dyslipidaemia:
The benefits of statin usage (atorvastatin and rosuvastatin) are proven in the elderly. They significantly reduce heart attacks and strokes. The time frame for reducing these events is however 2 to 2.5 years. It is therefore important to make an estimate of the patients predicted longevity before staring the drugs in full steam. Their side effects like myalgias, sarcopenia and polypharmacy which is often the case has to be kept in mind which has a potential to harm which should not be overlooked.
Diabetes Management:
Diabetes is highly prevalent in the elderly and needs careful management. Using high doses of insulin and sulfonylureas (glimepiride etc) to achieve a tight control has not been shown to have much benefit in preventing heart attacks . Likewise, care should be taken to monitor the kidney function (serum creatinine and glomerular function rates). Metformin, a commonly used drug, needs lower doses in renally compromised patients. The agents like SGLT2 inhibitors (dapagliflozin and empagliflozin) which prevent heart failure and GLP1 analogues ( semaglutide, dulaglutide) which prevent vascular events and promote weight reduction seen so often in diabetics should be used liberally in adequate doses.
Healthy Lifestyle:
Promotion of heart healthy diet, consisting of plenty of fruits, fresh vegetables, almonds and nuts and salads along with regular exercise tailored to the individual’s physical capacity is a very important accompaniment. Keeping fish and egg white in good proportions is very useful. It is very important to counsel the smokers to give it up and advocating that “it is never too late”.
What about Aspirin:
The usage of this important anti platelet drug has been subjected to a lot of scrutiny in the last decade. No doubt its use is very important for persons with known blockages of coronary arteries in the form of heart attacks and patients who have had angioplasty or bypass surgery. In fact, in these situations also the possibility of bleeding should be kept in mind and a watch over hemoglobin is needed from time to time.
For primary prevention it has no role based upon evidence-based medicine. The miniscule benefits are overshadowed by the risk of bleeding. This is true at all ages including the elderly population. Patients who are on anticoagulants for various chronic conditions including atrial fibrillation also need to be cautioned against consuming it. It is no substitute for anticoagulants like dabigatran, apixaban and Rivaroxaban in management of atrial fibrillation. So, the concept of one Aspirin a day keeps heart attack away for primary prevention is obsolete and given up.
Invasive procedures like Angioplasty, Bypass surgery and Valve Replacement:
Historically there has been a reluctance to carry out invasive procedures in the elderly. However, with better techniques, improved skills and advances in technology the results have improved substantially with acceptable morbidity and mortality. These procedures are very important in sick patients with unstable patients with impending heart attacks and early after sustaining major attacks. They also have a place in stable patients. Less invasive procedures like angioplasty are preferred in general wherever possible. In severe left main disease with or without multi-vessel blockages often surgery may be a better and more lasting procedure.
Valve replacement using the non-surgical approach for aortic valve disease in elderly , especially with co-morbidities, has become an accepted procedure in experienced hands. The decision again needs to be individualized keeping in mind the other comorbidities which are associated. A detailed discussion with the family and the patient with a heart team is the best way to gain the confidence of the patient and the family accepting the adversities if these are seen after the procedure.
Polypharmacy in the elderly and need of a Geriatric Consultant:
It is essential to keep in mind the other illnesses of the elderly population while treating their cardiac problem. Common associations are, degenerative joint problems like osteo-arthritis, prostate enlargement in males or prolapsed uterus in ladies. Overactive urinary bladder needing frequent toilet visits, Impaired hearing and failing visual acuity. Cancers active or old, needing long term drugs, radiation. Depression, anxiety and lack of sleep. Neurological problems like Parkinsonism, old strokes and Alzheimer’s disease. Chronic lung disease like bronchitis. For these reasons, a Geriatric consultant being a part of the team is desirable and a necessity. This would help in avoiding drug-drug interactions and avoiding drugs with opposing actions and reactions and yet getting the best treatment.
Concept of Palliative Care in end stage heart disease like Chronic Heart Failure:
Progressive decline and loss of independence, poor quality of life despite optimal treatment, frequent hospitalization, cardiac transplant or mechanical circulatory devices not possible and clinical assessment indicating close to end of life, calls for a palliative care.
Adding life to years versus adding years to life is an important decision especially in elderly patients with chronic worsening heart failure who are already on all the pillars of pharmacotherapy.
Focus should be on optimizing the quality of life, focussing on symptom relief, psychological and often spiritual support. Patients’ preferences around death time need assessment by having a meeting with close family members and avoiding energetic and painful treatment algorithms.
Take Home Message:
The increasing elderly population represents a major challenge to the physicians, health care providers and the society at large. Long exposure to risk factors along with age related co-morbidities frequently result in complex cardiovascular problems in them .The available therapies have been proven to be beneficial but there are several issues in using them and need to provoke a thought process and a debate.
The narrow therapeutic window of several drugs, cognitive impairment, frailty and the important question of quality-of-life vs mortality are the issues . The treatment using drugs and mechanical interventions should always focus on the patient’s preference and the quality of life. The optimal therapy should be determined by a multidisciplinary team which involves the patient and the family in the decision-making process.
Prof U Kaul, Founder Director Gauri Kaul Foundation, a Recipient of Padma Shri and Dr B C Roy Award
DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.