Patients with cardiovascular disease are missing out on crucial treatments

By Mark Waghorn via SWNS

Elderly patients with cardiovascular disease are missing out on simple treatments that could prolong and improve their lives, according to new research.

They need personalized drugs and rehab as hearts and bodies change with age, so treatments need to change too, the American Heart Association (AHA) report states.

Some suffer other common age-related medical conditions, with potential impacts on therapy and follow-up care.

Medications for specific individuals are becoming increasingly important as the proportion of old folk continues to rise.

The AHA study points out alterations in the general health, heart and blood vessels of those over 75.

This age group comprises up to 40 percent of those hospitalized with acute coronary syndrome (ACS) - such as heart attacks and severe angina.

Cardiovascular disease is the world's number one killer, claiming almost 18 million lives a year. Current practice guidelines are based on clinical trial research.

Lead author Professor Abdulla Damluji, of Johns Hopkins School of Medicine in Baltimore, Md., said: "However, older adults are often excluded from clinical trials because their health care needs are more complex when compared to younger patients.

"Older patients have more pronounced anatomical changes and more severe functional impairment, and they are more likely to have additional health conditions not related to heart disease.

"These include frailty, other chronic disorders (treated with multiple medications), physical dysfunction, cognitive decline and/or urinary incontinence - and these are not regularly studied in the context of ACS."

Cardiovascular changes that occur with normal aging make ACS more likely and may make diagnoses and treatment more complex.

Large arteries become stiffer. The heart muscle often works harder but pumps less effectively.

Blood vessels are less flexible and less able to respond to changes in the heart’s oxygen needs. There is an increased tendency to form blood clots.

Sensory decline may also alter hearing, vision and pain sensations. More than a third of those over 65 have chronic kidney disease.

ACS is more likely to occur without chest pain in older adults, presenting with symptoms such as shortness of breath, fainting or sudden confusion.

Measuring levels of the enzyme troponin in the blood is a standard test to diagnose a heart attack in younger people.

However, troponin levels may already be higher in older people, especially those with kidney disease and a stiffened heart muscle.

Evaluating patterns of the rise and fall of troponin levels may be more appropriate when using it to diagnose heart attacks in older adults.

Age-related changes in metabolism, weight and muscle mass may necessitate different choices in anti-clotting medications to lower bleeding risk.

Many clinicians avoid cardiac rehabilitation for patients who are frail, even though they often benefit the most.

Ensuring medications and other therapies are continued when people are transferred from the hospital to an outpatient care center is particularly important.

Older adults are more vulnerable to frailty, decline and complications during these transitions.

As people age, they are often diagnosed with health conditions that may be worsened by ACS or may complicate it.

The number of medications prescribed may result in unwanted interactions or medications that treat one condition may worsen another.

Prof Damluji said: "Geriatric syndromes and the complexities of their care may undermine the effectiveness of treatments for ACS, as well as the resiliency of older adults to survive and recover.

"A detailed review of all medications - including supplements and over-the-counter medicines - is essential, ideally in consultation with a pharmacist who has geriatric expertise."

An individualized and patient-centered approach to ACS care, considering coexisting conditions and the need for input from multiple specialists, is best for older adults.

Ideally, multidisciplinary teams include cardiologists, surgeons, geriatricians, primary care clinicians, nutritionists, pharmacists, cardiac rehabilitation professionals, social workers, nurses and family members.

In addition, people with cognitive difficulties and limited mobility may benefit from a simplified medication schedule.

This would include fewer doses per day and 90-day supplies of medications so fewer refills are necessary.

Monitoring symptom burden, functional status and quality of life during post-discharge follow-up are important to provide insight into how the patient is progressing.

Although risks are greater, bypass surgery or procedures to reopen a clogged artery are beneficial to select older patients.

The AHA's findings update a 2007 statement about the treatment of the elderly. It has been published in their flagship journal Circulation.