Acute Coronary Syndromes in Older Adults Case 1 of 2

Published on May 2016 | Categories: Documents | Downloads: 20 | Comments: 0 | Views: 124
of 8
Download PDF   Embed   Report

Comments

Content





ACUTE CORONARY SYNDROMES IN OLDER ADULTS

Case 1 (87 year old woman with fatigue and chest tightness)

An 87 year old widow, living independently, has one week of fatigue and chest tightness with
minor tasks preventing her from attending usual activities. Her past history is remarkable only
for systolic hypertension and osteoarthritis for which she takes HCTZ and Naprosyn.

On the day of admission, she awoke from sleep at 5am with sudden chest tightness, heart
pounding, and an inability to breathe. She lives alone, but despite her moderate distress, she
was able to get to the phone and call 911. EMS found her in respiratory distress with an
irregular HR @ 110 bpm, BP 200/85 mmHg, and oxygen saturation of 90%. After two
sublingual nitroglycerin tablets and nasal canula oxygen, she was breathing more comfortably
and her chest tightness was resolving.

In the ER, she was alert and comfortable. BP 165/81mm Hg, HR 89 bpm, and oxygen saturation
on 4LNC was 96%. Initial EKG showed new atrial fibrillation with an IVCD and 1mm ST
depression inferolaterally. There was mild JVD, and a right carotid bruit. Lung exam revealed
distant breath sounds. Cardiac exam revealed no murmurs or gallops, and no lower extremity
edema was noted. Chest x-ray showed mild interstitial edema. Initial CKMB was 15 and
troponin T was 2.1, and B-type natriuretic peptide is 830 ng/ml. Serum creatinine was 1.2 mg/dl,
sodium was 135 mg/dl, and HCT 33%. She was admitted to the CCU with a non-ST elevation
MI.

Is her presentation typical?

Presenting symptoms associated with acute myocardial ischemia in older adults include acute
shortness of breath, confusion, profound fatigue, and chest heaviness. In addition, back pain,
nausea and syncope may be symptoms of myocardial ischemia. This patient had a week of
typical exertional chest pain and fatigue but her acute presentation was marked by heart failure
and rapid atrial fibrillation. Although her ejection fraction is unknown, it is likely to be normal
without a prior cardiac history. In the ischemic cascade, increased LVEDP occurs early and
elevates intra-cardiac pressures already high from diastolic dysfunction. Atrial fibrillation occurs
more commonly with advanced age due to the fibrotic changes within the sinus node,
pulmonary veins and atrial tissue. Her rapid atrial fibrillation shortens diastolic filling time and
contributes to her heart failure presentation. Older adults are more likely have heart failure with
their MI, as in this case. The age-related increase in arterial stiffness, demonstrated here by an
increased pulse pressure (>80 mmHg), increases the load on the left ventricle of older persons
and increases the risk of heart failure in the setting of myocardial damage. Among patients with
atypical presentations (eg. shortness of breath, nausea, or syncope), nearly half (43%) are over
age 75. Atypical MI presentations are also more commonly seen in women, diabetics, and those
with heart failure. Yet, it is important to remember that typical chest pain also occurs commonly
in older adults.

Older adults with acute myocardial ischemia may present with symptoms other than chest
discomfort. In addition, their presentation may be confounded by coexisting disease states or
altered physiology. These non-cardiac and atypical cardiac presentations have been
demonstrated to substantially increase the risk of adverse outcomes including cardiac arrest,


shock, heart failure, bleeding, arrhythmias, and length of stay. Comorbid illnesses are the main
reason for these worse outcomes, yet age-related changes in other organ systems such as
kidneys and lungs, more severe CAD, higher prevalence of prior MI, and less aggressive
treatment also contribute. Much of this risk also remains unexplained by standard adjustment
methodology. Age-related declines in CV reserve capacity, contributed by the age-related
decline in beta adrenergic responsiveness, limit the ability of older patients to maintain cardiac
performance in response to acute stress (such as an myocardial infarction), hence the observed
increased propensity for heart failure, shock, and death.

Case Continued

Her echocardiogram confirms a left ventricular ejection fraction of 77% with mild hypertrophy
and mild MR. She was treated with IV furosemide for pulmonary congestion and her ventricular
rate was controlled with beta blockers. She was started on aspirin, clopidogrel, unfractionated
heparin and a GP IIb/IIIa inhibitor (by standard protocol) in the CCU with a plan for cardiac
catheterization the following day. Her NSAIDs, contraindicated in the setting of an acute
coronary syndrome, were discontinued. On morning rounds, she reports an episode of chest
tightness when using the bedside commode during the night. When discussing cardiac
catheterization, she expressed concern that she could not withstand it due to her age.

What would you recommend next?

While an imaging study would clarify ischemic burden, it would do little to reduce post-MI risk.
Given her recurrent chest pain and positive markers her risk is known to be high. Cardioverting
her atrial fibrillation is reasonable but likely to be premature as she may have an ischemic
trigger for her atrial fibrillation. Correcting her ischemia first would be prudent.

Decision making, regardless of age, requires weighing clinical risk and benefit in the context of
patient wishes. At age 87, her health care priorities may differ from those of younger patients.
Unfamiliarity with health care technologies may heighten her concerns regarding her ability to
withstand procedures. Therefore, additional communication may be necessary to alleviate her
fears. Although she still could have non-obstructive coronary artery disease with demand
ischemia from hypertension, LVH, and rapid atrial fibrillation, she has positive biomarkers and
an ischemia prodrome. Her episode of chest pain on anticoagulants provides further evidence of
an ongoing ischemic and thrombotic process. Therefore, diagnostic catheterization is the most
direct risk stratification approach. Therefore, you outline the benefits and risks of catheterization
emphasizing her elevated risk with recurrent chest pain and positive cardiac markers.

On further discussion, she is not interested in bypass surgery, but agrees to PCI if indicated. An
early invasive approach has been shown to be beneficial in troponin positive patients over age
75 in the TACTICS TIMI 18 trial. This is likely due to the benefit from an intervention being the
greatest where absolute risks are highest. Recent data has raised questions about an early
invasive approach in women, however those with positive cardiac markers benefit to the same
degree as men. Bleeding risks are heightened in women and older adults, so anticoagulation
with intervention should be carefully considered.

Case Continued
Cardiac catheterization demonstrates two vessel disease with a hazy 90% lesion in the mid LAD
and a 75% stenosis in the distal RCA. A bare metal stent was successfully deployed in the LAD.


To minimize complications, the RCA lesion was not approached. She was continued on GP
IIb/IIIa inhibitors for 18 hours following catheterization. She spontaneously reverted to sinus
rhythm after returning from cardiac catheterization. Later that day, the nurse calls to inform you
of a blood pressure of 75/50 mmHg, and a medium-size hematoma at her groin site. Repeat
hematocrit is 25%. She is typed and crossed for two units of packed red blood cells. Her blood
pressure is stabilized with IV fluids.

What factors contributed to her increased risk for bleeding?

Bleeding increases as a function of age and comorbid conditions common in older adults, but
must be considered in light of the benefit of anticoagulant therapy and catheter interventions. In
addition to age, renal function and gender, other patient factors which increase bleeding risk
during acute coronary syndromes include baseline anemia (indicating prior bleeding, less
“hemocyte reserve”), heart failure, diabetes, low body weight, history of bleeding and peripheral
vascular disease. With advancing age, there are alterations in hemostatic factors (Factor V, VII,
VIII, XIII) as well as coagulation proteins which both increase and decrease the susceptibility to
bleeding. In addition, vascular response to injury and vascular repair is altered. Vascular
integrity, along with subcutaneous tissue, may be diminished, furthering risk of catheter based
injury. Increased risk of bleeding is also related to the use of anticoagulant therapy and catheter
based interventions. Some of this risk is unavoidable, but modifiable factors include appropriate
dosing of anticoagulants based on weight and renal function.

Renal function should be determined based on calculation of the creatinine clearance rather
than relying on the serum creatinine. The patient is 5 feet 2 inches tall and weighs 145 pounds
(66 kilos). With a creatinine of 1.2mg/dL, her creatinine clearance by Cockroft-Gault is
~28ml/min. Her GP IIb/IIIa inhibitor dose should have been reduced, but was not. In addition,
she received the “standard” heparin bolus of 5,000 units with 1,000 units per hour infusion.
Based on her weight, she should have received 4,000 unit bolus and 800 units/hour infusion (60
units/kg bolus and 12 units/ kg/ hour infusion). Therefore, she received two therapies in excess
dose, which increased her likelihood of bleeding. With increasing age, the number of therapies
increases the risk of bleeding among invasively managed patients. In addition, the number of
therapies given in excess dose (for her it was two), increases further the likelihood of a bleeding
complication. The location of her bleeding was not identified, but likely sources include the
catheterization site and gastrointestinal bleeding. Recall that she chronically uses NSAIDs for
her arthritis. The guidelines emphasize the importance of evidence-based care in older adults,
and also encourage careful dosing.

Case Continued

She stabilizes with the transfusion and her hemoglobin stabilizes around 11mg/dL. Her lipid
panel was favorable with an LDL-C of 88mg/dL and HDL-C of 65mg/dL. At discharge, her
medication regimen includes metoprolol succinate at 50mg, simvastatin 20mg, low dose
aspirin, and clopidogrel. The day of discharge, his BP is 130/55 mmHg and pulse is 61 bpm.

With regard to the patient’s post MI management, which medications are likely to lower her risk
of a future adverse event?

Benefits of adjunctive therapy (antiplatelet, beta-blockers, ACE inhibitors and statins) are as
great, if not greater, in older adults as in younger adults. Hydroxymethyl glutaryl-coenyme A


reductase inhibitors (“statins”) are Class Ia recommended therapies in post-MI patients based
on significant reductions in vascular events and death. Statins are among the best studied
pharmacologic therapies in terms of safety and efficacy. The recent update to the National
Cholesterol Education Panel (NCEP)-Adult Treatment Panel III guidelines suggest an optional
LDL-C treatment goal of less than 70mg/dL may be particularly desirable in high-risk patients.
Although evidence is somewhat sparse in the oldest patients, data for statins with secondary
prevention in general is strong. In the PROVE-IT TIMI 22 study (PRavastain Or atorVastatin
Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22), 4,162 patients
within 10 days of ACS were randomized to standard versus high intensity statin therapy. The
trial demonstrated that high-dose atorvastatin resulted in significantly lower LDL cholesterol and
a greater reduction death or MI at 30 days. In addition, age sub-group data suggests a greater
benefit in older patients (≥70 years of age, n=730, median 75.3 years) treated to an LDL-C
below 70mg/dL. A recent meta-analysis of statins for secondary prevention confirmed that
clinical event reduction was greater in older adults (>65 years of age). Despite this evidence,
there is a declining use of statins as a function of patient risk and age. Beginning therapy at the
time of hospital discharge improves adherence. As older patients are more likely to be taking
other agents which work via the cytochrome P450 system, careful follow up for symptoms of
myopathy is warranted, but in this post-MI patient without a history of statin intolerance, a low-
dose statin can be initiated prior to discharge.

The guidelines recommend aspirin, statin, and beta blockers for all AMI patients, ACE or ARB in
those with reduced EF, DM or HTN, and clopidogrel post PCI, and preferably in all AMI patients
for up to one year. No distinctions are made in the guidelines in terms of age limits for treatment
benefits, however adverse effects in older adults in general may require a patient-centered
approach.

Case Continued
The family raises concern that she has functionally declined over the past weeks, but mostly
they note that due to the bleeding event, and prolonged hospital stay, she has not been very
mobile in the hospital. She is having trouble getting to the bathroom and her hematoma is still
uncomfortable, limiting her mobility. She was assessed by physical therapy and a skilled nursing
rehabilitation facility was recommended for conditioning, balance, and strength training at
discharge. The family identified a local facility that they have used in the past and arrangements
are made. The patient, who lives independently, agrees to in-patient rehabilitation prior to
returning home.

What are the issues related to hospital discharge in this patient?

The post-discharge interval is a vulnerable period for health deterioration, and transitions
between health care settings increase the risk for medication errors. About half of older adults
experience a medical error after hospital discharge, and 19%-23% suffer an adverse event,
most commonly an adverse drug event. Diminished functional capacity, health literacy,
uncertainty regarding diagnoses, poor communication between patient and provider, and
absence of appropriate follow-up are factors associated with increased risk for adverse
outcomes. A study by Kriplani et al, found that just 25% of discharge summaries include a list of
discharge medications, 18% reached the primary care provider, and of those, only 65% did so
within the first 2 weeks. Given the projected growth of the elderly population, efforts to improve
care transitions will be needed. Studies have suggested that techniques to promote
communication between care givers, and empower and educate patients across health care


settings result in significantly reduced rehospitalizations. In addition, provider attentiveness early
on to reviewing symptoms as potential side effects from medication can improve both safety and
quality of life. Transitions of care are particularly important to enable independent functioning
and medication safety after discharge. Early mobilization and cardiac rehabilitation programs
are very effective in older adults. Clear follow up plans, medication regimens, and activity
progression will enable her return to independent functioning. Recalling her initial presentation
in the middle of the night, she would be wise to consider a personal alert button when she
returns to independent living.



References

1. Lee PY, Alexander KP, Hammill BG, et al. Representation of elderly persons and
women in published randomized trials of acute coronary syndromes. JAMA
2001;286(6):708-13.

2. Alter DA, Manuel DG, Gunraj N, Anderson G, Naylor CD, Laupacis A. Age, Risk-Benefit
Tradeoffs, and the Projected Effects of Evidence-based Therapies. Am J Med.
2004;116:540-5.

3. Rich MW, Bosner MS, Chung MK, et al. Is age an independent predictor of early and
late mortality in patients with acute myocardial infarction? Am J Med 1992; 92:7-13

4. Lichtman JH, Spertus JA, Reid KJ, Radford MJ, Rumsfeld JS, Allen NB, Masoudi FA,
Weintraub WS, Krumholz HM. Acute non-cardiac conditions and in-hospital mortality in
patients with acute myocardial infarction. Circulation 2007; 166: 1925-1930.

5. Avezum A, Makdisse M, Spencer M, Gore JM, Fox KAA, Montalescot G, Eagle KA,
White K, Mehta RH, Knobel E, Collet JP and GRACE Investigators. Impact of age on
management and outcome of acute coronary syndrome: Observations from the global
registry of acute coronary events (GRACE) Am Heart J 2005:149:67-73.

6. Brieger D, Eagle KA, Goodman SG, et al., for the GRACE Investigators: Acute coronary
syndromes without chest pain, an underdiagnosed and undertreated high-risk group:
insights from the Global Registry of Acute Coronary Events. Chest 2004;126:461-9.

7. Pinto DS, Ho KK, Zimetbaum PJ, Pedan A, Goldberger AL. Sinus versus nonsinus
tachycardia in the emergency department: importance of age and heart rate. BMC
Cardiovasc Disord. 2003;3:7

8. Bach RG, Cannon CP, Weintraub WS, DiBattiste PM, Demopoulos LA, Anderson HV,
DeLucca PT, Mahoney EM, Murphy SA, Braunwald E. The effect of routine, early
invasive management on outcome for elderly patients with non-ST-segment elevation
acute coronary syndromes. Annals of Internal Medicine 2004;141:186-95

9. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, Van de
Werf F, White HD, Weaver WD, Naylor MD, Gore JM, Krumholz HM, Ohman EM
(Chair), Acute Coronary Care in the Elderly (Part 1) Non ST Segment Elevation Acute
Coronary Syndromes. A scientific statement for Healthcare Professionals from the
American Heart Association Council on Clinical Cardiology. Circulation 2007;115:2549-
69.

10. Alexander KP, Chen, AY, Roe MT, Newby LK, Gibson CM, Allen-LaPointe N, Pollack C,
Gibler WB, Ohman EM, Peterson ED. Excess Dosing of Anti-Platelet and Anti-thrombin
Agents in the Treatment of Non-ST Segment Elevation Acute Coronary Syndromes.
JAMA 2005;294:3108-3116.

11. Skolnick AH, Alexander KP, Chen AY, Roe MT, Pollack CV, Ohman EM, Rumsfeld JS,
Gibler WB, Peterson ED, Cohen DJ, Characteristics, Management, and Outcomes of


5,557 Patients Age > 90 years with Acute Coronary Syndromes: Results from the
CRUSADE (Can

12. Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with
Early implementation of the ACC/AHA guidelines) initiative. J Am Coll Cardiol
2007;49:1790-7.

13. Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA Focused Update of the
Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation
Myocardial Infarction (Updating the 2007 Guideline) A Report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Developed in Collaboration With the American College of Emergency Physicians,
Society for Cardiovascular Angiography and Interventions, and Society of Thoracic
Surgeons. J Am Coll Cardiol, 2011; 57:1920-1959.

14. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group.
Prevention of cardiovascular events and death with pravastatin in patients with coronary
heart disease and a broad range of initial cholesterol levels. N Engl J
Med1998;339:1349-57.

15. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastain on coronary events after
myocardial infarction in patients with average cholesterol levels. Cholesterol and
Recurrent Events Trial investigators. N Engl J Med 1996;335:1001-9.

16. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering
with statin after acute coronary syndromes. N Engl J Med 2004;350:1495-504.

17. Ray KK, Bach RG, Cannon CP, Cairns R, Kirtane AJ, Wiviott SD, McCabe CH,
Braunwald E, Gibson CM. PROVE IT-TIMI 22 Investigators. Benefits of achieving the
NCEP optional LDL-C goal among elderly patients with ACS. European Heart Journal
2006;27:2310-6

18. Afilalo J, Duque G, Steele R, et al. Statins for secondary prevention in elderly patients:
a hierarchical Bayesian meta-analysis. J Am Coll Cardiol 2008;51:37-45.

19. Muhlestein JB, Horne BD, Bair TL, et al. Usefulness of in-hospital prescription of statin
agents after angiographic diagnosis of coronary artery disease in improving continued
compliance and reduced mortality. Am J Cardiol 2001;87:257-61.

20. Rogers AM, Ramanath VS, Grzybowski M, et al. The association between guideline-
based treatment instructions at the point of discharge and lower 1-year mortality in
Medicare patients after acute myocardial infarction: the American College of
Cardiology’s Guidelines Applied in Practice (GAP) initiative in Michigan. Am Heart J
2007;3:461-9.

21. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events due to discontinuations in
drug use and dose changes in patients transferred between acute and long-term
facilities. Arch Intern Med 2004;5:545-50.




22. Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a
randomized controlled trial. Arch Intern Med 2006;17:1822-8.

23. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in
communication and information transfer between hospital-based and primary care
physicians: implications for patient safety and continuity of care. JAMA 2007;297:831-
840

24. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of
care at hospital discharge: a review of key issues for hospitalists. J Hosp Med
2007;2:314-23

25. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG.
Systematic review: impact of health information technology on quality, efficiency, and
costs of medical care. Ann Intern Med 2006;144:742-52






Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close