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cardiovascular disease

Selecting Initial Antihypertensive Therapy for Older Adults

Selecting Initial Antihypertensive Therapy for Older Adults

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2
Teaser: 

Norm Campbell, MD, FRCPC, Departments of Medicine, Community Health Sciences, and Pharmacology and Therapeutics, University of Calgary, Calgary; Libin Cardiovascular Institute, Calgary, AB.
Sailesh Mohan, MD, MPH, Departments of Medicine, Community Health Sciences, and Pharmacology and Therapeutics, University of Calgary, Calgary; Libin Cardiovascular Institute, Calgary, AB.

As over 9 in 10 older adults will develop hypertension, it is important for clinicians to routinely assess blood pressure. It is as important to treat hypertension in older adults as it is in younger people. In general, select a low-dose diuretic. Beta-blockers are not as effective at preventing stroke as other major antihypertensive drug classes. Specific indications for drug classes are provided. Target the blood pressure levels to <140/90 mmHg in general, <130/80 mmHg in people with diabetes or chronic kidney disease, and focus on systolic blood pressure control. If blood pressure control is not achieved using a moderate dose of your initial selection, add a second antihypertensive drug.
Key words: hypertension, antihypertensive drugs, pharmacotherapy, cardiovascular disease, stroke.

Cardiovascular Disease and the Older Adult

Cardiovascular Disease and the Older Adult

Teaser: 

I am writing this article a day after attending a meeting of the soon-to-be PGY3’s in core internal medicine at the University of Toronto. The meeting was an information session on how to apply for subspecialty training in internal medicine. Part of the session showed the number of residents who entered various training programs in previous years. The number of trainees entering cardiology was staggering in comparison to those entering geriatrics. After my initial intense burst of jealousy, I had to acknowledge a few truths: cardiology is more popular than geriatrics, older patients have a high burden of CVS disease and need cardiologists, and most cardiologists see large numbers of older adults. Cardiovascular disease remains the most important cause of mortality among older adults, and even for those of us with a particular interest in dementia it is vital to recognize the important role of vascular disease in cognitive impairment. For these reasons (and many more), we offer a theme issue on cardiovascular disease each year. I would recommend the brilliant article in the April 2004 American Journal of Medicine by David Alter and David Naylor showing that modern cardiovascular interventions, if anything, benefit older people more than younger adults.

One of the most common problems we see in older adults is hypertension, and substantial data prove that blood pressure control is quite beneficial to older people. How to control the pressure is the content of the article “Selecting Initial Antihypertensive Therapy for Older Adults” by Dr. Norm Campbell and Dr. Sailesh Mohan. Angina is a common problem in older individuals (and can be quite atypical and difficult to diagnose). “Nonsurgical Management of Chronic Exertional Angina in Older Adults” by Dr. Kenneth Melvin and Lindsay Melvin addresses medical management of angina while Dr. Sameer Satija and Dr. Nanette Wenger review the topic of “Revascularization of Chronic Angina among Older Adults.” Antiplatelet therapy has been a great advance in the treatment of CVS diseases but does carry some risks. The article “Dual Antiplatelet Therapy for Cardiovascular Protection: Indication, Duration, and Other Considerations” by Nastaran Ostad and Dr. Glen Pearson addresses the topic of more intensive antiplatelet therapy.

As well as articles on our focus of CVS disease we have our usual varied group of articles. One of Canada’s most eminent geriatricians and also an expert on dementia, David Hogan, contributed the article “A Practical Approach to the Use of Cholinesterase Inhibitors in Patients Newly Diagnosed with Alzheimer’s Disease.” Usually when we talk about technology in medicine, we are thinking “high tech.” However, the article “Canes and Walkers: A Practical Guide to Prescribing” by Dr. Robert Lam and Alison Wong reminds us that some very low tech interventions can make an enormous difference for our older patients. The eyes are perhaps the “mirror to the soul,” but for older adults the eyes and vision are a vital connection not only to the soul but to the world around them. The article “Current Options in Low Vision Rehabilitation” by Dr. Samuel Markowitz is very important in order to maximize the visual capabilities of those with impairment.

Enjoy this issue,
Barry Goldlist

Glycemic Control in Older Adults: Applying Recent Evidence to Clinical Practice

Glycemic Control in Older Adults: Applying Recent Evidence to Clinical Practice

Teaser: 

Ajay Sood, MD, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine; Louis Stokes Cleveland Veterans Affairs (VA) Medical Center, Cleveland, OH, USA.
David C. Aron, MD, MS, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine; VA Network 10 Geriatric Research, Education, and Clinical Centers, VA Health Services Research and Development Quality Enhancement Research Initiative Diabetes Clinical Coordinating Center; Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.

Glycemic goals and the decision to intensify glycemic control among older adults with diabetes must be individualized based on comorbid conditions and the risks associated with treatment. The duration of diabetes mellitus, baseline glycosylated hemoglobin value, prior history of cardiovascular disease, and history of severe hypoglycemia are important factors to consider. This article reviews how the management of diabetes mellitus in this subgroup is changing in view of three recently reported randomized trials of intensive glycemic control.
Key words: diabetes, older adults, glycemic control, cardiovascular disease, glycemic goal.

Update in Endocarditis Prophylaxis

Update in Endocarditis Prophylaxis

Teaser: 


Jason Andrade, MD, Division of Cardiology, University of British Columbia, Department of Medicine, Vancouver, BC.
Aneez Mohamed, MD, Division of Cardiology, University of British Columbia, Department of Medicine, Vancouver, BC.
Chris Rauscher, MD, Division of Geriatric Medicine, University of British Columbia, Department of Medicine, Vancouver, BC.

Infective endocarditis (IE) is a rare but potentially devastating clinical entity with a well-delineated pathogenesis. While previously thought to be a disorder of younger individuals, older adults now represent one of the highest risk groups for the acquisition of and adverse outcomes related to IE. Prior to focusing on the updated recommendations for IE prophylaxis and the rationale behind them, we briefly review the clinical aspects of IE in the general population, as well as special considerations for older adults.
Key words: endocarditis, prophylaxis, older adults, cardiovascular disease, antibiotics.

Diabetes and Cardiovascular Disease among Older Adults: An Update on the Evidence

Diabetes and Cardiovascular Disease among Older Adults: An Update on the Evidence

Teaser: 


Pamela Katz, MD, Department of Endocrinology and Metabolism, University of Toronto, Toronto, ON.
Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, University Health Network, Toronto, ON.

The global prevalence of diabetes has increased substantially in recent years, attributable to an increase in new cases and declining mortality. Aging is associated with changes in beta cell function and insulin resistance that predispose to diabetes. Cardiovascular disease is the leading cause of death among older adults with diabetes. In order to reduce the excessive risk of cardiovascular disease, all coronary risk factors must be addressed and treated aggressively. This article will focus on the importance of blood pressure and glycemic control and lipid lowering with statin therapy. Specific considerations in this patient population include high rates of comorbid disease, shorter life expectancy, polypharmacy and falls risk. These factors may alter the therapeutic goals. Treatment should therefore be individualized with consideration given to patient preference and quality of life.
Key words: diabetes, cardiovascular disease, older adults, metabolic syndrome.

Primary Care Issues in Renal Transplant Recipients

Primary Care Issues in Renal Transplant Recipients

Teaser: 

Jeffrey Schiff, MD, FRCP(C), Instructor, Division of Medicine, University of Toronto; Division of Nephrology and Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON.

Due to the excellent outcomes of renal transplantation, there is an increasing number of people surviving with, or receiving a transplant, at an older age. While the transplant centre usually manages the immunosuppression and renal problems, these individuals also require primary care. This article will review the common health issues that primary care physicians encounter routinely among these patients. Common problems include managing cardiovascular risk factors, screening for malignancy, vaccinations, treatment of uncomplicated infections, and bone disease. Important drug interactions will be reviewed. Communication between the primary care physician and the transplant centre will also improve care of these patients.
Key words: renal transplantation, primary care, cardiovascular disease, drug interactions, chronic kidney disease.

Management of Cardiovascular Disease Risk Factors among Older Adults with Peripheral Arterial Disease

Management of Cardiovascular Disease Risk Factors among Older Adults with Peripheral Arterial Disease

Teaser: 


Nicholas J. Giacomini, BS, Research Assistant, University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, USA.
Roberta K. Oka, RN, ANP, DNSc, Associate Professor, University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, USA.

Peripheral arterial disease (PAD) is a common but frequently undetected and undertreated condition among older adults. Untreated PAD and cardiovascular disease (CVD) risk factors results in functional impairment, poor quality of life and increased risk for cardiovascular disease morbidity and mortality. The increased risk for CVD events associated with PAD necessitates raising public awareness of PAD and the potential impact on health, and placing greater emphasis by providers on detection and management of PAD to maximize survival and life quality. This article briefly describes the detection and medical management of PAD, with greater emphasis on lifestyle modification among older adults with PAD.
Key words: vascular disease, cardiovascular disease, risk factor reduction, lifestyle modification.

The Gold Standard in Caring for Older Adults

The Gold Standard in Caring for Older Adults

Teaser: 

Every time I write an introduction for Geriatrics & Aging, I seem to stress how important the focus of this particular issue is for the care of older adults. Often I compare the condition with heart disease to emphasize its importance. This month we address the gold standard for what is important in caring for older adults, namely vascular disease. Vascular disease is still the most common cause of death among older adults, and vascular disease is often the final end for many other common problems faced by older adults, such as diabetes mellitus or chronic renal disease. Vascular disease is frequently a cause or a contributor to dementia in old age as well. Traditionally, February is the month to be aware of the heart and it is only fitting, therefore, that we make this month our heart month as well.

From a public health point of view, control of hypertension and smoking cessation are two of the most important interventions that doctors can pursue with their patients. Some estimates conclude that one third or more of all older adults have hypertension, and persuasive evidence exists to control hypertension even in extreme old age (although data for those over 80 are very limited). However, some individuals have difficult-to-control hypertension, and this topic is addressed by Dr. Mohammed Shafiee, Dr. Fatemeh Akbarian, and Dr. Vahid Ghafarian in their article “Treatment-Resistant Hypertension among Older Adults.” This article is also the basis for this month’s CME program. Another of our cardiovascular features is “Essentials of Hypertrophic Cardiomyopathy” by Gursharan Soor, Adriana Luk, Dr. Anna Woo, Dr. Anthony Ralph-Edwards, Dr. Heather Ross, and Dr. Jagdish Butany. The commonest reason for hospital admission for older adults in North America is heart failure. This statistic suggests that our current management paradigms could be improved, which is the point of the article “Heart Failure: Old Disease, Older Adults, Fresh Perspective” by Drs. George Heckman, Catherine Demers, David Hogan, and Robert McKelvie. I recently had the pleasure of hearing Dr. Heckman present grand medical rounds on this topic, and I think you will be just as impressed with the article as I was with the presentation. Cardiology is the most technical of internal medicine specialties, and some of that technology is discussed in the article “The Role of Implantable Cardiac Devices in the Prevention of Sudden Cardiac Death” by Dr.Vikas Kuriachan and Dr.Robert Sheldon. Our Drugs & Aging column this month also has a cardiac focus, namely, “An Update on the Role of Digoxin in Older Adults with Chronic Heart Failure” by Dr. Ali Ahmed.

As usual, our nonfocus articles are also superb. Dr. Bhaskar Ghosh and Dr. Oksana Suchowersky present in the Movement Disorders column the article “Chorea among Older Adults.” Our Women’s Health column, “Pelvic Organ Prolapse among Older Women” is by Dr. Emily Saks and Dr. Lily Arya. Our GI Disorders column this month is on the topic “Low-Dose Acetylsalicylic Acid and the Use of Gastroprotectors among Older Adults” and is written by Dr. Neeraj Bhala and Dr. Angel Lanas.

Enjoy this issue,
Barry Goldlist

Older Adults and Illegal Drugs

Older Adults and Illegal Drugs

Teaser: 

Katherine R. Schlaerth, MD, Fellow, American Academy of Pediatrics; Fellow, American Academy of Family Practice; Fellow, Pediatric Infectious Disease Society; Associate Professor, Department of Family Medicine, Loma Linda University School of Medicine, Loma Linda, California; Associate Professor Emeritus, Departments of Family Practice and Pediatrics, University of Southern California School of Medicine, Los Angeles, California, USA.

Most practitioners assume that the use of illegal or “street” drugs is confined to the young. However, a recent phenomenon has been the use of such drugs by individuals above the age of 50. Social trends play a part: many older addicts began using in the 1960s. Others share the use of illegal drugs with other family members as a mode of family recreation. The latter trend is probably more common in inner cities where drugs are more easily obtained. Older men are twice as likely to use illegal drugs as are older women, though the latter outnumber the former demographically. Many illegal drugs, especially cocaine, methamphetamines, and even marijuana have cardiovascular effects that are especially dangerous when they occur in older individuals who may already have underlying cardiovascular disease. Practitioners must be vigilant about querying patients about their use of illegal drugs, no matter what their age, and especially if cardiovascular illness is involved.
Key words: older adults, illegal drugs, cardiovascular disease, cocaine, methamphetamines.

Gender and Coronary Heart Disease in Older Adults

Gender and Coronary Heart Disease in Older Adults

Teaser: 


Nahid Azad, MD, Associate Professor, Faculty of Medicine, University of Ottawa, Ottawa, ON.
Arlene S. Bierman, MD, MS, FRCPC, Ontario Women’s Health Council Chair in Women’s Health, Centre for Research on Inner City Health, St. Michael’s Hospital; Faculties of Medicine and Nursing, University of Toronto, Toronto, ON.

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality for both men and women. Among individuals with coronary heart disease (CHD), there are gender differences in clinical epidemiology, prevalence of risk factors, clinical presentation, and quality and outcomes of care. Older adults and older women in particular are at risk for underdiagnosis and suboptimal management of CHD and its risk factors. Adherence to clinical practice guidelines for diagnosis and management of CHD can improve outcomes of care for older men and women with CHD and narrow gender disparities in clinical outcomes.
Key words: cardiovascular disease, gender, older adults, quality of care, women’s health, coronary heart disease.