292.1 🎓 醫孞生版

292.1.0.1 📌 䞀頁重點

292.1.0.1.1 Epidemiology
292.1.0.1.1.1 Aging + CV
  • 65+: 60-80% have some CV disease
  • 85+: > 80%
  • Aging is largest risk factor for HF, AF, AS, CAD
  • Taiwan 2024: > 65 yo population ≥ 20%; rapidly aging
292.1.0.1.1.2 Disease Burden
  • HF: most common cause of hospitalization in elderly
  • AF: ~ 10% in 80+
  • AS: 5-7% > 75 yo (moderate-severe)
  • HTN: 65% > 65 yo
  • Stroke: top 3 cause of death + disability
292.1.0.1.2 Physiologic Changes With Aging
292.1.0.1.2.1 Cardiovascular System
  • Arterial stiffening: ↓ elastin, ↑ collagen → ↑ PWV → isolated systolic HTN, wide pulse pressure
  • LV hypertrophy (mild concentric)
  • Diastolic dysfunction: ↓ early filling, ↑ atrial contraction; precursor to HFpEF
  • Myocardial fibrosis: subclinical, ↑ amyloid (ATTR-CM in 25% of HFpEF > 80)
  • ↓ β-adrenergic responsiveness: blunted HR response, ↓ contractility reserve
  • Baroreflex impairment: ↑ orthostatic hypotension
  • Autonomic dysfunction: ↓ HRV
  • Atrial remodeling: AF, atrial flutter
292.1.0.1.2.2 Vascular Changes
  • ↓ NO bioavailability
  • ↑ Vascular calcification (medial calcinosis vs intimal in atherosclerosis)
  • Diastolic ↓ blood pressure (late stage)
292.1.0.1.2.3 Other Aging Issues
  • ↓ Renal function (eGFR ↓ ~ 1 mL/min/year after 30s, faster > 60)
  • ↓ Lung function
  • Sarcopenia, frailty
  • Cognitive decline
  • Sensory impairment (vision, hearing)
292.1.0.1.3 Major CV Diseases in Elderly
292.1.0.1.3.1 Hypertension
  • Isolated systolic HTN (ISH): SBP > 140, DBP < 90; most common pattern in elderly
  • Mechanism: arterial stiffening
  • Treatment:
    • SPRINT (2015) + SPRINT-Senior: < 120 SBP target benefit even in elderly (but caution orthostasis)
    • STEP (2021): Chinese elderly, < 130 vs < 150 → ↓ CV events
    • 2024 ACC/AHA: target < 130/80; individualize for frail
    • Start low, go slow; check standing BP
    • Watch for orthostatic hypotension (fall risk)
  • Drugs:
    • First-line: CCB + thiazide-like (chlorthalidone) — work well in elderly
    • ACEi/ARB: add-on
    • β-blocker: only for specific indications
    • Avoid α-blockers (orthostasis)
292.1.0.1.3.2 Heart Failure
  • HFpEF predominant in elderly (60-70% of HF in 80+)
  • HFrEF also common
  • Phenotypes complex
  • ATTR-CM (transthyretin cardiac amyloidosis) in 13-25% of HFpEF > 80
    • PYP scan for screening
    • Tafamidis treatment (ATTR-ACT)
  • GDMT in elderly:
    • ARNI/ACEi/ARB
    • β-blocker
    • MRA
    • SGLT2i
    • Cautious dosing, monitor renal/K
  • CRT, ICD considerations modified by life expectancy
  • Cardiac rehab beneficial (REHAB-HF 2021)
292.1.0.1.3.3 Atrial Fibrillation
  • Prevalence ↑ steeply with age (1-2% < 60, 10-15% > 80)
  • Anticoagulation crucial for stroke prevention
  • CHA₂DS₂-VASc (age ≥ 65 = 1 point; ≥ 75 = 2)
  • HAS-BLED for bleeding risk (age > 65 = 1)
  • DOACs preferred over warfarin in most (ELDERCARE-AF for edoxaban low-dose)
  • Rate control (β-blocker, digoxin) often better than rhythm in elderly
  • Catheter ablation still beneficial in select elderly
  • Cardioversion + anticoagulation crucial
292.1.0.1.3.4 Aortic Stenosis
  • 5-7% > 75 yo
  • TAVR has revolutionized treatment for elderly
  • All risk levels Class I ≥ 65 yo in 2024 update
  • Frailty + life expectancy assessment
  • EARLY-TAVR (2024): consider earlier intervention
292.1.0.1.3.5 Coronary Artery Disease
  • Common in elderly
  • Atypical presentation often (dyspnea-equivalent, fatigue)
  • “Silent” MI more common
  • ACS management same principles + adjusted dosing
  • PCI risk-benefit weighed in frail patients
  • CABG outcomes worse with age, frailty
  • Statin: still beneficial (PROVE-IT, HOPE-3 elderly subgroups)
  • Antiplatelet: bleeding risk consideration
292.1.0.1.3.6 Stroke
  • Top cause of disability
  • AF-related cardioembolic stroke common in elderly
  • Anticoagulation key prevention
  • IV tPA / mechanical thrombectomy benefits elderly
  • Post-stroke rehab + secondary prevention
292.1.0.1.4 Geriatric Assessment
292.1.0.1.4.1 Frailty
  • Definition: state of vulnerability to stressors
  • Tools:
    • Clinical Frailty Scale (CFS) 1-9 (1 very fit → 9 terminally ill)
    • Edmonton Frail Scale
    • Fried Frailty Phenotype: 5 criteria (slow gait, weak grip, weight loss, exhaustion, low activity)
    • Gait speed alone (slow < 0.8 m/s) — independent CV mortality predictor
  • Affects:
    • TAVR vs SAVR decision (high frailty → TAVR)
    • PCI vs CABG vs OMT
    • Goals of care, palliative
    • Drug dosing
    • Procedural risk
292.1.0.1.4.2 Functional Status
  • ADL (Activities of Daily Living)
  • IADL (Instrumental ADL)
  • Cognitive function (MMSE, MoCA)
  • Depression screening (PHQ-9, GDS)
292.1.0.1.4.3 Polypharmacy
  • ≥ 5 medications very common
  • Drug-drug interactions
  • Adherence issues
  • Cognitive impairment + memory
  • Deprescribing when appropriate
  • STOPP/START criteria (geriatric specific)
292.1.0.1.5 Orthostatic Hypotension
292.1.0.1.5.1 Definition
  • ↓ SBP ≥ 20 OR DBP ≥ 10 within 3 min of standing
  • “Initial” (immediate), “classic” (3 min), “delayed” (> 3 min)
  • Symptoms: dizziness, syncope, fall risk
292.1.0.1.5.2 Causes
  • Volume depletion (dehydration, diuretics)
  • Medications (α-blockers, vasodilators, diuretics, antidepressants)
  • Autonomic dysfunction (DM, Parkinson, MSA)
  • Cardiac (HF)
  • Deconditioning
292.1.0.1.5.3 Management
  • Adjust medications
  • Compression stockings
  • Increase Na, fluid (if not HF/HTN)
  • Sleep with HOB elevated
  • Pharmacologic: fludrocortisone, midodrine, droxidopa
292.1.0.1.6 Procedural Considerations in Elderly
292.1.0.1.6.1 TAVR
  • All risk levels Class I in elderly
  • Frailty informs benefit
  • Vascular access (calcification)
  • Stroke risk (3-5%)
  • Permanent pacer risk (5-15%)
292.1.0.1.6.2 CABG
  • Worse outcomes than younger
  • Combined valve + CABG: high risk
  • Off-pump alternative in select
  • Hybrid approaches emerging
292.1.0.1.6.3 PCI
  • Generally safe in elderly
  • Bleeding risk higher (radial preferred)
  • DOAC + DAPT considerations in elderly + AF + ACS
292.1.0.1.6.4 Cardiac Surgery
  • Frailty assessment essential
  • Mortality + morbidity ↑ with age
  • Delirium common post-op (40-60%)
  • ICU + rehab needs longer
292.1.0.1.6.5 Anesthesia
  • Reduced doses
  • Slower onset/offset
  • Avoid benzodiazepines (delirium, fall)
  • Multimodal analgesia
292.1.0.1.7 Polypharmacy + Deprescribing
292.1.0.1.7.1 High-Yield Geriatric Pharmacotherapy
  • Anticholinergic burden: avoid (cognition, fall, delirium)
  • Benzodiazepines: avoid (delirium, fall)
  • NSAIDs: AKI, HTN, bleeding
  • PPI long-term: bone health, B12, magnesium
  • Statins: continue if tolerated; benefit confirmed in elderly
292.1.0.1.7.2 Cardiovascular Drug Adjustments
  • ACEi/ARB: half-doses, watch K+, Cr
  • Diuretics: cautious, monitor electrolytes
  • β-blocker: bradycardia, hypotension risk
  • DOAC: dose-adjust for renal function, body weight, age
  • Digoxin: dose by renal function, monitor levels
292.1.0.1.8 End-of-Life Considerations
292.1.0.1.8.1 Advance Care Planning
  • Discussions on goals of care
  • Code status
  • DNR/DNI
  • POLST (Physician Orders for Life-Sustaining Treatment)
  • Family discussions
292.1.0.1.8.2 Palliative Cardiology
  • HF palliation
  • ICD deactivation when goals shift
  • Symptom management (dyspnea, edema, pain)
  • Hospice referral

292.1.0.2 🩺 床邊速查

  • Aging CV physiology: arterial stiffening, ↓ baroreflex, ↓ β-response, diastolic dysfunction
  • HFpEF predominant in elderly (ATTR-CM 13-25% of HFpEF > 80)
  • AF anticoagulation: DOAC preferred; don’t avoid AC due to age alone (bleeding risk vs stroke benefit)
  • TAVR ≥ 65 all risk levels (2024)
  • Frailty assessment (CFS, gait speed) — guides interventions
  • Polypharmacy + Beers/STOPP for deprescribing
  • Orthostatic hypotension: ↓ SBP ≥ 20 / DBP ≥ 10 in 3 min