6/26/2017
Geriatric
Cardiology
Review
Kim Posey, DNP, AGPCNP-BC
CASE 1 (1 of 4)
A 70-year-old man comes to the office for follow-up
after hospitalization for exacerbation of HF.
History includes HF with preserved systolic function,
hypertension, and atrial fibrillation.
Longstanding medications include extended-release
metoprolol 100 mg/day, enalapril 10 mg q12h, and
hydrochlorothiazide 25 mg/day. In addition, he was
given both torsemide 40 mg q12h and digoxin 0.125
mg every other day during hospitalization and at
discharge.
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CASE 1 (2 of 4)
Today he reports new symptoms of fatigue and light-
headedness when he initially stands. He has no chest
pain, and there has been no change in SOB.
BP is 92/50 mmHg, pulse is 84 bpm, and O2
saturation is 97% on room air. Jugular venous
pressure is 5 cm2 HO; neck veins are flat, even when
he is supine. Chest is clear bilaterally. Heart sounds
are irregularly irregular with no murmur. The
abdomen is soft and nontender, with normal bowel
sounds and no distension. Extremities are mildly
cool; there is no edema, and dorsalis pedis pulses
are 1+ bilaterally.
CASE 1 (3 of 4)
Which of the following is the best next step?
A. Administer furosemide 80 mg by IV.
B. Discontinue enalapril and metoprolol.
C. Hold torsemide and hydrochlorothiazide
and prescribe fluids.
D. Obtain serum digoxin levels and
discontinue digoxin.
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CASE 1 (4 of 4)
Which of the following is the best next step?
A. Administer furosemide 80 mg by IV.
B. Discontinue enalapril and metoprolol.
C. Hold torsemide and hydrochlorothiazide
and prescribe fluids.
D. Obtain serum digoxin levels and
discontinue digoxin.
CASE 2 (1 of 4)
A 78-year-old woman is brought to the emergency
department because she has had shortness of breath
for 2 weeks; it has become more severe over the past
2 days.
She has difficulty sleeping and now requires 2 or 3
pillows to elevate her head at night.
History includes hypertension, osteoarthritis, and
COPD secondary to 50 pack-years of smoking.
Medications include amlodipine, hydrochlorothiazide,
and montelukast.
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CASE 2 (2 of 4)
Blood pressure is 160/90 mmHg, pulse is 84 bpm,
and respirations are 18 breaths per minute.
There are jugular venous pulsations 5 cm above the
sternal notch. Bibasilar crackles are heard, and
cardiovascular examination reveals normal S1 and S2
without S3. The abdomen is soft and nontender.
There is pitting pedal edema.
ECG is unchanged from a year ago; it shows normal
sinus rhythm at 84 beats per minute and left
ventricular hypertrophy with repolarization
abnormalities.
CASE 2 (3 of 4)
Which of the following tests would be most helpful in
differentiating COPD from heart failure?
A. B-type natriuretic peptide level
B. Troponin level
C. Electrolyte panel
D. Coronary calcium score
E. Chest radiography
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CASE 2 (4 of 4)
Which of the following tests would be most helpful in
differentiating COPD from heart failure?
A. B-type natriuretic peptide level
B. Troponin level
C. Electrolyte panel
D. Coronary calcium score
E. Chest radiography
CASE 3 (1 of 3)
A 75-year-old man comes to the office to establish care because he
has difficulty breathing. The breathing difficulty limits his ability to walk
2 blocks to the corner store, and he often has to sleep upright in his
recliner.
He takes no medication except chewable calcium carbonate tablets
for chronic indigestion.
BP is 154/88 mmHg, pulse is 80 bpm, and respirations are 16 breaths
per minute. There are bibasilar fine crackles. Cardiac examination is
notable for normal rhythm with ectopy and a II/VI holosystolic murmur
at the apex. There is no peripheral edema. ECG, electrolyte panel,
and CBC are ordered. The presumptive diagnosis is heart failure.
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CASE 3 (2 of 3)
Which of the following tests should be ordered
next to help establish diagnosis and treatment?
A. Cardiac catheterization
B. Echocardiography
C. Radionuclide ventriculography
D. MRI
E. Chest radiography
CASE 3 (3 of 3)
Which of the following tests should be ordered
next to help establish diagnosis and treatment?
A. Cardiac catheterization
B. Echocardiography
C. Radionuclide ventriculography
D. MRI
E. Chest radiography
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CASE 1 (1 of 4)
• An 86-year-old woman is brought to the ER of a rural
community hospital because she has shortness of breath.
The previous evening, she had been watching TV when,
about an hour after dinner, she suddenly felt that she
could not catch her breath. The episode spontaneously
subsided after 15 minutes.
• This morning she awoke feeling normal, but at mid-
morning she suddenly became very short of breath. She
had no chest pain or palpitations.
• History includes hypertension and diverticulosis. She has
taken hydrochlorothiazide for 12 years. She is physically
active and volunteers at the hospital gift shop.
CASE 1 (2 of 4)
• BP is 100/70 mmHg, pulse is 100 bpm, and respirations
are 20 breaths per minute; O2 saturation is 88% on room
air. Neck veins have normal carotid upstrokes with 11-
mm jugular venous distension. Bibasilar rales are heard.
The examination is otherwise unremarkable.
• ECG displays sinus rhythm. There are 3-mm ST-segment
convex elevations in the precordial leads (V1–V3), with
1-mm horizontal ST depressions in the inferoapical leads.
Laboratory findings include normal CBC and electrolyte
levels. Creatinine level is 0.9 mg/dL. High-sensitivity
troponin T level is 0.16 ng/mL.
• The nearest tertiary care hospital is 30 minutes away.
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CASE 1 (3 of 4)
Which of the following is most appropriate?
A. Administer furosemide and schedule a
pharmacologic stress test in the morning.
B. Admit to the hospital telemetry unit and monitor
troponin levels.
C. Arrange urgent transfer to tertiary care hospital
for acute mechanical revascularization.
D. Administer thrombolytic therapy and admit to
intensive care.
CASE 1 (4 of 4)
Which of the following is most appropriate?
A. Administer furosemide and schedule a
pharmacologic stress test in the morning.
B. Admit to the hospital telemetry unit and monitor
troponin levels.
C. Arrange urgent transfer to tertiary care hospital
for acute mechanical revascularization.
D. Administer thrombolytic therapy and admit to
intensive care.
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CASE 2 (1 of 4)
• An 81-year-old man comes to the office for a routine
appointment.
• History includes moderate aortic stenosis for the past 8
years, managed with β-blockers; chronic CAD, prostate
carcinoma (stage 2), and mild COPD. He received a left
anterior descending artery stent in 2001.
• At previous appointments, he reported that he felt well
and that he was maintaining his normal, active
lifestyle. At this appointment, his daughter notes that
her father is much less active than in the past.
CASE 2 (2 of 4)
• Echocardiography undertaken last month was limited
by poor echo windows due to COPD, but Doppler
imaging detected a peak aortic velocity of 6 m/sec, an
increase from 3 m/sec 2 years earlier.
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CASE 2 (3 of 4)
Which of the following is true regarding management of
this patient?
A. Annual echocardiography is sufficient follow-up.
B. Given that he has no chest pain, syncope, or heart
failure, current management is optimal.
C. Addition of nitrates will alleviate the patient’s
symptoms.
D. Valve replacement should be considered in the
near future.
CASE 2 (4 of 4)
Which of the following is true regarding management of
this patient?
A. Annual echocardiography is sufficient follow-up.
B. Given that he has no chest pain, syncope, or heart
failure, current management is optimal.
C. Addition of nitrates will alleviate the patient’s
symptoms.
D. Valve replacement should be considered in the
near future.
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CASE 3 (1 of 4)
An 80-year-old man comes to the office for follow-up
after a recent hospitalization. Last week he had new-
onset chest pain, and a non–ST-elevation myocardial
infarction was diagnosed. He received drug-eluting
stents to the left anterior descending artery and the
first obtuse marginal branch off the circumflex artery.
During hospitalization, atrial fibrillation was also
diagnosed.
At discharge, he was prescribed aspirin, clopidogrel,
warfarin, metoprolol succinate, lisinopril, and
atorvastatin.
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CASE 3 (2 of 4)
Before the myocardial infarction, his health was good
and he had an active lifestyle. Blood pressure and
cholesterol had always been within normal range.
At today’s office visit, he asks whether he can
discontinue the atorvastatin.
CASE 3 (3 of 4)
Which of the following would be the most appropriate
recommendation?
A. Recheck low-density lipoprotein (LDL) cholesterol; if
level is ≤70 mg/dL, discontinue atorvastatin.
B. Continue atorvastatin for 3 months, and then recheck
LDL cholesterol, because lipid levels may be
misleading in the interval after myocardial
infarction.
C. Continue atorvastatin.
D. Discontinue atorvastatin and start niacin.
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CASE 3 (4 of 4)
Which of the following would be the most appropriate
recommendation?
A. Recheck low-density lipoprotein (LDL) cholesterol; if
level is ≤70 mg/dL, discontinue atorvastatin.
B. Continue atorvastatin for 3 months, and then recheck
LDL cholesterol, because lipid levels may be
misleading in the interval after myocardial
infarction.
C. Continue atorvastatin.
D. Discontinue atorvastatin and start niacin.
Case Study – Stroke Prevention AF
Peter is a 67 year old mechanic
He was diagnosed with AF after an episode of
lightheadedness and almost fainting at work
Height 69”; weight 200lbs
Current medications: HCTZ 25mg/day, benazepril
20mg/day, metformin 500mg bid
Medical history:
Undertreatment for hypertension 142/94 mmHg
Newly diagnosed with T2DM 2 mos ago (A1c 7.2)
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Case Study – Peter
Other relevant aspects of his medical history:
Smokes ½ ppd for last 30 years
Drinks 2-3 beers on weekend
Family History:
Maternal history of stroke, hypertension, and heart failure
Paternal history of hypertension
Younger sister with T2DM
Case Study - Peter
What is Peter’s CHA2DS2-VASc?
What is Peter’s HAS-BLED score?
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Assessment of Stroke and
Bleeding Risk
Summary of Recommendations for Risk-Based Antithrombotic Therapy.
Craig T. January et al. Circulation. 2014;130:e199-e267
Copyright © American Heart Association, Inc. All rights reserved.
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Assessment of Stroke and
Bleeding Risk
Peter:
CHADS-VAS = 3
HAS-BLED = 1
Choosing “Right” Anticoagulant
Clinical factors
Clinician and patient preferences
Cost
Renal Function
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6/26/2017
Clinical Indications for Warfarin
Mechanical or bioprosthetic heart valves
Hemodynamically significant mitral stenosis
Pregnant or lactating women
Severe hypertension
Reversible AF
Children
Recent stroke
Significant liver disease
Multiple comorbidities
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