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7 - Cardiovascular Disorders |
187
fied by age.
110
The investigators reported that
the average weekly warfarin dose decreased
by 0.4 mg for every year of age. The average
daily dose for men and women 80 and older
was 4.0 mg and 2.0–3.6 mg, respectively. The
recommended initial daily dose of 5 mg would
have been too high for 82% of women and 65%
of men older than 70 in this study.
110
KEY POINT:
In the geriatric population,
therapy with warfarin should be initiated
at 4–5 mg daily or less, with frequent
early INR monitoring. If other factors
such as heart failure, malnourishment
(decline in total protein and albumin),
or debilitation are present, an even
lower dose should be considered.
The ACCP guidelines also suggest that for
patients who desire less frequent INR monitoring,
the intensity of anticoagulation can be lowered to
a goal INR of 1.5–1.9 after the first 3 months of
conventional therapy (INR 2.0–3.0).
96
This lower
target may work for geriatric patients, as they
are perceived to be at higher risk for bleeding.
However, the Extended Low-Intensity Anticoagu-
lation for Thromboembolism Investigators (ELATE)
trial compared the lower intensity warfarin regimen
(INR 1.5–1.9) to the more conventional regimen
(2.0–3.0) for prevention of VTE and found the
conventional regimen to be more effective than
lower-intensity warfarin, with incidences of recur-
rent VTE of 0.6% per patient-year and 1.9% per
patient-year, respectively. The lower-intensity recur-
rence rate does provide benefit when compared
with placebo rates in other studies.
106-111
Further-
more, the lower-intensity regimen was not associ-
ated with a lower incidence of bleeding compared
with the conventional regimen.
Barriers to Treatment in the
Geriatric Population
Dose adjustments of LMWH and fondaparinux
for patients with kidney disease must be consid-
ered. For patients requiring VTE prophylaxis
with estimated CrCl <30 mL/min, the dose of
enoxaparin should be 30 mg subcutaneously
once daily. For patients requiring VTE treat-
ment who have an estimated CrCl <30 mL/min,
the enoxaparin dose should be 1 mg/kg once
daily. The manufacturers of dalteparin and tinza-
parin suggest caution with use of these drugs in
patients with severe kidney disease and mention
the potential need to monitor antifactor Xa activity.
Fondaparinux should be used with caution in
patients with estimated CrCl 30–50 mL/min, and
the drug is contraindicated in patients with esti-
mated CrCl <30 mL/min.
53
These medications
are administered subcutaneously, and the ability
of the geriatric patient to perform self-injections,
or the ability of a caregiver to consistently admin-
ister injections, should be evaluated before the
patient is placed on outpatient treatment.
The same concerns with rivaroxaban
discussed in the Atrial Fibrillation section apply
to VTE. Geriatric patients may have less access
to transportation and may have difficulty meeting
the monitoring requirements for warfarin therapy.
Alternatives in this case may include continued
treatment with LMWH/fondaparinux or the
possible use of point-of-care INR monitoring.
Medicare now has expanded coverage for point-
of-care testing for patients undergoing chronic
warfarin therapy for VTE. It is only approved after
the patient has been on anticoagulation therapy
for 3 months, has undergone face-to-face educa-
tion, and is not monitoring more than once
weekly.
112
The patient’s dexterity should also be
assessed to determine whether he or she has the
capacity to perform this monitoring.
Older adults may be more sensitive to the
effects of warfarin. As discussed previously,
elderly patients generally require lower warfarin
doses, and higher initiation doses in the past may
have contributed to some of the data indicating a
higher risk of bleeding. Lower body weight and
volume of distribution may also be factors.
Hypoalbuminemia, malnourishment, or
decreased dietary vitamin K intake may also
contribute to higher sensitivity. A few studies
have suggested that receptor sensitivity may be
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altered or greater inhibition of vitamin K–depen-
dent clotting factors may occur in the elderly,
113
but currently there are few data to support this.
Management of warfarin therapy is also compli-
cated by the potential for numerous drug inter-
actions, as polypharmacy tends to be more
common in geriatrics.
Bleeding is a major concern for any patient
on anticoagulation therapy, and even more so for
the elderly. The risk of falls must be assessed and
considered in the risk versus benefit analysis, as
discussed in the Atrial Fibrillation section.
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C 1: D-V T
Setting:
Ambulatory anticoagulation clinic.
Subjective:
JT is an 80-year-old male referred to your anticoagulation clinic for initiation of therapy with
enoxaparin and warfarin after his deep-vein thrombosis diagnosis today. The patient presents
using walker and appears very unsteady in movement.
Past Medical History:
Hypertension, osteoarthritis, heart failure (left ventricular ejection fraction 30%), hyperlipidemia,
CKD, coronary artery disease, coronary artery bypass graft ×3 in 2001.
Medications:
Hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, metoprolol XL 100 mg daily,
furosemide 20 mg daily as needed, aspirin 81 mg daily, simvastatin 40 mg bedtime, ibuprofen
600 mg three times daily prn.
Allergies:
NKDA.
Social History:
Married to wife ×60 years. She sets up a medication organizer weekly for JT and reports that
he is adherent to regimen. Nonsmoker. Drinks 1 beer nightly and 1 cup of regular coffee each
morning.
Family History:
Mother: diabetes and Alzheimer disease
Brother: Parkinson disease
Objective:
Wt 168 lb, Ht 70˝, BP 125/72 mmHg, AST 27 international units/L (15–46), ALT 48 international
units/L (11–66), creatinine 2.2 mg/dL.
Assessment:
1.
Deep-vein thrombosis requiring anticoagulation with warfarin and enoxaparin complicated
by kidney disease, heart failure, and potential falls risk.
2.
Heart failure well controlled on diuretic, beta blocker, and ACE inhibitor. Ibuprofen should
not be used in this patient, because it is an NSAID.
3. Hypertension well controlled. Hydrochlorothiazide not beneficial in patients with CrCl
<30 mL/min.
Plan:
1.
Given JT’s significantly impaired renal function (estimated CrCl 28 mL/min), enoxaparin
should be administered at a dose of 1 mg/kg once daily, based on the patient’s weight
of 76 kilograms (= 80 mg once daily). Assess ability to perform injections or educate
caregiver on technique for injections. Assess the risk of falls with questions regarding
frequency of falls, daily activities, orthostatic symptoms, etc. Warfarin therapy should be
initiated at a dose <5 mg daily in this patient given his age, concomitant medications,
mobility problems, and heart failure. Recommend warfarin 3 mg daily. Re-check INR in
5–7 days. JT likely requires more frequent monitoring as he is at high risk for complica
-
tions for the above reasons.
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2. Continue current heart failure therapy. Discontinue ibuprofen and recommend scheduled
acetaminophen for osteoarthritis pain.
3. Discontinue hydrochlorothiazide. Recommend home blood pressure monitoring and, if
needed, increase lisinopril dose.
Rationale:
1. Enoxaparin dose must be reduced due to diminished kidney function. Warfarin therapy is
initiated at lower dose because of age, medications, falls risk, and heart failure. Osteo-
arthritis can interfere with ability to perform injections. Potential for falls needs special
attention, as falls may lead to more severe complications for patients on warfarin.
2.
Diuretics, ACE inhibitors, and beta blockers are all therapies indicated for heart failure and
should be used in the geriatric population. Ibuprofen is an NSAID that can exacerbate fluid
retention in heart failure, complicate kidney disease, and lead to higher risk of GI bleeds in
patients taking warfarin.
3.
Hydrochlorothiazide provides little blood pressure benefit for patients with CrCl <30 mL/min.
Home blood pressures can be used to assess control off medication. Lisinopril is not at
target dose for heart failure, and the dose could be increased to benefit both heart failure
and hypertension.
Case Summary:
The geriatric patient needs a thorough assessment when anticoagulation therapy is initiated.
Elderly patients are typically taking a larger number of medications and have more disease
states and social issues that need to be addressed compared with younger patients.
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C 2: O H
Setting:
Long-term care facility.
Subjective:
LM is an 89-year-old female resident of a long-term care facility who has been experiencing
multiple falls, some resulting in injuries such as bruising and skin tears. Over the last 6 months,
her ambulation status has declined from independent to wheelchair level. She complains of
pain in her legs when walking more than short distances across the nursing unit.
Past Medical History:
Hypertension, Alzheimer disease, hypothyroidism, osteoarthritis.
Medications:
Amlodipine 10 mg daily, donepezil 10 mg at bedtime, levothyroxine 0.88 mg every morning,
celecoxib 200 mg daily, furosemide 40 mg every morning.
Allergies:
NKDA.
Social History:
LM is widowed, with two adult children living in town; retired photographer; and owner of an
art supply store.
Family History:
Unknown
Objective:
Wt 129 lb, Ht 64˝, BP (supine) 177/82 mmHg, BP (standing) 105/60 mmHg, P 78/min.
Physical Examination:
HEENT: Normocephalic, no evidence of trauma, PERRLA, EOMI, dry mucous membranes
CV: Regular rate and rhythm
Respiratory: Clear to auscultation bilaterally
Abdomen: Soft, nontender, no masses or guarding
G/U: Skin intact, assisted with toileting and personal hygiene by staff
Extremities: Bilateral 2+ edema to lower extremities; skin dry, dark bruising and skin tear to
right elbow and forearm
Neuro: Alert and oriented to person only. MMSE 18/30, stable over last 12 months
Labs:
TSH 2.45, Free T4 0.98
Serum chemistry: Na 135, K 3.8, Cl 99, CO
2
25, glucose 101, SCr 0.9, BUN 42
CBC: WBC 7.0, RBC 4.5, Hgb 11.9, Hct 34.1, platelet 255
UA: clear
Assessment:
1. Using the faces pain scale, no pain is occurring at rest. On walking LM complains of
moderate-severe pain.
2. Orthostatic hypotension resulting in falls, possibly associated with medications. While
each of LM’s medications could relate to falls by some mechanism, the drug of primary
concern is furosemide.
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3. Medication without clear indication: furosemide. This is being used to treat edema, but
the etiology of the edema is not clear and could be induced or exacerbated by her current
drug therapy.
4.
Decrease in ambulation status associated with increased pain on walking and recent falls.
Plan:
Recommend discontinuation of amlodipine, celecoxib, and furosemide, and replacement with
hydrochlorothiazide 25 mg daily and acetaminophen 500 mg four times daily. Recommend
physician evaluation for peripheral vascular disease and IC and to rule out heart failure or other
causes of edema. Monitor vitals (including orthostatic hypotension assessments), edema, and
pain daily, and follow-up serum chemistry within 30 days.
Rationale:
1.
LM may be experiencing falls due to orthostatic hypotension associated with uncontrolled
supine hypertension and an unnecessary loop diuretic. Her sodium and potassium, though
in the normal range, are lower than optimal and continued use of a diuretic without potas
-
sium supplementation can further exacerbate electrolyte status.
2.
Her SCr:BUN ratio and dry mucous membranes suggest she is a little dehydrated.
Although she is currently experiencing bilateral edema, she does not have a diagnosis
that explains the cause of the edema. She currently takes two medications that could be
causing, or at least exacerbating, the edema: amlodipine and celecoxib. If edema were
to improve or resolve on discontinuation, the furosemide would not be necessary. The
amlodipine is not currently controlling her hypertension. Hydrochlorothiazide alone may
not either, but it is a reasonable initial choice and combination therapy can be considered
if necessary.
3.
It is difficult to assess the efficacy of celecoxib for osteoarthritis. There is no pain at rest,
and she may achieve similar pain control with scheduled acetaminophen while avoiding
NSAID side effects. The pain on walking could suggest peripheral vascular disease with
IC, and she should be evaluated for this. Ruling out heart failure as a cause of her edema
is important because the choice of drug therapy for PVD depends on her comorbidities.
LM does have other risk factors for dizziness and falls, including dementia, cholinesterase
inhibitor use, and a thyroid disorder. However, these conditions have been stable on the
current drug therapy, and any considerations for adjustments should be deferred until
after the effects of the above changes are observed.
Case Summary:
LM’s case illustrates several examples of drug therapy problems in a frail elderly patient. These
include (1) the use of medication to treat a symptom without investigating the underlying
cause, (2) a prescribing cascade where new medications are prescribed to treat side effects
of existing medications, (3) failure to assess efficacy of the drug regimen, and (4) a potential
unrecognized and untreated medical condition.
Furosemide has been prescribed to treat edema, but it is not clear if the edema was
caused by medication side effects, PVD, or heart failure. Failure to assess the root cause has
resulted in the lack of intervention for a potential underlying problem. Also, the new medication
prescribed to treat the edema is now causing new problems, such as orthostatic hypotension
and dehydration, and LM continues to experience supine hypertension and pain interfering with
ambulation despite amlodipine and celecoxib use. The underlying problem is cardiovascular but
has implications for functional status and quality of life.
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C S
The prevalence and incidence of vascular
diseases increases with advancing age, and
are highest in the elderly population. Treat-
ment guidelines exist for many cardiovascular
diseases, but in many instances specific recom-
mendations for elderly patients are lacking. For
some treatments, elderly patients derive greater
benefit than younger patients. However, in many
cases, elderly patients are more susceptible to
the adverse effects associated with drugs used
to treat cardiovascular diseases, and close moni-
toring in this population is particularly warranted.
S-A Q
1. How does the presence or absence of
hypertension in elderly patients in different
subgroups affect their expected survival,
and how do blood pressure goals differ in
the subgroups?
2. What are some potential barriers in diag-
nosing peripheral arterial disease and the
risks associated with not overcoming them?
3. What criteria are used to determine whether
an elderly patient with atrial fibrillation
should receive warfarin or aspirin for stroke
prevention?
4. What are the documented benefits of
treating elevated serum LDL cholesterol in
elderly patients?
5. What are the risks and benefits of using
beta blocker, ACE inhibitors, and digoxin in
elderly patients with heart failure?
6. How does the risk of stroke change with
every decade over age 55?
7.
What are some comorbidities in elderly
patients who have complicated anticoagu-
lation for VTE?
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