Cardiovascular Drug Therapy in the Elderly: Theoretical and Practical Considerations

Abstract

The elderly population is expanding rapidly throughout the world. Hypertension, heart disease and other cardiovascular disorders are prevalent conditions among this age group. Consequently, clinicians will spend a large proportion of their practices managing older adults with cardiovascular disorders. A large proportion of this time will be devoted to using pharmacotherapeutic strategies for the long-term management of chronic conditions. The physiological changes that accompany aging affect cardiovascular function, and the pharmacokinetics and pharmacodynamics of many cardiovascular medications are altered by these physiological changes. The interactions of these changes can have a profound effect on the agents used to treat cardiovascular disorders and may alter their therapeutic outcomes. Several classes of medications are used to treat chronic cardiovascular disorders in older adults. These include the ACE inhibitors and angiotensin II receptor antagonists, calcium channel antagonists, beta-adrenoceptor antagonists (beta-blockers), oral antiarrhythmic agents and warfarin. Drugs such as beta-blockers may aggravate decreased cardiac output and increase peripheral resistance, but are valuable adjuncts in many patients with congestive heart failure. Agents that reduce angiotensin II activity may have several benefits for treating heart failure and hypertension. Successful treatment of cardiovascular disorders in older adults requires the choice of the most appropriate agent, taking into consideration the complex interactions of pharmacokinetics, pharmacodynamics and disease effects.

Angiotensin-Converting Enzyme Inhibitor Use in Elderly Patients Hospitalized with Heart Failure and Left Ventricular Systolic Dysfunction

“…The relationship between creatinine clearance and ACE inhibitor dosing may be due to the mode of clearance of these medications. The majority of commercially available ACE inhibitors are eliminated through the kidney, making those with low renal clearance more sensitive to the hemodynamic effects of the medication [13]. ACE inhibitors may be more likely to accumulate in elderly patients with heart failure and lead to increased phamacodynamic responses at lower doses.…”

Atrial fibrillation and heart failure in the elderly

“…Sotalol, dofetilide and procainamide are primarily excreted renally. Given the higher prevalence of renal dysfunction in the elderly population, either these medications should be avoided or their dosages adjusted according to the degree of renal dysfunction [118]. Amiodarone is a lipophilic drug that is distributed into adipose tissue.…”

Pharmacologic management of chronic stable angina

“…10,11 The decision to use a beta-blocker or calcium channel blockers as a fi rstline drug depends on the patient's comorbidities, contraindications, and potential adverse reactions. For example, a patient with systolic heart failure and a history of MI should be prescribed a beta-blocker for chronic stable angina rather than a calcium channel blocker.…”

“…41 Use the lowest starting dose, and prescribe a long-acting formulation for patients with poor adherence or safety concerns with short-acting calcium channel blockers. 10,42 Because calcium channel blockers are cytochrome P450 3A4 substrates, be alert for drug-drug interactions. Verapamil and diltiazem also are inhibitors of the cytochrome P450 3A4 pathway, and should be used carefully in patients taking other drugs that are cytochrome P450 3A4 substrates, such as simvastatin.…”