Kardiologische Therapie im Alter aus geriatrischer Sicht

Zusammenfassung

Kardiovaskuläre Erkrankungen, wie Arteriosklerose, arterielle Hypertonie, Herzinsuffizienz oder Vorhofflimmern, haben die höchste Prävalenz im fortgeschrittenen Lebensalter. Als Grundlage für die pharmakologische Therapie dienen jeweils die aktuellen Leitlinien. Allerdings bedarf es aufgrund der Komplexizität und Vulnerabilität geriatrischer Patienten eines individuellen Behandlungsansatzes, welcher sich im Einzelfall von Leitlinien unterscheiden kann. Im folgenden Beitrag werden einige relevante kardiovaskuläre Erkrankungen aus der Perspektive eines geriatrischen Behandlungsansatzes beleuchtet sowie Empfehlungen ausgesprochen.

Abstract

Cardiovascular diseases, like arteriosclerosis, hypertension, heart failure or atrial fibrillation have the highest prevalence among older adults. Pharmacological treatment is based on current guidelines. However, due to the complexity and vulnerability of older adults, there is a high need for an individual treatment approach. Individual recommendations may be different from guidelines. The paper discusses relevant cardiovascular diseases from a geriatric perspective.

Was ist wichtig?

• Geriatrische Patienten erfordern einen individuellen Behandlungsansatz, welcher auf den aktuellen Leitlinien und ergänzenden Hilfsmitteln, wie zum Beispiel der FORTA-Lite, basieren sollte.

• Der überwiegende Teil der pharmakologischen Therapie bei kardiovaskulären Erkrankungen hat einen präventiven Ansatz. Mit fortgeschrittenem Alter sollte der Fokus in der Therapie auf einer Symptomkontrolle liegen. Eine individuelle Risiko-Nutzen-Bewertung ist zwingend zu fordern.

• Die Beurteilung der Funktionalität sollte in der Therapie und der Therapiezielplanung Berücksichtigung finden.

Schlüsselwörter

Geriatrie - ASS - Hypertonie - Herzinsuffizienz - orale Antikoagulation

Key words

older adults - Aspirin - hypertension - heart failure - oral anticoagulation

Publication History

Article published online:
25 May 2020

• Literatur

• 1 Konrat C, Boutron I, Trinquart L. et al. Underrepresentation of elderly people in randomised controlled trials. The example of trials of 4 widely prescribed drugs. PLoS One 2012; 7: e33559 doi:10.1371/journal.pone.0033559
• 2 Kuijpers MA, van Marum RJ, Egberts AC. et al. Relationship between polypharmacy and underprescribing. Br J Clin Pharmacol 2008; 65: 130-133 doi:10.1111/j.1365-2125.2007.02961.x
• 3 Linssen GCM, Veenis JF, Kleberger A. et al. Medical treatment of octogenarians with chronic heart failure: data from CHECK-HF. Clin Res Cardiol 2020; DOI: 10.1007/s00392-020-01607-y.
• 4 Fried LP, Tangen CM, Walston J. et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146-M156
• 5 Leendertse AJ, Egberts AC, Stoker LJ. et al. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med 2008; 168: 1890-1896 doi:10.1001/archinternmed.2008.3
• 6 Howard RL, Avery AJ, Slavenburg S. et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 2007; 63: 136-147 doi:10.1111/j.1365-2125.2006.02698.x
• 7 Gosch M, Heppner H-J. Pharmakotherapie. In: Pantel J, Schröder J, Bollheimer C, Sieber C, Kruse A. Hrsg. Praxishandbuch Altersmedizin. Stuttgart: Kohlhammer; 2014: 642-650
• 8 Antithrombotic Trialists Collaboration. Baigent C, Blackwell L, Collins R. et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009; 373: 1849-1860 doi:10.1016/S0140-6736(09)60503-1
• 9 Fowkes FG, Price JF, Stewart MC. et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA 2010; 303: 841-848 doi:10.1001/jama.2010.221
• 10 Bibbins-Domingo K. U.S. Preventive Services Task Force. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2016; 164: 836-845 doi:10.7326/M16-0577
• 11 Arnett DK, Blumenthal RS, Albert MA. et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 140: e596 doi:10.1161/CIR.0000000000000678
• 12 Seshasai SR, Wijesuriya S, Sivakumaran R. et al. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med 2012; 172: 209-216 doi:10.1001/archinternmed.2011.628
• 13 Beckett NS, Peters R, Fletcher AE. et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358: 1887-1898 doi:10.1056/NEJMoa0801369
• 14 Williamson JD, Supiano MA, Applegate WB. et al. Intensive vs. Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥ 75 Years: A Randomized Clinical Trial. JAMA 2016; 315: 2673-2682 doi:10.1001/jama.2016.7050
• 15 Tulner LR, Kuper IM, van Campen JP. et al. Treatment of hypertension in an elderly outpatient population in the Netherlands. Am J Geriatr Pharmacother 2009; 7: 204-209 doi:10.1016/j.amjopharm.2009.08.002
• 16 Warwick J, Falaschetti E, Rockwood K. et al. No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study, a double-blind, placebo-controlled study of antihypertensives in people with hypertension aged 80 and over. BMC Med 2015; 13: 78 doi:10.1186/s12916-015-0328-1
• 17 Welsh TJ, Gordon AL, Gladman JRF. Treatment of Hypertension in People With Dementia: A Multicenter Prospective Observational Cohort Study. J Am Med Dir Assoc 2019; 20: 1111-1115 doi:10.1016/j.jamda.2019.03.036
• 18 Richardson K, Bennett K, Kenny RA. Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. Age Ageing 2015; 44: 90-96 doi:10.1093/ageing/afu141
• 19 Butt DA, Mamdani M, Austin PC. et al. The risk of falls on initiation of antihypertensive drugs in the elderly. Osteoporos Int 2013; 24: 2649-2657 doi:10.1007/s00198-013-2369-7
• 20 Muhlbauer V, Dallmeier D, Brefka S. et al. The Pharmacological Treatment of Arterial Hypertension in Frail, Older Patients-a Systematic Review. Dtsch Arztebl Int 2019; 116: 23-30 doi:10.3238/arztebl.2019.0023
• 21 Freund T, Gerste B, Jeschke E. Qualität der poststationären Arzneimittelversorgung von Patienten mit Herzinsuffizienz. In: Klauber J, Geraedts M, Friedrich J, Wasem J. Hrsg. Krankenhaus-Report. Stuttgart: Schattauer; 2016: 229-246
• 22 Bruno N, Sinagra G, Paolillo S. et al. Mineralocorticoid receptor antagonists for heart failure: a real-life observational study. ESC Heart Fail 2018; 5: 267-274 doi:10.1002/ehf2.12244
• 23 Flather MD, Yusuf S, Kober L. et al. Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet 2000; 355: 1575-1581 doi:10.1016/s0140-6736(00)02212-1
• 24 Dulin BR, Krum H. Drug therapy of chronic heart failure in the elderly: the current state of clinical-trial evidence. Curr Opin Cardiol 2006; 21: 393-399 doi:10.1097/01.hco.0000231411.15049.20
• 25 Komajda M, Schope J, Wagenpfeil S. et al. Physiciansʼ guideline adherence is associated with long-term heart failure mortality in outpatients with heart failure with reduced ejection fraction: the QUALIFY International Registry. Eur J Heart Fail 2019; 21: 921-929 doi:10.1002/ejhf.1459
• 26 Cacciatore F, Abete P, Mazzella F. et al. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Eur J Clin Invest 2005; 35: 723-730 doi:10.1111/j.1365-2362.2005.01572.x
• 27 Hylek EM, Evans-Molina C, Shea C. et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 2007; 115: 2689-2696 doi:10.1161/CIRCULATIONAHA.106.653048
• 28 Friberg L, Rosenqvist M, Lip GY. Net clinical benefit of warfarin in patients with atrial fibrillation: a report from the Swedish atrial fibrillation cohort study. Circulation 2012; 125: 2298-2307 doi:10.1161/CIRCULATIONAHA.111.055079
• 29 Donze J, Rodondi N, Waeber G. et al. Scores to predict major bleeding risk during oral anticoagulation therapy: a prospective validation study. Am J Med 2012; 125: 1095-1102 doi:10.1016/j.amjmed.2012.04.005
• 30 Larsen TB, Skjoth F, Nielsen PB. et al. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ 2016; 353: i3189 doi:10.1136/bmj.i3189