What common side effects of cardiac medications are the elderly most vulnerable to?

Side effects of cardiac medications that present a real danger to the elderly can be divided into four broad categories:

How common is atrial fibrillation in the elderly?

Atrial fibrillation affects 5-10% of ambulatory elderly. The incidence among hospitalized elderly is probably twice that. Unlike in younger people, atrial fibrillation is a harbinger of underlying cardiac disease in the elderly. The rate of stroke is 10 times higher in older than younger patients with atrial fibrillation.

1Is anticoagulation therapy more risky in an elderly patient with atrial fibrillation than in younger patients?

Solid evidence demonstrates that the risk of bleeding from appropriately dosed and monitored warfarin does not rise with age alone. Instead, increased risk of bleeding is associated with frailty, a tendency to fall, history of peptic ulcer disease, or underlying malignancy.

1Who is too old for a pacemaker?

No one. Sinus and atrioventricular nodal dysfunction are more common in the elderly and are a common cause of syncope and falls. Both quality and length of life can be improved by appropriate use of pacemakers.

Who should be considered for heart transplantation?

Approximately 40,000 people/year under age 65 die of heart failure. In most of these patients, heart transplantation could be life-saving, but unfortunately only about 2,100 heart transplants are being done per year, predominantly due to a shortage of donor organs.

Adult patients are generally considered to be candidates for transplantation when medical therapy has been maximized and the patient’s prognosis or quality of life can still be significantly improved by transplantation. This is generally the case if a patient’s maximal oxygen consumption is 14 mL/kg/min and the left ventricular ejection fraction is 25%. Occasionally, transplantation is considered for patients with better left ventricular function but with severe ischemia not amenable to revascularization by angioplasty or surgery or those with recurrent symptomatic ventricular arrhythmias unresponsive to therapy.

Are there patients who cannot be considered for a heart transplant?

Contraindications to transplantation include coexisting systemic illness that limits a patient’s survival:

Severe irreversible pulmonary, renal, or hepatic disease

Irreversible pulmonary hypertension (pulmonary vascular resistance 6 Wood units)

Active infection

Insulin-dependent diabetes mellitus with end-organ damage Acute pulmonary embolism History of recent malignancy Psychosocial instability.

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