Taking Care of Your Cardiovascular Health While Aging

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Abdulla Damluji, MD:

Welcome, everyone. My name is Abdulla Damluji. I'm an interventional cardiologist here at the Cleveland Clinic Heart, Vascular and Thoracic Institute. My research interest is in treating older adults presenting to us with complex cardiovascular disease.

Ardeshir Hashmi, MD:

Thank you for joining us, Dr. Damluji. I'm Ardeshir Hashmi. I am the Center Director for the enterprise for Geriatrics. I specialize in the care for older adults, from normal aging to all the pathology that sometimes comes up as we get older. Wonderful to have you join.

We're talking today about Cleveland Clinic's brand new program in cardiovascular diseases and aging and all the wonderful things that our larger team has brought together with the expertise of the best in Cleveland Clinic, but now specifically what is important as we get older.

One of the questions, Dr. Damluji, that I have for you is what are some of the common heart conditions that older adults experience as we age?

Abdulla Damluji, MD:

Older adults are disproportionately affected by cardiovascular disease. About 40% of all heart attacks happen in older adults above 75 years of age. The most common conditions, one of which is coronary artery disease, when you have blockages in the blood vessels surrounding the heart muscle. That can present with stable disease, like when patients have substernal chest pain (angina pectorus) with exertion or at rest, or it can present itself as a heart attack, what we call acute coronary syndrome.

Another prevalent heart condition in the older adult population is heart failure, where the heart muscle becomes stiff. That is what we call heart failure with preserved ejection fraction. Sometimes older adults present with arrhythmias. The most common arrhythmia is atrial fibrillation or atrial flutter, where older patients present with palpitations or irregular heartbeats. Older patients also present with peripheral vascular disease, where they get pains, what we call claudications, upon walking. Older patients also present with valvular heart disease where the valves are affected, most commonly the aortic valve, we call it aortic stenosis, or when the mitral valve becomes leaky, what we call mitral regurgitation. These are the most common conditions that an older patient presents to the hospital complaining of cardiovascular symptoms that are a result of these common conditions.

Ardeshir Hashmi, MD:

Wonderful. Dr. Damluji, how do these conditions uniquely impact older adults? Do they present differently? Do they impact differently?

Abdulla Damluji, MD:

Older patients can present in an atypical fashion. For example, a mid-age adult can present with a heart attack with typical symptoms, they would get substernal chest pain that radiates to their jaw, to their left arm. They're presenting the most typical presenting symptoms, while for an older adult, they can present with atypical symptoms. They can have shortness of breath, they can have nausea, they can have lightheadedness, and sometimes they can syncopize where they lose consciousness. They can have abdominal pains. All these atypical symptoms are quite unique to the older adult population, especially those with diabetes and neuropathy.

Ardeshir Hashmi, MD:

I would assume early screening and picking up things early before they get to an advanced stage is very important. What would you recommend for screening? What should we check for and how early?

Abdulla Damluji, MD:

The older adult population would benefit from cardiovascular prevention, both primary prevention and secondary prevention. The screening starts early. We have to screen for certain cardiovascular risk factors, including blood pressure and hypertension.

Hypertension is quite prevalent in the older adult population. More than two-thirds of older adults live with high blood pressure. We also screen for cholesterol, for obesity and diabetes. All these conditions increase the risk of developing frank phenotypic cardiovascular disease. But also, older adults live with geriatric syndromes, and I would like to ask you, Dr. Hashmi, what are these geriatric syndromes and how do we screen for them?

Ardeshir Hashmi, MD:

Great question. We think about the geriatric syndromes in the four M's of aging, so mentation or brain health, mobility or physical health, medications (all of your medications, the heart ones and the non-heart ones). Then, at the heart of it is what matters most to us as we age, that quality of life goal. If my shortness of breath, for example, and heart failure were better, what would that allow me to do more of? Would it be walking my grandchild to school? That quality of life goal I think is important jointly to our entire team and what we always start with.

Geriatric syndromes are any medical condition or medication that can uniquely impact older adults and actually take away from the success of the care that you just outlined for the important condition. If you can understand your treatments, understand your condition with a very sharp mind, that is the goal. But if there's anything like a medication that's interfering with that, obviously, we talk about that. We try to do everything we can to optimize that brain health.

For physical health, the same sort of thing, so our ability to recover from these conditions Is compromised as we get older, lower ability to bounce back, lower immune system, but how can we be proactive about that with exercise to counter that frailty? Then, same thing with medications. Every single visit we look at those medications and say which of these are taking away from the brain health and physical health? Again, as I said, always with what matters most. These are some of the geriatric syndromes and other medical conditions like hearing loss, urinary incontinence that are common as we get older, but they really impact overall quality of life.

Abdulla Damluji, MD:

How do we distinguish between a normal aging for an older patient living with cardiovascular disease and pathologic aging, those older patients who come in deteriorating physically, mentally. They live with these geriatric syndromes that affect their cardiovascular disease, and cardiovascular disease also affects their geriatric syndrome. How can we distinguish between normal aging, Dr. Hashmi, and those who have pathologic aging or accelerated aging?

Ardeshir Hashmi, MD:

Great question. I mean to us in aging, whether it's from cardiology or geriatrics, we say age is just a number. It doesn't matter, that chronology. These changes start early, in our 40s and 50s, and then they progress over time. Really, I don't think that we can leave anything to chance. Some of these symptoms we may think they're all a normal part of aging, and the next thing that we say to ourselves is nothing can be done about them. Nothing can be further from the truth, as you know.

To come to an expert like yourself and our team and say, I'm the expert in my symptoms, here's what's happening. Is that the question? I mean that's really the question, is this all normal aging, or is there something here that I need to be concerned about? With all the examinations and testing that we have at our disposal here at the Cleveland Clinic, we're able to pick that up very early and very accurately.

I had a question about treatments. Let's say I came in and you screened me and I had something, one of these conditions, you picked it up early and I'm very thankful for that. Would I respond differently as an older adult to those treatments? What is your experience in that?

Abdulla Damluji, MD:

Older patients, as you were explaining, Dr. Hashmi, live with these geriatric conditions. These conditions do not fit into one disease category. You have an older patient who's quite frail. They have physical deterioration. They have mild cognitive impairments. They have multiple chronic conditions like chronic obstructive lung disease, heart failure, coronary artery disease all at once. They're all being managed, but they live with multiple chronic conditions. At the same time, they are treated with multiple medications. They have five to 10 and sometimes more than 10 medications at the same time, taking them at different frequencies throughout the day.

Older adults, when they come into the hospital with acute cardiovascular illness, say heart failure, when we add medications to them, these medications can interact with their conditions. This is called drug-disease interaction. These medications can interact with pre-existing medications, drug-drug interactions. They may have an impairment in their kidney function, so they respond differently than a younger patient.

That's why we need a more comprehensive approach in treating older adults. A cardiologist might follow the guidelines and start all these medications, but an older patient may be more frail. Their response to these treatments can be different. We might have to adjust the medications and also adjust our approach to procedures, particularly those who have complex cardiovascular disease like complex coronary disease or complex valvular heart disease. That's where a team approach to an older patient living with cardiovascular disease is essential.

I wanted to bounce back to you, Dr. Hashmi, to tell us about this innovative program that we're starting here at the Cleveland Clinic, the Cardiovascular Center on Aging, and how this innovative approach to treating older adults with cardiovascular disease may benefit the patient, their families and caregivers.

Ardeshir Hashmi, MD:

Thank you for asking and thank you for making it possible. I mean it's the expertise and experience of wonderful forward-thinking visionary cardiologists like yourself who've embraced the future. All of us are getting older. Your expertise, coupled with the expertise of our aging specialists, our geriatricians, our successful aging specialists, our goal is the same. It’s a united one, to keep you healthy and successful as we get into our older years, and be safe at home with a great quality of life. We can't do that alone. Obviously, in humility, we are experts in our own fields, but there's a whole village that comes together in service of all patients and family members. That could be nutritionists, it could be a physical therapist, it could be a pharmacist. It's much more about the collective impact of the team, of us being greater than the sum of our parts, than any individual. But each individual has their own lens of seeing a very complex situation and really trying to unpack that and simplify it for patients and families.

I think the impact of co-location is perhaps also very important in traditionally what has been a very fragmented health system in general. I think the unique thing about Cleveland Clinic is it allows us to have multiple resources at our disposal as patients and family members and as physicians all in one place uniquely. What other aspects would you say make our program very unique and special?

Abdulla Damluji, MD:

Absolutely. From a cardiology and cardiac surgery perspective, we have one of the top programs in the country treating older patients with cardiovascular disease. That applies to all cardiology and cardiac surgery subspecialties. The volumes here are unmatched when compared to other hospital systems. But at the same time, when an older patient comes into the hospital with an acute cardiovascular illness, we want to approach them not from a disease perspective but with a holistic approach to management.

That's where Dr. Hashmi's team, which is the geriatric medicine team, would integrate the care for an older patient who comes in with an acute cardiovascular illness. It becomes essential because now the patient not only gets their cardiovascular disease addressed, but also these geriatric syndromes, if they have frailty, if they have multi-morbidity, if they have polypharmacy, if they have tendency to develop delirium. When they get admitted to the hospital, we get to address their goals of care as they approach procedures and also as they approach end of life.

All of these things, really this program is so unique, that it can encompass the patient as a whole. We're not only addressing a disease, but we're really addressing the patient as a whole. In that context, Dr. Hashmi, how do you think the Cleveland Clinic geriatric assessment should be done in the inpatient setting versus an outpatient setting? How do you think that we can complement each other as we approach an older patient with cardiovascular disease?

Ardeshir Hashmi, MD:

Yeah, wonderful question. I think it is incredibly important in two ways. One, the goal is obviously to age successfully at home and prevent bad things from happening in the first place, hospitalization, emergency room visits. That early screening, early intervention happens mainly in the outpatient space. If you're planning a procedure, are you in the best shape possible? It's almost like preparing for a major sporting event. The better shape you are in physically, mentally, we try to optimize that so that your procedure goes smoothly with the great outcomes that we have at the Cleveland Clinic, and then after your procedure as well. I think that's one transition point where you pass that baton.

The other transition point I think is if you are in the hospital and unfortunately hospitalized or having a procedure done to get this new lease on life, if you will, that our wonderful care enables, how do we sustain that? When we come back into our home setting with our usual diet and family structure and home surroundings, how can we continue that outstanding care even in the home setting? There, that continuity really helps a lot.

One other thing that I wanted to ask you about is, as an expert in cardiovascular aging I would think that that definition of aging that we have, that needle is moving all the time, right? As you said, it's important to screen early but perhaps a lot of these changes are happening in our 40s and 50s. Speak a little bit to the importance of sort of that. There's 52 different ways that the body can change between the ages of 50 and 80, I know. So, that same concept of what is normal and what is not, how important is that? Is it important to start early in terms of even age-wise?

Abdulla Damluji, MD:

Traditionally speaking, we thought about aging as a chronologic process. It's the time from birth until the current date. If you were born in 1940 and today is 2000, you're 60 years of age. But in practice, we have noticed that some patients look much older than their counterparts at the same age because they get exposed to multiple chronic conditions. They get exposed to bad environments like radiation, for example. They can get exposed to chronic conditions. They can get exposed to risk factors like smoking and hypertension, diabetes, uncontrolled glucose levels, and that would make them, on the long run, much older than their stated age. That's the concept that we came up with recently in the literature, which is called biologic aging.

So then, it comes into how do we quantify biologic aging? There are certain ways we can quantify it clinically, where we can measure these geriatric syndromes that Dr. Hashmi was talking about, including frailty, physical function, mental function, cognitive functioning, and their overall age-associated risks. At the same time, we can quantify their cardiovascular risk. By combining the two, we can get a measure of an overall biologic age. Now, there is more advancement in understanding aging at a cellular level and at a molecular level with epigenetic clocks and other biologic metric risk scores. The field is moving very rapidly, and hopefully we are collaborating with other centers here at the Cleveland Clinic about understanding biologic age. Overall, this is a really exciting time for us, and for all the patients who are coming into Cleveland Clinic.

I want to reflect back to you, Dr. Hashmi, about a final take-home message an older patient who wants to come into the Cleveland Clinic for cardiovascular care, whether they have heart failure, valvular heart disease, coronary disease or peripheral vascular disease, but they also live with geriatric syndromes, whether they're diagnosed or they're not diagnosed and they need to be screened for them. Tell us a final take-home message for a patient who is coming to Cleveland Clinic.

Ardeshir Hashmi, MD:

I think this is incredibly good news in that it brings together the best in heart care, that Cleveland Clinic has been always known for the world over, with the best in care and expertise in aging and successful aging. My take-home would be that we've got to redefine this. This is actually amazing news that we are as old as we feel. The number doesn't matter. There is a lot of expertise available in a unified place that makes it easy to access this care and also to sustain it over time with the best expertise that we have. We are an age-friendly health system through the Institute of Healthcare Improvement, and for good reason.

It's only a phone call or an email message to us away. Accessing that care has become incredibly easy, right in your neighborhood. We get patients from all over the world really. What a great boon for patients and families.

I'd also like to ask you, what is your message for families as well, how can they be involved? What can they do to support our older loved ones?

Abdulla Damluji, MD:

Yes, absolutely. Families, for most older adults, depend on the social structure in managing day-to-day activities, bringing a patient to the hospital, bringing them to clinic and managing transportation and their medication sometimes. Cleveland Clinic provides support not only to patients, but to caregivers and family members as we approach the management of an older patient, not only from a cardiovascular disease perspective but also from an aging perspective, and also from supporting caregivers in delivering this care. We try to teach the caregivers about the condition itself and about the age-associated risks and how they integrate together in the management.

It's really an exciting time for all of us here at the Cleveland Clinic, having a world-class geriatric team and a world-class cardiology team, in managing older patients with really complex cardiovascular disease.

As the population is aging, this is just timely and exciting. I would like to thank you, Dr. Hashmi, for this wonderful time discussing this. We look forward to providing care for all of our patients coming here to the clinic.

Ardeshir Hashmi, MD:

Thank you for listening to Love Your Heart, appreciate it.

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