21st March 2024

Cardiovascular system

Several agents have been implicated in the STOPP/START criteria relating to the cardiovascular system. For the treatment of oedema with limited evidence of organ dysfunction, one should consider non-pharmacological treatments such as compression bandages and leg elevation. Loop diuretics should not be used for dependent oedema or as a first-line agent for hypertension.

ACE inhibitors (ACEi) are encouraged for systolic heart failure or coronary heart disease but should be stopped in those with hyperkalaemia. If co-prescribed with potassium sparring agents such as spironolactone, eplerenone and amiloride one must monitor potassium regularly. Beta-blockers and calcium channel blockers (CCBs) are encouraged for stable angina, although both dihydropyridines and non-dihydropyridine CCBs may exacerbate heart failure. Non-selective beta antagonists are best avoided in patients with bradycardia and obstructive airway disease. Thiazide diuretics act on the sodium/chloride co-transporter and have a propensity to cause electrolyte disturbances particularly hyponatraemia, hypokalaemia, hypercalcaemia and can exacerbate gout. Alpha blockers such as doxazosin and prazosin should be stopped in those with orthostatic hypotension or micturition syncope.

Amiodarone is a class III anti-arrhythmic which blocks potassium channels. It has a long half-life with significant adverse effects including hepatoxicity, lung fibrosis and thyroid dysfunction. It is effective in the treatment of supraventricular tachyarrhythmias however, in the elderly, other agents should be considered first-line if possible following review.

Digoxin works by inhibiting the sodium/potassium pump. It must be monitored with the levels taken usually 6 hours after the most recent dose. There is limited evidence for digoxin use in those with preserved ejection fraction and in accordance with the STOPP criteria should be stopped.  As well as this, cessation should occur if there is significant renal impairment (eGFR <30ml/min/1.73m^2) as it can lead to toxicity.

Statins are recommended for patients with known coronary heart disease, QRISK scores >10% and in patients with diabetes or chronic kidney disease of eGFR <60min/1.73m^2.

Hypertension

Antihypertensives should only be used if blood pressure is consistently greater than 140 / 90 mmHg. In those >80 years of age, a higher range of 150 / 90 mmHg is acceptable unless there is evidence of diabetes. Centrally acting antihypertensives (methyldopa, clonidine and moxonidine) are not as well tolerated by the elderly.