TOPIC 2: CARDIOVASCULAR SYSTEM

Like any organ system in the body, the ageing cardiovascular system loses
functional capacity.
However, the cardiovascular system has a large functional reserve, and
declining capacity need not limit the ability to lead a healthy life.
Often, it is pathological changes associated with poor diet and lifestyle that
cause the greatest problems in the aged.

This is a practical example of the reserve capacity concept, and an important

theme that you will find recurring in subsequent modules.

The presence of disease can accelerate the normal processes of ageing, and
normal ageing can lower the threshold at which clinical signs of disease are
observed.
When reviewing the effects of ageing, it is important (but difficult) to
differentiate age related changes from those related to pathology and lifestyle.
We cannot prevent age related changes, but often simple interventions will
limit the losses due to pathology or lifestyle.
The difficulty is that some of these interventions need to commence at a young
age in order to be of maximum benefit.
In the last module is an abstract from the paper by Langie et al. describing how
things that occurred before birth could influence ageing.

This highlights a key concept in gerontology that first appeared in the previous
module.
The best way to maximise your chances of experiencing good health in old age
is to follow good health practices throughout your life.
However, it is never too late to get benefits from the modification of
cardiovascular risk factors.

We will now consider specific age-related changes that occur in the

cardiovascular system.
In the early modules of this unit, the emphasis will be on describing the
physiological changes that occur.
This will enable you to identify the general concepts that can then be applied
to other body systems.

1. THE HEART
Normal physiological changes in the ageing heart
The size of the ageing heart can decrease, remain unchanged or
increase. Disease (such as hypertension) can contribute to enlargement
of the heart. Some enlargement of the heart is usual in serial x-ray
examinations of clinically normal people.11

There is a gradual loss of pacemaker cells and changes in the normal

rhythm of the heart.
Although resting heart rate remains largely unchanged, there is a
progressive decrease in maximum heart rate.
Various equations have been used to describe this change in maximum
heart rate.
A simple, reasonably accurate equation states that:
maximum heart rate = (220 age) beats per minute.
This equation can be used to illustrate the decrease in reserve capacity
that occurs with ageing.

Age Resting heart Maximum heart % of total

rate rate capacity used at
rest
20 70 200 35%
50 70 170 41%
80 70 140 50%

The heart muscle becomes stiffer with ageing, with muscle cells being
replaced by fibrous tissue as they undergo apoptosis.
Overall, the number of myocardial (muscle) cells decreases, although
some lost cells can be replaced from stem cells present in the heart.
The use of stem cells to replace damaged myocardial cells offers
considerable hope for improvements in the future treatment of
cardiovascular disease.
The loss of myocardial cells decreases the capacity of the heart to pump
blood.
This is not important at rest, and the volume of blood pumped (the
stroke volume) remains unchanged.
However, during exercise, the inability to increase stroke volume can
limit functional capacity.

As a result of the increasing fibrosis, the capacity of the myocardium to

relax decreases.
 There is no change in the filling of the heart at rest.
However, during exercise, filling of the heart may be limited, as the time
available for filling between contractions is decreased.
This may limit exercise capacity.

The valves become thicker, potentially decreasing their ability to form

an effective seal between chambers.
As a result, heart murmurs may develop and the pumping efficiency of
the heart may decrease.

There is decreased blood flow in the coronary arteries.

This may limit the delivery of oxygen to the heart.
This may be of only minor significance when heart rates are low, but at
higher heart rates, oxygen delivery may become inadequate.
When oxygen delivery is limited, there is an increased reliance on
anaerobic (=not needing oxygen) metabolism.
Lactic acid (lactate), the end product of anaerobic metabolism, is
thought to cause the pain in the heart muscle that is known as angina.

The increase in the volume of the heart is associated with increased

ventricular thickness.
This prolongs contraction of the heart.
When the wall of the heart thickens, blood supply to the muscle
decreases. Blood supply also decreases during the time when the heart
muscle is contracted.
These changes may further increase the risk of angina (a symptom of
inadequate oxygen delivery to the myocardium) developing.

What the age related changes mean

Cardiovascular function is determined by the interaction of several variables,

each of which can be influenced by ageing and/or disease.
It is the end result of these changes that is important, because it is the end
result that impacts on function.

Because there is no significant change in heart rate or stroke volume, cardiac

output can be maintained at rest.
Cardiac output is the volume of blood pumped by one ventricle each minute
and is equal to the heart rate multiplied by the stroke volume.
It is a measure of the amount of blood being delivered to the tissues.
However, the increase in cardiac mass, and the prolongation of contraction
increase the total amount of work that the heart is required to do.
Combined with the decrease in coronary blood flow, the reserve capacity of
the heart is decreased.
However, the magnitude of this decrease is generally small.
In other words, adequate cardiac function to support normal activities can be
maintained despite the age related changes in reserve capacity.

Lakatta11 has suggested that the cardiac changes that occur in healthy older
individuals are adaptive.
This means that they occur in response to arterial changes that are due to
ageing.
True functional limitations will develop when disease is added to the normal
ageing process.

2. THE BLOOD VESSELS

Normal physiological changes in the vessels

With ageing, there is a loss of elasticity in the vessels.
This may lead to an increase in the systolic blood pressure, and a fall in
the diastolic blood pressure.

This decrease in elasticity is partly the result of the deposition of

oxidised lipid within the arterial walls resulting in changes in muscle and
connective tissue.
This is the disease process known as atherosclerosis.
Damage to the blood vessel walls will increase the development of
atherosclerosis.

High pressure exacerbates the process of vessel damage - the process

becomes self perpetuating (=continuing without any outside influence)
as increased blood pressure will increase the development of
atherosclerosis, resulting in a further increase the blood pressure.

What these changes mean

The loss of blood vessel elasticity increases the resistance against which the
heart has to pump - it has to work harder and generate higher pressures to
maintain cardiac output, so more of the reserve capacity is used up.
The heart muscle hypertrophies (increases in thickness) in response to the
increased work load it is required to do.
This is no different to the increase in muscle size which occurs when someone
does weight training.
You should recall the effects of increasing muscle thickness on blood flow to
the heart - if you can't, review the preceding section of this unit.

Atherosclerosis causes significant narrowing of the blood vessels which may in

turn result in decreased blood flow to the tissues supplied by the affected
vessels.
The vessels supplying the heart are frequently narrowed, so oxygen delivery
and the work capacity of the heart muscle are decreased.
Narrowed vessels provide greater resistance to blood flow, which must be
matched by increased pressure in the vessels if blood flow is to occur.
The higher pressures generated result in continuing vessel damage and further
narrowing.

The loss of elasticity in the arteries means they lose the ability to do one of
their most important jobs - preventing excessive systolic blood pressure.
Mean systolic pressure is generally observed to increase progressively with
increasing age.

Describe how the reserve capacity of the cardiovascular system changes as

people age, and describe some of the factors underlying this change.
The overall effect of ageing is to decrease the reserve capacity of the
cardiovascular system.
These are normal age-related changes.
If disease is superimposed on these changes, then the decrease in reserve
capacity would be accelerated.

3. CONTROL OF BLOOD PRESSURE

Maintaining blood pressure is an essential aspect of cardiovascular function.

We need to have enough blood pressure to maintain blood flow, but don't
want that pressure to be excessive.
Excessive blood pressure results in tissue damage and increases the workload
on the heart.
In a general sense, we can say that blood pressure is determined by two main
things:
the volume of blood in the vessels
the diameter of the vessels.

The volume of blood in the vessels can be controlled by two things:

the cardiac output, which we can change very quickly by changing heart
rate and/or stroke volume.
the total blood volume (which is really determined by the amount of
water in the blood - change water excretion by the kidneys and you can
change the blood volume).

Changes in the activity of the sympathetic activity help us cope with the
changes in blood pressure produced by changes in posture.
When we stand, gravity pulls blood to our feet and decreases blood flow to the
brain.
However, in order to maintain consciousness we need to maintain blood flow
to our head, so blood pressure must be increased when we stand.
This is achieved by increases in cardiac output and vasoconstriction that are
initiated by the sympathetic nervous system.

With ageing, activity in the sympathetic nervous system is increased.

This results in increased blood concentrations of catecholamines, the
hormonal messages of the sympathetic nervous system.
However, the heart and blood vessels become less sensitive to catecholamines
when there is a sustained increase in their levels.

An age-related decrease in baroreceptor sensitivity (the structures which

measure blood pressure) slows the rate at which blood pressure changes are
detected, and is another factor which can limit the ability of the body to
control blood pressure in the short term.
Therefore, the ability to maintain cardiovascular homoeostasis is decreased.
An obvious and important manifestation of the loss of homoeostasis is
postural hypotension, and excessive or prolonged decrease in blood pressure
that occurs when someone stands up.
Postural hypotension is important because it contributes to falls.
A fall is one of the most devastating events that can occur in an older person's
life.
Postural hypotension is discussed in more detail below.
 blockers were commonly used to treat high blood pressure.
They work by blocking the effects of the sympathetic nervous system.
But as we have seen above, the sympathetic nervous system protects us from
postural hypotension.
blockers may contribute to postural hypotension by blocking the blood
pressure adjusting mechanisms.

Hypertension
High blood pressure (hypertension) is common in the aged.
Studies have shown that some of the increase in systolic blood pressure that
occurs with age is due to lifestyle and diet.
However, there is some loss of elasticity in the arteries which is related to the
normal ageing process.
Age and disease related changes in other body systems can also contribute to
hypertension.1

The loss of elasticity in the arteries which occurs with ageing contributes to the
rise in systolic pressure.

Hypertension is also a significant risk factor for death in the aged.

A series of large studies in the US found the following:

In males 65 - 75 years old:

blood pressure greater 165/95 resulted in a 2.4 times higher risk of
death than males with blood pressure less than 140/90
blood pressure between 140/90 and 165/95 resulted in a 2.1 times
higher risk of death than males with blood pressure less than 140/90

In females 65 - 75 years old:

blood pressure greater than 165/95 resulted in an 8 times higher risk of
death than females with blood pressure less than 140/90
blood pressure between 140/90 and 165/95 resulted in a 4.3 times
higher risk of death than females with blood pressure less than 140/90 2

Hypertension is not a normal part of ageing, and it significantly increases the

risk of death.

1 Fukutomi M. Kario K. Aging and hypertension. Expert Review of Cardiovascular Therapy. 8(11):1531-9, 2010
2
You will not be expected to know the actual numbers examination, but you will need to understand their
implications.
There are no obvious signs of hypertension - only blood pressure
measurement will detect if the problem is present.
When hypertension is present, there are significant benefits to be derived
from treating the condition.
Although blockers can increase the risk of postural hypotension, they are
only one of the treatments available for hypertension and today are used
sparingly (=in a way that is careful to use or give only a little of something).
There are many other treatments available that are effective and do not
appear to increase the risk of falls.

Hypotension
When blood pressure falls, the brain is deprived of oxygen, and fainting may
result.
The effects of gravity on blood flow are particularly important, as gravity tends
to pull blood down towards the feet.
Hypotension is a problem because it contributes to the incidence of falls.
Like hypertension, low blood pressure occurs as the result of an inability to
maintain cardiovascular homoeostasis, and its another one of the problems
that can't simply be written off as a normal part of ageing.

You should be aware that hypotension can result from:

eating a meal;
defaecating;
urinating.

Older men frequently have enlargement of the prostate which makes them
strain (=make an effort to do something) to urinate.
Straining decreases venous return to the heart, which in turn lowers blood
pressure (straining to defaecate has the same effect).
The provision of rails next to toilets is a sensible environmental modification
that may reduce the falls rate.

Because the volume of blood in the body helps to determine blood pressure,
dehydration is also an important risk factor for falling.
Dehydration is common in older people due to age-related changes in the
kidneys.
However it can also occur in people who are experiencing incontinence and
limiting water intake in order to decrease their need to urinate.
Explain how control blood pressure changes as people age, and discuss its
potential effects.
Normal age-related changes in the structure of the arteries result in an increase
in blood pressure.
This increases the workload on the heart, and decreases reserve capacity.
High blood pressure accelerates the rate at which damage occurs in the blood
vessels, making the situation even worse.

Drugs that are used to treat high blood pressure can decrease the ability to
control the blood pressure resulting in an increased risk of falling.
Diuretics (=a substance that causes an increase in the flow of urine) that
decrease blood volume by increasing urine production are also used to treat
high blood pressure and can contribute to falls.
Hypertension can also result from a variety of physiological processes such as
eating, urinating, and defaecating.

If a persons cardiovascular capacity decreases, it is likely that they will find

exercise more difficult.
If they exercise less, they will lose fitness, resulting in further decreases in
exercise capacity, and poorer blood pressure control.

Syncope
The most common manifestation of hypotension is syncope (fainting).
Syncope is a transient (=temporary) loss of consciousness caused by decreased
blood flow to the brain.
It is characterised by a sudden onset (usually with no warning signs except a
period of light-headedness (=not completely in control of your thoughts or
movements)) and spontaneous recovery usually within sixty seconds.

It is useful for those caring for the aged to have an understanding of the
different mechanisms by which syncope can occur.
With this understanding, it may be possible to plan interventions to minimise
its incidence.

A number of factors can limit blood flow to the brain.

Inadequate pumping capacity of the heart (due to cardiac disease).
Low blood volume due to dehydration.
Inadequate blood flow back to the heart (only blood which is returning
to the heart can be pumped on into the tissues).
 Prolonged standing or sitting can decrease venous return due to
decreased muscle pumping activity.
Straining to defaecate or urinate and coughing can restrict venous return
to the heart and produce syncope.
Bending to lift heavy objects can have the same effect.

Dysfunction of the autonomic nervous system which affects control of

blood pressure and blood flow distribution.
This is particularly important in the development of postural
hypotension and can be significantly influenced by drugs used to treat
hypertension.
Redistribution of blood flow to the digestive tract - if more blood is going
to the digestive tract less is available to go to the brain.
The bigger the meal, the bigger the shift in blood flow.
Redistribution of blood flow to the skin to facilitate heat loss (which may
occur after taking a hot shower or in hot weather).
Within the brain itself, atherosclerosis may limit oxygen delivery.

Interventions to limit syncope

Because syncope causes falls that often result in fractures, it is prevented.
Prevention is based on addressing the risk factors listed above.

Inadequate blood flow back to the heart (only blood which is returning
to the heart can be pumped on into the tissues).
Prolonged standing or sitting can decrease venous return due to
decreased muscle pumping activity.
Interventions:
Avoid sudden position changes.
Stand for several minutes before walking.

Low blood volume may decrease blood pressure

Intervention
Ensure that fluid intake is adequate to prevent dehydration.

Straining to defaecate or urinate and coughing can restrict venous return

to the heart and produce syncope.
Intervention:
Provide bran (=the outer covering of grain which is left when the grain is
made into flour) in the diet to decrease the chance of constipation.
Provide rails next to toilets.
 Dysfunction of the autonomic nervous system which affects control of
blood pressure and blood flow distribution.
This is particularly important in the development of postural
hypotension.
Intervention:
Encourage muscle contraction and deep breathing before moving in
order to stimulate venous return.
People should be encouraged to stand slowly, progressing from sitting to
having their legs over the side of the bed to supported standing.
People should sit in stable chairs with solid arms and support themselves
when rising.

Development of hypotension after eating

Intervention
Provide smaller meals more frequently.

Taking a hot shower can cause syncope, as blood flow is directed to the
skin in order for heat loss to occur (this may also occur in hot weather)
Intervention
Avoid overheating.

4. ATHEROSCLEROSIS

The end effect of atherosclerosis is the inability of the arteries to supply blood
(and therefore oxygen) to the tissues.
Atherosclerosis usually develops slowly, and many people have severe
atherosclerosis without showing obvious clinical signs.

It is concerning that signs of atherosclerosis are being seen today in

increasingly younger people.
These people are at an increased risk of experiencing health problems in the
future.
There are some specific conditions which can be attributed to atherosclerosis,
such as myocardial infarction, stroke and angina. (athero => MI)
Intermittent claudication (severe pain in the legs developing even during light
exercise and when lying down) and postural hypotension are other
cardiovascular problems related to atherosclerosis.
Atherosclerosis is increasingly being recognised as a potentially significant
contributor to the development of Alzheimer's type dementia.
It is already well recognised as the cause of vascular dementia, the 2nd most
common cause of dementia in Australia.

Atherosclerosis begins with the development of lesions in the muscular middle

layers of the arteries.
The changes are related to the deposition of fat in the tissues, followed by
changes in the structure of the muscle tissue, and deposition of connective
tissue.
The structure formed by this process is known as a plaque.
These lesions narrow the artery, and may rupture through the vessel wall to
initiate clotting in the bloodstream.
Once a clot develops, blood flow in the artery may be completely blocked.
If the blockage is in an artery supplying the heart, a myocardial infarction may
occur; if it occurs in the brain, a stroke may occur.
Infarction refers to tissue death due to a lack of oxygen.

High blood pressure, high fat diets and smoking are important risk factors for
atherosclerosis.
Diabetes mellitus is also a very significant risk factor.
It is now believed that free radical formation may exacerbate the condition,
and Vitamin E and C supplementation may be partially protective.

Because the prevalence of atherosclerosis increases with age, carers often see
people who have well developed atherosclerosis - but this doesn't mean that it
should be ignored.
Risk factor modification can be very useful, even when it is initiated at an
advanced age.

Women develop less atherosclerosis than men before menopause - oestrogen

has a protective effect.
Once menopause has occurred, and oestrogen production has ceased, the risk
of disease in women increases faster than in men, and the overall death rate
from myocardial infarction in women is higher than in men.
Some people think this is because people expect women to suffer infarctions
less frequently than men, and therefore fail to recognise the signs of the
disease.
Hormone replacement therapy will help protect against the development of
cardiovascular disease in post menopausal women.

5. ANGINA AND MYOCARDIAL INFARCTION

Angina and myocardial infarction (heart attack) both result from

atherosclerosis.
The early changes in the coronary arteries that lead to the development of
angina are often the forerunners (=a sign of what is going to happen) of
myocardial infarction, so angina can be looked on as a warning sign.
Although angina often occurs before myocardial infarction this is not always
the case.
People can have myocardial infarctions without a previous history of angina.

Angina occurs when the cardiac workload requires more oxygen in the blood
vessels can deliver.
When this happens, cellular metabolism produces lactic acid as a by product
(=a substance that is produced during the process of making or destroying
something else) of energy production.
The accumulation of the acid in the muscle causes pain - the same pain you
feel in your legs when running too hard, or in the arms when carrying a heavy
load.
Atherosclerosis decreases blood supply to the heart muscle by narrowing the
vessels.
Nitrates, which are tablets placed under the tongue to relieve angina attacks,
work by dilating the blood vessels, and increasing blood flow.
Rest is also important in controlling angina.

6. DRUGS USED TO TREAT CVS DISEASE

The drugs used to treat the cardiovascular system are important for two
reasons.
Firstly, they are amongst the most commonly prescribed drugs in Australia.
Second, they are commonly associated with adverse reactions.

7. AGEING AND SYMPTOMS OF OTHER DISEASES

An older person needs to be looked at in a holistic (= treating the whole person

rather than just the symptoms of a disease) fashion.
Age-related changes are occurring simultaneously in body systems, although
not necessarily at the same rate.

Often abnormalities in one body system are related to changes in other

systems.
For example, erectile dysfunction is a common problem affecting men over
the age of 50.
Many sufferers attribute the problem to getting older, and therefore ignore it.
They may also be too embarrassed by their condition to seek help.
However, erectile dysfunction frequently indicates cardiovascular disease.
By ignoring their condition, men increase the risk that they will experience
significant cardiovascular problems.3

This reminds us that the symptoms of disease may not be obvious in the body
system in which the primary disease is occurring.
Vascular dementia is another common complication of cardiovascular disease.

The presence of vascular pathology involving arterial stiffness,

arteriolosclerosis, endothelial degeneration and bloodbrain barrier
dysfunction leads to chronic cerebral hypoperfusion (=decreased blood flow
through an organ).
Pathological changes in human brain and animal studies suggest cerebral
hypoperfusion induces several features of Alzheimers Disease pathology
including selective brain atrophy, white matter changes and accumulation of
abnormal proteins such as amyloid .
Cerebral pathological changes may be further modified by genetic factors.4

Explain the relationship between changes in the cardiovascular system, and

changes in other parts of the body.
The changes specifically occurring in the cardiovascular system are known as
the direct changes.
The changes that result in other body systems, are known as the compensatory
changes.
Changes in the function of other body systems can occur as the direct result of
age-related changes, and more particularly diseases, affecting the
cardiovascular system.

3 Bouwman II. Van Der Heide WK. Van Der Meer K. Nijman R. Correlations between lower urinary tract symptoms, erectile
dysfunction, and cardiovascular diseases: are there differences between male populations from primary healthcare and
urology clinics? A review of the current knowledge. European Journal of General Practice. 15(3):128-35, 2009.
4 Kalaria RN, Akinyemi R, Ihara M (2012) Does vascular pathology contribute to Alzheimer changes?

Journal of the Neurological Sciences 322 (2012) 141147

There is a close link between decreases in cognitive function and changes in the
cardiovascular system.
Hypertension can be a significant cause of renal disease.
Erectile dysfunction is one of the most sensitive indicators of cardiovascular
disease in men.
These are examples of compensatory changes.

The Key Point

Normal ageing of the cardiovascular system overlaps with the development of
cardiovascular disease.

It is characterised by changes which decrease cardiovascular reserve through

senescent (=old and showing the effects of being old) changes which are
compounded (=make something bad become even worse by causing further
damage or problems) by co-existing cardiovascular disease, multisystem co-
morbidities (=number of people who have a particular disease) and
polypharmacy (excess prescription of medication).5

One of the aims of this unit is to enable you to produce an overview of the
ageing process as it affects a person, rather than simply focusing on individual
body systems.
You should try to create a concept shown how various changes can interact.
Try to produce a concept map showing the relationship between changes in
the cardiovascular system and problems that older people may experience.

Here are some suggested interactions.

Decreased the reserve capacity in the cardiovascular system leads to
decreased exercise tolerance.
Decreased exercise tolerance leads to loss of fitness and mobility.
Loss of mobility can lead to inability to care for oneself, and lack of social
contact.
Changes in the cardiovascular system can increase the risk of falls.
CVS medications can reduce the ability to control blood pressure
and therefore increased risk of falls.
Loss of fitness leads to immobility and instability.
A person being treated with diuretics may need to urinate more
frequently in the night, increasing the risk of falls and insomnia.

5 Corcoran TB. Hillyard S. Cardiopulmonary aspects of anaesthesia for the elderly. Best Practice & Research.
Clinical Anaesthesiology. 25(3):329-54, 2011
 A person lacking social contact may develop depression which is a
risk factor for falls and insomnia.
Medications used to treat insomnia may increase the risk of falls.
Cardiovascular changes may be associated with cognitive decline
that increases the risk of falls.