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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #18

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LEARNING OBJECTIVES

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Learning Objectives

  • Understand the prevalence of coronary heart disease (CHD) in older adults.

  • Describe the clinical features—including symptoms, signs, and results of diagnostic tests—that distinguish CHD in older adults from that occurring during middle age.

  • Understand current treatment of CHD in older adults.

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Key Clinical Points

  1. CHD is common in older adults; more than 80% of CHD deaths occur in persons older than 65 years.

  2. Overt CHD represents the tip of the coronary disease iceberg; many older patients have asymptomatic, subclinical disease.

  3. The prevalence of angina increases with age, but older individuals also complain of atypical features such as dyspnea, abdominal pain, fatigue, confusion, or malaise.

  4. Delay in recognizing symptoms contributes to later presentation in older patients.

  5. Older patients with symptoms suggestive of CHD should undergo a similar assessment for coronary disease as younger patients. Yet, older patients frequently experience difficulty with exercise testing and may need modified protocols or pharmacologic-based stress tests.

  6. Without high-risk features, an initial attempt to manage symptoms with medical therapy is warranted.

  7. Management of coronary heart disease must be individualized in older patients with competing morbidities and in accordance with goals of care.

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DEFINITION

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Coronary heart disease (CHD) describes the spectrum of clinical presentations resulting from insufficient oxygen supply for the demands of the myocardium. Atherosclerosis in the coronary circulation causes luminal narrowing and provides the substrate for vascular dysfunction and thrombosis. The clinical manifestations of CHD include stable ischemic heart disease as well as unstable angina and acute myocardial infarction (MI).

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EPIDEMIOLOGY

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Despite a decline in mortality from coronary heart disease during the past three decades, it remains the leading killer of both men and women in the United States. More than 80% of CHD deaths occur in persons older than 65 years. In addition, 37% of recognized acute MIs occur in those older than 75 years, and, although these account for roughly 6% of the US population, 60% of all MI-related deaths affect patients 75 years or older.

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The spectrum of CHD includes asymptomatic or subclinical CHD, stable angina, unstable angina, and acute MI. In the United States, the prevalence of CHD, MI, and angina all increase with age in both men and women (Figures 77-1 and 77-2). The initial manifestation of CHD may be an acute MI, occurring in about in 40% of cases, or sudden death in 10% to 20% of cases. Furthermore, despite the fact that women typically have a 10-year lag in CHD manifestations as compared with men, the majority of patients with CHD older than 75 years are women because of survival biases.

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FIGURE 77-1.

Estimated prevalence of coronary heart disease by age and sex. (Adapted with permission from Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 ...

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