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INTRODUCTION

ESSENTIALS OF DIAGNOSIS

  • Presence of risk factors (hypertension, dyslipidemia, smoking, diabetes, renal disease, male, older age) accompanying symptoms.

  • Chest discomfort or dyspnea provoked by exertion and subsiding with rest or nitroglycerin.

  • Older adults with coronary disease often have atypical or nonspecific symptoms such as abdominal pain, dizziness, confusion, or fatigue instead of (or in addition to) more classic symptoms.

  • Electrocardiographic changes: ST elevation, ST depression, T-wave changes, and new Q waves.

  • Exercise or pharmacologic stress test evidence of myocardial ischemia.

  • Angiographic evidence of coronary stenosis.

GENERAL PRINCIPLES

The prevalence of cardiovascular disease (CVD), and especially coronary artery disease (CAD), is increasing and associated with both all-cause and cardiovascular mortality. In the United States, 92.1 million people have CVD. In adults aged 60 to 79 years, 69.6% of men and 68.6% of women have CVD; by age 80 years, >80% of individuals have CVD. Among people free of CVD at age 50 years, the lifetime risk for developing it is 51.7% for men and 39.2% for women.

CAD accounts for 43.8% of deaths from CVD in the United States and approximately 14% of all-cause mortality. One of the strongest risk factors for developing CAD is age, and the prevalence of CAD increases with age. Based on autopsy data, obstructive CAD (≥70% stenosis) is present in approximately 60% of people >80 years old. The good news is that the overall rate of death attributable to CVD declined by 34.4% from 2005 to 2015, and the actual number of patients dying in the same period decreased by 17.7%. A large percentage of this decrease is related to better therapy for patients with acute coronary syndromes (ACS) and chronic stable angina. Further improvements have come from better modification of CAD risk factors, although these improvements are increasingly being offset by higher obesity and type 2 diabetes mellitus rates.

In adults aged 85 to 94 years, the average annual rate of first cardiovascular events is 24 times that of those aged 35 to 44 years. For women, first cardiovascular events occur about 10 years later in life, with the difference narrowing with advancing age. Older adults are more likely to die from CAD compared to their younger counterparts due to the higher prevalence of CAD risk factors, multivessel disease, left main CAD, and left ventricular (LV) dysfunction, along with other noncardiovascular chronic conditions. Older adults also tend to have more chronic conditions, which contribute to them having fewer surgical and interventional procedures and more adverse events from medications. They are also less frequently referred for cardiac rehabilitation. Congestive heart failure, one of the long-term complications of CAD, is the most common diagnosis on hospital discharge, and the majority of these patients are age 65 years or older.

General principles of CAD management in older patients include thoughtful and careful assessment of CAD risk factors and their management. This means ...

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