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LEARNING OBJECTIVES

Learning Objectives

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

  • Recognize the clinical aspects—including symptoms, signs, and diagnostic test results—that are common among older adults with CHD.

  • Understand treatment of CHD, including treatment of dyslipidemias, in older adults.

Key Clinical Points

  1. CHD is common and has high morbidity and mortality in older adults.

  2. Many older patients have asymptomatic, stable, or subclinical ischemic heart disease.

  3. Total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglyceride (TG) levels increase from the third to seventh decade of life. Typically, LDL-C remains stable or even declines in older age cohorts.

  4. Dyslipidemia is a well-established risk factor for cardiovascular disease, but strength of this association is diminished with age and limited data exists for those older than age 80.

  5. Typical angina is the most common presenting symptom of CHD regardless of age.

  6. Delays in recognizing other symptoms such as dyspnea, fatigue, or epigastric discomfort may contribute to later presentations among older adults.

  7. Evaluation for symptoms suggestive of CHD should be similar in older and younger patients. Functional testing is a valuable diagnostic and prognostic tool in older adults. Modified protocols or pharmacologic-based stress tests may be used for those who experience difficulty with standard exercise protocols.

  8. Management of CHD should be similar in older and younger patients prioritizing risk factor modification, symptomatic relief, and goals of care.

  9. Revascularization is an effective method for relief of frequent angina particularly if symptoms remain despite optimally tolerated medical therapy.

INTRODUCTION

The spectrum of coronary heart disease (CHD) includes subclinical CHD, asymptomatic or stable ischemic heart disease, and acute coronary syndromes including unstable angina and acute myocardial infarction (MI). Atherosclerosis in the coronary circulation contributes to luminal narrowing and increases risk of vascular dysfunction and thrombosis. Clinical presentations of CHD result from insufficient oxygen supply for the demands of the myocardium. Dyslipidemia is a major risk factor for the development of CHD in individuals up to age 80. There are multiple available therapeutic options to reduce blood cholesterol levels, many of which also modify future risk of cardiovascular events.

EPIDEMIOLOGY

Despite declining mortality over the past three decades, CHD remains the leading killer of both men and women in the United States. More than 80% of deaths from CHD occur in those older than 65 years. In the United States, the prevalence of CHD, MI, and angina all increase with age in both men and women (Figures 74-1 and 74-2). The initial manifestation of CHD may be an acute MI, occurring in about 40% of cases, or sudden death in 10% to 20% of cases. The average age of first MI is 66 years for men and 72 years for women. In-hospital mortality following an MI also rises sharply with age: less than 1% in those younger than 50 years old, ~2.5% in those 60 to 69 ...

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