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Data from the National Center for Health Statistics have noted that the life expectancy at birth in the United States reached a record high of 77.5 years in 2003, attributable, in part, to the decline in mortality from heart disease during the past three decades. Despite this, coronary heart disease (CHD) 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 of age. In addition, 37% of recognized acute myocardial infarctions (MIs) occur in those older than 75 years of age, and, although these account for roughly 6% of the U.S. population, 60% of all MI-related deaths affect elderly patients 75 years of age or older.

The diagnosis, management, and posthospitalization care of elderly patients with CHD involve interplay of patient heterogeneity, comorbid conditions, functional status, drug pharmacology, and biological differences. This complexity is compounded by extrapolation of “evidence-based care” obtained from cardiovascular trials from which older patients were poorly represented. Given these characteristics, an adopted approach to cardiac care of elderly patients often requires developing a patient-centered plan of care and incorporating an individual's own goals and health expectations in the care decision process. While the term “elderly” has been used in the literature, no specific guideline to the care of elderly patients with CHD attributes a particular level of evidence to specific age. This chapter will reference specific age groups reported in the medical literature as available, bearing in mind that one's chronologic age may be a poor surrogate for one's overall health status.

The spectrum of CHD includes asymptomatic (or subclinical) CHD, chronic stable angina pectoris, unstable angina, and acute MI. Statistically, the first manifestation of CHD is an acute MI in 40% of cases and sudden death in 10% to 20% of cases. In the United States, the prevalence of overt CHD increases in a curvilinear fashion with advancing age in both men and women (Figure 76-1). Similarly, the annual rate of first heart attack rises with age in all race and gender subgroups. Furthermore, despite the fact that women typically have a 10-year lag in developing CHD as compared to men, the majority of patients with CHD ≥75 years of age or older are women because they typically have a longer lifespan.

Figure 76-1.

Estimated prevalence of coronary heart disease by age and sex. (Adapted with permission from Vargas et al. Cardiovascular Disease in the NHANES III. Ann Epidemiol 1997;7:523.)

It should also be realized that overt CHD represents just the tip of the coronary disease iceberg and a great number of elderly patients have asymptomatic, subclinical disease. Researchers for the Cardiovascular Health Study examined the prevalence of both clinical and subclinical cardiovascular disease in a large community-dwelling Medicare population by using a composite measure of MI on electrocardiogram (ECG) or echocardiography ...

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