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Essentials of Diagnosis

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

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

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

  • Exercise or pharmacologic stress test evidence of myocardial ischemia.

  • Angiographic evidence of coronary stenosis.

  • Older adults with coronary disease often have atypical or non-specific symptoms such as abdominal pain, dizziness, confusion, or fatigue instead of more classic symptoms.

General Principles in Older Adults

The prevalence of cardiovascular disease (CVD) and especially coronary artery disease (CAD) is increasing. In the United States, 82.6 million people have CVD, and of these, 40.4 million are older than age 60 years. Among people free of CVD at age 50 years, there is a lifetime risk for developing it of 51.7% for men and 39.2% for women. The good news is that the overall rate of death attributable to CVD has declined 30.6% from 1998 to 2008 and the actual number of patients dying in the same period decreased by 14.1%. A large percentage of this decrease is related to better therapy for patients with acute coronary syndromes (ACSs) and chronic stable angina.

Analysis of National Health and Nutrition Examination Survey (NHANES) data comparing death rates attributable to CAD between 1980 and 2000 found that approximately 47% of the decrease in coronary deaths was attributable to medical and surgical treatments and approximately 44% to changes in coronary risk factors. Unfortunately, these decreases in risk factors were partially offset by increases in obesity and type II diabetes.

Increasing age is a major factor in the increasing incidence of CVD, including aortic stenosis and CAD. In the age group 85 to 94 years, the average annual rate of first cardiovascular events is 24 times that of those in the age group 35 to 44 years. For women, comparable rates occur about 10 years later in life, with the difference narrowing with advancing age. Older adults also have a greater number of comorbidities. At least partly for this reason, they also have fewer surgical and interventional procedures, more adverse events from medication, more polypharmacy, are less frequently referred for cardiac rehabilitation and have a higher morbidity and mortality than younger patients with similar CVD. Congestive heart failure is the most common diagnosis on hospital discharge and the majority of these patients are age 65 years or older. Finally, approximately 80% of people who die are ≥65 years of age and most die with CAD.

Cardiovascular Changes with Normal Aging

With normal aging there are a number of changes seen in the heart and other organs that alter function and are precursors to a variety of diseases seen in older adults (Table 28–1). These changes occur in everyone as they age and must be distinguished from changes related ...

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