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CARDIOLOGY CASEBOOK |
Corresponding author and reprint requests: Louis Lemberg, University of Miami Miller School of Medicine, Division of Cardiology (D-39), PO Box 016960, Miami, FL 33101.
An 81-year-old retired male mathematics instructor had relocated to South Florida and came to a generalist for an initial evaluation. He had been inactive physically but considered himself to be in fairly good health. On detailed questioning, he admitted to having transient episodes of dyspnea lasting 2 to 4 minutes brought on by emotional stress. These attacks of transient dyspnea were considered to be a variant of angina pectoris and a rare isolated manifestation of transient coronary arterial vasoconstriction (ie, not the classic symptoms of precordial pain or pressure). He had no nocturnal symptoms.
Physical examination revealed the following: weight 212 lb (95.4 kg), height 5 ft 10 in (1 m 78), blood pressure 155/80 mm Hg in the right arm, and pulse 76/min. On auscultation, there was an S4 gallop, the aortic second sound was accentuated and tambour (drumlike) in quality, and a grade 4/6 aortic systolic murmur was heard at the base and transmitted to the mitral area, consistent with aortic valve sclerosis. A hepatojugular reflux could not be elicited.
The patient’s fasting blood sugar level was 126 mg/dL (7 mmol/L), glycohemoglobin A1C 7.5%, total cholesterol 246 mg/dL (6.36 mmol/L), high-density lipoprotein 46 mg/dL (1.19 mmol/L), low-density lipoprotein cholesterol (LDL-C) 138 mg/dL (3.57 mmol/L), triglycerides 322 mg/dL (3.64 mmol/L), high-sensitivity C-reactive protein 0.8 mg/L, and B-type brain natriuretic peptide 90 pg/mL. The electrocardiogram revealed evidence of left ventricular hypertrophy; abnormal Q waves in leads II, III, and aVF; and ST-T changes consistent with an old inferior myocardial infarction (MI).
The diagnoses were (1) anginal syndrome and old inferior MI due to atherosclerotic heart disease, (2) essential hypertension, (3) diabetes mellitus type 2, and (4) moderate exogenous obesity. The patient requested a trial of medical rather than invasive management and said he would adhere to strict medical management. His request was considered reasonable in light of the normal levels of high-sensitivity C-reactive protein and B-type natriuretic peptide. A statin was prescribed, with the dosage to be titrated to achieve an LDL-C of 40 to 50 mg/dL (1.03–1.29 mmol/L) to be followed by periodic hepatic function tests and assessment of blood lipid levels.1
In addition, the patient was started on a low-sodium, low-cholesterol, low-carbohydrate, weight-reduction diet and a daily progressive walking exercise program. Sublingual nitroglycerin 0.6 mg was ordered to be taken before his walking exercise and every 2 to 3 hours as tolerated, as well as when necessary for angina. His borderline type 2 diabetes was expected to respond to a low-caloric, low-cholesterol, weight-reduction diet and the exercise regimen. The test for glycohemoglobin A1C was to be repeated in 6 weeks.
QUESTIONS
ANSWERS
1. d. secondary prevention of CAD in elderly patients 75 years of age or more
Greater involvement in preventive measures that control the risk factors for CAD in elderly persons is imperative and needs to be emphasized. Older persons are often therapeutically neglected and considered by the younger generations as having attained a "ripe" old age. Statistics belie these attitudes; elderly persons have much to gain in extended healthy and productive lives when their risk factors are reduced with appropriate therapy.2 Thus secondary prevention of CAD in persons 75 years of age or more is a goal that should be advised.
2. b. the incidence of CAD increases with age
c. the clinical presentation of CAD in elderly persons tends to be atypical
d. medications that improve MI survival are underused in elderly patients
CAD is a major problem in industrialized countries. Increases in life expectancy and declines in fertility rates have produced a demographic shift toward an older population. The prevalence of heart disease increases with age; on autopsy 50% of elderly women and 70% to 80% of elderly men have obstructive CAD.2 Because our elderly populations have improved rates of survival and live longer, secondary prevention strategies such as exercise; smoking cessation; managing hyperlipidemia, hypertension, and diabetes; and weight control have become vitally important. Elderly persons who would benefit from these interventions are usually not referred.2 Octogenarians account for 20% of all hospitalizations for MI and 30% of all MI-related deaths even though they comprise only 5% of the population in the United States.3 The increase in mortality due to CAD in elderly persons can be attributed not only to the presence of comorbid conditions, but also to the fact that the signs and symptoms of CAD are atypical in elderly persons. Frequently, the only symptoms are dyspnea due to progressive heart failure, particularly in women.2 In addition, elderly persons tend to have extensive CAD. The lack of typical symptoms of chest pain with exertion in elderly persons could be due to their physical inactivity because many have orthopedic, pulmonary, or neurological conditions that limit activity and exercise.2 Half of the elderly population is inactive and one fourth is sedentary.3 After MI, all patients should be routinely treated with an ACE inhibitor, a ß-blocker, aspirin, and frequently a statin. It is worth noting that these medications are under-used in elderly persons.4,5
3. c. in elderly and high-risk patients, a goal of 50 mg/dL (1.29 mmol/L) for LDL-C level is reasonable
Despite the high prevalence of CAD in older persons, few studies have targeted this population vis-à-vis the benefits of cholesterol reduction. However, analysis of available data unequivocally demonstrates the benefits of lowering LDL-C levels in both the primary and secondary prevention of CAD. For every 1% reduction in LDL-C level, the relative risk for major CAD events is reduced 1%.6 This benefit held true for both younger and older patients, with a greater reduction in relative risk in older patients.2,3 Age is not a contraindication for lipid-lowering therapy.
LDL-C levels of 40 to 60 mg/dL (1.03–1.55 mmol/L) can be achieved with the use of adequate doses of a statin.1 A threshold LDL-C level below which no further benefit occurs has not been established. Statin drugs have an acceptable risk profile in older persons and are tolerated with few side effects. The risk of myopathy or liver dysfunction is low at any dose level. When levels of LDL-C have been driven down to 40 or 50 mg/dL (1.03 or 1.29 mmol/L) with adequate statin doses, a substantial increase in the level of high-density lipoprotein cholesterol is often observed (L.L., personal observation).
4. b. a wide pulse pressure greater than 50 mm Hg could be a better marker for heart failure and cerebrovascular disease in elderly persons than the diastolic blood pressure
c. morbidity and mortality from stroke, CAD, heart failure, and renal insufficiency are reduced when blood pressure is controlled
d. nonpharmacological interventions in the management of blood pressure are more beneficial in elderly patients
Congestive heart failure is characterized by vascular hypervolemia. The excess volume in congestive heart failure is in a vascular system that is less compliant, resulting in a widened pulse pressure. A wide pulse pressure (eg, >50 mm Hg) in an elderly person is a better marker of congestive heart failure than the diastolic pressure.
Management of hypertension is paramount for minimizing the risks of cardiovascular and cerebrovascular events in elderly persons. More than 50% of those over the age of 60 are hypertensive, especially women.7 The benefits of hypertensive therapy in older persons are well documented, and significant reductions in the risk of stroke, heart failure, and coronary events are achieved as a result of antihypertensive therapy. This fact is contrary to the concepts promulgated that blood pressures above normal in elderly persons are clinically irrelevant, and many older patients continue to receive inadequate hypertensive therapy. In fact, in the 1930s and 1940s, elevated blood pressures were considered to be appropriate because it was thought that elevated blood pressures were necessary to get blood to the brain and kidneys.
Two thirds of patients 75 years of age and older have uncontrolled hypertension. The target blood pressure is 130/90 mm Hg or less and is the same as in younger patients. A lower target of 120/80 mm Hg or less is advised in patients with diabetes, heart failure, CAD, or renal insufficiency. A reduction in morbidity and mortality due to stroke, CAD, heart failure, and chronic renal failure can be achieved with blood pressure control.2 Nonpharmacological interventions in blood pressure management (eg, weight reduction, exercise, and low salt intake) are often neglected even though they are more beneficial in older persons than in young persons.8
5. e. all of the above
Smoking, a primary risk factor in cardiovascular and cerebrovascular disease, is independently associated with sudden cardiac death. Increased carboxyhemoglobin levels from smoking have been associated with arrhythmias.9–12 The greatest risk from arrhythmias in an acute MI occurs within the first few days.13 Smoking cessation reduces heart rate and levels of carboxyhemoglobin to normal within days, resulting in a lower incidence of sudden cardiac death.14 Smoking cessation reduces mortality equally to or greater than the use of daily aspirin, ß-blockers, or ACE inhibitors.3 It is thus clinically imperative that smoking cessation programs be implemented promptly in the acute care setting.
6. a. a regular exercise program is beneficial in elderly persons
Exercise has an impact on elderly persons. A sedentary lifestyle is associated with a higher mortality rate. The level of activity was an independent predictor of 5-year survival in a group of elderly persons with a mean age of 73 years.3 Exercise has a positive influence on coronary risk factors such as hypertension, insulin-resistant diabetes, hypercholesteremia, and obesity. Exercise recommendations should address leisure time and occupational activities of daily living. Older persons who are on programmed exercise regimens achieve greater benefits in quality of life and total functional scores than are observed in younger persons.3
The beneficial effects of moderate and regular physical activity in older persons are universally acknowledged. Regular physical activity decreases the chances of cardiovascular mortality, and that includes lowering the incidence of stroke.15,16 Active older adults have a lower incidence of depression, and their quality and duration of sleep may be enhanced.17 Research performed in healthy, sedentary older adults has demonstrated that even a superficial exercise program can significantly increase their functional capacity measured by oxygen consumption. After 4 months of aerobic exercise, their functional capacity has been shown to increase by an average of 10% to 15%.18 The same group of older adults also achieved a reduction in total and LDL-C cholesterol, as well as an increase in high-density lipoproteins. These studies show that elderly persons can and should engage in regular, moderate physical activity (eg, walking for approximately 30 minutes 5 to 6 days a week).
The incidence of dementia increases exponentially with age.16 Ten percent of persons more than 65 years of age and 50% of persons more than 85 years of age have some form of cognitive impairment.16 This area of research also has shown that older adults who are physically active perform better in cognitive testing than do sedentary older adults. Prospective studies have shown that women with higher levels of physical activity were less likely to develop cognitive decline. In one study,16 women had 15% lower odds of cognitive decline for every 10 blocks walked per day. Possible mechanisms by which physical activity may influence cognitive function include the following: reduction in the risk of cardiovascular and cerebrovascular disease, stimulation of neuronal growth, and increased cerebral blood flow.16
The incidence of falling increases with age. Falling can be particularly problematic in very frail elderly persons because their slower reflexes, poor vision, and osteoporosis make them more susceptible to injuries. Evidence is increasing that participation in regular exercise programs can reduce the risk of falling, particularly when supplemented by education, review of medications, and modification in the home environment.17 Physical activity can improve balance; muscle strength can improve with progressive resistance training. Strength-building programs can improve mobility and balance, aiding in weight maintenance.
No adverse outcomes related to exercise in elderly persons have been reported in any study to date. There are no age limits to regular exercise.
SUMMARY
A composite of secondary prevention of CAD in elderly persons includes the following: exercise, weight control, and managing dyslipidemia, diabetes, and hypertension. Cardiac rehabilitation programs and exercise programs are additional measures in secondary prevention. Current studies support the following conclusions:
ACKNOWLEDGMENT
Supported in part by a grant from the Applebaum Foundation in loving memory of Mr Joseph Applebaum.
REFERENCES
75 years of age): an American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2002;105:1735–1743.
Amar D, Zhang H, Heerdt PM, Park B, Fleisher M, Thaler HT. Statin use is associated with a reduction in atrial fibrillation after noncardiac thoracic surgery independent of C-reactive protein. Chest. 2005;128:3421–3427.
De Servi S, Mariani M, Mariani G, Mazzone A. C-reactive protein increase in unstable coronary disease cause or effect? J Am Coll Cardiol. 2005;46:1496–1502.
Futterman LG, Lemberg L. Focus: hypertension in the aged population. Am J Crit Care. 2002;11:80–86.
Gotto AM Jr. Evolving concepts of dyslipidemia, atherosclerosis, and cardiovascular disease. J Am Coll Cardiol. 2005;46:1219–1224.
Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome. An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112: 2735–2752.
Keller KB, Lemberg L. Retirement is no excuse for physical inactivity or isolation. Am J Crit Care. 2002;11:270–272.
Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004;292:1433–1439.
LaRosa JC. At the heart of the statin benefit. J Am Coll Cardiol. 2005; 46:1863.
Libby P. The forgotten majority. J Am Coll Cardiol. 2005;46:1225–1228.
Nash DT. Relationship of C-reactive protein, metabolic syndrome and diabetes mellitus: potential role of statins. J Natl Med Assoc. 2005;97:1600–1607.[Medline]
Nissen SE, Nicholls SJ, Sipahi I, et al. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. JAMA. 2006;295:1556–1565.
Ray KK, Cannon CP. The potential relevance of the multiple lipid-independent (pleiotrophic) effects of statins in the management of acute coronary syndromes. J Am Coll Cardiol. 2005;46:1425–1433.
Ray KK, Cannon CP, Cairns R, et al. Relationship between uncontrolled risk factors and C-reactive protein levels in patients receiving standard or intensive statin therapy for acute coronary syndromes in the PROVE IT-TIMI 22 trial. J Am Coll Cardiol. 2005;46:1417–1424.
Ray KK, Cannon CP, McCabe CH, et al. Early and late benefits of high-dose atorvastatin in patients with acute coronary syndromes: results from the PROVE IT-TIMI 22 trial. J Am Coll Cardiol. 2005;46:1405–1410.
Robinson JG, Smith B, Maheshwari N, Schrott H. Pleiotrophic effects of statins: benefit beyond cholesterol reduction? A meta-regression analysis. J Am Coll Cardiol. 2005;46:1855–1862.
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