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Management of high-risk populations with coronary artery disease: rationale for improving prognosis in the elderlyP. Meurin Introduction
The efficacy and acceptability of trimetazidine
have been confirmed by Kölbel and Bada (unpublished data) in 120
elderly coronary patients (65–86 years) resistant to hemodynamic
monotherapy. At 12 weeks’ follow-up, trimetazidine 20 mg tid significantly
improved all exercise parameters (1-mm ST-segment depression,
exercise duration). Patient-assessed quality of life was rated
good or excellent in 89% of cases. Only two minor adverse events
(gastric pain and dyspepsia) were reported.
Demographics of the prevalence, incidence, and management of coronary heart disease in the elderly and in women. Kannel WB, Vokonas PS. Evans Memorial Department of Research and Department of Medicine, University Hospital, Boston University School of Medicine, MA. Cardiovascular disease constitutes an expanding problem in the elderly because of the increasing size of the aged population. Atherosclerosis, hypertension, and diabetes are responsible for the predonderance of cardiovascular disease, which causes 70% of all deaths beyond age 75. Coronary heart disease (CHD) is the most common and most lethal cardiovascular event in both sexes, exacting a large toll in disability and deteriorated quality of life in old age. Unrecognized myocardial infarctions are especially common and are as serious as symptomatic infarctions. beyond age 65, women are as vulnerable to cardiovascular death as men. The predisposing modifiable risk factors for coronary disease, stroke, peripheral arterial disease, and cardiac failure are similar in young and old and in men and women. These include hypertension, dyslipidemia, impaired glucose tolerance, physical indolence, and cigarette smoking. An attenuated risk ratio for some risk factors is offset by a greater incidence of cardiovascular events in advanced age so that the attributable risk and the potential benefit of treatment rise with age. Because the major risk factors predict CHD as efficiently in the elderly as in the young, and the decline in cardiovascular mortality has included the elderly, preventive efforts in the elderly may have substantial potential benefit. At advanced age, total cholesterol levels are considerably higher in women than in men. Some 10 million elderly, two-thirds of whom are women, may require investigation and treatment for elevated lipid levels, as determined by National Heart, Lung, and Blood Institute (NHLBI) guidelines. Because of the preponderance of women in the elderly population, trials of the efficacy of correcting risk factors in general, and lipids in particular, should include women. PMID: 1342264 [PubMed - indexed for MEDLINE]
Preventive cardiology in the elderly. Wenger NK. Emory University School of Medicine, Division of Cardiology, Atlanta, GA 30303, USA. Cardiovascular disease is the leading cause of death world-wide in populations older than 65 years of age. The variation in cardiovascular mortality rates in this population indicates a substantial potential for effective coronary prevention. The highest risk for development of coronary heart disease is in individuals older than 65 years of age; many of the risk factors for coronary disease are modifiable, such that an older population may benefit substantially from a preventive program aimed at reducing coronary heart disease. The promotion of cardiovascular health at elderly age requires emphasis on the adoption of healthy lifestyles and the use of pharmacologic intervention when appropriate. Publication Types:
Optimal treatment of angina in older patients. Doughty RN, Sharpe N. Department of Medicine, University of Auckland School of Medicine, New Zealand. Ischaemic heart disease is a major problem in the elderly. Compared with younger patients, coexisting medical conditions are more common and the patients are more likely to be receiving multiple drugs. In addition, drug pharmacodynamics are altered in the elderly and this needs to be carefully considered when commencing treatment for angina. In practice, the general principles of management of elderly patients with angina are similar to that of younger patients. However, particular care needs to be taken with the therapeutic regimens used. This article reviews the approach to the treatment of stable exertional angina in the elderly. Publication Types:
Angina pectoris in the elderly. Fleg JL. Laboratory of Cardiovascular Science, National Institute on Aging, Baltimore, Maryland. Although the ability to document angina pectoris in the elderly patient may be compromised by atypical symptoms, limited activity levels, and blunted recall, anginal symptoms convey a similar adverse prognosis regardless of age. In general, the therapeutic approach to the older anginal patient should be dictated more by achievement of symptomatic relief than by considerations of long-term survival. No randomized trial exists to guide the decision of medical versus coronary artery bypass surgery versus angioplasty in the older patient with coronary artery disease; symptomatic relief, however, appears greater after revascularization procedures. Publication Types:
Cardiologists' perception of risk of coronary revascularization procedures. Vaitkus PT, Witmer WT, Adele C. Cardiology Unit, University of Vermont College of Medicine, Burlington, USA. We sought to determine if differences exist between interventional and noninterventional cardiologists in the perception of risk of revascularization procedures and to compare the physicians' estimates with a computer-based predictor formula from a large regional database. We found that interventional cardiologists perceived greater risk of percutaneous transluminal coronary angioplasty-related morbidity and mortality than noninterventionalists and that these differences were accentuated in female patients, the elderly, and the most seriously ill patients. PMID: 9264430 [PubMed - indexed for MEDLINE]
Acute coronary interventions in the elderly. Overview. Rich MW. Washington University School of Medicine, St Louis, Missouri, USA. PMID: 11041647 [PubMed - indexed for MEDLINE]
Epidemiology of adverse drug events in the nursing home setting. Monette J, Gurwitz JH, Avorn J. Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. There is widespread concern about the level of use, particularly the inappropriate use, of drugs among elderly residents of nursing homes. Medication consumption by these individuals is among the highest of any patient population; residents of nursing homes are prescribed an average of 5 to 8 regularly scheduled medications in addition to those drugs prescribed on an as needed ('prn') basis. Ideally, drug therapy should result in beneficial effects and improved quality of life for patients. However, the development of adverse drug events (ADEs) can compromise the expected benefits of pharmacotherapy for the individual nursing-home resident and may represent a public health problem of considerable magnitude. Publication Types:
The antiischemic effects and tolerability of trimetazidine in coronary diabetic patients. A substudy from TRIMPOL-1. Szwed H, Sadowski Z, Pachocki R, Domzal-Bochenska M, Szymczak K, Szydlowski Z, Paradowski A, Gajos G, Kaluza G, Kulon I, Wator-Brzezinska A, Elikowski W, Kuzniak M. National Institute of Cardiology, Warsaw, Poland. Diabetes mellitus, a disease with a wide prevalence, has major cardiovascular effects, being a risk factor for the development of ischemic heart disease and congestive heart failure. The aim of this open, multicenter study was to assess the antiischemic efficacy and tolerability of trimetazidine, a metabolic agent acting at the myocardial mitochondrial level, in diabetic patients with stable effort angina treated previously with a single conventional antianginal drug. Fifty diabetic patients (mean age 58 years) with proven coronary artery disease, stable effort angina for at least 3 months, and positive, comparable results of two initial treadmill exercise tests separated by a 1-week interval were included in the study. They continued their conventional antianginal monotherapy with a long-acting nitrate, beta-blocker, or calcium channel blocker. After stabilization, 4-week therapy with trimetazidine, three times daily, 20 mg was initiated in combination with previous treatment. The results showed a significant improvement in exercise tolerance (440.2 vs. 383.2 s; P < 0.01), time to 1-mm ST-segment depression (358.3 vs. 301.6 s; P < 0.01), time to onset of anginal pain (400.0 vs. 238.3 s; P < 0.01), and total work (9.39 vs. 8.67 metabolic equivalents, P < 0.01). Maximal ST-segment depression was attenuated compared with baseline (1.82 vs. 1.91 mm). Other findings included a significant decrease in the mean frequency of anginal episodes (3.06 vs. 4.79 per week; P < 0.01) and in mean nitrate consumption (2.29 vs. 4.2 doses/week). These results suggest that trimetazidine may be effective and is well tolerated as combination therapy for diabetic coronary artery disease patients uncontrolled with a single hemodynamic agent. Publication Types:
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