Stable
angina in the elderly
Graham Jackson
Consultant Cardiologist, Guy’s and St Thomas’ Hospitals NHS Trust,
Cardiothoracic Centre, St Thomas’ Hospital, London, UK
Correspondence: Dr Graham Jackson, Guy’s and St Thomas’ Hospitals
NHS Trust, Cardiothoracic Centre, 6th Floor East Wing, St Thomas’
Hospital, Lambeth Palace Road, London SE1 7EH, UK. Tel: +44 20
7928 9292, fax: +44 20 7960 5680,
e-mail:
lilian.crossley@gstt.sthames.nhs.uk
Introduction
In both sexes the prevalence of ischemic heart disease increases
with age and is the leading cause of death in the elderly. Between
45 and 54 years of age, 2% to 5% of men and 0.5% to 1% of women
have angina, but this rises to 11% to 20% of men and 10% to 14%
of women aged 65 to 74 years. Over 75 years of age, the prevalence
is the same for men and women at 25% to 33%.[1]
As our population ages and more people survive myocardial infarction,
managing angina in the elderly will become an increasing challenge,
and one that we cannot and must not avoid.
Natural history
As approximately 80% of all deaths due to myocardial infarction
occur in those over 65 years of age, the elderly can be seen to
be at higher absolute risk than younger patients and therefore
may benefit more from treatment in terms of survival and symptom
relief.[2] Stable angina has a good prognosis
whatever we do. Each year only 2% to 3% will die and a similar
number will suffer from nonfatal myocardial infarction.[1]
However, some patients are more at risk of cardiac events than
others and they can usually be identified by noninvasive exercise
testing with or without echocardiography or nuclear imaging. Because
of the low event rate we have time to stratify for risk whilst
simultaneously optimizing risk factor management and medical therapy
for relief of symptoms. By identifying those at increased risk
(eg, left main stem disease, three-vessel disease with reduced
left ventricular function), we imply the need to reduce that risk,
for example by CABG. However, the elderly may not share our enthusiasm
for intervention, preferring symptomatic relief rather than intervention
purely to improve prognosis. After a long life, quality of life
assumes an ever-increasing priority, and in the presence of comorbid
conditions (eg, arthritis), which may in turn limit mobility,
acceptance of mild-to-moderate angina is not unusual. The elderly,
however, must not be denied intervention if their quality of life
is impaired, but the options are fewer and the complications more
frequent due to the often diffuse CAD, reduced left ventricular
function, and associated atheroma of the carotid, renal, and peripheral
arteries.[3] We give our advice on the basis
of statistics, but we need to remember always to individualize
our management decision, especially in the elderly — statistics
must never be allowed to hide the individual. Although we live
in an era of evidence-based medicine, treatment should never be
divorced from good clinical judgment: neither is valid without
the other.
Diagnosis
Anginal symptoms in the elderly may not be the textbook story
of chest pain on effort. Older people often perceive the symptoms
as breathlessness, so it is important to probe for what exactly
makes the person feel breathless. It is often the tightness of
angina which leads to a feeling of restricted breathing. More
advanced CAD in the elderly can induce ischemic left ventricular
dysfunction where the symptom of breathlessness on effort can
be confusing, therefore CAD should always be considered, even
if left ventricular function is normal on resting echocardiography.
Older people may have variable degrees of mobility which may influence
their symptoms and coexisting diseases; musculoskeletal (arthritic)
disorders and esophageal symptoms make history-taking a particular
diagnostic challenge.[4] A good, basic, and
simple history is essential: where is the pain, what brings it
on, what does it feel like, where else is it felt, how is it relieved?
I often ask older people to imagine walking up an incline and
then ask them to describe what happens: using a real situation
rather than an abstract concept is often of great help in extracting
the history.
The elderly more frequently have coexisting cardiac disorders
and these, along with the possibility of anemia or hyperthyroidism,
should be investigated as part of the overall evaluation (Table
I).
Table I. Conditions other than CAD which
can independently cause angina or exacerbate angina due to underlying
CAD.
It is useful to have an examination checklist (Table
II). Routine blood tests should be performed to assess renal function,
lipid status, and blood glucose (diabetes is common in the older
age group and increases cardiovascular risk).
Table II. Examination checklist.
Noninvasive cardiac tests
If there are suggestions of valvular heart disease, left ventricular
dysfunction, or left ventricular hypertrophy, an echocardiogram
is essential. The 12-lead ECG is abnormal in over 50% of older
people and may identify previous silent infarction or atrial fibrillation.
The fit elderly should be considered for exercise testing to stratify
for risk, or where diagnostic doubts exist. Those unable to exercise
can undergo pharmacologic stress echocardiography or nuclear imaging.
Care is needed when embarking on risk stratification: the elderly
need to understand the possibility of surgical intervention as
an option which they may not wish to pursue, rendering extensive
testing wasteful of time and resources. Exercise testing criteria
for risk remain as valid in the elderly as in the younger population,
even though maximal heart rate responses are lower (Table III).
Table III. Exercise testing end points suggesting
high or low risk.
The presence of an abdominal aortic aneurysm may
be indicated by careful examination of the abdomen and should
be clarified by ultrasound or CT scanning. Similarly, carotid
bruits should be evaluated using ultrasonic angiology.
Medical treatment
With increasing age, there are differences in the pharmacokinetics
and pharmacodynamics of cardiovascular drugs.[2,5]
Hepatic clearance of many drugs is reduced in elderly people and
there is an age-related fall in glomerular filtration rate and
creatinine clearance. The elderly also have a tendency to postural
hypotension secondary to age-related cardiovascular responses
to posture. Drugs excreted via hepatic or renal pathways need
to be used carefully, starting low and titrating to effect. Recognizing
greater drug sensitivity should not lead to suboptimal therapy
but a slower and more cautious titration.[6]
Using conventional hemodynamic drugs (b-blockers, calcium antagonists,
nitrates, nicorandil) the elderly usually obtain symptomatic benefit,
but they are more vulnerable to the adverse effects (Table IV).
Table IV. Common adverse effects of hemodynamic
antianginal drugs in the elderly.
Suggested starting doses are listed in Table V.
Combining two low-dose hemodynamic agents (eg, atenolol 25 mg
plus long-acting isosorbide mononitrate 25 mg) daily may maximize
symptom relief and minimize adverse effects.
 Table
V. Suggested starting doses of antianginal drugs in the elderly.
Metabolic agents
Metabolic agents such as trimetazidine do not have hemodynamic
actions and therefore represent useful alternative agents in the
elderly, avoiding the adverse effects listed in Table IV. In the
elderly substudy of Trimpol-1 (Trimetazidine in Poland), trimetazidine
significantly increased exercise duration, time to onset of angina,
time to 1-mm ST-segment depression, and total work during maximal
exercise testing. Importantly, there was also a significant reduction
in anginal episodes and glyceryl trinitrate consumption, and minimal
adverse effects.[7] (See also page 24-26). Combining
a low-dose hemodynamic agent with trimetazidine may maximize symptom
relief and minimize adverse events. Patients intolerant of hemodynamic
agents may benefit from trimetazidine as monotherapy. The acronym
RAMPS (Table VI) offers sensible guidelines.
Table VI. The “RAMPS” approach.
The benefits of lipid-lowering therapy in the presence
of CAD in those up to 75 years of age have recently been confirmed
for pravastatin and simvastatin on the background of 80% aspirin
usage.[8] The secondary prevention trials LIPID[8]
(pravastatin), CARE[9] (pravastatin), and 4S[10]
(simvastatin) on average reduced the risk for all cardiovascular
events to the same degree in older compared with younger patients,
but because of the greater prevalence of CAD in the elderly, the
absolute benefit is greater: treating 1000 older patients over
6 years prevented 45 deaths, 33 myocardial infarcts, 32 unstable
angina episodes, 33 coronary revascularization procedures, and
13 strokes.[8] In the absence of contraindications,
all patients with CAD up to the age of 75 years should be commenced
on statin therapy; the strongest evidence base is for pravastatin
40 mg daily. Trials in the 75+ age group are ongoing, so decision-making
here must be individualized and the subject of clinical judgment.
Interventions
If symptomatic despite medical therapy, or presenting acutely,
intervention by angioplasty (± stent) or CABG benefits the elderly,
so that age per se should not be a contraindication. However,
we need to recognize the importance of symptom relief and not
embark on an anatomic correction crusade. Symptom relief may follow
from dilating the culprit stenosis with minimal risk, or allow
medical therapy to gain symptomatic control. The elderly in general
have more diffuse disease which is often calcified, so the careful
targeting and stenting of lesions at angioplasty are essential.
Similarly, advising on CABG assumes not only anatomic suitability
but also the patients’ overall risk (are they frail, what is their
renal status?) and their wishes (most do not want surgery).
Cardiac surgery in octogenarians has recently been reviewed.[11]
Among 182 patients, 24 (13%) died in hospital and 107 (59%) had
one or more major complications, with most recovering, and five
(3%) suffered a stroke. Hospital mortality increased to 26.5%
with combined valve and coronary surgery. Outcomes were worse
if the surgery was urgent or delayed until the patient was functional
class III or IV. These figures compare with an 8.2% inhospital
mortality for percutaneous coronary interventions in a similar
age group.[12] Considering overall risk, a
conservative approach should be adopted and PTCA used for symptoms
despite medical therapy and CABG, when PTCA is not an option.
Lifestyle changes
Most old people believe “it’s too late to change.” Given their
higher absolute risk, the elderly are likely to benefit more and
the benefit will almost certainly be cost-effective. It is never
too late to stop smoking, reduce weight, and take sensible exercise.
Lipid-lowering therapy has proven beneficial in those up to 75
years of age, and may well reduce CAD and stroke beyond 75 years
of age. Social support is important. Family and friends can help,
both in the home and with the shopping, but they should not be
an alternative to good medical therapy. Rather, they should be
complementary. Local difficulties can be helped by a home assessment:
would a stair lift help, can a mobility bus be arranged?
Conclusions
The elderly come from an era where respect was commonplace, courtesy
routine, and good manners plentiful. They now live in a less caring
world, but this should not diminish the respect they deserve.
We need to acknowledge their feelings and wishes, treat them carefully
and gently, and strive to maximize the quality of their remaining
years. By combining advice on lifestyle with family support, using
drugs selectively (and monitoring adverse effects), and choosing
intervention when appropriate, we have a lot to offer: neither
age nor cost should be a barrier to therapy in the elderly.
REFERENCES
Management of stable angina pectoris.
Recommendations of the Task Force of the European Society of
Cardiology.
Publication Types:
- Guideline
- Practice Guideline
- Review
- Review, Tutorial
PMID: 9076376 [PubMed - indexed for MEDLINE]
Heart disease in the elderly.
Lye M, Donnellan C.
Department of Geriatric Medicine, University of Liverpool,
Liverpool, UK. germed@liv.ac.uk
Publication Types:
PMID: 11040022 [PubMed - indexed for MEDLINE]
Coronary heart disease at 70, 75 and 79 years
of age: a longitudinal study with special reference to sex
differences and mortality.
Lernfelt B, Landahl S, Svanborg A.
Department of Geriatric and Long-term Care Medicine, Vasa
Hospital, Goteborg, Sweden.
In a population study of 70-year-old people in Goteborg, Sweden, a
representative sample of 449 men and 524 women was followed for
nine years. The prevalence of coronary heart disease (CHD) at age
70 was about 30% in both sexes and did not change up to age 79.
Myocardial infarction appeared twice as often in men as in women
at age 70 but angina pectoris and ST-T changes on ECG showed no
sex difference. Myocardial infarction and probable ischaemia on
ECG increased significantly between ages 70 and 79 in both sexes.
Half of the men with angina pectoris had a history of myocardial
infarction and/or probable ischaemia on ECG criteria compared with
23% of the women. The mortality rate was twice as high in men as
in women irrespective of CHD. When CHD was present at age 70 the
nine-year mortality was doubled. CHD was shown to be a strong
independent risk factor for death also in this age group.
PMID: 2251963 [PubMed - indexed for MEDLINE]
Angina in the elderly.
Duprez DA.
Department of Cardiology and Angiology, University Hospital, Gent,
Belgium.
Coronary artery disease (CAD) remains the most common cause of
heart disease in the elderly, in whom it exhibits some unique
features. It is more likely to be diffuse and severe and left main
coronary artery stenosis and triple-vessel disease are more
prevalent. Diagnosis is less dependent on the presence of chest
pain since other symptoms may present as an anginal equivalent in
such patients. The ECG of elderly patients often shows
abnormalities that are not specific for myocardial ischaemia. In
such patients, and in those who are unable to perform sufficient
exercise to increase the heart rate to > or = 85% of predicted
maximal heart rate for age and sex, radionuclide or
pharmacological stress testing may be used. When the diagnosis of
CAD remains questionable, coronary arteriography should be
considered. Physical examination and basic laboratory screening
should be used to identify conditions which exacerbate myocardial
ischaemia and will, therefore, affect treatment. The initial
approach to treatment should include risk factor modification and
initiation of an anti-ischaemic pharmacological regimen. The usual
anti-anginal medications are as efficacious in the elderly as in
the young; however, attention must be paid to altered
pharmacodynamics and pharmacokinetics. When symptoms are poorly
controlled by medical therapy or when multivessel or left main
coronary artery stenosis is identified, myocardial
revascularization should be considered. In elderly patients with
symptomatic angina or unstable angina symptoms, uncontrolled by
medical therapy, percutaneous transluminal coronary angiography
may be a reasonable alternative to surgical revascularization.
Publication Types:
PMID: 8960449 [PubMed - indexed for MEDLINE]
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:
PMID: 8935397 [PubMed - indexed for MEDLINE]
Cardiovascular disease in the elderly.
O'Kane P, Jackson G.
Guy's & St Thomas' Hospital Trust, London.
Publication Types:
PMID: 10534873 [PubMed - indexed for MEDLINE]
7. Szwed H, Sadowski Z, Pachocki
R, et al. Anti-ischaemic efficacy and tolerability of trimetazidine
in elderly patients with angina pectoris. Clin Drug Invest. 2000;19:1–8.
Benefits of pravastatin on cardiovascular
events and mortality in older patients with coronary heart disease
are equal to or exceed those seen in younger patients: Results
from the LIPID trial.
Hunt D, Young P, Simes J, Hague W, Mann S, Owensby D, Lane G,
Tonkin A.
Department of Cardiology, Royal Melbourne Hospital, Grattan
Street, Parkville Vic 3050, Australia.
BACKGROUND: The effect of cholesterol-lowering therapy on death
from coronary heart disease in older patients with previous
coronary heart disease and average cholesterol levels is
uncertain. OBJECTIVE: To compare the relative and absolute effects
of pravastatin on cardiovascular disease outcomes in patients with
coronary heart disease who are 65 years of age or older with those
in patients 31 to 64 years of age. DESIGN: Subgroup analysis of a
randomized, placebo-controlled trial. SETTING: 87 centers in
Australia and New Zealand. PATIENTS: 3514 patients 65 to 75 years
of age, chosen from among 9014 patients with previous myocardial
infarction or unstable angina and a baseline plasma cholesterol
level of 4.0 to 7.0 mmol/L (155 to 271 mg/dL). INTERVENTION:
Pravastatin, 40 mg/d, or placebo. MEASUREMENTS: Major
cardiovascular disease events over 6 years. RESULTS: Older
patients were at greater risk than younger patients (31 to 64
years of age) for death (20.6% vs. 9.8%), myocardial infarction
(11.4% vs. 9.5%), unstable angina (26.7% vs. 23.2%), and stroke
(6.7% vs. 3.1%) (all P < 0.001). Pravastatin reduced the risk for
all cardiovascular disease events, and similar relative effects
were observed in older and younger patients. In patients 65 to 75
years of age, pravastatin therapy reduced mortality by 21% (CI, 7%
to 32%), death from coronary heart disease by 24% (CI, 7% to 38%),
coronary heart disease death or nonfatal myocardial infarction by
22% (CI, 9% to 34%), myocardial infarction by 26% (CI, 9% to 40%),
and stroke by 12% (CI, -15% to 32%). For every 1000 older patients
treated over 6 years, pravastatin prevented 45 deaths, 33
myocardial infarctions, 32 unstable angina events, 34 coronary
revascularization procedures, 13 strokes, or 133 major
cardiovascular events, compared with 22 deaths and 107 major
cardiovascular events per 1000 younger patients. Among older
patients, the numbers needed to treat were 22 (CI, 17 to 36) to
prevent one death from any cause, 35 (CI, 24 to 67) to prevent one
death from coronary heart disease, and 21 (CI, 17 to 31) to
prevent one coronary heart disease death or nonfatal myocardial
infarction. CONCLUSIONS: In older patients with coronary heart
disease and average or moderately elevated cholesterol levels,
pravastatin therapy reduced the risk for all major cardiovascular
events and all-cause mortality. Since older patients are at
greater risk than younger patients for these events, the absolute
benefit of treatment is significantly greater in older patients.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 11352694 [PubMed - indexed for MEDLINE]
Comment in:
The effect of pravastatin on coronary events
after myocardial infarction in patients with average cholesterol
levels. Cholesterol and Recurrent Events Trial investigators.
Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole
TG, Brown L, Warnica JW, Arnold JM, Wun CC, Davis BR, Braunwald E.
Department of Medicine, Brigham and Women's Hospital and Harvard
Medical School, Boston, MA 02115, USA.
BACKGROUND: In patients with high cholesterol levels, lowering the
cholesterol level reduces the risk of coronary events, but the
effect of lowering cholesterol levels in the majority of patients
with coronary disease, who have average levels, is less clear.
METHODS: In a double-blind trial lasting five years we
administered either 40 mg of pravastatin per day or placebo to
4159 patients (3583 men and 576 women) with myocardial infarction
who had plasma total cholesterol levels below 240 mg per deciliter
(mean, 209) and low-density lipoprotein (LDL) cholesterol levels
of 115 to 174 mg per deciliter (mean, 139). The primary end point
was a fatal coronary event or a nonfatal myocardial infarction.
RESULTS: The frequency of the primary end point was 10.2 percent
in the pravastatin group and 13.2 percent in the placebo group, an
absolute difference of 3 percentage points and a 24 percent
reduction in risk (95 percent confidence interval, 9 to 36
percent; P = 0.003). Coronary bypass surgery was needed in 7.5
percent of the patients in the pravastatin group and 10 percent of
those in the placebo group, a 26 percent reduction (P=0.005), and
coronary angioplasty was needed in 8.3 percent of the pravastatin
group and 10.5 percent of the placebo group, a 23 percent
reduction (P=0.01). The frequency of stroke was reduced by 31
percent (P=0.03). There were no significant differences in overall
mortality or mortality from noncardiovascular causes. Pravastatin
lowered the rate of coronary events more among women than among
men. The reduction in coronary events was also greater in patients
with higher pretreatment levels of LDL cholesterol. CONCLUSIONS:
These results demonstrate that the benefit of cholesterol-lowering
therapy extends to the majority of patients with coronary disease
who have average cholesterol levels.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 8801446 [PubMed - indexed for MEDLINE]
Comment in:
Randomised trial of cholesterol lowering in
4444 patients with coronary heart disease: the Scandinavian
Simvastatin Survival Study (4S)
Drug therapy for hypercholesterolaemia has remained controversial
mainly because of insufficient clinical trial evidence for
improved survival. The present trial was designed to evaluate the
effect of cholesterol lowering with simvastatin on mortality and
morbidity in patients with coronary heart disease (CHD). 4444
patients with angina pectoris or previous myocardial infarction
and serum cholesterol 5.5-8.0 mmol/L on a lipid-lowering diet were
randomised to double-blind treatment with simvastatin or placebo.
Over the 5.4 years median follow-up period, simvastatin produced
mean changes in total cholesterol, low-density-lipoprotein
cholesterol, and high-density-lipoprotein cholesterol of -25%,
-35%, and +8%, respectively, with few adverse effects. 256
patients (12%) in the placebo group died, compared with 182 (8%)
in the simvastatin group. The relative risk of death in the
simvastatin group was 0.70 (95% CI 0.58-0.85, p = 0.0003). The
6-year probabilities of survival in the placebo and simvastatin
groups were 87.6% and 91.3%, respectively. There were 189 coronary
deaths in the placebo group and 111 in the simvastatin group
(relative risk 0.58, 95% CI 0.46-0.73), while noncardiovascular
causes accounted for 49 and 46 deaths, respectively. 622 patients
(28%) in the placebo group and 431 (19%) in the simvastatin group
had one or more major coronary events. The relative risk was 0.66
(95% CI 0.59-0.75, p < 0.00001), and the respective probabilities
of escaping such events were 70.5% and 79.6%. This risk was also
significantly reduced in subgroups consisting of women and
patients of both sexes aged 60 or more. Other benefits of
treatment included a 37% reduction (p < 0.00001) in the risk of
undergoing myocardial revascularisation procedures. This study
shows that long-term treatment with simvastatin is safe and
improves survival in CHD patients.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 7968073 [PubMed - indexed for MEDLINE]
Comment in:
Cardiac surgery in octogenarians; peri-operative
outcome and long-term results.
Kolh P, Kerzmann A, Lahaye L, Gerard P, Limet R.
Cardiothoracic Surgery Department, University Hospital of Liege, B
35 Sart Tilman, 4000 Liege, Belgium.
AIMS: Because the elderly are increasingly referred for operation,
we reviewed the results of cardiac surgery in patients of 80 years
or older. METHODS AND RESULTS: Records of 182 consecutive
octogenarians who had had cardiac operations between 1992 and 1998
were reviewed. Follow-up was 100% complete. Seventy patients had
coronary grafting (CABG), 70 aortic valve replacement, 30 aortic
valve replacement+CABG, and 12 mitral valve repair/replacement.
Rates of hospital death, stroke, and prolonged stay (>14 days)
were as follows: CABG: 7 (10%), 2 (2.8%) and 41 (58%); aortic
valve replacement: 6 (8.5%), 2 (2.8%) and 32 (45.7%); aortic valve
replacement+CABG: 8 (26.5%), 1 (3.8%) and 14 (46.6%); mitral valve
repair/replacement: 3 (25%), 1 (8.3%) and 5 (41.6%). Multivariate
predictors (P<0.05) of hospital death were New York Heart
Association functional class, urgent procedure, prolonged
cardiopulmonary bypass time, and, after aortic valve replacement,
previous percutaneous aortic valvuloplasty. Ascending aortic
atheromatous disease was predictive of stroke, while pre-operative
myocardial infarction was predictive of prolonged hospital stay.
Actuarial 5-year survival was as follows: CABG, 65.8+/-8.8%;
aortic valve replacement, 63.6+/-7.1%; aortic valve
replacement+CABG, 62.4+/-6.8%; mitral valve repair/replacement,
57.1+/-5.6%; and total, 63.0+/-5.6%. Multivariate predictors of
late death were pre-operative myocardial infarction, and urgent
procedure. Ninety percent of long-term survivors were in New York
Heart Association class I or II, and 87% believed having a heart
operation after age 80 years was a good choice. CONCLUSION:
Cardiac operations are successful in most octogenarians with
increased hospital mortality, and longer hospital stay. Long-term
survival and quality of life are good. Copyright 2001 The European
Society of Cardiology.
PMID: 11440496 [PubMed - indexed for MEDLINE]
Comment on:
Cardiac surgery in octogenarians: who, when
and how?
Pierard LA.
Publication Types:
PMID: 11440489 [PubMed - indexed for MEDLINE]
|
Books,