Cardiology

CAD and the Elderly: Diagnostic and Therapeutic Considerations

I. CAD and the Elderly: What every physician needs to know.

Although age has a direct bearing on cardiovascular disease, the pace and nature of aging vary among individuals. Relative differences in biology (e.g., telomere length, genetic constitution), lifelong health habits (e.g., nutrition, exercise, dental care), cardiac risk factors (e.g., hypertension, cholesterol, tobacco, insulin resistance), comorbidities (e.g., infection, chronic obstructive pulmonary disease, renal disease, anemia, arthritis, depression, dementia, vision, and hearing deficits), psychological factors (e.g., interpersonal capacities, self-efficacy, coping skills), social structure (e.g., class, community, access, spouse, family support), economic resources (personal, governmental), and culture (religion, ethnicity, transcendent sense of meaning and purpose) influence each person’s aging process.

Despite such individual variation, 75 years is often cited as the beginning of old age. Likewise, 85 years is often used as an expedient threshold to classify very old age. These designations presume that by 75 and 85 years, respectively, most adults have sustained sufficient aging changes to exhibit clinically relevant differences in physiology and organ function and reserve.

Aging predisposes to a high incidence and prevalence of coronary artery disease (CAD) in both men and women. Aging is associated with cellular oxidative stress, inflammation, and shifts in gene expression that contribute to increased vascular stiffness, endothelial dysfunction, and thrombogenicity.

These pathophysiologic progressions are intrinsically conducive to CAD, and coronary susceptibility is typically compounded by traditional risk factors (e.g., hypertension, smoking, dyslipidemia, diabetes mellitus, obesity, and sedentary lifestyle) whose injurious effects accumulate over a lifetime. Autopsy studies indicate that obstructive CAD is present in approximately 50% of elderly women and 70% to 80% of such men.

Older CAD patients tend to have more extensive coronary atherosclerosis than younger adults, with a higher prevalence of multivessel disease, left main coronary artery obstruction, and prior myocardial infarction (MI). CAD is the leading cause of death in older adults, and its complications, including heart failure and heart rhythm disorders, are a major source of chronic disability, loss of independence, and impaired quality of life.

Since atherosclerosis is a systemic process, older patients with CAD often have concomitant peripheral arterial disease and/or cerebrovascular disease that further compromise functional capacity and contribute to diminished quality of life. Subclinical disease is also common, with exercise intolerance, cognitive changes, and dyspnea among the many age-related complaints often resulting from underlying CAD.

Challenges for clinicians caring for older adults relate both to recognition of CAD and to treatment decisions once it is detected. As in younger populations, evidence-based therapies include medical therapy and revascularization, but guidelines determining if/when they should be applied for older patients are often uncertain.

Older adults have the greatest mortality and morbidity risks attributable to CAD, providing a rationale for aggressive management; aging also increases the risks associated with treatments. High vulnerability to treatment complications (e.g., bleeding, renal failure, confusion/delirium) confound therapeutic choices for older adults, as benefits of therapy may be outweighed by associated complications and iatrogenic effects.

Current evidence-based CAD guidelines provide recommendations that often seem incongruous with the dynamics of typical old adults. These guidelines were derived predominantly from data pertaining to younger adults.

Some data for patients in their 70s were incorporated, but their eligibility criteria for research studies typically excluded comorbidities and complexities such that generalizability of today’s evidence-based guidelines to average community-dwelling elderly patients is uncertain. Additionally, data for patients older than 80 years are virtually absent from randomized clinical trials, providing no objective evidence to guide care for the burgeoning population of octogenarians and the very old prone to CAD.

II. Diagnostic Confirmation: Are you sure your patient has CAD?

Although adults ≥75 years of age account for only 6% of the U.S. population, 35% to 40% of MIs and up to 60% of deaths attributable to MI occur in this age group. ACS and/or chronic CAD symptoms often arise spontaneously in older adults, but are also more likely to occur secondary to noncardiac medical problems (e.g., infection, anemia, and emotional stress), which more likely provoke thrombosis and overwhelm cardiovascular reserve in older adults.

Ironically, the so-called "typical" CAD symptom of chest discomfort is less likely to be experienced by older CAD patients, while so-called "atypical" symptoms are more likely to be reported. Dyspnea is an extremely common presenting symptom, both for acute coronary syndromes (ACS) and chronic CAD.

Impaired diastolic relaxation (a process that relies on energy-dependent calcium flux into the myocyte sarcoplasmic reticulum to facilitate diastolic ventricular filling) is more likely to develop in older CAD patients. This is due in part to insufficient blood supply to meet physiologic needs (energy-dependent biomechanical abnormalities), but also due to age-related myocardial fibrosis and stiffening (age-related constitutional changes within the myocardium).

Both heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) occur commonly in association with CAD in older adults. Dyspnea, heart failure, and a wide range of other symptoms in older adults are often more subtle than CAD symptoms in younger adults. Even symptoms of confusion, agitation, or malaise can be manifestations of acute or escalating chronic CAD in older adults.

As with younger patients, evaluation for ACS includes serial assessment of biomarkers and ECGs. It is prudent to consider these measures as a routine part of noncardiac assessments because ACS often arises secondary to noncardiac precipitants.

Exercise stress testing is an important procedure to evaluate for chronic CAD. Exercise stress testing increases cardiac workload, as a means to provoke ischemic ECG changes and/or symptoms for diagnosis of chronic CAD.

Given that cardiovascular risk factors (hypertension, dyslipidemia, smoking, diabetes) typically increase with age, older adults are usually categorized as having an intermediate pre-stress test probably of CAD. Stress testing has value in distinguishing additional diagnostic criteria that are induced by exercise provocation.

This often has particular benefit for older adults, since many seniors become sedentary to self-moderate ischemic symptoms, a cycle that often obscures CAD in sedentary patients who claim to be asymptomatic.

By increasing cardiac workload, exercise stress testing exposes symptoms and signs masked by inactivity, thereby clarifying utility for management (medications, revascularization, and/or cardiac rehabilitation) that can potentially restore physical function and improve quality of life and independence, as well as reduce morbidity and mortality.

Exercise stress testing in older adults provides both diagnostic (based on symptoms, ECG changes, and/or heart rhythm changes induced by cardiac workload) and prognostic (based on exercise performance measures) assessment. However, the specificity of ECG stress testing to diagnose ischemia is confounded by a high prevalence of age-related ECG abnormalities (i.e., reduced diagnostic specificity of ECG data in relation to age).

Furthermore, since exercise stress testing requires a sufficient physiologic workload to induce ischemia, sensitivity of exercise is limited by age-related deconditioning, sarcopenia, frailty, and other exercise-limiting factors (i.e., reduced diagnostic sensitivity of ECG stress testing in relation to age).

Pharmacologic stress testing with imaging for older adults increases diagnostic sensitivity and specificity over exercise stress testing, but without the same clinical insight regarding physical function and exercise-associated symptoms/signs that can help determine clinical management choices. Assessments relying exclusively on imaging increase the likelihood of an evaluation bias; CAD diagnosis in very old adults frequently leads to revascularization and adjunctive medications, but without certainty that patients will benefit symptomatically from these management choices.

A. History Part I: Pattern Recognition

ACS symptoms are often "atypical" relative to younger adults. Dyspnea rather than chest pain is a more frequent symptom of acute CAD.

Diaphoresis, nausea and vomiting, dizziness, and syncope are also common ACS symptoms. The high prevalence of atypical or nonspecific symptoms contributes to the rising proportion of MIs that are clinically silent or unrecognized at older age, approximately 25% in younger patients increasing to 60% in those 85 years or older.

The proportion of ACS patients with heart failure at presentation increases from <20% in patients <65 years of age to >40% in patients 85 years or older. Cardiogenic shock is 2- to 4-fold more common in older ACS patients, and sudden death is also more prevalent.

Chest pain, dyspnea, weakness, and GI pain are all common symptoms of chronic CAD, as are subtle symptoms of exercise intolerance or even malaise.

B. History Part 2: Prevalence:

CAD is present in about 7% of the population aged 45 to 65 years, and escalates to >20% in those 65 and older. In adults >70 years there is a progressive rise in CAD, rising to over 30% in the decades after age 70.

In 2004, ACS accounted for 35% of all deaths at age 65 years in the United States; 83% of individuals who died of ischemic heart disease were aged >65 years. Insidious subclinical CAD also tends to increase (e.g., exercise intolerance, executive function cognitive decline, and renal insufficiency).

The average age at a first MI is 65.8 years for U.S. men and 70.4 years for U.S. women. According to U.S. life expectancy statistics, at 65 years of age, a man can expect 16 remaining years of life, and at 70 years of age, a woman can expect to live up to 17.5 more years.

As the population of older adults increases, the prevalence of CAD is certain to rise. Not only will ACS increase but symptoms of chronic CAD and subclinical symptoms are likely to escalate. A key challenge is to generate dynamic therapeutic responses that address the high prevalence of CAD in this growing older adult population – preventive, therapeutic, and rehabilitative.

C. History Part 3: Competing diagnoses that can mimic CAD.

CAD is prevalent in the spectrum of cardiovascular diseases that increase with aging. Heart failure, arrhythmias (ventricular and supraventricular), and valvular heart disease all arise from the same substrate underlying CAD (oxidative stress and inflammation) and often occur in association with CAD.

In older adults, diagnosis is often less of an issue of excluding other diseases that may mimic CAD, but of the awareness that multiple cardiac processes are likely to occur with CAD (heart failure, arrhythmias, valvular heart disease). Older adults are also susceptible to noncardiac diseases (e.g., pneumonia) that can produce symptoms similar to CAD, but which commonly provoke CAD instability, such that the diagnosis of one should not exclude consideration of the other. Thromboembolic phenomena are also more common, meriting vigilance for pulmonary embolism as an alternative and/or concomitant basis of dyspnea or chest pain.

D. Physical Examination Findings.

Because CAD is often associated with systemic atherosclerotic disease as a function of aging, evaluation includes signs and symptoms pertaining to the total CV system. Vital signs are extremely important.

Both hypertension or hypotension can be indicators of cardiovascular instability. Heart rate usually is increased in high noradrenaline responsiveness, but this becomes a less reliable sign with the chronotropic incompetence associated with old age.

Cardiac examination is important to delineate cardiomegaly, heart failure, pulmonary hypertension, and/or valvular disease that are all likely in older adults. Auscultation, particularly for new gallops can arise from CAD-associated heart failure.

Both HFpEF (for which a S4 may be audible) and HFrEF (for which a S3 and S4 may be audible) are associated with CAD. A new mitral holosystolic murmur of MR may be associated with papillary muscle dysfunction.

Careful assessment of pulses, auscultation for bruits, and for any evidence of venous thrombosis is essential. A vigilant neurologic exam is critical for these patients who are susceptible to stroke and/or TIA.

E. What diagnostic tests should be performed?

As in younger adults, an ECG is essential; but older patients are more likely to have prior MI, left ventricular hypertrophy, conduction abnormalities (especially left bundle branch block), and paced rhythm, all of which may contribute to difficulties in the electrocardiographic diagnosis of ACS or chronic CAD.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

ACS diagnosis also depends on serial serologic troponin evaluations. In contrast to younger adults, the value of quantifying risk based on the magnitude of a troponin elevation can be misleading.

Any ACS must be regarded as a high morbidity and mortality event, with appropriate vigilance for peri-MI instability, and a strong rationale for medications and early invasive management for appropriate patients.

The theoretical value of C-reactive protein (CRP) and other inflammatory serologic markers to assess for CAD risk is confounded by age, as most baseline values of inflammatory markers increase with age, especially in patients with multiple cardiovascular risk factors and/or comorbidities.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

As with younger adults, cardiac imaging modalities provide increased sensitivity and specificity over ECG stress assessments. The option of pharmacologic myocardial perfusion imaging (MPI) is particularly valuable for patients with exercise limitations. Studies have demonstrated the utility of pharmacologic MPI to guide care for older adults, and to thereby reduce morbidity and mortality. Nonetheless, imaging indices do not provide the perspectives regarding physical function and exercise-associated symptoms/signs that can also help guide clinical management choices.

Likewise, cardiac CT is more likely to reveal CAD and/or calcifications but without a functional context that can help clarify the rationale for aggressive medical therapy and/or revascularization. Whereas cardiac CT is well recognized for its negative predictive value in ruling out CAD, the likelihood of a negative CT in very old adults is small, and the implications of calcifications or stenoses are often much less certain.

Cardiac echocardiography is often helpful in the management of CAD. Given the reduced specificity of ECG waveforms, an urgent echocardiogram can help discriminate focal wall motion abnormalities associated with CAD as part of ACS management.

Similarly, urgent echocardiography can detect sequelae associated with ACS (e.g., acute papillary muscle dysfunction) that often factor critically into management decisions. Echocardiography is also helpful in clarifying details pertaining to heart failure, valvular heart disease, and other cardiac abnormalities that are frequently associated with CAD.

III. Management.

CAD in the elderly includes both ACS and chronic stable CAD. ACS includes ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). In each clinical situation, issues pertaining to age are highly relevant.

For older ACS patients (both STEMI and NSTEMI), initial management focuses on the utility of acute revascularization.

Landmark trials, such as Treat Angina With Aggrastat and Determine the Cost of Therapy With an Invasive or Conservative Strategy-Thrombolytics in Myocardial Infarction (TACTICS-TIMI) 18 show relatively greater mortality reduction for acute myocardial infarction (AMI) patients aged 75 and over, based primarily on the efficacy of revascularization and associated adjunctive therapy (including antithrombin and antiplatelet therapy) to modify age-related high mortality risk.

Despite such compelling rationale for revascularization, the CRUSADE Quality Improvement Initiative, a community-based registry, showed that 7% of eligible STEMI patients did not receive reperfusion therapy, with older age being the most common reason cited for its omission.

For STEMI patients, mechanical revascularization with percutaneous coronary intervention (PCI) within 90 minutes remains the standard of care, especially given the increased bleeding risk associated with thrombolysis at elderly age.

However, logistical impediments associated with revascularization escalate as a function of age. Misinterpretation of the "atypical" nature of ACS symptoms in very old adults often contributes to delay in transporting patients to appropriate ACS hospitals.

High prevalence of baseline ECG abnormalities often obscures critical ECG diagnostic assessments. High prevalence of comorbidity and/or polypharmacy often leads to uncertainty whether risks associated with PCI (bleeding, renal failure, delirium) outweigh intended benefits.

The mortality benefits of revascularization in very old patients may be overshadowed by other concerns. Quality of life and/or the morbidity associated with processes of care often become equally or even greater priorities for many older ACS patients.

Many may, for example, prefer less aggressive management, often due to overriding apprehension that invasive procedures will become predominant ordeals with relatively greater harm than benefit. In contrast, proponents of revascularization assert that revascularization better ensures improved physical function, cognition, and reduced reliance on medications than does conservative management.

Clinical tools to help gauge composite health and vigor of older adults are potentially helpful to guide therapy. Frailty, a phenotypic characterization of features related to unsuccessful aging (weight loss, exhaustion, weakness, slowness, and low levels of activity) is an increasingly recognized parameter that indicates poor prognosis, and relatively less likely benefit from aggressive interventional or even intensive medical therapy.

Therefore a tiered medical approach based on frailty may help guide care more successfully for older adults. For example, the utility of a frailty index based on slow gait speed was demonstrated to predict patients who would best tolerate aortic valve surgery. However, such assessment does not acknowledge the possibility that frailty may be modifiable. Frail adults may benefit from the same therapy as those who are not frail, but may require greater emphasis on rehabilitation, nutrition, and other supplemental treatments.

PCI and CABG surgery may be better structured to address concerns/risks pertaining to older adults. Radial artery catheterization may provide superior outcomes to femoral artery access (e.g., more rapid mobilization; less bleeding risk); more precise hydration may help patients predisposed to heart failure and/or prerenal failure; adjunctive care with specific antithrombin (e.g., bivalirudin vs. enoxaparin) and antiplatelet agents (e.g., clopidogrel vs. prasugrel) may provide superior outcomes in bleeding complications. It is particularly important to adjust medication doses to body weight and renal function.

Measures to hasten mobilization, reduce sedation, and avoid polypharmacy are important for older patients vulnerable to delirium.

A related issue is the use of drug eluting stents (DES) vs. bare metal stents (BMS) for older CAD patients. Whereas revascularization is usually more complete and durable with DES vs. BMS at all ages, the medicated stent technology requires prolonged use of multiple antiplatelet agents, usually aspirin and clopidogrel for at least a year, and in many cases longer.

This is complicated by increased bleeding sequelae as a function of age (e.g., GI bleeding, cystitis, epistaxis), as well as increased age-related prevalence of atrial fibrillation for which antithrombin therapy is indicated to reduce stroke risk (e.g., warfarin or a newer oral antithrombin agent [dabigatran, rivaroxaban, or apixaban]). Since BMS require shorter courses of antiplatelet therapy, they may be better suited for older adults, but at the expense of the relatively better outcomes attributed to DES technology.

For NSTEMI patients, ambiguities regarding the benefit of invasive management are often greater than for STEMI patients. NSTEMI ACS guidelines emphasize a greater range of therapeutic options.

While acknowledging the mortality benefits of revascularization, they also highlight patient-centered care, and the rationale of tailoring choices relative to physical function, cognition, aggregate morbidity, prognosis and other dimensions of health status relevant to management choices. Higher risk NSTEMI patients derive the greatest benefit from revascularization and most older NSTEMI patients are at high risk.

PCI and CABG surgery are also considerations for ACS and chronic CAD patients with extensive disease. In general, revascularization for ACS provides critical, life-prolonging benefit. However, for acute or chronic CAD, revascularization can also reduce symptoms and often reduces reliance on multiple antiischemic medications.

Older patients with chronic CAD surgery referred for CABG are more likely to have severe coronary artery disease (left main or multivessel disease), left ventricular systolic dysfunction, concomitant valvular disease, and to previously have had a sternotomy. Frequent comorbid conditions include diabetes mellitus, hypertension, chronic obstructive pulmonary disease, peripheral arterial disease, and chronic kidney disease.

Consequently, elderly patients have a higher perioperative morbidity and mortality. Operative mortality among older patients ranges from 2.6% at >75 years to 11% at >80 years.

Octogenarians also have a higher incidence of neurologic complications, renal failure, respiratory failure, and gastrointestinal complications. Additionally, they have longer lengths of intensive care unit and hospital stays and are less likely to be discharged home. In the New York state registry, the length of stay was 8.5 days for patients <50 years compared with 14.1 days for those >age 80, with discharge-to-home rates of 96% and 52%, respectively.

Despite their higher rates of in-hospital morbidity and mortality, the majority of octogenarians achieve functional improvement following CABG surgery. Two studies of patients >80 years of age demonstrated improvements in quality of life. In one study, angina relief and quality-of-life improvement scores did not differ between patients older and younger than 75 years. Of 136 octogenarians following CABG surgery, at an average of 2 years postoperative, 81% felt they had little or no disability in daily activities and 93% reported substantial symptomatic improvement.

Compared with PCI, CABG surgery facilitates more complete revascularization, and the option of combining coronary artery surgery with valvular surgery. Furthermore, newer surgical techniques are associated with reduced morbidity and mortality.

Transcatheter treatment for CAD is also steadily improving, with newer and more effective stents and medications, and even options for transcatheter valvular repair. Percutaneous intervention is a compelling consideration for older adults who are usually inclined to avoid the physical and emotional stress associated with open heart surgery.

Acute care for ACS management requires antiplatelet therapy irrespective of the revascularization choice. Thienopyridine therapy with clopidogrel, prasugrel, or ticagrelor are all effective, although trials suggest that clopidogrel and ticagrelor may be better tolerated than prasugrel in older adults.

Whichever thienopyridine is selected, it is usually given in combination with aspirin. Concomitant antithrombin therapy (heparin [unfractionated or low molecular weight], heparin-like medications [e.g., fondaparinux] or thrombin inhibitors [e.g., bivalirudin]) are also vital. Beta-blockers, ACE inhibitors for reduced left ventricular function, and high dose statin therapy also have demonstrated benefit.

While each medication is individually indicated per evidence-based guidelines, there is implicit polypharmacologic risk for older adults who have multiple morbidities necessitating many other medications. Among the concerns, chronic use of nonsteroidal antiinflammatory drugs (NSAIDs) can exacerbate risks of GI bleeding for older ACS patients. Use of empiric proton pump inhibitors is common to mitigate bleeding risk, particularly in the context of ACS, but at the expense of greater risk of polypharmacy.

Antiplatelet therapy for chronic CAD often depends on the choice made regarding stent technology. While low dose aspirin is almost always indicated, the combination of aspirin and clopidogrel to provide antiplatelet benefit has been demonstrated, but at the risk of increased bleeding.

For patients with stent placement, aspirin and clopidogrel in combination to reduce thrombosis is of even greater priority. Chronic beta-blocker and statin therapy have also been demonstrated as beneficial.

Nitrates provide value for patients with persistent chest pain symptoms, but can generally be avoided in those whose symptoms are well-controlled. Consideration of ranolazine is important for patients with persistent chest discomfort, particularly those who are not candidates for revascularization.

A key consideration for CAD management in older adults is referral to cardiac rehabilitation. Older CAD patients benefit significantly from cardiac rehabilitation with reduced mortality, and improved quality of life, reduced symptoms, and increased functional capacity, independence, and self-efficacy.

Cardiac rehabilitation addresses many issues associated with CAD management, from the emotional trauma associated with an AMI and/or revascularization to the complexities of polypharmacy, multimorbidity, and frailty, and to the critical value of increasing exercise and risk factor modification. Older patients, both frail and robust, benefit. Cardiac rehabilitation provides care that can be tailored to address each older patient's circumstances.

A. Immediate management.

A key priority for older adults is rapid assessment and initiation of therapy for ACS. As noted above, atypical symptoms often delay responsiveness and care, and contribute to poor outcomes for older ACS patients. Rapid access to medical care and rapid onset of pharmacologic and invasive management for eligible patients will yield substantial benefit.

Assessment also requires added vigilance as ACS often occurs in the context of comorbid diseases that can obscure and delay CAD-oriented priorities. Noncardiac morbidity often provokes CAD instability and factors into its management.

B. Physical Examination Tips to Guide Management.

While older ACS/CAD patients are particularly vulnerable to CAD-related instability and benefit from therapy, they are also more susceptible to iatrogenic consequences of therapy. Vigilant monitoring of hemodynamics ( hypotension or hypertension), ECG ( ST changes, atrial fibrillation, ventricular ectopy, and/or AV block), and clinical examination (oxygen saturation, temperature, respiratory rate , peripheral pulses, edema, lung examination, new gallops or murmurs, and bruits). Monitoring urine output is also indicated, but avoiding Foley catheterization is also helpful in reducing immobility and morbidity.

Early mobilization, providing patients with their audiovisual assist aids (eyeglasses, hearing aids, etc.), family prompts, and minimizing oversedation are essential.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

Serology is critical to follow troponin, but also electrolytes, glucose, metabolic fluctuations, renal deterioration, and anemia.

Troponin is a key measure of initial injury confirming ACS. For ACS patients (usually NSTEMI) whose revascularization is initially deferred, troponin levels provide perspective about progressing ischemia, and can serve as a basis to reconsider the benefit vs. risk of subsequent revascularization.

Hematocrit (Hct) and/or hemoglobin (Hg) are important indices for patients receiving antithrombin and antiplatelet therapy, given the high prevalence of comorbid conditions that entail use of NSAIDs, steroids, and other medications that increase bleeding risk. Decrease in Hct or Hg (especially in the context of hemodynamic changes) are important parameters to guide therapy.

Critical considerations include blood transfusion and modifying the antiplatelet and/or antithrombin regimens. However, the implications of an occluded stent are more severe than GI bleeding; thus most clinicians would transfuse blood rather than discontinuing critical antiplatelet therapy.

D. Long-term management.

Whereas post-ACS management previously entailed routine exercise stress testing for prognostic risk assessment as part of initial management, this is now less common for those who are revascularized and/or treated with the antiischemic (beta-blockers), antiplatelet (aspirin and thienopyridines), and cholesterol lowering (statins) therapies. Residual instability in comprehensively managed patients is relatively low.

A submaximal exercise protocol early after ACS can help exclude residual ischemia, pro-arrhythmia, and/or hemodynamic instability for patients in whom only partial revascularization was achieved (more typical among older adults) and/or in whom a conservative strategy was chosen owing to significant comorbidity, frailty, or preference (also more typical in older adults). A symptom-limited exercise stress test 6 weeks after ACS is useful to assess for residual ischemia, prognosis, and as the basis of an exercise prescription.

Most older CAD patients (either ACS patients or those with chronic CAD) benefit from cardiac rehabilitation (see above). A symptom-limited exercise stress test can guide exercise prescription, both to screen for ischemia, but also to rule-out arrhythmia and/or hemodynamic instability.

Cardiac rehabilitation provides comprehensive behavioral modification, risk reduction, and exercise enhancement that reduces morbidity and mortality in older adults, but also increases quality of life, independence, and self-efficacy in those who participate.

E. Common Pitfalls and Side-Effects of Management

See Table I and Table II.

Table I.

Medication Side Effects

Table II.

Therapeutic dynamics that commonly affect older patients

IV. Management with Co-Morbidities

There is an increased risk of polypharmacy, as most older adults receive multiple medications for comorbidities as well as cardiac and coronary diseases.

Atrial fibrillation is common among CAD patients, with added complexity regarding antithrombin therapy (warfarin vs. newer oral antithrombin agents [dabigatran, rivaroxaban, or apixaban]). CAD patients with atrial fibrillation who receive stents are usually treated with aspirin, a thienopyridine (e.g., clopidogrel or ticagrelor) in addition to an antithrombin agent for a year following stent placement; after 1 year, only the antithrombin agent (+ ASA) is usually indicated.

For the common comorbidity of arthritis and other sources of pain, many patients take nonsteroidal antiinflammatory medications, and substitute therapy may lessen bleeding and renal complications. Patient education is a priority to help reduce the persistent possibility of bleeding sequelae.

Heart failure is common among CAD patients. Polypharmacy is implicit with the standardized regimens of heart failure and CAD medications. Added concerns regard diet (emphasizing sodium, saturated fat, and often calorie reduction). Careful monitoring of medications, side effects, and weight are all critical.

Older adults are prone to reduced lean body mass (sarcopenia) and weight gain (persistent high-calorie diet in the context of reduced activity). Even if weight remains stable, the relative increase in fat mass is common, increasing inflammation and metabolic consequences (insulin resistance, etc.). Weight reduction and increased exercise are often indicated.

Ventricular arrhythmias are common in patients with CAD, especially those with concomitant heart failure. Beta-blockers provide value, but consideration of implantable cardioverter-defibrillator (ICD) placement is indicated, based on evidence-based criteria for younger populations.

The overall prognosis (i.e., incorporating elements of comorbidity and frailty) is an important perspective for this decision. Life-prolonging ICD benefits are diminished or even outweighed by the detrimental effects of severe noncardiac disease. Intermittent and inappropriate ICD shocks can diminish quality of life and increase depression.

V. Patient Safety and Quality Measures

A. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Follow-up with a primary provider within 2 weeks of discharge provides the important opportunity to review symptoms and medications, and if needed, to take steps that reduce chances of rehospitalization. Health literacy is a vital dimension of care that should be emphasized during early reassessment, as it provides patients (and their families) opportunities to better understand symptoms, lifestyle changes, medications, and other key components of management.

Cardiac rehabilitation also helps reduce readmission. It provides a mechanism of oversight to mitigate the complexities of new medications, comorbidity, and basic coping skills in the context of a recent hospitalization and procedures, learning challenges, understanding symptoms, and new behaviors. Cardiac rehabilitation goals are tailored to each patient’s needs, addressing diet (cooking, shopping, eating out), medications, exercise and physical activity, affect, social support, and other dimensions of care.

Cardiac rehabilitation can be helpful in compliance with medications as can routine attention from a nurse and/or family member who helps monitor medication use and avoidance of prior prescription medications that might interact adversely with new management. Compliance may be additionally complicated by physical, emotional, or cognitive comorbidities that impede acquisition and/or organization of a daily regimen.

Physical function plays a key role in moderating prognosis and morbidity. Cardiac rehabilitation helps older adults initiate and/or advance exercise routines that include critical elements of aerobic, strength, flexibility, and balance training. This can also occur in a home or community environment, guided by a medical care team.

B. What's the Evidence for specific management and treatment recommendations?

Forman, DE, Rich, MW, Alexander, KP. "Cardiac care for older adults. Time for a new paradigm". J Am Coll Cardiol. vol. 57. 2011. pp. 1801-1810.

(White paper highlighting the impact of aging on cardiovascular disease and the need for modifications to the cardiovascular therapeutic paradigm to better respond to age-related dimensions inherent to patient-centered care.)

Lakatta, EG, Levy, D. "Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part I: aging arteries: a “set up” for vascular disease". Circulation. vol. 107. 2003. pp. 139-146.

Lakatta, EG, Levy, D. "Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part II: the aging heart in health: links to heart disease". Circulation. vol. 107. 2003. pp. 346-354.

(A comprehensive analysis of the biologic changes associated with aging and their association with cardiovascular disease.)

Alexander, KP, Newby, LK, Cannon, CP. "Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology". Circulation. vol. 115. 2007. pp. 2549-2569.

Alexander, KP, Newby, LK, Armstrong, PW. "Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology". Circulation. vol. 115. 2007. pp. 2570-2589.

(Comprehensive analysis of the limitations of current data regarding age-dimensions of care for older ACS patients.)

Murad, K, Kitzman, DW. "Frailty and multiple comorbidities in the elderly patient with heart failure: implications for management". Heart Fail Rev. vol. 17. 2012. pp. 581-588.

(Study demonstrating the implications of frailty and comorbidity on cardiovascular outcomes.)

Afilalo, J, Eisenberg, MJ, Morin, JF. "Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery". J Am Coll Cardiol. vol. 56. 2010. pp. 1668-1676.

(Study demonstrating the utility of gait speed to serve as an index of frailty and its efficacy to predict outcomes among older adults undergoing cardiac surgery.)

Lloyd-Jones, DM, Leip, EP, Larson, MG. "Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age". Circulation. vol. 113. 2006. pp. 791-798.

(Study showing the long-term impact of traditional cardiovascular risk factors. The impact of duration of risk factors is substantial, such that over time the likelihood of progression from risk factors to cardiovascular disease is progressive and powerful.)

Suaya, JA, Stason, WB, Ades, PA, Normand, SL, Shepard, DS. " Cardiac rehabilitation and survival in older coronary patients". J Am Coll Cardiol. vol. 54. 2009. pp. 25-33.

(Study showing strong mortality benefit of cardiac rehabilitation for older CAD patients irrespective of patient age, extent of CAD, and/or extent of comorbidity.)

Williams, MA, Fleg, JL, Ades, PA. "Secondary prevention of coronary heart disease in the elderly (with emphasis on patients > or =75 years of age): an American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention". Circulation. vol. 105. 2002. pp. 1735-1743.

(Scientific statement delineating the benefits of comprehensive secondary prevention for older adults with CAD.)

Daniels, K, Arena, R, Lavie, CJ, Forman, DE. "Cardiac rehabilitation for women across the lifespan". Am J Med. vol. 125. 2012. pp. 937.e1-e7.

(Review of the benefits of cardiac rehabilitation for older adults, highlighting that benefits extend to men and women.)

Gharacholou, SM, Alexander, KP, Chen, AY. "Implications and reasons for the lack of use of reperfusion therapy in patients with ST-segment elevation myocardial infarction: findings from the CRUSADE initiative". Am Heart J. vol. 159. 2010. pp. 757-763.

(One of many studies highlighting the underuse of evidence-based therapy for older cardiac patients.)

Afilalo, J, Duque, G, Steele, R, Jukema, JW, de Craen, AJ, Eisenberg, MJ. "Statins for secondary prevention in elderly patients: a hierarchical Bayesian meta-analysis". J Am Coll Cardiol. vol. 51. 2008. pp. 37-45.

(One of many studies showing the benefits of statin lipid-lowering therapy in older CAD patients.

C. DRG Codes and Expected Length of Stay.

N/A

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