Diagnosis and Management of Myocardial Ischemia (Angina) in the...
Coronary artery disease is a major problem in the elderly population. Approximately 60% of all acute myocardial infarctions in the United States occur in people 65 years or older, and 30% occur in persons older than 75 years. Morbidity and mortality are high in elderly patients who sustain a myocardial infarction. Due to the atypical presentation of myocardial ischemia and absence of classic symptoms, coronary artery disease may not be diagnosed in many of these patients until an acute myocardial infarction occurs. Early diagnosis of coronary artery disease and reduction of all coronary risk factors are beneficial in reducing future coronary events in older as well as in younger patients. Many studies have shown that anti-ischemic and acute myocardial infarction therapies have been underutilized in the elderly population. The principles of drug therapy for myocardial ischemia are the same as those for younger patients. Aggressive therapy, including early coronary angiography and revascularization, has been found to be as beneficial in high-risk, unstable older patients as in younger patients. Therapy should be individualized according to the patient's clinical condition. On the basis of current knowledge, elderly, high-risk patients with acute coronary syndromes may be treated with a combination of intensive medical therapy and early coronary angiography with revascularization.

In the last few decades, significant advances have been made in understanding the pathophysiology of coronary artery disease (CAD). New therapies have been developed and mortality and morbidity have been reduced. CAD, however, remains a major problem in the elderly population.

Approximately 60% of all acute myocardial infarctions (MIs) in the United States occur in persons 65 years or older, and 30% of MIs occur in persons older than 75 years. Furthermore, hospital mortality associated with acute MI is three times higher in elderly than in younger patients. Eighty percent of deaths attributed to acute MI occur in patients 65 years or older. Morbidity is also high in elderly patients who sustain an MI. Many of these elderly patients have significant left ventricular (LV) dysfunction and will have a limited lifestyle due to heart failure.

The main underlying pathophysiologic process in CAD is coronary atherosclerosis, with plaque formation and narrowing of the vessel luminal diameter, plus intermittent rupture of atherosclerotic plaques. Clinically, patients may experience stable symptoms of myocardial ischemia due to narrowing of the vessel lumen. Plaque rupture, however, is associated with thrombus formation and further reduction of luminal diameter or total occlusion, causing acute coronary syndromes of unstable angina or acute MI.