Adrienne H. Kovacs, PhD, CPsych, Behaviour Cardiology, Division of Cardiology, University Health Network, Toronto, ON.

Approximately 20% of older adults with cardiovascular disease (CVD) experience significant depression. Further, in a pattern consistent with the general adult population, women with CVD have double the rates of depression compared to men. Among older men and women with CVD, depression is associated with poorer cardiac outcomes, although patterns of depressive symptoms appear to differ between men and women. Treatment approaches include traditional modalities, namely psychotherapy and pharmacotherapy. Additional recommendations involve emphasizing adherence to prescribed medical and behavioural health regimens, fostering social support, and increasing referrals to cardiac rehabilitation programs as medically appropriate.
Key words: depression, gender differences, cardiovascular disease, myocardial infarction, mortality.

Lynne T. Shuster, MD, Women’s Health Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Sharonne N. Hayes, MD, Women’s Heart Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Mary L. Marnach, MD, Women’s Heart Clinic, Department of Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA.
Virginia M. Miller, PhD, Departments of Surgery and Physiology and Biomedical Enginering and Office of Women’s Health, Mayo Clinic College of Medicine, Rochester,MN,USA.

Women in the Western world may expect to spend a significant portion of their lives in postmenopause. After menopause, women are at increasing risk for several conditions associated with aging that may or may not be related to declining hormone levels. Caring for women seeking advice and treatment for menopausal concerns presents a golden opportunity to not only identify individuals at risk for early intervention but also to address prevention and screening strategies important to sustaining health.
Keywords: cancer, cardiovascular disease, menopause, osteoporosis, screening.

Rachel L. McIntosh, B.Orth, Grad Dip Journ, Research Orthoptist, Retinal Vascular Imaging Centre, Eye Research Australia, University of Melbourne, Melbourne, Australia.
Tien Y. Wong, FRANZCO, FRCSE, PhD, Associate Professor of Ophthalmology, Retinal Vascular Imaging Centre, Eye Research Australia, University of Melbourne, Melbourne, Australia.

Hypertensive retinopathy has long been regarded as a risk indicator of mortality in persons with severe hypertension, but its value in contemporary clinical practice is uncertain. New population-based studies now show that hypertensive retinopathy signs are common in the general population of adults age 40 and older, including persons without a clinical diagnosis of hypertension. Some hypertensive retinopathy signs are associated not only with concurrent blood pressure levels, but with past blood pressure levels as well, suggesting that they reflect chronic hypertensive damage. Mild hypertensive retinopathy, such as generalized and focal retinal arteriolar narrowing and arteriovenous nicking, are only weakly associated with cardiovascular diseases. In contrast, moderate hypertensive retinopathy, such as retinal hemorrhages, cotton wool spots, and microaneurysms, are strongly associated with both subclinical and clinical cardiovascular diseases, including stroke and congestive heart failure. Thus, a clinical assessment of hypertensive retinopathy signs in older persons may provide useful information for cardiovascular risk stratification.
Key words: hypertensive retinopathy, retinal microvascular disease, hypertension, cardiovascular disease.

Fatim Ajwani, BSc RD, ARAMARK Canada Ltd at the Toronto Rehabilitation Institute, Toronto, ON.
Maria Ricupero, BA, RD, CDE, ARAMARK Canada Ltd at the Toronto Rehabilitation Institute, Toronto, ON.

Dietary trans fatty acids (TFA) have been implicated in contributing to cardiovascular disease (CVD). Higher intakes of industrial TFA negatively impact cholesterol and inflammation levels, endothelial function, and LDL particle size. Dietary TFA are also associated with myocardial infarction and death. Due to the negative impact of TFA on cardiovascular health, the current recommendation is to keep total TFA intake to less than 2 grams/day. New labeling legislation has made it easier to achieve this goal. However, nutrition claims can be misleading. Despite positive new changes, patient counseling will still be required for accurate and careful interpretation of nutrition information.
Key words: trans fatty acids, diet, cholesterol, cardiovascular disease, conjugated linoleic acid.

Karin H. Humphries, MBA, DSC, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC.
Janet McElhaney, MD, Department of Geriatrics, University of British Columbia, Vancouver, BC.

The growth in information about hormone replacement therapy (HRT) over the past few years has been impressive. This review summarizes the latest information on HRT and cardiovascular disease, osteoporotic fractures, and cognitive function. The risks of HRT (e.g., stroke, breast cancer, and venous thromboembolism) clearly outweigh the benefits (e.g., reduction in osteoporotic fractures). The use of HRT for primary or secondary prevention of coronary heart disease or to decrease the risk of cognitive dysfunction is also not supported. While the evidence in older adults is substantial, there is some controversy regarding the effectiveness of HRT initiated in women at the start of menopause.
Key words: hormone replacement therapy, cardiovascular disease, osteoporosis, cognitive function, dementia.

This month I am writing my editorial while attending on a general medical unit in an acute teaching hospital. As usual, the service is very busy, and this morning’s intake resulted in a total of 25 patients on my team. Two things struck me as I started rounding with my team at 6:30 this morning. First, it is hard to distinguish a general medical service from a geriatric service. Although we do admit patients of all ages on our service, there are relatively few young admissions, and their length of stay is so short that the overwhelming majority of patients on the service at any one time are older adults. The second observation was that cardiac problems were the commonest reason for admission, and even those who were admitted for other reasons had significant cardiovascular issues. Thus, it is always appropriate when cardiovascular disease is our theme topic, as it is this month.

The article “When Is a Systolic Murmur Important?” by Dr. Michael Borger and Dr. Tirone David is particularly important, as over 50% of older patients will have an audible systolic murmur. Clinical acumen is required to decide which patients require further investigations. Considering that it is the single most common reason for admission to hospital for older patients in North America, the article “Congestive Heart Failure: A Brief Review” by Drs. Molly Thangaroopan, Anusha Jegatheeswaran, Vivek Rao, and Jagdish Butany will be useful for me during my month of general medical attending! The article “Primary Presentations of Syncope in the Older Adult Population” by Dr. Kenneth Madden is not only part of our focus on cardiovascular disease, it is also the theme of our CME exercise this month. Even our book review this month, “Cardiovascular Disease in the Elderly” (3rd Edition, Revised and Expanded. Edited by Wilbert S. Aronow, Jerome L. Fleg) reviewed by Dr. Jagdish Butany is part of our cardiac focus. I am proud to note that one of the authors of this textbook, Dr. Wilbert Aronow, is one of the world’s leading authorities on geriatric cardiology and has also been a frequent contributor to Geriatrics & Aging.

As usual, we also have several articles on other themes. We now have modestly effective drug treatments for dementia, but so much research is in progress that there is great optimism for the future. New possibilities are highlighted in the article “Emerging Drug Therapies for Dementia” by Dr. Edward Zamrini. In our drugs and aging column, the topic “Hormone Replacement Therapy in the Older Adult” is reviewed by Karin Humphries and Dr. Janet McElhaney. As a further reminder that endocrine concerns are not exclusive to the aging female we have the article “Erectile Dysfunction in Older Males: Why Not Investigate and Treat It?” by Dr. Peter Pommerville. It is an unfortunate reality that in the past physicians, mostly male, defined the health priorities of women, including older women. This is fortunately rapidly changing, and some of the data on what older women are actually concerned about is highlighted in the article “A Review of Older Women’s Health Priorities” by Drs. Cara Tannenbaum & Deborah Radcliffe-Branch. Finally, our ever-important palliative care column by Drs. Wendy Duggleby and David Popkin addresses the issue of “Effective Physician-Patient Communication at the End of Life: What Patients Want to Hear and How to Say It.”

Enjoy this issue,

Barry Goldlist

David Fitchett, MD, FRCP(C), Cardiologist, St. Michael’s Hospital; Associate Professor of Medicine, University of Toronto, Toronto, ON.

Coronary and cerebrovascular disease is the leading cause of death and disability in the older population. Control of vascular risk factors such as blood pressure, lipids, and glucose is important in higher risk patients to reduce the impact of stroke and myocardial infarction, whatever their age. Although total and LDL cholesterol levels are less predictive of coronary heart disease in the older patient, clinical trials demonstrate an important benefit from statin therapy in high-risk individuals over a wide age range with either established cardiovascular disease or diabetes. Older patients with multiple risk factors for vascular disease, yet without coronary, cerebrovascular, or peripheral vascular disease, should also be considered for statin treatment.
Key words: cholesterol, lipid management, statin, cardiovascular disease.

Kevin L. Billups, MD, Urologist & Medical Director, The EpiCenter for Sexual Health & Medicine, Edina; Adjunct Assistant Professor, Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA.

Erectile dysfunction (ED) is a prevalent vascular disorder that, like cardiovascular disease, is now believed to cause endothelial dysfunction. In fact, a growing body of literature now suggests that ED may be an early marker for atherosclerosis, increased cardiovascular risk, and subclinical vascular disease. The emerging awareness of ED as a barometer of overall cardiovascular health represents a unique opportunity for primary prevention of vascular disease in all men. Although the implications of this relationship for primary and secondary prevention of cardiovascular disease are not yet fully appreciated, the available literature makes a strong argument for the role of erectile dysfunction as an early marker for the development of significant cardiovascular risk factors and cardiovascular disease. Early detection of erectile dysfunction could play a major role in improving male cardiovascular health.
Key words: erectile dysfunction, cardiovascular disease, atherosclerosis, endothelium, prevention.

Raymond Fung, MD, BSc, Fellow, Division of Endocrinology, University of Toronto, Toronto, ON.

Lorraine L. Lipscombe, MD, FRCPC, Clinical Associate, Research Fellow, Division of Endocrinology, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

The prevalence of diabetes has been increasing significantly in the last several years, especially in the older population. Cardiovascular disease (CVD) represents the most important complication of diabetes in this age group, as up to 80% of persons with diabetes die from CVD. The treatment of dyslipidemia and hypertension are both key in ameliorating CVD risk. Recent randomized controlled trials have included older persons with diabetes and have demonstrated that both statin therapy for dyslipidemia and antihypertensive agents are highly effective and safe in preventing CVD in this population. This review will examine the evidence for treatment in both areas, outlining the special considerations in the aged.

Key words: diabetes mellitus, cardiovascular disease, statins, hypertension, cholesterol.

David Fitchett, MD FRCP(C), St Michael’s Hospital, University of Toronto, Toronto, ON.

As a response to recent clinical trials of low-density lipoprotein (LDL) lowering, the Adult Treatment Panel III (ATP III) has proposed new thresholds and targets for treatment. In addition, the population that is considered to benefit from LDL lowering has been extended to include the diabetic and the older patient. This article reviews the clinical trial evidence, and the new recommendations, and provides commentary with special reference to management of the older person.

Key words: cardiovascular disease, LDL cholesterol, statin therapy, older patients, diabetes.