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cardiovascular disease

Coronary Revascularization in Older Adults

Coronary Revascularization in Older Adults

Teaser: 

Colin A. Barry, MD, FRCPC and Marino Labinaz, MD, FRCPC, University of Ottawa Heart Institute, Ottawa, ON.

Cardiovascular disease remains the number one cause of mortality in Canada. Persons over 65 represent the most rapidly growing demographic group in Canada. These factors will result in a significant increase in the total number of cardiovascular cases in the next several decades. Coronary revascularization procedures such as coronary artery bypass grafting and percutaneous coronary interventions have steadily increased over the past decade and will continue to do so as the population ages. Several studies have demonstrated that older patients derive significant benefit in terms of reduced morbidity and mortality, but these procedures are often underutilized in this patient group.

Key words: coronary artery bypass grafting, percutaneous coronary intervention, cardiovascular disease

Introduction
Cardiovascular disease remains the number one cause of mortality in Canada, representing 36% of all deaths in Canada (1999) with death from coronary artery disease accounting for 19.

Importance and Management of Low Levels of High-density Lipoprotein Cholesterol in Older Adults - Part I: Role and Mechanism

Importance and Management of Low Levels of High-density Lipoprotein Cholesterol in Older Adults - Part I: Role and Mechanism

Teaser: 

Gustavo A. Cardenas, MD, Carl J. Lavie, MD and Richard V. Milani, MD, Department of Cardiology, Ochsner Medical Institutions, New Orleans, LA, USA.

There is growing evidence that risk factors, which predict cardiovascular disease in younger people, are also predictive in older adults. Given the huge burden of cardiovascular disease in this latter population, older adults should not be excluded from primary or secondary prevention strategies, such as management of dyslipidemia. Low levels of high- density lipoprotein cholesterol (HDL-C) have a stronger association with cardiovascular disease than do high levels of low-density lipoprotein cholesterol (LDL-C). This article focuses on the importance of HDL-C as a risk factor for older patients, the evidence that exists supporting this association, the factors associated with low levels of HDL-C, and the mechanisms by which low HDL-C is related to an increased risk of cardiovascular diseases.
Key words: high-density lipoprotein cholesterol, aging, older adults, dyslipidemia, lipoprotein, atherosclerosis, cardiovascular disease.

The Morphology of the Aging Heart

The Morphology of the Aging Heart

Teaser: 

Jagdish Butany, MBBS, MS, FRCPC and Manmeet S. Ahluwalia, MBBS, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.

With advancing age, the cardiovascular system undergoes subtle but progressive changes that result in altered function. The endocardium becomes thicker and opaque, left ventricular (LV) wall thickness increases and there is increased interstitial fibrosis in the myocardium. Although myocyte size increases, the number of myocytes decreases, as does the number of cells in the conduction system. The decrease in the filling rate of LV in early diastole is accompanied by a greater rate of filling in late diastole augmented by atrial contraction. Maximum achievable heart rate and ejection fraction (with exercise) decreases. All these changes make increasing age a significant independent risk factor for heart failure, the most common reason for hospitalisation in patients older than 65 years.
Key words: aging, cardiovascular disease, myocardium, fibrosis, heart failure.

Fodor Hypertension in the Elderly

Fodor Hypertension in the Elderly

Teaser: 

J. George Fodor, MD, PhD, FRCPC, FAHA, Professor of Medicine, Head of Research, University of Ottawa Heart Institute Prevention and Rehabilitation Centre, Ottawa, ON.

It is worthwhile to review the issue of hypertension in the elderly not only because it will become an ever-increasing problem with our aging population, but also because of the robust database currently at our disposal concerning improved risk assessment and efficacious therapy.

The Epidemiology
Generally, the elderly are considered those above 65 years of age. Dealing with hypertension in this age group, we quickly realize that this disease is a major epidemic with far-reaching consequences for both the health status of this segment of the population as well as our health care system.

The Canadian Heart Health Survey ascertained that among people in the age group 65-74 years, 56% of males and 58% of females were hypertensive.1 This survey defined hypertension as systolic blood pressure (SBP) > 140mmHg or diastolic blood pressure (DBP) > 90mmHg, or current treatment with a prescription antihypertension medication or non-pharmacological treatment of blood pressure (weight control or sodium/salt restriction). The problem of hypertension in the elderly will continue to increase steadily in importance.

A Review of Smoking in the Elderly

A Review of Smoking in the Elderly

Teaser: 

D'Arcy Little, MD, CCFP, Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; Director of Medical Education, York Community Services; 2002 Royal Canadian Legion Fellow in Care of Elderly at Baycrest Centre, Toronto, ON.

Prevalence of Smoking in the Elderly
Smoking is one of the major causes of morbidity and mortality in Canada. In fact, it has been called the leading preventable cause of death in North America.1 This is because smoking is a known risk factor for four of the leading causes of death in the industrialized world--coronary heart disease, cancer, lung disease and stroke--and because it contributes to many other causes of morbidity.2 While the current prevalence of smoking in Canadians aged 15 years and older declined by 10.3% between 1985 and 1999, the numbers remain high for both men and women (26.8% and 22.9%, respectively, in 1999).3 In those aged 65 and older, current smoking prevalence decreased by 8.9% over the same time period. However, it is estimated that 11.6% of seniors continue to smoke. The prevalence of smoking is highest in the Atlantic provinces and Quebec, and lowest in Saskatchewan and Ontario.4

Impact of Smoking on Health of the Elderly

Mortality
The health-related impact of smoking in the elderly is manifold. The increase in mortality has already been mentioned.

Highlights from the American Heart Association’s Prevention Conference VI: Diabetes and Cardiovascular Disease

Highlights from the American Heart Association’s Prevention Conference VI: Diabetes and Cardiovascular Disease

Teaser: 

  • Office-based risk factor evaluation is mandatory in people with diabetes, and aggressive risk factor modification should be based on those results.
  • The metabolic syndrome commonly precedes the onset of diabetes by several years. Insulin resistance apparently predates the risk factors associated with metabolic syndrome, thus detection of insulin resistance relatively early in life offers the opportunity to identify, at an early stage, those people likely to develop blood fat abnormalities, high blood pressure (HBP) and, ultimately, diabetes.
  • A person with diabetes who smokes is at double the risk for cardiovascular disease (CVD). Therefore, every effort must be made to convince the patient to stop smoking.
  • HBP increases a diabetic patient's risk of coronary heart disease (CHD), stroke, kidney failure and heart failure. Treatment of HBP in people with diabetes should be intensive enough to reach blood pressure goals.
  • The common drugs to treat high blood pressure--diuretics, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers--are generally effective in treating patients with diabetes.
  • Assiduous treatment of high blood pressure in people with diabetes can delay the progression of diabetic nephropathy and retinopathy, as well as CVD.

Cardiovascular Disease: Reason to Fear

Cardiovascular Disease: Reason to Fear

Teaser: 

For some reason, the paradigm for death in our society seems to be cancer, and it is this disease that many elderly fear the most. Yet statistics still show that cardiac disease is by far the most common cause of death in western societies, despite the recent (40 years) age-adjusted decline in mortality for cardiac disease. What this means is that even though a 75-year-old man is less likely to die in the next year of heart disease than a similarly aged man would have in 1960, it is still the most likely cause of death. The greatest misconception is probably among women, who often think that breast cancer is a more common cause of death than heart disease.

Why is this the case? Although it is true that breast cancer can affect very young women, advancing age is the biggest risk for the prevalence of both cancer and cardiac disease. I think the more likely reason for the societal fear of cancer is the belief that cancer is likely to cause a particularly difficult death. This popular conception is based on two factors: a lack of appreciation of the effectiveness (and often a lack of availability) of modern palliative care, and a mistaken belief that cardiac death results in sudden death, usually in the setting of an acute myocardial infarction (MI). However, in the elderly, this is not usually the case.

There has been a recent dramatic increase in the prevalence of congestive heart failure in the elderly, partially at least as a result of modern advances in treatment of acute MI that allows more patients to survive the acute incident. Patients with Grade IV ventricular function have a 50% annual mortality rate, worse than many cancers. Patients can be severely symptomatic and have very poor quality of life. Frequently in these patients, palliative care would seem to be appropriate, and yet it is not often 'prescribed.' Part of the reasoning is that for many of us the word 'palliative' is only associated with cancer. As well, our ability to predict survival in specific individuals with congestive heart failure is poor, thus making them inappropriate for some palliative care services that expect a very limited time frame per patient.

This topic was recently discussed in the British Medical Journal in an article entitled 'Cancer isn't the only malignant disease.1 The case described a man with incurable and severe peripheral vascular disease, and the reasons for lack of a palliative focus in his management. Fortunately, in this case the physicians eventually recognized the need for palliation, and the patient was able to die at home. The article is definitely worth reading and the BMJ (like Geriatrics & Aging!) is one of the few journals available on line (at bmj.com) in its entirety at no cost to the user.

This month's journal focuses on some of the key issues primary care doctors face in managing the cardiovascular problems of their patients. Current issues in heart failure management are discussed and there are articles on the management of multi-vessel coronary artery disease (stenting vs. bypass). The internationally renowned expert in geriatric cardiology, Dr. W.S. Aronow, has contributed an article on the controversies in treatment of low HDL cholesterol levels and elevated triglycerides.

The issue also contains articles on frontotemporal dementias, treatment of depression in the elderly, acute urinary retention and screening for urogenital cancers in elderly women. Dr. Madhuri Reddy has contributed an article on the difficulties inherent in making long term predictions of patients' needs, and Dr. Mark Clarfield has provided an entertaining article on the history of geriatrics. Enjoy this issue.

Reference

  1. Moulder E. Cancer isn't the only malignant disease. BMJ 2002;324:07.

Cyclooxygenase Inhibitors and Cardiovascular Disease

Cyclooxygenase Inhibitors and Cardiovascular Disease

Teaser: 

A study published in the Journal of the American Medical Association has raised the question of whether the use of selective cyclooxygenase-2 (Cox-2) inhibitors might be associated with an increased incidence of cardiovascular events.

Cox-2 selective inhibitors were developed in an attempt to reduce the adverse gastrointestinal events associated with the use of traditional, non-specific non-steroidal anti-inflammatories (NSAIDs). This was based on the premise that Cox-1 predominates in the gastric mucosa and yields protective prostaglandins, whereas Cox-2 is induced in inflammation and leads to pain, swelling and discomfort. However, selective Cox-2 inhibitors are known to decrease vascular prostacyclin (PGI2) production and may affect the balance between prothrombotic and antithrombotic eicosanoids, perhaps leading to increased cardiovascular thrombotic events. Cox-1 inhibitors afford a measure of platelet inhibition that reduces this effect.

A recent meta-analysis suggests that there may be an increase in cardiovascular events in patients taking Cox-2 inhibitors relative to those taking traditional, non-specific NSAIDs. The researchers analyzed the rates of cardiovacular events occurring in participants in 4 trials: the VIGOR trial, the CLASS study, and Study 085 and Study 090, submitted to the US Food and Drug administration.

The study suggested that patients taking rofecoxib had a relative risk of 2.38 (p<0.001) for developing a cardiovascular event when compared to those taking the traditional NSAID, naproxen. In contrast, the analysis of patients taking celecoxib as compared to ibuprofen or diclofenac did not show the same results--there was no significant increase in cardiovascular events in this group.

There are many caveats to the study and critics have pointed out major flaws in the analysis. The differences in the rates of cardiovascular events between patients taking rofecoxib and those taking naproxen may result from a number of factors. Most of the patients involved in the VIGOR study suffered from rheumatoid arthritis, a condition known to predispose patients to a higher risk for MI. Further analysis is required in a more representative sampling of patients. In addition, the trials analyzed in this study focused solely on continuous use of Cox-2 inhibitors and did not examine the more common method of using the drugs sporadically for musculoskeletal pain.

Finally, it remains to be determined whether the higher rate of cardiovascular events associated with rofecoxib relative to naproxen results from a negative impact of rofecoxib or from a positive impact of naproxen on platelet inhibition. This result would more readily explain the lack of difference in cardiovascular events seen with the CLASS study comparing celecoxib to ibuprofen and diclofenac, two NSAIDs that do not have the same antiplatelet effects as naproxen.

Source

  1. Mukherjee D, Nissen SE, Topol EJ. Risk of cardiovascular events associated with selective Cox-2 inhibitors. JAMA. 2001:286:954-9.

Prevalence of Cardiovascular Disease in Older Nursing Home Residents

Prevalence of Cardiovascular Disease in Older Nursing Home Residents

Teaser: 

Wilbert S. Aronow, MD, CMD
Department of Medicine,
Divisions of Cardiology and Geriatrics,
Westchester Medical Center/New York Medical College,
Valhalla, NY.

Cardiovascular disease (CVD) is the most common cause of death of older persons in a nursing home (NH). In a prospective study, we investigated the major clinical cause of death of all persons aged 60 years and older residing in a large NH with full-time staff physicians over a 15-year period.1

CVD was the cause of death in 63% of the 2,372 persons who died. Another 25 persons (1%) died of bacterial endocarditis. Of the 2,372 persons who died, 25% died of sudden cardiac death, 18% died of a documented fatal myocardial infarction, 11% died of refractory congestive heart failure, 6% died of thromboembolic stroke, 1% died of cerebral hemorrhage, 2% died of pulmonary embolism, 1% died of mesenteric vascular infarction diagnosed at surgery, and <1% died of peripheral vascular disease including dissecting aneurysm of the aorta and ruptured abdominal aneurysm.1

In a prospective study, we investigated the prevalence and incidence of CVD in 1,160 men, mean age 80 years, and in 2,464 women, mean age 81 years, residing in a NH.2 Of the 3,624 persons, 60% were white, 26% African-American, 14% Hispanic, and <1% Asian. Follow-up was 46 months (range 1 to 196 months).

Primary Prevention of Cardiovascular Disease

Primary Prevention of Cardiovascular Disease

Teaser: 

Jane Oshinowo, RNEC,
Primary health care Nurse Practitioner,
York Community Services,
Toronto, ON.

Sharon Dolman, RN
Medical copy writer,
HEADCAN,
Toronto, ON.

Introduction
Cardiovascular disease (CVD) is the leading cause of death in Canada and the second leading cause of disability. Since the mid-1960's there has been a gradual decline in overall mortality rates due to heart disease; however, there has been little improvement in the mortality rates from ischemic heart diseases (HD) and acute myocardial infarction (MI).1 Abookire27 noted that many physicians failed to adhere to the guidelines designed to reduce CVD risks. One strategy in this arena is to expand collaborative practice with nurse practitioners and other health care providers.

This paper will review the epidemiology of coronary heart disease (CHD) and the evidence about primary prevention designed to reduce cardiovascular risk factors, highlighting the role of the primary health care provider.

Epidemiology of Cardiovascular Disease
CVD is responsible for 36% of the deaths in Canada every year. Of these deaths, 21% are attributed to ischemic heart disease, and half of those are ascribed to acute MI (See Figure 1).1 Huge costs are accrued to society from CVD.