Wilbert S. Aronow, MD, FACC, FAHA, AGSF, Department of Medicine, Cardiology Division, New York Medical College, Valhalla, NY, USA.

Numerous double-blind, randomized, placebo-controlled studies have documented that antihypertensive drug therapy reduces cardiovascular events in older adults. In the Hypertension in the Very Elderly Trial, individuals 80 years of age and older treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke, a 39% reduction in fatal stroke, a 21% reduction in all-cause mortality (p=0.02), a 23% reduction in death from cardiovascular causes, and a 64% reduction in heart failure. The goal of treatment of hypertension in older adults is to reduce the blood pressure to <140/90 mmHg and to <130/80 mmHg in older persons with diabetes or chronic renal insufficiency. Older adults with diastolic hypertension should have their diastolic blood pressure reduced to 80-85 mmHg. Diuretics should be used as initial therapy in persons with no associated medical conditions. The selection of antihypertensive drug therapy in persons with associated medical conditions depends on their medical conditions. If the blood pressure is >20/10 mmHg above the goal blood pressure, drug therapy should be initiated with two antihypertensive drugs, one of which should be a thiazide-type diuretic. Other coronary risk factors must be treated.
Key words: hypertension, older adults, antihypertensive drug therapy, angiotensin-converting enzyme inhibitors, beta-blockers.

Wilbert S. Aronow, MD, CMD, Clinical Professor of Medicine, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care Medicine; Chief, Cardiology Clinic; Senior Associate Program Director and Research Mentor, Fellowship Programs, Department of Medicine, New York Medical College, Valhalla, NY; Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City, NY, USA.

Older patients are more likely to have hypertension and isolated systolic hypertension, to have target organ damage and clinical cardiovascular disease, and to develop myocardial infarction, angina pectoris, stroke, congestive heart failure, and peripheral arterial disease. Yet, considering the increased risk of cardiovascular death, older patients are less likely to have hypertension controlled. Antihypertensive drug therapy reduces coronary events, stroke, heart failure, and cardiovascular death in older patients. The goal of treatment of hypertension in older patients is to reduce the blood pressure to less than 140/90mmHg and to ≤130/80mmHg in older patients with diabetes mellitus or chronic renal insufficiency. Diuretics should be used as initial drug therapy in older patients with hypertension and no associated medical conditions. The selection of antihypertensive drug therapy in older patients depends on the associated medical conditions.

Key words: hypertension, diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers.

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

Chronic stable angina is a common condition in older patients. Although lifestyle modifications such as weight loss, smoking cessation, and risk factor control remain fundamental components of the management strategy, pharmacological agents are necessary to prevent and control anginal symptoms. Sublingual nitroglycerin (either as tablets or a spray) is the most effective agent to terminate an episode of anginal pain. Anginal frequency and exercise tolerance are improved with beta-adrenergic blockers, calcium channel blockers, and long-acting nitrate preparations. A strategy for the optimal use of these agents both alone and in combination is discussed.

Key words: angina pectoris, nitrates, beta-blockers, calcium channel blockers.

Wilbert S. Aronow, MD, Department of Medicine, Divisions of Cardiology and Geriatrics, Westchester Medical Center/New York Medical College, Valhalla, NY; Clinical Professor of Medicine and Chief, Cardiology Clinic, Westchester Medical Center/New York Medical College, and Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine.

In older women, ischemic heart disease (IHD) is diagnosed if there is coronary angiographic evidence of significant IHD, a documented myocardial infarction, a typical history of angina with myocardial ischemia diagnosed by stress testing, or sudden cardiac death. Clinical manifestations of acute myocardial infarction in older women include dyspnea (the most common presenting symptom), chest pain, neurological symptoms and gastrointestinal symptoms. The prognosis of Q-wave myocardial infarction is not significantly different if the myocardial infarction is clinically recognized or unrecognized. IHD should be treated with intensive risk factor modification, antiplatelet therapy, beta-blockers and angiotensin-converting enzyme inhibitors.

Key words: ischemic heart disease, myocardial infarction, antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors.

The most common cause of death in older women is ischemic heart disease (IHD). The prevalence of IHD is similar in older women compared to older men.¹ In one study of 2,464 women with an average age of 81 years, the prevalence of IHD was 41%.

Wilbert S. Aronow, MD, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY, USA.

The American College of Cardiology/American Heart Association guidelines recommend that patients with asymptomatic left ventricular systolic dysfunction or with congestive heart failure (CHF) be treated with angiotensin-converting enzyme (ACE) inhibitors plus beta-blockers unless there are contraindications to the use of these drugs. Beta-blockers have been demonstrated to significantly reduce all-cause mortality associated with abnormal or normal left ventricular ejection fraction in older and younger patients with CHF. An angiotensin receptor blocker should not be administered to patients with CHF who are being treated with a beta-blocker plus ACE inhibitor, but should be given to patients with CHF treated with beta-blockers who cannot tolerate ACE inhibitors due to cough, angioneurotic edema, rash or altered taste sensation.
Key words: congestive heart failure, left ventricular ejection fraction, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptors blockers.

Ali Ahmed, MD, MPH, FACP, FACC, Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, Department of Epidemiology and International Health, School of Public Health and Geriatric Heart Failure Clinic, University of Alabama at Birmingham; Section of Geriatrics and Geriatric Heart Failure Clinic, VA Medical Center; and Alabama Heart Failure Project, Alabama Quality Assurance Foundation; Birmingham, AB, USA.
Phillip L. Thornton, PhD, CGP, FASCP, Department of Pharmacy Practice, Auburn University James I. Harrison School of Pharmacy and Department of Medicine, Division of Gerontology and Geriatric Medicine and Geriatric Heart Failure Clinic, University of Alabama at Birmingham; Birmingham, AB, USA.

Heart failure is common in older adults and is associated with high mortality and hospitalization rates, and is the only cardiovascular syndrome with increasing incidence and mortality. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers reduce mortality and hospitalization rates for heart failure patients with left ventricular systolic dysfunction. Unfortunately, these life-saving drugs continue to be underutilized. ACE inhibitors and beta-blockers should be prescribed to all eligible systolic heart failure patients. Generalist physicians, who care for most heart failure patients, are perfectly capable of prescribing these life-saving drugs to older adults with systolic heart failure and should be encouraged to do so.

Jonathan B. Shammash, MD
Assistant Professor of Medicine,
Director of General Medical Consultation Service,
Department of Medicine,
Weill Medical College of Cornell University,
New York, NY, USA.

Julie M. Gold, BA
Weill Medical College of Cornell University,
New York, NY, USA.

Overview
Cardiovascular complications are the leading cause of morbidity and mortality in patients undergoing major noncardiac surgeries. It is estimated that 20-40% of patients at risk for cardiac events will experience perioperative cardiac ischemia, conferring a nine-fold increase in risk of perioperative cardiac death, myocardial infarction or unstable angina. This is a serious concern in North America. In the United States, about 1.5 of the 30 million patients undergoing noncardiac surgery each year will experience cardiovascular morbidity.¹ Since many of these patients have identifiable risk factors for cardiac ischemia, research efforts have been channeled toward finding modifiable risk factors and introducing pharmacological interventions that may offer cardiovascular protection during the perioperative period. Several small clinical trials have examined the perioperative use of nitrates² and calcium channel blockers,³ but these did not show a significant reduction in the incidence of cardiac ischemic events.

Neil Fam, BSc, MSc

Heart failure can be defined as a pathophysiological syndrome in which the heart fails to pump an adequate flow of blood to meet the metabolic demands of the body. This condition carries extremely high morbidity and mortality, with a five year survival rate of 50%. It is also one of the most common reasons for hospital admission in Canada. As our population ages, heart failure is becoming increasingly prevalent, placing serious strain on health care resources. In the past decade, medications such as angiotensin converting enzyme (ACE) inhibitors have been shown to improve survival in patients with heart failure. However, mortality has remained high. New research has focused on the use of b-blockers, a class of drugs traditionally used in the treatment of angina and myocardial infarction. Recently, two large randomised trials, the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II) and the Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF) clearly demonstrated a survival benefit in heart failure patients taking b-blockers. This article summarizes the main findings of these studies and outlines the practical use of b-blockers in heart failure.

An understanding of the pathophysiology underlying heart failure is helpful in the selection of appropriate medical therapy.

Andrea Sotirakopoulos, BSc

Atrial fibrillation (AF) is one of the most common sustained arrhythmias encountered by clinicians. Its incidence increases with age and the presence of structural heart disease, although it may also be present in patients without identifiable heart disease. When healthy, the atria contract at a rate that is coordinated with the contractions in the ventricles. In AF instead of beating effectively, the atria produce numerous chaotic electrical impulses that result in a non-organized, quivering movement of the heart muscle called fibrillation. As a result, the ventricles then beat too quickly, generating a rapid pulse rate and possibly allowing the blood to pool and clot. If a piece of the blood clot in the atria becomes lodged in an artery in the brain, a stroke occurs. A rapid or irregular heart rate during AF can cause symptoms such as palpitations, exertional breathlessness, fatigue, or hypotension. AF may be classified as Paroxysmal, defined as recurrent episodes reverting spontaneously or following treatment to sinus rhythm or Chronic, referring to persistent arrhythmia.

Treatment of AF should be of special interest to doctors treating the elderly. The prevalence of AF is 0.5% for the group aged 50 to 59 years and rises to 8.8% in the group aged 80 to 89 years.