Wilbert S. Aronow, MD, FACC, FAHA, AGSF, FCCP, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care, Department of Medicine, New York Medical College, Valhalla, NY, USA.

Low bone mineral density (BMD) is associated with obstructive coronary artery disease (CAD); this article reviews several recent studies that have demonstrated the association. In one study, for every 1-unit reduction in femoral neck T score, a 0.23 minute decrease in treadmill exercise duration was found after values were adjusted for age and other patient characteristics (95% confidence interval [CI], 0.11–0.35, p<0.001). For every 1-unit reduction in femoral neck T score, there was a 22% increased risk of myocardial ischemia after values were adjusted for age and other patient characteristics (95% CI, 1.06–1.41, p = 0.004). Overall after adjustments, patients with a low BMD who were referred for exercise echocardiographic stress testing had a 43% greater risk of myocardial ischemia than did patients with normal BMD referred for exercise echocardiographic stress testing (95% CI, 1.06–1.94, p = 0.02). Reduced physical activity may contribute to both low BMD and CAD through the development of atherosclerotic vascular disease.
In a second study, stress test-induced myocardial ischemia developed in 95 of 254 patients (37%) with osteoporosis, in 81 of 260 patients (31%) with osteopenia, and in 62 of 251 patients (25%) with normal BMD (p= 0.009) (p= 0.002 comparing osteoporosis with normal BMD; p=0.007 comparing osteoporosis or osteopenia with normal BMD). Patients with osteoporosis or osteopenia had a 1.7 times higher chance of stress test-induced myocardial ischemia than those with normal BMD after controlling the confounding effects of systemic hypertension, diabetes mellitus, body mass index, and age.
Key words: osteoporosis, osteopenia, bone mineral density, coronary artery disease, myocardial ischemia.

Abdul Razakjr Omar, MBBS, MMed (Int Med), MRCP (UK), FAMS (Cardiology) Consultant Cardiologist, National University Hospital, Singapore.
Kumaraswamy Nanthakumar, MD, FRCPC, Staff Cardiologist, Cardiac Electrophysiologist, University Health Network, Toronto General Hospital; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

In older patients the aging process is complicated by underlying comorbid diseases. An implantable cardioverter-defibrillator (ICD) has been shown to reduce mortality due to sudden cardiac death and improve survival in patients at risk of lethal arrhythmia. However, its role in older adults with coronary artery disease (CAD) is less well understood. A literature review of ICD trials was conducted, assessing efficacy and feasibility of the device in older adults.
The use of an ICD should be individualized in older patients. ICD therapy is feasible and safe in preventing sudden cardiac death. Age is insufficient to exclude an older adult with CAD from ICD therapy.
Key words: coronary artery disease, implantable cardioverter-defibrillator, sudden cardiac death, ventricular tachycardia, cardiac resynchronization therapy.

C. Tissa Kappagoda, MBBS, PhD, Professor of Medicine, Department of Internal Medicine, University of California, CA, USA.
Dianne A. Hyson, RD, PhD, Assistant Professor, Department of Consumer Sciences, California State University of Sacramento, CA, USA.

This paper examines the potential impact of some popular diets on cardiovascular risk factors in aging populations. The compositions of these diets are compared against the broader recommendations of the Food and Nutrition Board and the American Heart Association. The Atkins and South Beach diets have been advanced as components of weight loss programs, while the Mediterranean type of diet has been promoted as being especially beneficial to those who are at risk of developing cardiovascular disease. When viewed against the recommendations of the Food and Nutrition Board, it is apparent that these diets are unlikely to meet the special nutritional needs of the older population.
Key words: Atkins, South Beach, Mediterranean diet, nutrition, coronary artery disease.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Secondary prevention has been shown to decrease coronary artery disease morbidity and mortality by 20-25%. Exercise, smoking cessation, and management of dyslipidemia, hypertension, diabetes, and obesity, along with psychological therapies, are typical elements of secondary prevention programs offered by a multidisciplinary clinical team often including physicians, nurses, pharmacists, exercise physiologists, registered dieticians, and psychologists. Special considerations for older adults in a secondary prevention setting in reference to medications, exercise, diet, smoking cessation, and hypertension are addressed. Current practice guidelines and clinical trials are presented, along with practical tools for the primary care physician treating the older coronary artery disease patient.
Key words: multidisciplinary, cardiac rehabilitation, coronary artery disease, secondary prevention.

In recent editorials, I have commented on the importance of dementing disorders, the fact that arthritis is the major issue affecting older adults’ quality of life, and the growing burden of cancer as our society ages. I might have seemed to forget the importance of cardiovascular diseases, but in fact cardiovascular disease is never far from the mind of doctors caring for older adults. At times it seems universal in our patients. As cardiologists become more and more involved in invasive procedures and sophisticated diagnostic testing, it seems that ever more of the burden of the actual day-to-day care of these patients is returning to the hands of family physicians (and, at times, general internists and geriatricians). Congestive heart failure remains the commonest reason for hospital admission in North America, and the disorder affects predominantly older adults. We hope that this edition of Geriatrics & Aging will help you care for patients with cardiac disease.

Family doctors provide almost all the care for patients after they suffer an acute cardiac event, and proper care to prevent recurrences is one of their most important jobs. This area is explored in the CME article “Secondary Prevention in Coronary Artery Disease” by Tanya M. Holloway, Lisa Kwok, Margaret Brum, and Dr. Caroline Chessex. In the early 1990s there was a bitter debate in the medical community, much of it published in the CMAJ, about the role of screening for, and then treating, dyslipidemias. We now have much better evidence on which to base our actions, and this is reviewed in the article “Lipid Management--Who to Screen? Who to Treat?’ by Dr. David Fitchett. Part of secondary prevention is dietary advice, and the article “Popular Diets and Coronary Artery Disease” by Drs. C. Tissa Kappagoda and Dianne A. Hyson will help family doctors answer their patients’ queries.

As well, we have our usual group of columns and articles of general interest. Our movement disorders article is “Pharmacologic Options in Parkinson’s Disease: A Treatment Guide” by Drs. Steven E. Lo and Steven J. Frucht. Our Drugs & Aging column is entitled “Aging and the Neurobiology of Addiction” by Drs. Paul J. Christo, Greg Hobelmann, and Amit Sharma. Our ophthalmology article is on a very important topic, “Medical Management of Glaucoma: Clinical and Research Update” by Drs. Elliott M. Kanner and James C. Tsai. Dr. Roger Wong considers the “Assessment of Mobility Impairment” in our Biology of Aging column. The Caregiving column, “Ethnic Differences in the Caregiving Experience: Implications for Interventions,” by Drs. Martin Pinquart and Silvia Sörensen is very important in a multicultural society such as ours.

Our final two columns are related to our focus on cardiovascular disease. The technology in medicine article is on “Syncope in the Older Adult: When Is a Pacemaker Indicated?” and is written by Dr. Gabriel Gregoratos. Our cardiovascular column is on that most common of disorders that doctors manage: hypertension. It is entitled “Hypertension in the Older Adult: An Update on Canadian Hypertension Education Program Recommendations” and is by Drs. Norm R.C. Campbell, J. George Fodor, Robert Herman, and Pavel Hamet.

Enjoy this issue, and best wishes for the season.

Barry Goldlist

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

The incidence of coronary heart disease increases with advancing age. Although older patients may develop classical symptoms of ischemic heart disease, other symptoms such as dyspnea, syncope, and fatigue are often the dominant presenting features of angina and myocardial infarction. The present discussion aims to heighten awareness of the atypical nature of myocardial ischemic symptoms in the older adult and to suggest a structured approach to facilitate achieving a more accurate diagnosis.
Key words: chest pain, myocardial ischemia, dyspnea, coronary artery disease, infarction.

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

Serum High-Density Lipoprotein Cholesterol
A low serum, high-density lipoprotein (HDL) cholesterol is a risk factor for the development of new coronary events in older men and women.^1-6 In the Framingham Heart Study,¹ in the Established Population for Epidemiologic Studies of the Elderly Study,⁴ and in 2,152 older men and women,³ a low serum HDL cholesterol was a more powerful predictor of new coronary events than was serum total cholesterol. In 1,793 older men and women, mean age 81 years, a decrease of 10 mg/dL (0.26 mmol/L) of serum HDL cholesterol significantly increased by 2.56 times, the probability of having coronary artery disease after controlling for other prognostic variables.² At 48-month follow-up of 1,488 older women, mean age 82 years, and at 40-month follow-up of 664 older men, mean age 80 years, a decrease of 10 mg/dL (0.26 mmol/L) of serum HDL cholesterol significantly increased the relative risk of developing new coronary events by 1.95 times in women and by 1.7 times in men, after controlling for other prognostic variables.

Results from the Multicentre Randomized Arterial Revascularization Therapy Study

V. Legrand¹ MD, PhD, FESC,
P. Serruys² MD, PhD, FACC, FESC,
WK Lindeboom³ PhD,
M. Vrolix⁴ MD,
G. Fransen⁴ MD,
P. Materne⁵ MD,
G. Dekoster⁵ MD,
R. Seabra-Gomes⁶ MD,FESC,
J. Queiroz E Melo⁶ MD

¹CHU Liege Belgium.
²Thoraxcenter, Rotterdam, The Netherlands.
³Cardialysis, Rotterdam, The Netherlands.
⁴St Jansziekenhuis, Genk, Belgium.
⁵CHR Citadelle, Liege, Belgium.
⁶Hosp Santa Cruz, Carnaxide, Portugal.

Key words : coronary angioplasty, stent, coronary bypass surgery, elderly.

Introduction
As the population ages, an increasing number of elderly patients are presenting with symptomatic multivessel coronary artery disease requiring revascularization. However, the most appropriate myocardial revascularization procedure for older patients with multivessel disease is still controversial. Indeed, it is well recognized that the procedure-related morbidity associated with either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) increases dramatically with age.