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.

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.