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.

Silja Majahalme, MD, PhD, FESC, Cardiologist and Clinical Hypertension Specialist, Appleton Heart Institute/Appleton Cardiology Associates, Appleton, WI, USA.

Heart failure (HF) is an increasing problem in the older adult population, specifically among women. The majority of health care expenses are generated in the last few years of life, and hospitalization for HF is one of the major medical conditions influencing the expenditure. The nature of women’s HF differs from men: coronary artery disease is the most common etiologic factor for HF in men while women more often suffer from hypertensive heart disease, which results in stiffness of the left ventricle with relaxation problems, and diastolic HF. Most commonly there is a long history of poorly controlled hypertension. In acute situations these patients often present with florid edema and congestion along with significantly elevated blood pressure levels, which are both challenging to treat. This short review covers issues related to gender differences in etiology and epidemiology of HF, and evaluates current evidence for drug therapies.
Key words: epidemiology, heart failure, gender, myocardial infarction, hypertension.

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.htm

L. Creed Pettigrew, MD, MPH, Professor of Neurology, Director, Stroke Program, Sanders-Brown Center on Aging, University of Kentucky College of Medicine, Lexington, KY, USA.

Stroke is the most common life-threatening neurological disease and is the fourth leading cause of death among adult Canadians. Aspirin is the most frequently prescribed antithrombotic drug to prevent stroke but may not be a suitable choice in older patients who have already had stroke symptoms despite its use, or cannot tolerate its side effects. For these patients, clopidogrel or the combination of low-dose aspirin with extended release (ER) dipyridamole should be considered for prevention of stroke. This review will compare the relative benefits of aspirin, clopidogrel, and low-dose aspirin/ER-dipyridamole in geriatric patients at risk for stroke.

Key words: stroke, myocardial infarction, aspirin, clopidogrel, dipyridamole.

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.

Patients with unstable angina pectoris/non-ST-segment elevation myocardial infarction should be treated with nitrates, beta-blockers, Aspirin plus clopidogrel and angiotensin-converting enzyme inhibitors, as well as with diet plus statins if the serum low-density lipoprotein cholesterol is = 100mg/dL. Intravenous unfractionated heparin or preferably low-molecular-weight heparin should be given to high-risk or intermediate-risk patients. A platelet glycoprotein IIb/IIIa inhibitor should be administered if percutaneous coronary intervention is planned. Eptifibatide or tirofiban should be given to patients with continuous myocardial ischemia, an elevated troponin T or I level, or other high-risk features, and in whom an invasive strategy is not planned. High-risk patients should have early invasive management.
Key words: acute coronary syndromes, unstable angina pectoris, non-ST-segment elevation myocardial infarction, percutaneous coronary intervention.

Roy C. Ziegelstein, MD, Department of Medicine, Division of Cardiology, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD.

Depressed mood is common after a myocardial infarction and is associated with increased mortality risk. Although mild forms of depression often resolve without specific treatment, moderate to severe depression is typically longer lasting. Depression is particularly unlikely to resolve spontaneously in those who are socially isolated, a common problem in older individuals. Patients may be screened for depression using one of several short and valid instruments. If antidepressant treatment is indicated, a selective serotonin reuptake inhibitor is preferred and should be combined with efforts to improve social support, to address medication adherence issues and to encourage participation in a cardiac rehabilitation program.
Key words: depression, myocardial infarction, screening, social support, antidepressants.