Kenneth R. Melvin, MD, FRCPC, Associate Professor, Department of Medicine, Cardiology, University Health Network, University of Toronto, Toronto, ON.
Lindsay J. Melvin, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON.

The increasing average age of natural survival and effective therapies for many previously fatal illnesses have increased the older adult population. Thus, there is a concomitant increase in long-term treatment requirements for many conditions, including chronic angina pectoris. Advances in nonsurgical interventions include angioplasty and stent technology. The medical treatment of angina should be individualized to the patient and usually involves multiple-drug regimens. Mainstays of therapy include acetylsalicylic acid and nitroglycerin 0.4 mg spray with combinations of long-acting nitrates, beta-blockers, calcium channel blockers, and the ancillary use of angiotensin-converting enzyme inhibitors and statins. Risk reduction involves controlling modifiable factors, including smoking, weight control, hypertension, and hyperlipidemia; this will reduce disease progression and cardiac event occurrences. Older adults should be monitored for drug interactions and sensitivity to medication in the presence of associated medical problems and other therapies. Cardiac rehabilitation programs are a useful addition to comprehensive medical treatments for chronic stable angina.
Key words: angina, antianginal drug therapy, risk reduction, cardiac rehabilitation, percutaneous coronary intervention, PCI.

Anna J.M. van de Sande, BSc, Medical Student, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands. Visiting Medical Student, Canadian VIGOUR Center, University of Alberta, Edmonton, AB.
Paul W. Armstrong, MD, Professor, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.
Padma Kaul, PhD, Assistant Professor, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.

The burden of cardiovascular disease increases significantly with age. One of the most complex decisions facing clinicians is whether or not to perform coronary revascularization in an older patient. Our review of recent evidence on revascularization therapies for aging patients with non-ST-elevation acute coronary syndromes found an inverse relationship between age and the use of evidence-based medications as well as revascularization procedures. Older patients undergoing revascularization had a higher likelihood of adverse outcomes compared with younger patients undergoing revascularization. However, older patients who underwent revascularization had significantly better outcomes than their counterparts who did not undergo revascularization, suggesting that they deserve the same consideration as younger patients in the use of coronary interventions.
Key words: acute coronary syndromes, percutaneous coronary intervention, coronary artery bypass graft surgery, evidence-based medications, outcomes.

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.

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.

Cynthia M. Westerhout, MSc and Eric Boersma, PhD
From the Department of Cardiology, Erasmus Medical Centre,
Rotterdam, The Netherlands and the University of Alberta, Edmonton, AB, Canada.

Introduction
The introduction of balloon angioplasty in the early 1980s and stents in the mid-1990s has revolutionized mechanical reperfusion therapy in patients with stenotic coronary arteries.^1,2 In fact, percutaneous coronary interventions (PCI) are one of most frequently performed procedures, with more than 1.3 million performed worldwide in 1999.³ However, an important limitation of PCI is the risk of inducing platelet aggregation. As a result of the disruption of the culprit plaque and injury to the coronary vessel during the procedure, the periprocedural risk of reocclusion of the vessel and myocardial infarction (MI) is high, and there is a 20-40% incidence of restenosis at 6-12 months after the index procedure.³

In an attempt to reduce the risk of these complications, several new strategies have been explored. Glycoprotein IIb/IIIa receptor inhibitors (GPIs), for example, have been enthusiastically tested in over 25,000 patients undergoing PCI over the last decade (Table 1). Gp IIb/IIIa receptors are found in great abundance on the surface of platelets and blocking these receptors obstructs the final common pathway leading to platelet aggregation.