Dyspnoea on exertion is a more common clinical manifestation of IHD in elderly persons than is the typical chest pain of angina pectoris. The dyspnoea is usually exertional and is related to a transient rise in left ventricular (LV) end-diastolic pressure caused by ischaemia superimposed on decreased LV compliance. Because elderly persons are more limited in their activities, angina pectoris in elderly persons is less often associated with exertion. Elderly persons with angina pectoris are less likely to have substernal chest pain, and they describe their anginal pain as less severe and of shorter duration than do younger persons. Angina pectoris in elderly persons may occur as a burning post-prandial epigastric pain or as pain in the back or shoulders. Acute pulmonary oedema unassociated with an acute MI may be a clinical manifestation of unstable angina pectoris due to extensive IHD in elderly persons.

Myocardial ischaemia, appearing as shoulder or back pain in elderly persons, may be misdiagnosed as degenerative joint disease. Myocardial ischaemia, appearing as epigastric pain, may be misdiagnosed as peptic ulcer disease. Nocturnal or post-prandial epigastric discomfort that is burning in quality may be misdiagnosed as hiatus hernia or oesophageal reflux instead of myocardial ischaemia due to IHD. The presence of comorbid conditions in elderly persons may also lead to misdiagnosis of symptoms due to myocardial ischaemia.

Elderly persons with IHD may have silent or asymptomatic myocardial ischaemia. In a prospective study, 133 of 195 men (34%), mean age 80 years, with IHD and 256 of 771 women (33%), mean age 81 years, with IHD had silent myocardial ischaemia detected by 24-hour ambulatory electrocardiograms (ECGs). At 45-month follow-up, the incidence of new coronary events in elderly men with IHD was 90% in men with silent myocardial ischaemia versus 44% in men without silent ischaemia. At 47-month follow-up, the incidence of new coronary events in elderly women with IHD was 88% in women with silent ischaemia versus 43% in women without silent ischaemia.2

Resting ECG

In addition to diagnosing recent or prior MI, the resting ECG may show ischaemic ST-segment depression, arrhythmias, conduction defects, and LV hypertrophy that are related to subsequent coronary events. At 37-month mean follow-up, elderly patients with ischaemic ST-segment depression 1 mm or greater on the resting ECG were 3.1 times more likely to develop new coronary events than were elderly patients with no significant ST-segment depression.3 Elderly patients with ischaemic ST-segment depression 0.5 to 0.9 mm on the resting ECG were 1.9 times more likely to develop new coronary events during 37-month follow-up than were elderly patients with no significant ST-segment depression. At 45-month mean follow-up, pacemaker rhythm, atrial fibrillation, premature ventricular complexes, left bundle branch block, intraventricular conduction defect, and type II second-degree atrioventricular block were associated with a higher incidence of new coronary events in patients.3 Numerous studies have also documented that elderly patients with ECG LV hypertrophy have an increased incidence of new coronary events.3

Many studies have shown that complex ventricular arrhythmias in elderly persons with IHD are associated with an increased incidence of new coronary events including sudden cardiac death.3 The incidence of new coronary events is especially increased in elderly persons with complex ventricular arrhythmias and abnormal LV ejection fraction or LV hypertrophy. At 45-month follow-up of 395 men, mean age 80 years, with IHD, complex ventricular arrhythmias detected by 24-hour ambulatory ECGs increased the incidence of new coronary events 2.4 times.4 At 47-month follow-up of 771 women, mean age 81 years, with IHD, complex ventricular arrhythmias detected by 24-hour ambulatory ECGs increased the incidence of new coronary events 2.5 times.4

Exercise Stress Testing

Hlatky et al. found the exercise ECG to have a sensitivity of 84% and a specificity of 70% for the diagnosis of IHD in persons older than 60 years of age.3 Newman and Phillips found a sensitivity of 85%, a specificity of 56%, and a positive predictive value of 86% for the exercise ECG in diagnosing IHD.3 The increased sensitivity of the exercise ECG with increasing age found in these two treadmill exercise studies was probably due to the increased prevalence and severity of IHD in elderly persons.

Exercise stress testing also has prognostic value in elderly patients with IHD. Deckers et al.3 showed that the one-year mortality was 4% for 48 patients 65 years of age or older who were able to do an exercise stress test after acute MI and 37% for the 63 elderly patients unable to do the exercise stress test after acute MI.

Exercise stress testing using thallium perfusion scintigraphy, radionuclide ventriculography, and echocardiography are also useful in the diagnosis and prognosis of CHD. Iskandirian et al.3 showed that exercise thallium-201 imaging can be used for risk stratification of elderly patients with IHD. The risk for cardiac death or non-fatal MI at 25-month follow-up in 449 patients 60 years of age or older was less than 1% in patients with normal images, 5% in patients with single-vessel thallium-201 abnormality, and 13% in patients with multivessel thallium-201 abnormality.

Pharmacological Stress Testing

Intravenous dipyridamole-thallium imaging may be used to determine the presence of IHD in elderly patients who are unable to undergo treadmill or bicycle exercise stress testing. In patients 70 years of age or older, the sensitivity of intravenous dipyridamole-thallium imaging for diagnosing significant IHD was 86%, and the specificity was 75%.3 In 120 patients older than 70 years, adenosine echocardiography had a 66% sensitivity and a 90% specificity in diagnosing IHD.3 An abnormal adenosine echocardiogram predicted a threefold risk of future coronary events, independent of coronary risk factors.3 In 120 patients older than 70 years, dobutamine echocardiography had a 87% sensitivity and a 84% specificity in diagnosing IHD.3 An abnormal dobutamine echocardiogram predicted a 7.3-fold risk of future coronary events.3

Signal-Averaged Electrocardiography

Signal-averaged electrocardiography (SAECG) was performed in 121 elderly post-infarction patients with asymptomatic complex ventricular arrhythmias detected by 24-hour ambulatory ECGs and a LV ejection fraction of 40% or higher.3 At 29-month follow-up, the sensitivity, specificity, positive predictive value, and negative predictive value for predicting sudden cardiac death were 52%, 68%, 32%, and 83%, respectively for a positive SAECG; 63%, 70%, 38%, and 87%, respectively for non-sustained ventricular tachycardia; and 26%, 89%, 41%, and 81%, respectively for a positive SAECG plus non-sustained ventricular tachycardia.3

Cigarette Smoking

The Cardiovascular Health Study demonstrated in 5201 men and women 65 years of age or older that >50 pack-years of smoking increased five-year mortality 1.6 times.5 The Systolic Hypertension in the Elderly Program pilot project showed that smoking was a predictor of first cardiovascular event and MI/sudden death.5 At five-year follow-up of 7178 persons ≥65 years of age in three communities, the relative risk for CVD mortality was 2.0 for male smokers and 1.6 for female smokers.5 The incidence of CVD mortality in former smokers was similar to those who had never smoked.5 At 40-month follow-up of 664 men, mean age 80 years, and at 48-month follow-up of 1488 women, mean age 82 years, current cigarette smoking increased the relative risk of new coronary events 2.2 times in men and 2.0 times in women.6 At six-year follow-up of older men and women in the Coronary Artery Surgery Study registry, the relative risk of MI or death was 1.5 for persons 65–69 years of age and 2.9 for persons 70 years of age and older who continued smoking compared with quitters during the year before study enrolment.5

Elderly men and women who smoke cigarettes should be strongly encouraged to stop smoking to reduce the development of IHD. Smoking cessation will decrease mortality from IHD, other cardiovascular disease, and all-cause mortality in elderly men and women. A smoking cessation programme should strongly be recommended.

Hypertension

Systolic hypertension in elderly persons is diagnosed if the systolic blood pressure is 140 mmHg or higher from two or more readings on two or more visits.7 Diastolic hypertension in elderly persons is similarly diagnosed if the diastolic blood pressure is 90 mmHg or higher. In a study of 1819 persons, mean age 80 years, living in the community, the prevalence of hypertension was 71% in elderly African Americans, 64% in elderly Asians, 62% in elderly Hispanics, and 52% in elderly whites.5 Isolated systolic hypertension in elderly persons is diagnosed if the systolic blood pressure is 140 mmHg or higher with a diastolic blood pressure of less than 90 mmHg. Approximately two-thirds of elderly persons with hypertension have isolated systolic hypertension.

Isolated systolic hypertension and diastolic hypertension are both associated with increased IHD morbidity and mortality in elderly persons.5 Increased systolic blood pressure is a greater risk factor for IHD morbidity and mortality than is increased diastolic blood pressure. The higher the systolic or diastolic blood pressure, the greater the morbidity and mortality from IHD in elderly women and men. The Cardiovascular Health Study demonstrated in 5202 elderly men and women that a brachial systolic blood pressure >169 mmHg was associated with a 2.4-fold greater five-year mortality.5

At 30-year follow-up of persons 65 years of age and older in the Framingham Heart Study, systolic hypertension was related to a greater incidence of IHD in elderly men and women.5 Diastolic hypertension correlated with the incidence of IHD in elderly men but not in elderly women. At 40-month follow-up of 664 elderly men and 48-month follow-up of 1488 elderly women, systolic or diastolic hypertension was associated with a relative risk of new coronary events of 2.0 in men and 1.6 in women.6 Data from Framingham also suggests the importance of increased pulse pressure, a measure of large artery stiffness. Among 1924 men and women aged 50–79 years, at any given level of systolic blood pressure of 120 mmHg or greater, the risk of IHD over 20 years rose with lower diastolic blood pressure, suggesting that higher pulse pressure was an important component of risk.5 Among 1061 men and women aged 60–79 years in the Framingham Heart Study, the strongest predictor of IHD risk was pulse pressure [hazard ratio(HR) = 1.24].

Elderly persons with hypertension should be treated with salt restriction, weight reduction if necessary, discontinuation of drugs that increase blood pressure, avoidance of alcohol and tobacco, increase in physical activity, decrease of dietary saturated fat and cholesterol, and maintenance of adequate dietary potassium, calcium and magnesium intake. In addition, antihypertensive drugs have been shown to reduce IHD events in elderly men and in elderly women with hypertension.7, 8

Despite multiple large randomized trials, treatment of hypertension in patients aged 80 years or older remained controversial until the publication of HYVET.8 In HYVET, 3845 persons aged 80 years and older (mean age 83.6 years) with a sustained systolic blood pressure of 160 mmHg or higher were randomized to indapamide (sustained-release 1.5 mg) or matching placebo. Perindopril 2 mg or 4 mg, or matching placebo, was added if needed to achieve the target blood pressure of 150/80 mmHg. The study was terminated early after a median follow-up of 1.8 years.

Antihypertensive drug treatment reduced the incidence of the primary endpoint (fatal or non-fatal stroke) by 30%, fatal stroke by 39%, all-cause mortality by 21%, death from cardiovascular causes by 23%, and heart failure by 64%. The significant 21% reduction in all-cause mortality by antihypertensive drug treatment was unexpected. The benefits of antihypertensive drug treatment appeared during the first year of follow-up.

The prevalence of cardiovascular disease was only 12% at baseline in HYVET patients (i.e. much lower than generally reported in community-based samples of octogenarians). For example, in a cohort of patients with hypertension, mean age 80 years, in a university geriatrics practice, 70% had cardiovascular disease, target organ damage, or diabetes mellitus.5 The absolute reduction in cardiovascular events resulting from antihypertensive drug therapy in an elderly population with a high prevalence of cardiovascular disease could be much greater than observed in HYVET.

Elderly persons with IHD should have their blood pressure reduced to <135/85 mmHg and to less than 130/80 mmHg if diabetes mellitus or chronic renal disease is present.7 JNC 7 pointed out that most patients with hypertension will require two or more antihypertensive drugs to achieve this blood pressure goal.7 The drugs of choice for treating IHD with hypertension are beta-blockers and angiotensin-converting enzyme (ACE) inhibitors. If a third antihypertensive drug is needed, a thiazide diuretic should be administered.

Left Ventricular Hypertrophy

Elderly men and women with ECG LV hypertrophy and echocardiographic LV hypertrophy have an increased risk of developing new coronary events.5 At four-year follow-up of 406 elderly men and 735 elderly women in the Framingham study, echocardiographic LV hypertrophy was 15.3 times more sensitive in predicting new coronary events in elderly men and 4.3 times more sensitive in predicting new coronary events in elderly women than was electrocardiographic LV hypertrophy.5 At 37-month follow-up of 360 men and women, mean age 82 years, with hypertension or IHD, echocardiographic LV hypertrophy was 4.3 times more sensitive in predicting new coronary events than was electrocardiographic LV hypertrophy.5

Physicians should try to prevent LV hypertrophy from developing or progressing in elderly men and women with IHD. A meta-analysis of 109 treatment studies found that ACE inhibitors were more effective than other antihypertensive drugs in decreasing LV mass.5

Dyslipidemia

Numerous studies have demonstrated that a high serum total cholesterol is a risk factor for new or recurrent coronary events in elderly men and women.5 At 40-month follow-up of 664 elderly men and at 48-month follow-up of 1488 elderly women, an increment of 10 mg dl−1 of serum total cholesterol was associated with an increase in the relative risk of 1.12 for new coronary events in both men and in women.6

A low serum high-density lipoprotein (HDL) cholesterol is a risk factor for new coronary events in elderly men and women.5 In the Framingham study, in the Established Populations for Epidemiologic Studies of the Elderly study, and in a large cohort of convalescent home patients,5 a low serum HDL cholesterol was a more powerful predictor of new coronary events than was serum total cholesterol. At 40-month follow-up of 664 elderly men and at 48-month follow-up of 1488 elderly women, a decrement of 10 mg dl−1 of serum HDL cholesterol increased the relative risk of new coronary events 1.70 times in men and 1.95 times in women.6

Hypertriglyceridemia is a risk factor for new coronary events in elderly women but not in elderly men.5 At 40-month follow-up of elderly men and at 48-month follow-up of elderly women, the level of serum triglycerides was not a risk factor for new coronary events in men and was a very weak risk factor for new coronary events in women.6

Numerous studies have demonstrated that statins reduce new coronary events in elderly men and in elderly women with IHD.9