ANGINA IN THE ELDERLY

Coronary artery disease (CAD) remains the most common cause of heart d isease in the elderly, in whom it exhibits some unique features. It is more likely to be diffuse and severe and left main coronary artery st enosis and triple-vessel disease are more prevalent. Diagnosis is less dependent on the presence of chest pain since other symptoms may pres ent as an anginal equivalent in such patients. The ECG of elderly pati ents often shows abnormalities that are not specific for myocardial is chaemia. In such patients, and in those who are unable to perform suff icient exercise to increase the heart rate to greater than or equal to 85% of predicted maximal heart rate for age and sex, radionuclide or pharmacological stress testing may be used. When the diagnosis of CAD remains questionable, coronary arteriography should be considered. Phy sical examination and basic laboratory screening should be used to ide ntify conditions which exacerbate myocardial ischaemia and will, there fore, affect treatment. The initial approach to treatment should inclu de risk factor modification and initiation of an anti-ischaemic pharma cological regimen. The usual anti-anginal medications are as efficacio us in the elderly as in the young; however, attention must be paid to altered pharmacodynamics and pharmacokinetics. When symptoms are poorl y controlled by medical therapy or when multivessel or left main coron ary artery stenosis is identified, myocardial revascularization should be considered. In elderly patients with symptomatic angina or unstabl e angina symptoms, uncontrolled by medical therapy, percutaneous trans luminal coronary angiography may be a reasonable alternative to surgic al revascularization.