Coronary Artery Disease In Elderly Patients Research Articles

TCT-49 A Comparison of 5 mg Prasugrel With 75 mg Clopidogrel in Very Elderly Coronary Artery Disease Patients: Pharmacodynamics and Rates of High on-Treatment Reactivity

A Comparison of 5 mg Prasugrel With 75 mg Clopidogrel in Very Elderly Coronary Artery Disease Patients : Pharmacodynamics and Rates of High on-Treatment Reactivity

Risk Stratification in Elderly Coronary Artery Disease Patients: Can We Predict Which Seniors Benefit Most from Revascularization Options?

With the increased global burden of an aging population manifesting cardiovascular disease, the decision process for use of coronary revascularization options in older adults has gained attention. Assessment of physiologic status has greater bearing than chronologic age; items that have proven of particular merit in evaluating comorbidities as they relate to treatment prognosis for both PCI and CABG in older adults include EuroSCORE and frailty scoring. Evaluation of neurocognitive function can uncover the presence and severity of all-cause dementia, which may be missed in simple medical history interaction. These data have significance when considering aggressive coronary artery disease treatments in this population for symptomatic and/or survival benefit, particularly when high priority is placed on quality of life and independent living post-treatment. Recovery after procedural intervention is slower and with increased morbidity in older adults. Older adults tend to have more complex coronary artery disease; for some, the risk/benefit of revascularization may be prohibitive. Proper selection by the cardiac team for appropriateness of treatment options for each patient’s circumstances can result in excellent percutaneous coronary intervention and coronary artery bypass graft revascularization outcomes, even in the older adult.

Relationship between Pulse Wave Velocity and Carotid Atherosclerosis in Geriatric People

Objective: To investigate the relationship between the pulse wave velocity (PWV) and angiographic carotid atherosclerosis in elderly patients. Method: 103 consecutive elderly patients were divided into two groups according to the results of cerebral angiography: carotid atherosclerosis group and normal carotid angiogram group. Basic clinical information was required by a standardized questionnaire. Carotid-femoral PWV (cfPWV) as a marker of Stiffness of artery was measured, Carotid intima media thickness (IMT) and carotid stenosis degree in angiography was evaluated. Independent-sample t test was used to evaluate the difference in cfPWV between the two groups, Bivariate associations between cfPWV and an index of extracoronary atherosclerosis (IMT and severity of stenosis) was performed. Result: Among 103 subjects, 55 with carotid atherosclerosis and 48 with a normal carotid angiogram, a significant difference between the two groups in IMT and PWV was found (P<0.05), and the cfPWV was significantly correlated with IMT (r = 0.3222, P = 0.0315), but not severity of carotid stenosis (r = 0.1573, P = 0.3137). Conclusion: cfPWV showed a positive correlation to carotid IMT, and maybe is a potentially useful adjunctive atherosclerotic risk marker to Identify of early carotid atherosclerosis.

Effects of Cardiac Rehabilitation on Cardiovascular Events in Elderly Patients with Stable Coronary Artery Disease

The elderly population has rapidly grown in Japan, resulting in a remarkable increase of patients with coronary artery disease (CAD). The elderly people have a higher incidence of acute myocardial infarction in comparison with younger population. Cardiac rehabilitation (CR) has numerous benefits including reduction of mortality and cardiovascular events in patients with CAD. Because of these high rates of morbidity and mortality, primary and secondary prevention programs are important strategies not only for modifying cardiovascular risk factors, but also for improving mortality and quality of life. However, the long-term effect of phase III CR in elderly patients with stable CAD is still unknown. PURPOSE: To assess the effects of phase III comprehensive CR on mobility and mortality of cardiovascular diseases in elderly male Japanese patients with CAD. METHODS: We analyzed 111 elderly male CAD patients (≥65 years) including 37 subjects participating in the supervised CR during six months and 74 age-matched controls. We followed the patients for up to 3,500 days, until the occurrence of death and one of the following major adverse cardiovascular events (MACE): cardiovascular death, acute coronary syndrome (ACS), refractory angina requiring revascularization, admission for congestive heart failure (CHF), and stroke. RESULTS: All cause mortality tended to be lower in the CR group than in the control group (14 vs. 28%, P=0.081). The MACE incidence was significantly lower in the CR group than in the control group (30% vs. 62%, P=0.001). The other incidences of cardiovascular death, ACS, refractory ischemia requiring percutaneous coronary intervention or coronary artery bypass grafting, admission for CHF, stroke, and cancer were not significantly different between the two groups. Kaplan Meier analysis demonstrated that the CR group had a significantly lower rate of MACE, but not all-cause death, during the entire follow-up period (P=0.007, P=0.194, respectively). Multivariate Cox proportional hazard analysis showed that the MACE incidence was significantly lower in the CR group than in the control group [adjusted hazard ratio 0.43 (95% CI 0.20-0.91), P=0.027]. CONCLUSIONS: Phase III CR has beneficial effects for reduction of cardiovascular events even in elderly patients with stable CAD.

Effects of Phase III Cardiac Rehabilitation on Mortality and Cardiovascular Events in Elderly Patients With Stable Coronary Artery Disease

Cardiac rehabilitation (CR) has numerous benefits, including reduction of mortality and cardiovascular events, in patients with coronary artery disease (CAD). However, the long-term effect of phase III CR in elderly patients with stable CAD is still unknown. The 111 elderly male CAD patients (>or=65 years), including 37 subjects participating in supervised CR for 6 months and 74 age-matched controls, were analyzed. The patients were followed for up to 3,500 days, until the occurrence of death or 1 of the following major adverse cardiovascular events (MACE): cardiovascular death, acute coronary syndrome, refractory angina requiring revascularization, admission for congestive heart failure, or stroke. All-cause mortality tended to be lower in the CR group than in the Control group (14% vs 28%, P=0.081). The MACE incidence was significantly lower in the CR group than in the Control group (30% vs 62%, P=0.001). Multivariate Cox proportional hazard analysis showed that the MACE incidence was significantly lower in the CR group than in the Control group [adjusted hazard ratio 0.43 (95% confidence interval 0.20-0.91), P=0.027]. Phase III CR has the beneficial effect of reducing cardiovascular events even in elderly patients with stable CAD.

Elastase in the prevention of arterial aging and the treatment of atherosclerosis.

Arterial aging is defined as the age-related structural and functional changes in arteries from the precapillary to the aortic level. These include atheromatous changes. Such changes can be estimated in medium-sized or larger arteries by clinical diagnostic studies, including B-mode echography of the carotid artery (thickening of the intima, plaque formation and increase in luminal diameter) and abdominal aorta (plaque formation and increase in luminal diameter). Doppler echography (pulse wave velocity; PWV) and autopsy studies. These changes include distension of the lumen, increased arterial wall thickness (which may be associated with atherosclerotic plaques) and decreased extensibility of the arterial wall. Since 1981, an anti-atherosclerotic drug containing porcine pancreatic elastase 1 (PPE1) has been used for the prevention of arterial aging and the treatment of atherosclerosis in elderly patients in Japan. So far, the age-related increase in PWV has been found to be lower in those who take PPE1 than in controls. The atherosclerotic index of the carotid artery has also been found to be lower in subjects receiving PPE1 treatment than in control subjects. The pharmacological basis of PPE1 therapy, although paradoxical to the consensus opinion of the pathogenic role of elastase in western countries, is discussed with reference to data gathered in Japan. The pathomechanism of arterial aging and atherosclerosis, with special reference to elastin, is reviewed along with the presentation of some of our data.

Hemodynamics in Elderly Coronary Artery Disease Patients Undergoing Propofol Sedation

The purpose of this study was to evaluate noninvasive intraoperative hemodynamics in an elderly population with coronary artery disease (CAD) undergoing midazolam/fentanyl intravenous sedation-analgesia, with or without propofol for dentoalveolar surgery. A retrospective chart analysis of 24 consecutive male patients aged 60 years or greater, with coronary artery disease, undergoing midazolam/fentanyl intravenous sedation-analgesia with or without propofol for dentoalveolar surgery. Data recorded included noninvasive baseline and intraoperative hemodynamic measurements at 5-minute intervals for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), and pulse (P). The addition of propofol to elderly CAD patients resulted in statistically significant lower averages for SBP (126.1 mm Hg vs 131.3 mm Hg, P < .01), DBP (64.1 mm Hg vs 74.3 mm Hg, P < .001), MAP (84.3 mm Hg vs 94.2 mm Hg, P < .001) and PP (57.7 mm Hg vs 61.8 mm Hg, P = .01) with statistically insignificant differences in pulse (74.2 beats per minute vs 75.8 beats per minute, P = .1). Baseline changes in elderly CAD patients who received propofol were within +/-20% (range: -13.8% to +6.9%). Midazolam/fentanyl intravenous sedation provided stable intraoperative hemodynamics in elderly CAD patients. The addition of propofol to elderly CAD patients also resulted in stable intraoperative hemodynamics and may be a safe adjunct to intravenous sedation in elderly CAD patients.

Prinzmetal’s Angina

Prinzmetal's angina, often referred to as "variant" angina, is a temporary increase in coronary vascular tone (vasospasm) causing a marked, but transient reduction in luminal diameter. This coronary vasospastic state is usually focal at a single site and can occur in either a normal or diseased vessel. Patients are predominantly younger women who may not have the classical cardiovascular risk factors (except for cigarette use). PVA has been associated with vasospastic disorders such as Raynaud's phenomenon and migraine headaches. Arrhythmias are common and may be life threatening especially when the effects of vasospasm are seen in those ECG leads that reflect the potential variations of the epicardial surface of the left ventricle. Endothelial dysfunction has been considered as primarily responsible for PVA. The diagnosis is made by observing transient ST-segment elevation during the attack of angina. Since PVA is not a "demand"- induced symptom, but rather a supply (vasospastic) abnormality, exercise treadmill stress testing is of no value in the diagnosis of PVA. The most sensitive and specific test for PVA is the administration of ergonovine intravenously. Fifty micrograms at 5-minute intervals is given until a positive result or a maximum dose of 400 microg has been administered. When positive, the symptoms and associated ST-segment elevation should be present. Nitroglycerin rapidly reverses the effects of ergonovine if refractory spasm occurs. Medical therapy classically employs vasodilator drugs, which include nitrates and calcium channel blockers. The prognosis is good when there is no significant coronary artery stenosis. Treatment of associated coronary atherosclerosis in elderly patients with PVA is advised. When PVA is associated with coronary atherosclerosis, the prognosis is determined by the severity of the underlying disease. beta-Blockers and large doses of aspirin are contraindicated in PVA.

Remnant-like lipoprotein particles as risk factors for coronary artery disease in elderly patients.

Although remnant-like lipoprotein particles (RLPs) are known to be atherogenic, the relationship between serum RLP-cholesterol (RLP-C) level and coronary artery disease (CAD) has not as yet been evaluated. This clinical study was aimed at investigating the pathological significance of serum RLP-C among several coronary risk factors with a clear focus on elderly patients. We took fasting venous blood samples to determine lipid profiles including RLP-C from 188 patients with angiographically identified CAD and 68 control patients. Overall analysis showed that the RLP-C/HDL-C ratio was higher in both single-vessel CAD group (n = 67; p < 0.01) and multi-vessel CAD group (n = 121; p < 0.001) compared to controls. Further, multiple logistic regression analysis indicated that the diabetes, HDL-C and the RLP-C/HDL-C ratio could discriminate CAD patients from controls. In patients younger than 65 years, diabetes, HDL-C, LDL-C and the LDL-C/HDL-C ratio as well as the RLP-C/HDL-C ratio could discriminate CAD. In patients 65 aged years or older, however, diabetes, triglyceride and RLP-C as well as the RLP-C/HDL-C ratio could discriminate CAD, whereas LDL-C and the LDL-C/HDL-C ratio could not. These results led us to believe that the contribution of a given risk factor to the development of CAD in elderly patients may be different from that in younger patients. In elderly patients, RLP-C rather than LDL-C was strongly associated with the development of CAD. Accordingly, serum RLP-C levels may serve as a convenient and reliable index for assessing CAD.

Anesthesia, pain control, facial pain, and pharmacology

Statement of Problem: The American population’s average age is increasing at a rapid rate, and with increased age there are higher incidences of cardiovascular diseases such as coronary artery disease (CAD). Oral and maxillofacial surgeons (OMFSs) are providing anesthesia services for elderly patients for dentoalveolar and cosmetic procedures at an ever-increasing rate and must be aware of the intraoperative hemodynamic changes that may indicate myocardial ischemia in elderly CAD patients undergoing midazolam/fentanyl intravenous sedation supplemented with propofol.

Recent topics on therapeutics for osteoporosis in patients complicated with vascular diseases

The association of osteoporosis with atherosclerosis in elderly patients has been often recognized. Recent evidence suggests that etiologic factors of osteoporosis may modulate the development of atherosclerosis, and vice versa. Furthermore, bisphosphonates may prevent the development of atherosclerosis, while statins may increase bone mineral density and thereby decrease the risk of osteoporotic fractures. These two drugs may have the common target of action, the mevalonate pathway. Therefore, it is important to consider the effects of therapeutic agents on cardiovascular system, when the treatment of osteoporosis in elderly patients is initiated.

Leucine 7 to Proline 7 Polymorphism in the Neuropeptide Y Gene Is Associated with Enhanced Carotid Atherosclerosis in Elderly Patients with Type 2 Diabetes and Control Subjects

Leucine 7 to Proline 7 Polymorphism in the Neuropeptide Y Gene Is Associated with Enhanced Carotid Atherosclerosis in Elderly Patients with Type 2 Diabetes and Control Subjects

Leucine 7 to proline 7 polymorphism in the neuropeptide Y gene is associated with enhanced carotid atherosclerosis in elderly patients with type 2 diabetes and control subjects.

We have recently demonstrated that subjects having Pro7 in the signal peptide ofneuropeptide Y (NPY) have higher serum cholesterol and apolipoprotein B levels than individuals with wild-type (Leu7Leu7) signal peptide sequence. We investigated the association of Leu7Pro polymorphism with common carotid intima media thickness (IMT) assessed by ultrasonograph in patients with type 2 diabetes (n = 81; 41 men and 40 women; mean age, 67.1 yr) and nondiabetic subjects (n = 105; 48 men and 57 women; mean age, 65.5 yr) and genotyped for the Leu7Pro polymorphism in prepro-NPY. The frequency of Pro7 in prepro-NPY was 9.9% (8 of 81) in diabetic patients and 14.3% (15 of 105) in control subjects (P = 0.360). The mean common carotid IMT was 1.04 +/- 0.02 mm in nondiabetic subjects without the Leu7Pro polymorphism and 1.14 +/- 0.04 mm in nondiabetic subjects with in (P = 0.156) and 1:18 +/- 0.03 and 1.58 +/- 0.21mm in diabetic patients without and with the Leu7Pro polymorphism (P = 0.004), respectively. In the analysis of covariance of the entire group, the mean common carotid IMT was independently associated with the Leu7Pro polymorphism (F = 5.165; P = 0.024) after adjustment for known risk factors. Thus, the presence of the Pro7 substitution in the prepro-NPY associates with increased carotid atherosclerosis.

Influence of aging on progression of cardiovascular complications associated with insulin resistance in patients with essential hypertension.

Hyperinsulinemia or insulin resistance is suggested to play a role in the pathogenesis of hypertension and its target organ diseases. It is also well documented that aging is associated with a decline in glucose tolerance and insulin sensitivity, but there are few reports on the relationship between aging and insulin sensitivity or on the effects of aging on the progression of cardiovascular complications in patients with essential hypertension. To clarify these effects of aging in essential hypertension, 44 patients were examined by the euglycemic hyperinsulinemic glucose clamp test and ultrasonography of the heart and carotid arteries. There was a significant negative correlation between aging and insulin sensitivity (r = -0.37, p < 0.05). Significant increases in left ventricular mass index and carotid wall thickening accompanied by insulin resistance were seen in only non-elderly patients but not in elderly patients. These results suggest that aging decreases insulin sensitivity even in essential hypertensive subjects and that insulin resistance does not affect the progression of cardiac hypertrophy and atherosclerosis in elderly patients with essential hypertension.

Differences in appraisal and coping between elderly coronary artery disease patients high and low in depressive symptoms

Coronary artery disease (CAD) is frequently found in the elderly and many CAD patients present depressive symptoms. The purpose of this study was to determine if elderly CAD patients high and low in depressive symptoms differ on how they appraise stressors associated with angina pectoris and how they cope with these stressors. Twenty elderly CAD patients high in depressive symptoms and 35 elderly CAD patients low in depressive symptoms identified their most severe chronic stressor attributed to angina and reported their appraisal and coping in relation with this stressor. Groups did not differ on sociodemographic, health-related or stressor-related characteristics. Compared with CAD patients low in depressive symptoms, CAD patients high in depressive symptoms reported appraisal of more harm to their own physical well-being and more threat to their self-esteem and a loved one's well-being. CAD patients high in depressive symptoms also reported using more escape-avoidance coping. These results suggest that ...