abstract
WOMEN’S HEALTH
Ischemic Heart Disease in
Older Women: An Overview
Wilbert S. Aronow, MD, Department of Medicine, Divisions of Cardiology and
Geriatrics, Westchester Medical Center/New York Medical College,Valhalla, NY; Clinical
In older women, ischemic heart disease
Professor of Medicine and Chief, Cardiology Clinic, Westchester Medical Center/New York
(IHD) is diagnosed if there is coronary
Medical College, and Adjunct Professor of Geriatrics and Adult Development, Mount Sinai
angiographic evidence of significant
School of Medicine.
IHD, a documented myocardial infarc-
tion, a typical history of angina with
myocardial ischemia diagnosed by The most common cause of death in unassociated with an acute myocardial
stress testing, or sudden cardiac death. older women is ischemic heart disease infarction may be a clinical manifestation
(IHD). The prevalence of IHD is similar of unstable angina pectoris due to exten-
Clinical manifestations of acute
in older women compared to older men.1 sive IHD in older women.2
myocardial infarction in older women
In one study of 2,464 women with an Clinical manifestations of acute
include dyspnea (the most common average age of 81 years, the prevalence of myocardial infarction in older women
presenting symptom), chest pain, neu- IHD was 41%.1 At 46-month follow-up, include dyspnea (the most common pre-
rological symptoms and gastrointesti- the incidence of new coronary events senting symptom), chest pain, neurolog-
nal symptoms. The prognosis of Q- (myocardial infarction or sudden cardiac ical symptoms and gastrointestinal
wave myocardial infarction is not sig- death) was 44%.1 symptoms.3 Q-wave myocardial infarc-
nificantly different if the myocardial tion documented by an electrocardio-
infarction is clinically recognized or
Diagnosis gram without a clinical history of
unrecognized. IHD should be treated IHD is diagnosed in older women if myocardial infarction is present in
with intensive risk factor modifica- there is either coronary angiographic evi- 21–68% of older women with Q-wave
tion, antiplatelet therapy, beta-block- dence of significant IHD, a documented myocardial infarction.3-6 The prognosis
myocardial infarction, a typical history of of Q-wave myocardial infarction in older
ers and angiotensin-converting
angina pectoris with myocardial women is not significantly different if the
enzyme inhibitors.
ischemia diagnosed by stress testing, or myocardial infarction is clinically recog-
sudden cardiac death.2 The incidence of nized or unrecognized.4,6,7
Key words: ischemic heart disease, sudden cardiac death as the first
myocardial infarction, antiplatelet clinical manifestation of IHD in women Coronary Risk Factors
drugs, beta-blockers, angiotensin-con- increases with age. Risk factors for the development of new
verting enzyme inhibitors. coronary events in older women
Clinical Manifestations include age,8-10 prior IHD,8-10 cigarette
Dyspnea on exertion is a more common smoking,8-11 hypertension,8-10 diabetes
clinical manifestation of IHD in older mellitus,8-10 increased serum total cho-
women than is the typical chest pain of lesterol or low-density lipoprotein cho-
angina pectoris.2 Because older women lesterol, 8-10 low-serum high-density
are more limited in their activities, angi- lipoprotein cholesterol,8-10,12 increased
na pectoris in this group is less often serum triglycerides,8-10 obesity,9-10 phys-
associated with exertion. Older women ical inactivity 13 and left ventricular
with angina pectoris are less likely to hypertrophy.14,15
have substernal chest pain, and they
describe their anginal pain as less severe Acute Coronary Syndromes
and of shorter duration than do younger Older women with IHD are less likely to
women. Angina pectoris in older women be referred for coronary angiography
may occur as a burning postprandial and coronary revascularization
epigastric pain or as pain in the back or than older men with stable or
shoulders. Acute pulmonary edema unstable IHD.16,17 A prospective
www.geriatricsandaging.ca 23
Ischemic Heart Desease
Acute Coronary Syndromes
Stable Angina
• acute condition
R • occurs during
exercise or elevated
stress levels
T • non-occlusive
thrombus
• ST-segment
Q S depression
• transient myocardial
ischemia
Unstable Angina
• chronic condition
• occurs at rest
• reperfusion less
than 20 min
• occlusive thrombus
• ST-segment
depression
• transient myocardial
ischemia
Non-Q-wave Myocardial Infarction
• reperfusion after
20 min, before 2 hr
• occlusive thrombus
• ST-segment
depression
• permanent ischemic
damage
• small infarct size
Q-wave Myocardial Infarction
• no reperfusion
• occlusive thrombus
• ST-segment
elevation
• permanent ischemic
damage
• large infarct size
24 GERIATRICS & AGING • April 2004 • Volume 7, Number 4
Ischemic Heart Desease
1160 older men and 2464 older women in a
study was performed in which 91 Therapy long-term health care facility. J Gerontol
consecutive women, mean age 79 years Older women with IHD should have Med Sci 2002; 57A:M45-M46.
(range 70–94 years), hospitalized with intensive management of modifiable 2. Aronow WS, Fleg JL. Diagnosis of coronary
acute coronary syndromes underwent coronary risk factors. Cigarette smoking artery disease in the elderly. In: Aronow WS,
Fleg JL, editors. Cardiovascular Disease in
coronary angiography.18 should be stopped. The blood pressure
the Elderly. 3rd edition. New York City:
Women hospitalized with ischemic- should be reduced to less than 135/85 Marcel Dekker, Inc., 2004:251-71.
type chest discomfort lasting longer than mmHg if necessary with beta-blockers 3. Aronow WS. Prevalence of presenting
30 minutes with ST-segment elevation of and angiotensin-converting enzyme symptoms of recognized acute myocardial
infarction and of unrecognized healed
≥ 0.2 mV in ≥ 2 contiguous precordial inhibitors.19 Patients with diabetes melli-
myocardial infarction in elderly patients.
leads, or ST-segment elevation of ≥ 0.1 tus or chronic renal insufficiency should Am J Cardiol 1987;60:1182.
mV in ≥ 2 limb leads plus an elevated have their blood pressure reduced to less 4. Kannel WB, Abbott RD. Incidence and prog-
serum creatine kinase-MB level or an ele- than 130/80 mmHg.19 The serum low- nosis of unrecognized myocardial infarction:
an update on the Framingham Study. N
vated serum cardiac-specific troponin I density lipoprotein cholesterol level
Engl J Med 1984;311:1144-7.
level, were diagnosed as having ST-seg- should be reduced to less than 100mg/dL 5. Aronow WS, Starling L, Etienne F, et al.
ment elevation myocardial infarction.18 with the use of statins if necessary.20 Dia- Unrecognized Q-wave myocardial infarction
Women hospitalized with ischemic-type betes mellitus should be controlled with in patients older than 64 years in a long-term
health care facility. Am J Cardiol 1985;56:483.
chest discomfort of longer than 30 min- the hemoglobin A1c level reduced to less
6. Nadelmann J, Frishman WH, Ooi WL, et al.
utes without ST-segment elevation but than 7%. Sulfonylureas should not be Prevalence, incidence, and prognosis of rec-
with an elevated serum creatine kinase- used if possible.21 Ideal body weight ognized and unrecognized myocardial
MB level or an increased serum cardiac- should be achieved. Daily physical activ- infarction in persons aged 75 years or older:
the Bronx aging study. Am J Cardiol
specific troponin I level were diagnosed ity should be performed.
1990;66:533-7.
as having non-ST-segment elevation Angina pectoris should be treated 7. Aronow WS. New coronary events at four-
myocardial infarction.18 Women hospi- with nitrates and beta-blockers and with year follow-up in elderly patients with rec-
talized with ischemic-type chest discom- the addition of long-acting nondihy- ognized or unrecognized myocardial
infarction. Am J Cardiol 1989;63:621-2.
fort of longer than 30 minutes with dropyridine calcium channel blockers if
8. Castelli WP, Wilson PWF, Levy D, et al. Car-
normal serum creatine kinase-MB and necessary.22 Antiplatelet therapy with diovascular disease in the elderly. Am J Car-
cardiac-specific troponin I levels aspirin or clopidogrel should be admin- diol 1989;63:12H-19H.
were diagnosed as having unstable istered indefinitely.23 Beta-blockers and 9. Aronow WS, Ahn C. Risk factors for new
coronary events in a large cohort of very eld-
angina pectoris.18 angiotensin-converting enzyme
erly patients with and without coronary
Of the 91 women, 50% were diag- inhibitors should be administered indef- artery disease. Am J Cardiol 1996;77:864-866.
nosed as having unstable angina pectoris, initely.23 Hormone replacement therapy 10. Vokonas PS, Kannel WB. Epidemiology of
35% were diagnosed as having non-ST- should not be started or continued in coronary artery disease in the elderly. In:
Aronow WS, Fleg JL, editors. Cardiovascu-
segment elevation myocardial infarction, postmenopausal women with IHD.24,25
lar Disease in the Elderly. 3rd edition. New
and 15% were diagnosed as having ST- Management of acute coronary syn- York City: Marcel Dekker, Inc., 2004:189-214.
segment elevation myocardial infarc- dromes,26 acute myocardial infarction27 11. LaCroix AZ, Lang J, Scherr P, et al. Smoking
tion.18 Therefore, 70% of the myocardial and postmyocardial infarction23 is dis- and mortality among older men and women
in three communities. N Engl J Med
infarctions in women 70 years of age and cussed in detail elsewhere.
1991;324:1619-25.
older were non-ST-segment elevation Coronary revascularization should 12. Corti M-C, Guralnik JM, Salive ME, et al.
myocardial infarctions.18 be performed in older women with IHD HDL cholesterol predicts coronary heart dis-
Of the 91 women with acute coro- to prolong life and to improve the quali- ease mortality in older persons. JAMA
1995;274:539-44.
nary syndromes, 80% had obstructive ty of life despite optimal medical thera-
13. Fried LP, Kronmal RA, Newman AB, et al.
IHD, 17% had nonobstructive IHD, 29% py. Coronary revascularization by Risk factors for 5-year mortality in older
had significant one-vessel IHD, 25% had coronary angioplasty28 or by coronary adults. The Cardiovascular Health Study.
significant two-vessel IHD, 26% had sig- artery bypass surgery29 is discussed in JAMA 1998;279:585-92.
14. Aronow WS, Koenigsberg M, Schwartz KS.
nificant three-vessel IHD, and 2% had left detail elsewhere. If coronary revascular-
Usefulness of echocardiographic left ventric-
main IHD.18 If obstructive IHD was pres- ization is performed in older women, ular hypertrophy in predicting new
ent, 51 of 73 women (70%) had coronary intensive medical management must be coronary events and atherothrombotic brain
angioplasty (62%) or coronary artery continued. x infarction in patients over 62 years of age.
Am J Cardiol 1988;61:1130-2.
bypass surgery (8%).18 This was not sig-
15. Levy D, Garrison RJ, Savage DD, et al. Left
nificantly different from the prevalence No competing financial interests declared. ventricular mass and incidence of coronary
of coronary revascularization performed heart disease in an elderly cohort: the Fram-
in the 86 consecutive elderly men hospi- References ingham Heart Study. Ann Intern Med
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