Coronary Heart Disease

 Aging is a normal biological process that affects all living creatures.  Aging is now recognized as a complex, genetically-governed, and highly programmed evolution of cellular events.  Although senescence is a technical term that means aging, it also characterizes fundamental processes, in which the capacity of cells within the body to divide, grow, and carry out specific activities declines over time.  Aging is a complex, genetically-governed, and highly programmed evolution of cellular events. Yet, environmentalEnvironmental factors and medical conditions contribute greatly to aging, and the trajectory and manifestations of the aging process. The effects of these exposures and conditionsthemselves are highly specific to individual organs in the body, ranging from the skin to the heart, brain, eyes, muscles, kidneys, lungs, and the blood vessels that carry blood and oxygen to all vital organs.

            Successful aging is both an individual and societal goal worth striving for-minimizing unwanted features and avoiding the complications of diseases through careful attention to food, activity, and avoidance of harmful conditions such as obesity, smoking, and excess alcohol consumption.

            It is important to distinguish normal aging from disease in older adults..  In the former, senescence causes graduations of functional decline that may or may not be accompanied by a noticeable change in performance. Disease, by definition, produces not only a change in function and performance, but alterations in overall homeostasis – an ability to regulate a life-sustaining internal environment. (Table 1)[D1] (Table 1)

Table 1           Aging by Decade

Demarian	Between ages 10 and 19
Vicenarian	Between ages 20 and 29
Tricenarian:	Between ages 30 and 39
Quadragenarian	Between ages 40  and 49
Quinquagenarian	Between ages 50 and 59
Sexagenarian	Between ages 60 and 69
Septagenarian	Between ages 70 and 79
Octogenarian	Between ages  80 and 89
Nonagenarian	Between ages 90 and 99
Centenarian	Between ages 100 and 109
Supercentenarian	Above age 110

 

            Though genetics is recognized as a major determinant of longevity, there is heightened interest in developing reliable methods of biological age assessment as a platform for the study of aging in humans. (1)  The science of evolutionary biology could stand to benefit considerably from establishing phenotypes (measurable characteristics) of aging.  This may be particularly useful in understanding the basis of disease progression and mortality for cancer and heart disease, as well as an early-life increase and late-life decrease in mortality acceleration.(2)

            The phenomenon of aging as a normal biological process raises questions about its determinants, both genetic and environmental determinants, natural history and potential for causing a variety of diseases, ranging from osteoarthritis (degeneration of the joints) and osteoporosis (thinning of the bones), to cancer and heart disease.  While affecting different parts of the body, each of these conditions may have a common thread or root cause.  If this is proven to be the case, considerable insight and opportunities for in-depth understanding, prevention and treatment could emerge over the next several decades.

The study of coronary heart disease in older adultsthe elderly, to comprehend its fundamental basis, incidence, prevalence, diagnosis, prevention, and treatment could ultimately translate to advances across the vast realm of gerontology (the scientific study of the biological, psychological and sociological phenomena associated with aging), as well as offering more direct and immediate returns toward reducing its role as the number one killer of men and women in the United States, Europe, and other industrialized parts of the world.

The Fundamental Biology of Aging

            As structural and functional unit of all living organisms, cells are considered a fundamental building block of life and contain two types of genetic material—deoxyribonucleic acid (DNA) and ribonucleic acid (RNA).  Cellular DNA stores vital information, the hereditary information of genes, while RNA is used to manufacture proteins and enzymes.  Humans are considered multicellular organisms, with an estimated 100 trillion cells. (Figure 1)( http://www.earthlife.net/images/eury-cell.gif)

            All cells have diverse potential—they reproduce through a process known as cell division or mitosis; use enzymes and other protein for specific purposes, extract and use chemical energy for organ-specific functions in metabolic pathways, and adapt to both internal and external stimuli. (Figure 2)

(http://scienceblogs.com/clock/upload/2006/12/a2%20cell%20 cell differentiation.gif)

 

           

            Cellular aging is characterized by an inability to divide:  cells can divide no more than 50 times – a replicative senescence referred to as the “Hayflick Phenomenon.” The limiting factor in a cell’s lifespan may be DNA damage that cannot be repaired.  In response, cells either age or self-destruct—a process known as apoptosis.

            Under normal circumstances, messenger RNA (mRNA) transferred from a senescent to a young cell tempers cell division, protecting the younger cell from aging.  In this particular case, mRNA serves as a gerotogene (a gene that increases a cell’s life span).  Mutations, inherited or acquired changes in gene sequences, within gerotogenes cause unchecked cell division. (http://www.nia.nih.gov/HealthInformation/Publications/AgingUndertheMicroscope/chapter02.htm )

            The National Institutes of Health- National Institute of Aging has established a Biology of Aging program designed to elucidate the basic biochemical, genetic, and physiological mechanisms underlying the process of aging and age-related changes in humans.  The federally funded initiative also studies the gradual and programmed alterations of cellular and organ structure and performance that characterize normal aging, as well as the relationship between aging and risk factors for disease states, including heart attack and stroke. (http://www.nia.nih.gov/ResearchInformation/ExtramuralPrograms/BiologyOfAging/)

 

Aging of the Heart and Blood Vessels

            Age, in and of itself, is a major risk factor for cardiovascular disease.  In fact, the overall incidence of heart disease and stroke rises sharply after age 65 in the United States, and as early as age 45 in other parts of the world where smoking, fast food consumption, and high salt-containing diets are rapidly becoming a way of life.  Greater than 40% of all deaths among individuals between the ages of 65 and 74 are from heart disease and stroke, increasing to nearly 60% for individuals aged 85 and above.  In addition, cardiovascular disease is a major cause of disability, limiting activity and overall quality of life.

Age-related changes in the heart and blood vessels are an important area of research, with world-wide translatability.  The National Institute of Aging and United States Department of Health and Human Services have devoted considerable resources to answering fundamental questions. (http://www.niapublications.org/pubs/hearts/Aging_Hearts_And_Arteries.pdf)

Genetics in general, and the biological warehouse (chromosomes) in particular may play a particularly important role.  At each end of a chromosome there are telomeres – specifically structured DNA whose physical makeup prevents chromosomes from either degrading (breaking apart) or fusing together.  As cells divide, telomeres become shorter.  Therefore, the longer a person lives, the shorter the average length of a telomere (Figure 3)(http://www.geneticsandhealth.com/wp-content/uploads/2007/01/telomeres-2.jpg)  A study performed in Scotland identified  a relationship between short telomeres and the risk of developing Coronary Heart Disease CHD. AN EARLY DEFINITION HERE WOULD BE HELPFUL, IN ADVANCE OF YOUR LENGTHY SECTION BELOW (3) the narrowing of the lumen of coronary arteries with cholesterol-laden atherosclerotic plaques.

·         For every 10 years in age, telomere length decreased by 9%.

·         Persons in the lower two tertiles of telomere length were nearly twice as likely to develop CHD than those in the upper tertile.

(http://www.aheartylife.com/?p=699&akst_action=share-this)21

            The process of aging on the heart adapts to aging, but the process of adaptation may, with time and circulatory system along with influences from external factors maysuch as the environment have detrimental effects – weakening of the heart (heart failure), stiffening of the blood vessels resulting in high blood pressure (hypertension), and progressionhardening of cholesterol-laden plaques in the arteries (atherosclerosis).

            One of the earliest observations of the effect of aging on the heart was its

 

 tendency to enlarge.  UltrasoundSpecifically, ultrasound tests, known as an echocardiograms, and more recently, Magnetic Resonance Imaging (MRI), reveal thickening of the heart muscle (myocardium) with age.  This alteration is in response to increased stiffness of the blood vessels, creating stress on the heart.  Increased thickness of other heart chambers has also been observed.(Figure 5) http://www.niapublications.org/pubs/hearts/Aging_Hearts_And_Arteries.pdf

The aging heart is also less compliant than a young heart.  As blood enters the main pumping chamber of the heart—the left ventricle—it is met by increased resistance to stretching and filling.  The filling phase of the cardiac cycle isThis property, referred to as diastole and is an active phenomenon. The heart muscle must actively relax to enable the heart chambers to receive blood return. Diastole, is particularly important during exercise, when the heart must be highly efficient in both phases of the cardiac cycle- systole, the pumping of blood, and diastole, the filling with blood.

            Several characteristics of the aging heart are summarized in Table 2Table 2.

Table 2.  Properties of the Aging Heart*

Increased Thickness of the left ventricle

Decreased relaxation

Slowed filling of the left ventricle

Increased late diastolic filling

Increased left atrial Pressure

Reduced Peak Heart Rate during Exercise

Reduced Response to Brain Signaling

Reduce Systolic Response to Circulating Adrenaline

Slowed Calcium transport

*compared with a young heart

 

            The human circulatory system, consisting of arteries, veins, and small vessels, (venules, capillaries, and arterioles) carry blood to and from all vital organs.  Like the heart, blood vessels undergo changes with advancing age, typically beginning with increased thickness and stiffening of the arterial wall—both are considered risk factors for atherosclerosis, commonly referred to as “hardening” of the arteries.  These age-related changes, coupled with the damaging effects of high blood pressure, high cholesterol, and exposure to environmental toxins such as tobacco smoke and airborne pollutants, provide an explanation for the very high incidence of atherosclerosis among individuals greater than age 65.  How high?  One out of every two adults (Figure 6)

(http://www.moondragon.org/images/artherosclerosis1.jpg)

            The impact of aging on arteries is summarized in Figure 7 . (http://www.niapublications.org/pubs/hearts/Aging_Hearts_And_Arteries.pdf).

Coronary Heart Disease

Coronary Heart Disease, by definition includes atherosclerosis and its complications of angina pectoris, heart attack, and cardiovascular death.

The incidence of CHD increases steadily with age, as does its overall severity, defined as the number of coronary arteries with a 50% or greater narrowing in diameter, and the potential to cause symptoms or provoke a heart attack.  A co-existing increase in overall life exptancy, and with it the number of individuals living beyond age 65, translates to a staggering prevalence of CHD- approaching 90 % OF THE US POPULACE? by age 75.

            The biology of atherosclerosis is well known, and typically follows a series of integrated steps- beginning with injury to the inner lining (endothelium) of the vessel wall, early deposition of fatty material  (fatty streak formation), and advanced plaque formation and remodeling – plaque build-up. A reduction of the inner dimension, also known as the vessel lumen, prompts an adaptive response, characterized by restructuring, remodeling, and stretching of its outer wall and inner lumen, permitting blood to flow . (Link to Figures showing atherosclerosis)

 

Is age-related atherosclerosis a distinct vascular phenomenon?

In animal models of atherosclerosis, fatty streak formation in response to a high cholesterol diet, forms at the same rate in young and old mice (4)[D2] , suggesting that susceptibility to atherosclerosis is not highly age-related.   In contrast, several studies have shown that older rabbits develop plaques of larger size and heightened inflammatory activity. Both characteristics may have clinical relevance given their association with heart attacks. 

            In humans, atherosclerosis progresses at different rates for men and women – particularly prior to menopause.  Approximately 5 years following menopause, the rates are similar. The means by which atherosclerosis progresses may be particularly important.  In some cases, there is slow and continuous plaque growth, with concomitant remodeling that effectively preserves a normal lumenal dimension.  In other cases, plaque growth occurs suddenly – so suddenly that there is not sufficient time for vascular remodeling.  As a result, the lumen is compromised, and consequently, blood flow is reduced.  Progression rates increase with age as do the number of plaques within a given blood vessel, supporting a biological amplification or  “autocatalytic” basis for the phenomenon. (5)

What is the relationship Between Aging and Heart Attack?

The proximate cause of a heart attack, in most instances, is “shattering” or “breakage” of an atherosclerotic plaque with formation of an overlying blood clot.  The sudden interruption of blood and oxygen delivery to the heart muscle (myocardium) causes damage (myocardial infarction).

Link to Google 1 – What is a Heart Attack?

As discussed in the prior section, age is associated with both a gradual decrease in coronary arterial lumen size and a sudden change in plaque dimensions. Either can predispose to heart attack, but it is the latter pathobiological event that is particularly dangerous.  Blood clot formation is the common theme for a heart attack.

 

The question may then be asked, “Are older individuals more prone to form blood clots, and if so, why should they be?”  The answer to the first question is a definitive “yes” – all types of blood-clot related conditions, ranging from heart attack and stroke, to deep vein thrombosis (DVT) and pulmonary embolism (blood clot traveling to the lungs), occur more commonly with advancing age.  The answer to the second question is we do not know, but one emerging theory, known as “maladaptive thrombotic preparedness of aging” places blood vessel injury and either faulty or insufficient repair at the center of attention.(6)

Signs and Symptoms of Coronary Heart Disease

            The American Heart Association has widely publicized the common signs and symptoms of heart attacks, including the triad of chest discomfort radiating to the left shoulder and arm, accompanied by sweating and nausea.  When older adults have heart attacks, they may experience these symptoms; however, the initial features may include sudden fatigue or generalized weakness, shortness of breath or confusion.  These more uncommon signs and symptoms may be difficult for an individual, friend, or family member to recognize, causing a delay in diagnosis and potentially life-saving treatment.(7)

 

A more gradual narrowing of a coronary artery may cause either chest discomfort or shortness of breath with exertion or during stressful situations. Fatigue and decreased stamina may also represent the effects of severe narrowing within one or more coronary arteries.

Diagnostic Testing for CHD in the Elderly:

            A variety of heart-related tests are available to physicians pursuing a diagnosis of CHD.  Non-invasive tests, including exercise stress tests and pharmacologic stress tests (dipyridamole, adenosine, dobutamine) employing nuclear imaging, magnetic resonance imaging, and echocardiography are available and can provide important information. Each is based on changes in the electrocardiogram (ECG), perfusion pattern (blood and oxygen delivery to the heart muscle) or functional activity (movement and squeezing action of the heart muscle), typically comparing information obtained at rest and following exertion (or simulated exertion with pharmacologic stress tests).  An abnormal test suggests a 50% or greater narrowing in one or more coronary arteries.

The diagnostic yield and accuracy of stress tests among the elderly is equal to that of younger individuals; however, a larger proportion of individuals of advanced age may not be able to perform exercise.  Accordingly, other modalities are often employed. (8,9)

Coronary angiography currently represents the most direct means to establish the presence, extent, and severity of CHD.  This diagnostic test utilizes contrast material or “dye” to visualize the individual’s coronary arteries throughout their course.  The information gathered is then used to determine the best course of treatment, ranging from medications (either an increasing number or dose of medications) to PCI-percutaneous coronary intervention (PCI Stent Figure) and coronary artery bypass grafting (CABG Figure).  The ultimate decision to use one or more these treatment modalities is based on several patient-specific considerations, and while the complication rates for PCI and surgery do increase with age, the benefit in terms of symptom reduction and improved quality of life are well-documented, even in selected individuals 90 years or greater. (10)

Preventing Coronary Heart Disease

            The development of atherosclerosis with advancing age, while common and a well-known risk for heart attack and cardiovascular death, is preventable and modifiable, even at advanced years.  The earliest stages of atherosclerosis are characterized by injury to the inner lining of blood vessels known as the endothelium.  Endothelial cells are a vital component of healthy blood vessels that regulate the flow of blood by opening (dilating) or closing (constricting and prevent blood clots from forming other than protective purpose).  Maintaining a healthy endothelium is the key to preventing heart attack and stroke.

            StrategiesAmong the strategies to maintainmaintaining healthy endothelium include modifying, are the modifiable risk factors for atherosclerosis, including controlling high blood pressure and  diabetes, lowering elevated cholesterol, and ceasing tobacco smoking (both first- and second-hand smoke damage endothelial cells and also impair their ability to repair areas of injury). The risk of a first cardiovascular event can be gauged using information derived from the Framingham Heart Study(11) but thewith a high predictive value for men and women 75 years or greater is less than for younger individuals.. (Link to Google 1-Reducing risk of a heart attack) Risk factors continue to influence risk of cardiac events across age, however the duration of exposure and competing risks also become important considerations in older adults.).

            It is important to recognize that the well-known risk factors for atherosclerosis may have a particularly pernicious effect on people age 65 and older.  While this provides all the more reason to institute preventive measures earlier in life, this does not mean prevention is ineffective or a less important goal in older adults.

The American Heart Association Council on Prevention (12) has emphasized the importance of risk factor interventions to include persons age 75 and older.

Smoking Cessation CONSIDER EMBEDDING LINKS TO USEFUL WEB RESOURCES AT THE END OF EACH OF THESE SUBSECTIONS ON PREVENTION MEASURES

Stopping smoking is an effective means to lower substantially the chances of heart attack, stroke, and other life-threatening and life-altering conditions in younger individuals, is also effective in older individuals, reducing the likelihood of both first and recurrent events. 

High Blood Pressure

Treatment of high blood pressure among older individuals 60-80 years of age prevents stroke and heart [D3] failure, and reduces mortality from cardiovascular causes as well.  There is no upper age limit for the benefit to lowering blood pressure with medication to prevent stroke, heart attack, and heart failure  While the target blood pressure was debated in the past, less than 140/90 mmHg represents the current goal of treatment.  A lower range, below 130/80 mmHg is recommended among individuals with diabetes, heart failure, and kidney disease.(13) 

Cholesterol

Cholesterol-lowering therapy, particularly with a class of medicines known as statins, has been shown to substantially lower the likelihood of coronary heart disease-related events, including stroke, heart attack and death.(14)  While the benefit is particularly evident among older adults with known coronary heart disease, protection occurs in healthy individuals at risk as well.  Accordingly, the National Cholesterol Education Program – (Link NCEP) has made the recommendations contained at the following Web site. (http://www.nhlbi.nih.gov/new/press/aug08-99.htm)

            While research is needed to more fully address the benefit of cholesterol-lowering treatment in people older than age 75, the available data do not suggest a diminishing effect of treatment with increasing age.  In fact, given the higher risk incurred by older adults, the absolute benefit is considerably greater than in younger individuals.(15)

           

Weight Control and Obesity

The relationship between obesity, considered in terms of body weight, body mass index, and waist circumference is an independent risk factor for coronary heart disease-related events, as well as for the development of high blood pressure and diabetes.  Weight loss is difficult in older adults, particularly among those with co-existing medical problems, but weight reduction programs and instructional counseling can effectively reduce recognized risk factors.

Diabetes

            Diabetes is a world-wide epidemic, which contributes strongly to the risk of coronary heart disease, stroke, and kidney failure.  The combination of diabetes and high blood pressure is particularly dangerous.  Effective treatment of diabetes, with achievement of a near-normal blood sugar level while fasting is recommended, but more research is needed. It is clear, however, that the best approach includes not only achievement of a favorable target blood sugar, but daily exercise, nutritional counseling, treatment of high blood pressure and, in many instances, weight reduction.

Exercise

The importance of exercise in overall cardiovascular health warrants particular emphasis.  Scientific research has shown that exercise improves efficiency of the heart, nourishes blood vessels through the production of several protective molecules, reduces blood pressure, assists in the regulation of blood sugar levels, and tempers the effects of adrenaline associated with mental and bodily stress. *****(link not working((www.niapublications.org/exercisebook/index.asphttp://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide).

exercised capacity, for black and white individuals, is inversely associated with cardiovascular mortality (16)

Unfortunately, information obtained from the Behavioral Risk Factor Surveillance System Survey, including a total of 297, 145 individuals, shows those individuals with CHD are less likely to comply with physical activity recommendations compared to those without CHD. (17)  This is particularly true in older adults.

 

The American Heart Association does not advise women to take post menopausal hormone therapy or selective estrogen modulators to reduce the risk of CHE or stroke.

 

Treating Coronary Heart Disease

            The treatment of coronary heart disease has evolved steadily over the past several decades, with substantial advances in medications and procedures ranging from coronary angioplasty (currently referred to as percutaneous coronary intervention) and coronary artery bypass surgery.  A wealth of information supports the benefit of those treatment options in older adults, while simultaneously underscoring the importance of medication selection, dosing, monitoring, and closedose observation.(Alexander, JAMA Circulation…which one??[D4] )[??](18)

Hospital-Based Management of Heart Attacks in the Elderly

The high incidence of CHD in the elderly leads to a proportionately high incidence of serious heart-related problems such as heart attack and threatened heart attack- collectively referred to as a cute coronary syndrome or ACS.

The available evidence suggests that patients greater than 65 years of age benefit from currently available cardiovascular medications and acute interventions, such as coronary angioplasty-referred to a percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). (18)19)The evidence also confirms that older patients may  delaydeal in seeking medical care and do not always receive the high-level treatment from which they stand to benefit. (Figure X) (http://circ.ahajournals.org/cgi/content/full/115/19/2570/FIG3182616)The American Heart Association in collaboration with the Society of Geriatric Cardiology has published a two-part series on guidelines for acute coronary care in the elderly (19,20),21)

The comprehensive and carefully crafted documents highlight the problemproblems scope (Figure Aa)( http://circ.ahajournals.org/cgi/content/full/115/19/2549/FIG1182615), diagnostic challenges that are specific to the elderly (Figure B) (http://circ.ahajournals.org/cgi/content/full/115/19/2549/FIG4182615)and life-threatening nature (Figure C)( http://circ.ahajournals.org/cgi/content/full/115/19/2549/FIG5182615).  Important and currently unmet needs in treatment and advancing the fields understanding of an emerging health consideration of unparalleled proportion is also featured.

Medication Use in The Elderly

The potential benefit of medications for the prevention and treatment of CHD are well known in most age ranges, including the elderly.  Also recognized, are slowed metabolism, clearance from the body and age-associated changes in drug activity with advancing age that can predispose to adverse reactions.  A summary of age-related pharmacologic changes is found in (Table ____.Reference)  Table 3) (22)

Table 3  Age-Related Pharmacologic Changes in the Elderly

GENERAL CONSIDERATIONS Multiple drugs usual (drug interactions common) Memory problems and confusion (lack of consistent use)   PHARMACOKINETICS (BIOAVAILABILITY) Decreased absorptive surface Reduced blood flow to the intestines Reduced gastric empting time and gastrointestinal motility Altered volume of distribution Less muscle mass and increased body fat Decreased total body water Reduced drug metabolism Less liver mass, reduced blood flow Reduced cellular enzyme activity Reduced drug elimination Reduced glomerular filtration rate and tubular secretion Altered protein binding Increased α-acid glycoprotein (owing to inflammation, illness) Reduced hepatic albumin synthesis and serum protein levels   PHARMACODYNAMICS (ALTERED SENSITIVITY TO DRUGS) Receptor Change(s) Reduced β1-adrenergic responsiveness Blunted reflex responses Reduced baroreceptor reflex  activity   *Adapted from Reference 21

 

 

 

            A basic understanding of drug effects and discussion between patients, pharmacists and health-care providers can minimize the potential for side-effects and medication errors. Patients can play an important role in medication safety by keeping an accurate list of medications, and bringing pill bottles to office visits to ensure the correct doses and pills are being taken.

 

Facts and Statistics

The presence of coronary atherosclerosis approaches 50% in older women and 70 to 80% in older men.  Individuals age 65 and older comprise nearly one-third of all hospitalizations for heart attack and an even greater proportion of heart-attack deaths.

Recent Heart and Stroke Statistics published by the American heart Association provide important insights and a telling view (http://americanheart.org/presenter.jhtml?identifier=1200000) of the problem’s overall scope (Link- Google 1 Facts and Statistics Section).Please confirm what you are referring to… Nearly 3 out of every 4 Americans aged 60 to 79 years have cardiovascular disease. The incidence exceeds that from cancer in most age groups, particularly in people older than 75 (Figure c). http://circ.ahajournals.org/cgi/content/full/115/19/2549/FIG5182615

The high incidence of coronary heart disease and its effects on longevity and quality of life among older American adults is paralleled in Western Europe and Scandinavia. (http://www.who.int/cardiovascular_diseases/resources/atlas/en/)

 

Aging and Health – 2008

 

The evolution of health care, coupled with prevention initiatives has led to a marked increase in life expectancy in the United States.  This dramatic trend, which began a century ago, has also caused a shift in the most prevalent causes of death from infections and sudden illnesses to chronic and degenerative diseases, including atherosclerosis and its consequences. This “demographic shift” will result in an aging health care crisis in developing countries over the next 50 years. These regions have only recently conquered issues of sanitation and infant mortality enabling a larger population to live to older age (akin to the influx of older adults in the US who are baby boomers).

 

Link:  www.cdc.gov/aging

 

The population of Americans aged 65 and older is expected to double over the next 25 years.  By 2030, there will be 71 million older adults in the United States, accounting for as much as 20% of the population.  As a result, the nation’s overall health care spending is anticipated to increase over the next two decades by nearly 25%.

The United States Department of Health and Human Services Healthy People 2010 initiative has yielded impressive results in several of the eleven targets, including screening for breast cancer, colorectal cancer, smoking cessation, and cholesterol checks.

Link –( http://www.healthypeople.gov/)

Societies and organizations from around the globe are responding to the needs of an aging population by forming alliances.  One example is an American College of Cardiology- Society of Geriatric Cardiology initiative – Essentials of Cardiovascular care in older Adults.  Implementation of the curriculum, aimed toward the fugue generation of cardiology specialists represents an important step toward maximizing health and minimizing treatment and outcome disparities in older patients.

            The goals are as follows:

·         Raise awareness of age-specific changes and how they impact disease assessment and management;

·         Appreciate evidence-based care of older adults;

·         Identify and pursue gaps in our knowledge;

·         Stimulate research efforts to fill the gap; and

·         Reduce morbidity and mortality through judicious and individualized care.(21)23)

 

1.         Karasik D, Demissie S, Cupples LA, Kiel DP. Disentangling the genetic determinants of human aging: biological age as an alternative to the use of survival measures. J Gerontol A Biol Sci Med Sci 2005;60:574-87.

2.         Frank SA. A multistage theory of age-specific acceleration in human mortality. BMC Biol 2004;2:16.

3.         Brouilette SW, Moore JS, McMahon AD, et al. Telomere length, risk of coronary heart disease, and statin treatment in the West of Scotland Primary Prevention Study: a nested case-control study. Lancet 2007;369:107-14.

4.         Li Y, Gilbert TR, Matsumoto AH, Shi W. Effect of Aging on Fatty Streak Formation in a Diet-Induced Mouse Model of Atherosclerosis.

5.         Kiechl S, Willeit J. The natural course of atherosclerosis. Part I: incidence and progression. Arterioscler Thromb Vasc Biol 1999;19:1484-90.

6.         Becker RC. Thrombotic preparedness in aging: a translatable construct for thrombophilias? J Thromb Thrombolysis 2007;24:323-5.

7.         Becker  RC. Chest Pain. Butterworth and Heinemann 2000.

8.         Wenger NK, Shaw LJ, Vaccarino V. Coronary Heart Disease in Women: Update 2008. Clin Pharmacol Ther 2007;83:37-51.

9.         Miller TD, DiCarli MF. Nuclear cardiac imaging for the assessment of coronary artery disease in the elderly. Am J Geriatr Cardiol 2007;16:355-62.

10.       Ullery BW, Peterson JC, Milla F, et al. Cardiac surgery in select nonagenarians: should we or shouldn't we? Ann Thorac Surg 2008;85:854-60.

11.       D'Agostino RB, Sr., Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008;117:743-53.

12.       Williams MA, Fleg JL, Ades PA, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients > or =75 years of age): an American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 2002;105:1735-43.

13.       Mourad J-J, Danchin N, Puel J, et al. Cardiovascular impact of exercise and drug therapy in older hypertensives with coronary heart disease: PREHACOR study. Heart and Vessels 2008;23:20-25.

14.       Miettinen TA, Pyorala K, Olsson AG, et al. Cholesterol-lowering therapy in women and elderly patients with myocardial infarction or angina pectoris: findings from the Scandinavian Simvastatin Survival Study (4S). Circulation 1997;96:4211-8.

15.       Ali R, Alexander KP. Statins for the primary prevention of cardiovascular events in older adults: a review of the evidence. Am J Geriatr Pharmacother 2007;5:52-63.

16.       Kokkinos P, Myers J, Kokkinos JP, et al. Exercise capacity and mortality in black and white men. Circulation 2008;117:614-22.

17.       Zhao G, Ford ES, Li C, Mokdad AH. Are United States adults with coronary heart disease meeting physical activity recommendations? Am J Cardiol 2008;101:557-61.

18.       Alexander KP, Chen AY, Newby LK, et al. Sex Differences in Major Bleeding With Glycoprotein IIb/IIIa Inhibitors: Results From the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Initiative. Circulation 2006;114:1380-1387.

19.       Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation 2008;117:686-97.

1920.   Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007;115:2549-69.

2021.   Alexander KP, Newby LK, Armstrong PW, et al. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007;115:2570-89.

2122.   Alexander KP, O'Connor CM. The Elderly and Aging: in Texbook of Cardiovascular Medicine, 3rd Edition by Eric J. Topol. 2007:561-586.

23.       Dove JT, Zieman SJ, Alexander K, Miller A. President's page: Cardiovascular care in older adults: the ACC and SGC partnership builds new curriculum. J Am Coll Cardiol 2008;51:672-3.