Stable ischemic heart disease in the older adults

1 Introduction Ischemic heart disease is caused by atherosclerotic and/or thrombotic obstruction of coronary arteries. Clinical spec- trum of ischemic heart disease expands from asymptomatic atherosclerosis of coronary arteries to acute coronary syn- dromes （ACS） including unstable angina, acute myocardial infarction （non-ST elevation myocardial infarction and ST elevation myocardial infarction）. Stable ischemic heart dis- ease （SIHD） refers to patients with known or suspected SIHD who have no recent or acute changes in their symp- tomatic status, suggesting no active thrombotic process is underway.

Secondary cardiovascular prevention in older adults： an evidence based review

1 BackgroundIn the United States, life expectancy is rising, particularly among the older population （〉 65 years）, with projected estimates approaching 20% by year 2050. Despite improved survival estimates, cardiovascular diseases remain the leading cause of morbidity and mortality resulting in substantial increase in health care cost. For younger adults, the evidence for secondary cardiovascular prevention is well established and corroborated by robust data. However, the application of risk reduction strategies in older populations remains an area of active debate. Many assume that vulnerability to chronic cardiovascular diseases is an inexorable part of aging such that the risks attributable to prevention outweigh potential benefits.

Influence of age in estimating maximal oxygen uptake

Objective To assess the influence of age on the error of estimate （EE） of maximal oxygen uptake （VO2max） using sex and population specific-equations in cycle ergometer exercise testing, since estimated VO2 max is associated with a substantial EE, often exceeding 20%, possibly due to intrinsic variability of mechanical efficiency. Methods 1850 adults （68% men）, aged 18 to 91 years, underwent maximal cycle ergometer cardiopulmonary exercise testing. Cardiorespiratory fitness （CRF） was assessed relative to sex and age [younger （18 to 35 years）, middle-aged （36 to 60 years） and older （〉 60 years）]. VO2max [mL.（kg.min）-1] was directly measured by assessment of gas exchange and estimated using sex and population specific-equations. Measured and estimated values of VO2max and related EE were compared among the three age- and sex-specific groups. Results Directly measured VO2max of men and women were 29.5 ± 10.5 mL.（kg.min）-1 and 24.2 ± 9.0 mL.（kg·min） -1 （P 〈 0.01）. EE [mL·（kg·min）-1] and percent errors （%E） for men and women had similar values, 0.5 ± 3.2 and 0.4 ± 2.9 mL·（kg·min）-1, and -0.8 ± 13.1% and -1.7 ± 15.4% （P 〉 0.05）, respectively. EE and %E for each age-group were, respectively, for men： younger = 1.9 ± 4.1 mL·（kg·min）-1 and 3.8 ± 10.5%, middle-aged = 0.6 ± 3.1 mL.（kg·min）-1 and 0.4 ± 10.3%, older = -0.2 ± 2.7 mL·（kg·min） -1 and -4.2 ± 16.6% （P 〈 0.01）; and for women： younger = 1.2 ± 3.1 mL.（kg.min）-1 and 2.7 ±10.0%, middle-aged = 0.7 ± 2.8 mL·（kg·min）-1 and 0.5 ± 11.1%, older = -0.8 ± 2.3 mL-（kg·min）-1 and -9.5 ± 22.4% （P 〈 0.01）. Conclusion VO2max were underestimated in younger age-groups and were overestimated in older age groups. Age significantly influences the magnitude of the EE of VO2max in both men and women and should be considered when CRF is estimated using population specific equations, rather than directly measured.

Clinical pharmacology relevant to older adults with cardiovascular disease

1 Introduction Although older adults are generally among the highest users of cardiovascular medications, they are typically underrepresented or excluded from most efficacy and safety trials. Drug developers are usually reluctant to include many senior adults in randomized controlled clinical trials in part due to their high prevalence of multiple comorbidities, frailty, and polypharmacy; and to age-related pharmacokinetic and pharmacodynamic complexities. Consequently, there is often insufficient high quality evidence-based data to inform pharmacologic management of common cardiovascular conditions on older adults. In the absence of data, clinicians often rely on conceptual principles regarding metabolism and drug-drug interactions to minimize adverse drug events, but this is often not well-substantiated or standardized. A related challenge is poor cardiovascular medication adherence among older adults, and its detrimental impact on their health outcomes. In this brief review we highlight some aspects of these topics.

Essentials of cardiovascular care for older adults： extending a US-based educational resource for collaboration with our China colleagues

1 The rationale for a geriatric cardiology skillset Throughout most of the world, people are living substantially longer. As a result, there is a rapidly expanding population of older adults who did not previously survive into old age. These adults are exposed to advanced aging processes that did not previously occur. Physiological changes of age predispose to cardiovascular diseases. Ironically, coronary heart disease, heart failure, valvular heart disease, peripheral artery disease, arrhythmias and other cardiovascular problems all soar with survival into senior years.

Care of older adults

In the United States, approximately 40 million adults over the age 65 are affected by one or more forms of cardiovascular disease and it remains the leading cause of morbidity and mortality in this population. Among older adults, therapeutic goals for cardiovascular diseases （CVD） are often confounded by comorbid diseases and/or conditions that dominate their overall sense of health and well-being. Thus, even while CVD is usually considered a principal concern,

Conditions for autonomous choice： a qualitative study of older adults＇ experience of decision-making in TAVR

Background Patient autonomy is a leading principle in bioethics and a basis for shared decision making. This study explores conditions for an autonomous choice experienced by older adults who recently underwent trans-catheter aortic valve replacement （TAVR）. Methods Qualitative study entailing semi-structured interviews of a purposive sample often older （range 73-89, median 83.5 years） adults after TAVR （median 23 days）. The study setting was a cardiac department at a university hospital performing TAVR since 2010. Analysis was by systematic text condensation. Results Even when choice seemed hard or absent, TAVR-patients deliberately took the chance offered them by processing risk assessment, ambivalence and fate. They regarded declining the treatment to be worse than accepting the risk related to the procedure. The experience of being thoroughly advised by their physician formed the basis of an autonomous trust. The trust they felt for the physicians＇ recommendations mitigated ambivalence about the procedure and risks. TAVR patients expressed feelings consistent with self-empowerment and claimed that it had to be their decision. Even so, choosing the intervention as an obligation to their family or passively accepting it was also reported. Conclusions Older TAVR patients＇ experience of an autonomous decision may encompass frank tradeoff; deliberate physician dependency as well as a resilient self-view. Physicians should be especially aware of how older adults＇ subtle cognitive declines and inclinations to preserve their identities which can influence their medical decision making when obtaining in- formed consent. Cardiologists and other providers may also use these insights to develop new strategies that better respond to such inherent complexities.

Medical decision making for older adults： an international perspective comparing the United States and India

There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutane- ous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advan- tages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac dis- ease with comparisons of West to East, focusing particularly on the United States versus India.

老年心血管疾病医护照料

年龄是心血管疾病的独立危险因素。随着老年人口的加速增长,老年医学与心脏病照护越来越息息相关。尽管年轻的心血管疾病患者一般不伴有其他疾病,但老年患者常伴随与年龄相关的多种疾病。因此,对心血管疾病的管理方案也会因其他共病、衰弱、多重用药、认知功能障碍、机体功能减退和年龄相关的复杂问题而变化。这意味着在管理老年心血管疾病患者时,需要更多的洞察力和技能来应对普遍存在的相关问题。本综述涵盖了治疗老年心血管疾病时可能存在的其他老年问题,特别是在心血管疾病管理方面应考虑的问题。传统的实践指南通常比较适合健康的老年人,用于应对多变的医疗状况、实现特殊照护目标的个体化治疗方案才会使更多人受益。这需要根据患者的总体状况权衡风险和效益,同时具备在决策时与患者沟通,并在适宜情况下与其他照护者进行交流的能力。这种个性化方案的效果尤为显著,为老年患者提供了改善机体功能和提升生活质量的机会,而这往往是治疗老年患者的首要目标。