The elderly patient with coronary heart disease: contemporary practices and future challenges.

The elderly population of most industrialized countries and many developing nations has ex­ panded exponentially during the past century, with the most prominent increases in the size of the "oldest old" subset. Concomitantly, advances in pre~entive strategies and improvements in the treatment of acute coronary events have radically altered the demography of coronary patients encountered in clinical practice. Today, elderly coronary patients predominate in many coronary care units, comprise from one-third to one-half of those undergoing invasive diagnostic and therapeutic cardiovascular procedures, and are increasingly visible among participants in cardiac rehabilitation programs. Recent attention also has been focused on el­ derly coronary patients owing to their increasing numbers and the sizeable costs of their cardio­ vascular care; within the next 35 years, one­ fourth of the population will be older than age 65 years. These factors have engendered world­ wide considerations of age-based restrictions in the allocation of health care resources (1) in general, and cardiovascular care in particular. Considerable information has accrued in recent years concerning both myocardial infarction and myocardial revascularization procedures in the geriatric population. The mortality from my­ ocardial infarction increases incrementally with age, such that over half of myocardial infarc­ tion hospital deaths in the United States occur in patients older than 75 years of age. A ten-fold in­ crease in hospital mortality in elderly patients was described in the Myocardial Infarction Triage and Intervention (MITI) project, 17.8% at age 75 years and older us 2% below age 55 years (2). Given this high mortality, as well as the sub­ stantial rate of complications of myocardial in­ farction at elderly age - recurrent myocardial is­ chemia, heart failure, stroke, cardiogenic shock, atrial arrhythmias, cardiac rupture - what con­ stitutes optimal care for elderly and very elderly patients with acute myocardial infarction? Thrombolytic therapy to restore myocardial perfusion imparts comparable early and late sur­ vival benefit at ages 65 -75 years as for younger patients, without apparent differences among the thrombolytic drugs tested. Based on pooled data from large randomized controlled trials in­ volving more than 36 000 patients, benefit per­ sisted despite more frequent bleeding complica­ tions at elderly age; stroke risk was not increased, presumably due to counterbalancing of the high­ er risk of hemorrhagic stroke by the lesser risk of embolic stroke with preservation of ventricular function. Importantly, although myocardial in­ farction mortality was greater at elderly than at younger age even with the application of throm­ bolytic therapy, mortality was even higher among elderly infarction patients not receiving throm­ bolytic drugs. Thus, use of thrombolytic therapy is warranted for elderly patients with myocardial infarction (3-8), because of its significant advan­ tage and acceptable risks, although data to gUide coronary thrombolysis are currently lacking for patients older than 75 years of age, and in par