Cardiovascular Disease in Elderly Women

Coronary Artery Disease

Coronary artery disease (CAD) increases with age in women and is the most common cause of death in elderly women. The prevalence of CAD is similar in elderly women and men. In one prospective study, CAD was present in 1010 of 2464 women (41%; mean age, 81 yr).¹ At 46-month follow-up in this study, new coronary events (myocardial infarction or sudden cardiac death) occurred in 1086 of the 2464 women (44%) older than age 60 years.¹

CAD is diagnosed if there is either coronary angiographic evidence of significant CAD, a documented myocardial infarction, a typical history of angina pectoris with myocardial ischemia demonstrated by stress testing, or sudden cardiac death. The incidence of sudden cardiac death as the first clinical manifestation of CAD in women increases with age.

Dyspnea on exertion is a more common clinical manifestation of CAD in elderly women than is the typical chest pain of angina pectoris.² Because elderly women are more limited in their activities, angina pectoris in older women is less often associated with exertion. Elderly women with angina pectoris are less likely to have substernal chest pain, and they describe their anginal pain as less severe and of shorter duration than do younger women. Angina pectoris in older women may occur as a burning postprandial epigastric pain or as pain in the back or shoulders. Acute pulmonary edema unassociated with an acute myocardial infarction may be a clinical manifestation of unstable angina pectoris due to extensive CAD in elderly women.²

Clinical manifestations of acute myocardial infarction in older women include dyspnea (the most common presenting symptom), chest pain, neurological symptoms, and gastrointestinal symptoms.³ Q-wave myocardial infarction documented by an electrocardiogram without a clinical history of myocardial infarction is present in 21-68% of elderly women with Q-wave myocardial infarction.^3-6 The prognosis of Q-wave myocardial infarction in elderly women is not significantly different if the myocardial infarction is clinically recognized or unrecognized.^4,6,7

Risk factors for the development of new coronary events in elderly women include age,^8-10 prior CAD,^8-10 cigarette smoking,^8-11 hypertension,^8-10 diabetes mellitus,^8-10 increased serum total cholesterol or low-density lipoprotein cholesterol,^8-10 low serum high-density lipoprotein cholesterol,^8-10,12 increased serum triglycerides,^8-10 obesity,^9,10 physical inactivity,¹³ and left ventricular hypertrophy.^14,15

Elderly women with CAD are less likely to be referred for coronary angiography and coronary revascularization than elderly men with stable or unstable CAD.^16,17 A prospective study was performed in which 91 consecutive women (range, 70-94 yr; mean age, 79 yr) hospitalized with acute coronary syndromes underwent coronary angiography.¹⁸

In the same study, women hospitalized with ischemic-type chest discomfort lasting longer than 30 minutes with ST-segment elevation of 0.2 mV or greater in 2 or more contiguous precordial leads or ST-segment elevation of 0.1 mV or greater in 2 or more limb leads plus an elevated serum creatine kinase-MB level or an elevated serum cardiac-specific troponin I level were diagnosed as having ST-segment elevation myocardial infarction.¹⁸ Women hospitalized with ischemic-type chest discomfort of longer than 30 minutes without ST-segment elevation but with an elevated serum creatine kinase-MB level or an increased serum cardiac-specific troponin I level were diagnosed as having non–ST-segment elevation myocardial infarction.¹⁸ Women hospitalized with ischemic-type chest discomfort of longer than 30 minutes with normal serum creatine kinase-MB and cardiac-specific troponin I levels were diagnosed as having unstable angina pectoris.¹⁸

Of the 91 women in this study, 45 women (49%) were diagnosed as having unstable angina pectoris, 32 women (35%) were diagnosed as having non–ST-segment elevation myocardial infarction, and 14 women (15%) were diagnosed as having ST-segment elevation myocardial infarction.¹⁸ Therefore, 70% of the myocardial infarctions in women 70 years of age and older were non–ST-segment elevation myocardial infarctions.¹⁸

Seventy-three (80%) of the 91 women with acute coronary syndromes had obstructive CAD (> 50% obstruction of 1 major coronary artery), 15 women (16%) had nonobstructive CAD (< 50% obstruction of 1 major coronary artery), 3 women (3%) had no CAD, 26 women (29%) had significant 1-vessel CAD, 23 women (25%) had significant 2-vessel CAD, 24 women (26%) had significant 3-vessel CAD, and 2 women (2%) had left main CAD.¹⁸ If obstructive CAD was present, 51 of 73 women (70%) had percutaneous coronary intervention (62%) or coronary artery bypass surgery (8%).¹⁸ This was not significantly different from the prevalence of coronary revascularization performed in the 86 consecutive elderly men hospitalized with acute coronary syndromes in this study.¹⁸

Stress testing for the diagnosis of myocardial ischemia in elderly women is discussed extensively elsewhere.² Exercise echocardiography is more specific than exercise electrocardiography in diagnosing CAD in women. Elderly women with angina pectoris, myocardial ischemia, and angiographically normal coronary arteries may have a vasculopathy with endothelial dysfunction, microvascular CAD, and impaired coronary vascular reactivity and functional capacity.^19,20 In a recent study, women with angiographically normal coronary arteries were 4.1 times more likely than men with angiographically normal coronary arteries to be re-admitted to a hospital within 180 days for an acute coronary syndrome or chest pain.²¹

Management
Older women with CAD should have intensive management of modifiable coronary risk factors. Cigarette smoking should be stopped. The blood pressure should be reduced to less than 135/85 mm Hg if necessary with beta blockers and angiotensin-converting enzyme inhibitors.^22-24 Patients with diabetes mellitus or chronic renal insufficiency should have their blood pressure reduced to less than 130/80 mm Hg.²² The serum low-density lipoprotein cholesterol level should be reduced to less than 70 mg/dL with the use of statins if necessary.^25-27 Diabetes mellitus should be controlled, with the hemoglobin A1c level reduced to less than 7%. Sulfonylureas should not be used if possible.²⁸ Ideal body weight should be achieved. Daily physical activity should be performed.

Angina pectoris should be treated with nitrates and beta blockers, and with the addition of long-acting nondihydropyridine calcium channel blockers if necessary.²⁹ Antiplatelet therapy with aspirin or clopidogrel should be administered indefinitely.^27,30 Beta blockers and angiotensin-converting enzyme inhibitors should be administered indefinitely.²⁷ Hormone replacement therapy should not be started or continued in postmenopausal women with CAD.^31,32 Management of acute coronary syndromes,³³ acute myocardial infarction,³⁴ and postmyocardial infarction²⁷ are discussed in detail elsewhere.

Coronary revascularization should be performed in older women with CAD to prolong life and to improve the quality of life despite optimal medical therapy. Coronary revascularization by coronary angioplasty³⁵ or by coronary artery bypass surgery³⁶ is discussed in detail elsewhere. If coronary revascularization is performed in older women, intensive medical management must be continued.

Nonobstructive CAD should be treated with intensive medical management.³⁷ Evidence-based guidelines for cardiovascular disease prevention in women is discussed extensively elsewhere.³⁸

Congestive Heart Failure

Congestive heart failure (CHF) is the most common cause of hospitalization in women or men. The prevalence of CHF increases with age and is similar in elderly women and men.¹ At 46-month follow-up, CHF developed in 643 of 2464 women (26%) older than age 60 years (mean age, 81 yr).¹

The prevalence of diastolic heart failure (CHF with a normal left ejection fraction) increases with age and is higher in elderly women with CHF than in elderly men with CHF.^39-45 Aronow et al⁴¹ found that in elderly patients with CHF, the prevalence of diastolic heart failure was 37% in 38 women age 60-69 years, 44% in 79 women age 70-79 years, 59% in 219 women age 80-89 years, and 73% in 59 women age 90 years and older. Diastolic heart failure was present in 58% of 110 older black women with CHF, in 56% of 34 older Hispanic women with CHF, and in 57% of 303 older white women with CHF.⁴²

The epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure are discussed extensively elsewhere.⁴⁶ The treatment of systolic and diastolic heart failure in older persons with heart failure is discussed extensively elsewhere.^47-49

Valvular Heart Disease

Aortic Stenosis
The prevalence of valvular aortic stenosis increases with age and is similar in elderly women and men.⁵⁰ In a study, Doppler echocardiography showed that valvular aortic stenosis was present in 17% of 1881 elderly women (mean age, 81 yr).⁵¹ The valvular aortic stenosis was severe in 2% of the elderly women, moderate in 5% of the elderly women, and mild in 10% of the elderly women.⁵¹ In the Helsinki Aging Study, Doppler echocardiography found that critical valvular aortic stenosis was present in 3% of 501 persons age 75-86 years.⁵²

Management of aortic stenosis in the elderly is discussed extensively elsewhere.50

Aortic Regurgitation
The prevalence of valvular aortic regurgitation increases with age and is similar in elderly women and men.⁵⁰ Doppler echocardiography showed that valvular aortic regurgitation was present in 29% of 1881 elderly women (mean age, 81 yr).⁵¹ The valvular aortic regurgitation was severe or moderate in 16% of the elderly women and was mild in 13% of the elderly women.⁵¹

Management of aortic regurgitation in the elderly is discussed extensively elsewhere.⁵⁰

Mitral Regurgitation
The prevalence of mitral regurgitation increases with age and is similar in elderly women and men.⁵³ Doppler echocardiography showed that mitral regurgitation was present in 33% of 1881 elderly women (mean age, 81 yr).⁵¹

Management of mitral regurgitation in the elderly is discussed extensively elsewhere.⁵³

Rheumatic Mitral Stenosis
The prevalence of rheumatic mitral stenosis is higher in elderly women than in elderly men, and was present in 2% of 1881 elderly women (mean age, 81 yr).⁵¹

Management of mitral stenosis in the elderly is discussed extensively elsewhere.⁵³

Mitral Annular Calcium
The prevalence of mitral annular calcium is higher in elderly women than in elderly men and was present in 52% of 1881 elderly women (mean age, 81 yr).⁵¹

Management of mitral annular calcium in the elderly is discussed extensively elsewhere.⁵³

Peripheral Arterial Disease

Peripheral arterial disease (PAD) is chronic arterial occlusive disease of the lower extremities caused by atherosclerosis. PAD may cause intermittent claudication, which is pain or weakness with walking that is relieved with rest. The muscle pain or weakness after exercise occurs distal to the arterial obstruction. The prevalence of PAD increases with age⁵⁴ and was higher in 1160 men (32%; mean age, 80 yr) than in 2464 women (26%; mean age, 81 yr).¹

Only one-half of elderly persons with documented PAD are symptomatic. Persons with PAD may not walk far or fast enough to induce muscle ischemic symptoms because of comorbidities such as pulmonary disease or arthritis, may have atypical symptoms unrecognized as intermittent claudication,⁵⁵ may fail to mention their symptoms to their physician, or may have sufficient collateral arterial channels to tolerate their arterial obstruction. Women with PAD have a higher prevalence of leg pain on exertion and at rest, poorer functioning, and greater walking impairment from leg symptoms than men with PAD.⁵⁶ Poorer leg strength in women contributes to poorer lower extremity functioning in women with PAD than in men with PAD.⁵⁶

PAD coexists with other atherosclerotic disorders.^57,58 Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and cardiovascular events.^59-63

Management of PAD in the elderly is discussed extensively elsewhere.^54,64

Ischemic Stroke

The prevalence of ischemic stroke increases with age and is similar in older women and men. In one prospective study, ischemic stroke was present in 761 of 2464 women (31%; mean age, 81 yr).¹ At 46-month follow-up in this study, new ischemic stroke occurred in 519 of the 2464 women (21%) older than age 60 years.¹

Ischemic stroke coexists with other atherosclerotic disorders.^57,58 Persons with ischemic stroke are at increased risk for all-cause mortality, cardiovascular mortality, and cardiovascular events.^65-68

Management of ischemic stroke in the elderly is discussed extensively elsewhere.⁶⁹

Atrial Fibrillation

The prevalence of atrial fibrillation (AF) increases with age and was higher in 1160 men (16%; mean age, 80 yr) than in 2464 women (13%; mean age, 81 yr).¹ In the Framingham Study, the incidence of death from cardiovascular causes was 2.7 times higher in women and 2.0 times higher in men with chronic AF than in women and men with sinus rhythm.⁷⁰ The Framingham Study also found that after adjustment for preexisting cardiovascular conditions, the odds ratio for mortality in persons with AF was 1.9 in women and 1.5 in men.⁷¹ At 42-month follow-up of 1359 persons with heart disease (mean age, 81 yr), patients with chronic AF had a 2.2-times increased risk of having new coronary events than patients with sinus rhythm after controlling for other prognostic variables.⁷² In the Copenhagen City Heart Study, the effect of AF on the risk of cardiovascular death was significantly increased 4.4 times in women and 2.2 times in men.⁷³

AF is also an independent risk factor for stroke, especially in the elderly.^74,75 In the Framingham Study, the relative risk of stroke in patients with nonvalvular AF as compared with patients with sinus rhythm was increased 2.6 times in patients age 60-69 years, increased 3.3 times in patients age 70-79 years, and increased 4.5 times in patients age 80-89 years.⁷⁴ Chronic AF was an independent risk factor for thromboembolic (TE) stroke with a relative risk of 3.3 in 2101 persons (mean age, 81 yr).⁷⁵ The 3-year incidence of TE stroke was 38% in elderly persons with chronic AF and 11% in elderly persons with sinus rhythm.⁷⁵ The 5-year incidence of TE stroke was 72% in elderly persons with AF and 24% in elderly persons with sinus rhythm.⁷⁵ At 37-month follow-up of 1476 patients who had 24-hour ambulatory electrocardiograms, the incidence of TE stroke was 43% for 201 patients with AF (relative risk = 3.3; 95% confidence interval, 2.4-4.5), 17% for 493 patients with paroxysmal supraventricular tachycardia, and 18% for 782 patients with sinus rhythm.⁷⁶ In the Copenhagen City Heart Study, the effect of AF on the risk of stroke was significantly increased 7.6 times in women and 1.7 times in men.⁷³ AF is also a risk factor for impaired cognitive function.⁷⁷

In the Anticoagulation and Risk Factors in Atrial Fibrillation Study, women who were not taking warfarin had significantly higher annual rates of TE events (3.5%) than men (1.8%).⁷⁸ Warfarin was associated with significantly lower adjusted TE rates for both women (60% reduction) and men (40% reduction), with similar annual rates of major bleeding (1.0% and 1.1%, respectively).⁷⁸

Management of AF is discussed extensively elsewhere.⁷⁹

Cardiomyopathies

Cardiomyopathies may be due to CAD or nonischemic heart disease. Cardiomyopathies due to nonischemic causes are discussed extensively elsewhere.⁸⁰

Pacemakers

The prevalence of cardiac pacemakers increases with age and was 5% in 1160 men (mean age, 80 yr) and 5% in 2464 women (mean age, 81 yr).¹ Bradyarrhythmias and cardiac pacemakers in the elderly are discussed extensively elsewhere.⁸¹

Conclusion

In a prospective study of 2464 elderly women (mean age, 81 yr), CAD was present in 41% of women, PAD in 26% of women, ischemic stroke in 31% of women, AF in 13% of women, and pacemaker rhythm in 5% of women. At 46-month follow-up in this study, new coronary events (myocardial infarction or sudden cardiac death) occurred in 44% of women, new ischemic stroke in 21% of women, and CHF in 26% of women. In another study, Doppler echocardiography demonstrated in 1881 elderly women (mean age, 81 yr) that valvular aortic stenosis was present in 17% of women (severe in 2%), valvular aortic regurgitation was present in 29% of women, mitral regurgitation in 33% of women, rheumatic mitral stenosis in 2% of women, and mitral annular calcium in 52% of elderly women.

The author reports no relevant financial relationships.

From the Department of Medicine, Cardiology Division, New York Medical College, Valhalla.