Approach to the management of coronary artery disease in the elderly.

Atherosclerotic coronary artery disease is an important problem in the elderly and is the leading cause of death. It is a diagnosis that is often difficult to make; signs and symptoms of angina pectoris and myocardial infarction can be atypical in the elderly patient for a variety of reasons. The chest radiograph, electrocardiogram, and echocardiogram can provide diagnostic clues as to the presence of coronary artery disease. Exercise testing is foremost among the noninvasive diagnostic modalities, but it has significant limitations particular to the elderly patient. These include a decreased ability to exercise in the elderly, difficulty in interpretation because of an abnormal resting electrocardiogram, and the nature of an imperfect test that provides a statement of probability rather than an unequivocal diagnosis. Cardiac catheterization can be performed with minimal risk in selected, particularly unstable patients, in whom a surgical alternative is contemplated. The elderly patient can benefit as much from coronary artery bypass graft surgery as younger counterparts, albeit with a modestly increased risk. The medical therapy of coronary artery disease, stable and unstable angina, and myocardial infarction is not substantially different in the older patient. Nitrates, beta blockers, and calcium antagonists provide relief of anginal symptoms. The older patient stands to derive the same benefits from CCU monitoring as does the younger patient. An increased awareness of adverse drug reactions is necessary, however, and as for patients of any age, the particular goals of therapy may differ substantially and require an individualized approach.