The elderly heart: Special signs and symptoms to watch for

Cardiovascular disease is both the most common medical problem and the greatest cause of death in the elderly. Most patients die from coronary artery disease (CAD)-either sudden death or myocardial failure. Yet, despite the high prevalence of CAD and its resultant morbidity and mortality, the physician may face a difficult diagnosis in many elderly patients. For instance, angina and myocardial infarction (MI) may go unrecognized due to an atypical pattern of presentation and the absence of chest pain. The presence of disease in the chest wall, lungs, or the esophagus and stomach may also mimic CAD. Additionally, older patients with impaired memory may neglect to report symptoms. CAD, MI, and congestive heart failure (CHF) may all show a nonspecific presentation in the elderly. The challenge to the physician is threefold: recognition of overt cardiovascular disease; awareness of the elderly patient's vulnerability to complications; and caution and judgment in prescribing potentially beneficial drugs while restricting the number and dosage of these agents to the lowest effective amount. In western cultures, the distinction between normal aging and cardiovascular atherosclerotic disease is difficult to make. Several substances are known to accumulate in the cardiovascular system with age. Such accumulations, in small amounts, probably cause no hemodynamic dysfunction. However, these accumulations may be related to the reduced cardiac reserve of the elderly, especially at maximal workloads. Physical and laboratory examinations of older individuals show notable changes compared with younger persons.