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Atypical Manifestation of Myocardial Ischemia in the Elderly

Myocardial Ischemia / physiopathology; Aged; Heart Failure; Coronary Artery Disease; Angina Pectoris

Often, elderly patients have atypical clinical picture for myocardial ischemia, or are asymptomatic. This review intends to re-examine the pathophysiology of atypical manifestation in elderly persons, its prognostic and therapeutic implications.

The coronary atherosclerotic disease is an increasing public health problem, of particular importance in higher age groups. Its prevalence increases significantly at the sixth decade of life, becoming the leading cause of death in older people, as well as the greatest responsible for hospitalization and invasive procedures11. Galon MZ, Meireles GC, Kreimer S, Marchiori GG, Favarato D, Almeida JA, et al. Perfil clínico-angiográfico na doença arterial coronariana: desfecho hospitalar com ênfase nos muito idosos. Arq Bras Cardiol. 2010;95(4):422-9..

The absent or atypical clinical signs in elderly persons hinder the management of coronary atherosclerotic disease. The cases of myocardial ischemia without pain, the so-called asymptomatic or silent ischemia, it is more frequent in elderly patient22. Fleg JL, Gerstenblith G, Zonderman AB, Becker LC, Weisfeldt ML, Costa Jr PT, et al. Prevalence and prognostic significance of exercise-induced silent myocardial ischemia detected by thallium scintigraphy and electrocardiography in asymptomatic volunteers. Circulation. 1990;81(2):428-36.. Considering patients with acute coronary syndrome, as myocardial infarction with ST-segment elevation, among those under 65 years of age, only 11.1% do not have precordial pain, unlike those over 85 years old, among which 43.2% have precordial pain33. Rogers WJ, Bowlby LJ, Chandra NC, French WJ, Gore JM, Lambrew CT, et al. Treatment of myocardial infarction in the United States (1990 to 1993). Observations from the National Registry of Myocardial Infarction. Circulation. 1994;90(4):2103-14.. Similarly, among elderly patients with Q wave in electrocardiogram (ECG), 78% did not have symptoms of precordial pain44. Aronow WS. Prevalence of presenting symptoms of recognized acute myocardial infarction and of unrecognized healed myocardial infarction in elderly patients. Am J Cardiol. 1987;60(14):1182. (Figure 1).

Figure 1
Clinical presentation of acute myocardial infarction according to age. Bayer AJ, Chadha JS, Farag RR, Pathy MS. J Am Geriatr Soc. 1986; 34:263-6.

Diabetes mellitus has been considered the biggest factor related to asymptomatic ischemia in patients with stable coronary disease. However, several studies found no such association55. Callaham PR, Frolicher VF, Klein J, Rish M, Dubach P, Friis R. Exercise-induced silent ischemia: age, diabetes mellitus, previous myocardial infarction and prognosis. J Am Coll Cardiol. 1989;14(5):1175-80.. These studies indicate that the only independent factor for silent ischemia is advanced age. In fact, progressive increase occurs in the interval between the beginning of ST segment depression and the onset of angina with increased age66. Umachandran V, Ranjadayalan K, Ambepityia G, Marchant B, Kopelman PG, Timmis AD. Aging, autonomic function, and the perception of angina. Br Heart J. 1991;66(1):15-8., indicating increased pain threshold among elderly.

When an episode of coronary blood flow reduction occurs, the first alteration is the suffering of myocyte, following changes of myocardial relaxation and ST segment depression. Pain is the last manifestation of myocardial ischemia77. Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol. 1987;59(7):23C-30C..

The higher prevalence of asymptomatic myocardial ischemia or with atypical symptoms in elderly is explained by increased pain threshold related to nociceptive changes and by the great prevalence of diseases such as depression and diabetes mellitus. Increased beta-endorphins levels have also been described in patients with asymptomatic myocardial ischemia88. Falcone C, Specchia G, Rondanelli R, Guasti L, Corsico G, Codega S, et al. Correlation between beta-endorphin plasma levels and anginal symptoms in patients with coronary artery disease. J Am Coll Cardiol. 1988;11(4):719-23.. However, there are studies with different findings99. Kurita A, Takase B, Uehata A, Sugahara H, Nishioka T, Maruyama T, et al. Differences in plasma beta-endorphin and bradykinin levels between patients with painless or with painful myocardial ischemia. Am Heart J. 1992;123(2):304-9. , 1010. Heller GV, Garber CE, Connolly MJ, Allen-Rowlands CF, Siconolfi SF, Gann DS, et al. Plasma beta-endorphin levels in silent myocardial ischemia induced by exercise. Am J Cardiol. 1987;59(8):735-9.. Additionally, patients suffering from silent ischemia have central nervous activation different from those with angina when subjected to ischemic dobutamine stress, predominating the frontal cortex and ventral temporal activation1111. Rosen SD, Paulesu E, Nihoyannopoulos P, Tousoulis D, Frackowiak RS, Frith CD, et al. Silent ischemia as a central problem: regional brain activation compared in silent and painful myocardial ischemia. Ann Intern Med. 1996;124(11):939-49.. Interestingly, the thalamic area, which is responsible for the recognition of pain, had similar activation in patients with and without angina1212. Machado A. Neuroanatomia funcional. 2ª. ed. São Paulo: Atheneu; 2001..

On the other hand, the elderly patients have comorbidities that may influence the clinical manifestation of myocardial ischemia. Even the diabetes mellitus is a condition whose prevalence increases with age, as well as diabetic neuropathy.

Fibromyalgia and depression are neuropsychiatric conditions that interfere with the painful sensation. Sometimes, elderly persons complain of precordial pain, with rejected diagnosis of myocardial ischemia, improve with antidepressants. The opposite can also occur, with elderly people with atypical pain for myocardial ischemia, generally attributed to depression, having significant coronary disease. The relationship between depression and coronary atherosclerotic disease is well defined1313. Whang W, Kubzansky LD, Kawachi I, Rexrode KM, Kroenke CH, Glynn RJ, et al. Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses' Health Study. J Am Coll Cardiol. 2009;53(11):950-8.. However, there are several reasons why depression increases the occurrence of coronary disease. Patients with depression have less treatment adherence to drug and lifestyle changes. Additionally, depression1414. Summers KM, Martin KE, Watson K. Impact and clinical management of depression in patients with coronary artery disease. Pharmacotherapy. 2010;30(3):304-22. can cause change of endothelial function, deregulation of the hypothalamic-pituitary-adrenal axis, increased platelet reactivity and inflammatory markers with interleukin 6.

Memory changes, which are frequent in elderly patients, as Alzheimer's disease and vascular dementia, are characterized by the loss of short term memory. Consequently, in these patients, the reliable reporting of symptoms of recent onset is affected. Both Alzheimer's disease and vascular dementia have risk factors similar to those of coronary disease. As a result, besides frequent concomitance, memory deficit causes elderly to have memorization difficulty and describe the pain resulting from myocardial ischemia.

Among elderly patients with heart failure, 50-70% have myocardial ischemia as etiology, and considerable part of them have prior myocardial revascularization. Both heart failure1515. Ochiai ME, Franco LL, Gebara OC, Nussbacher A, Serro-Azul JB, Pierri H, et al. [Correlation between evolution of the cognitive function and mortality after hospital discharge in elderly patients with advanced heart failure]. Arq Bras Cardiol. 2004;82(3):251-4. and myocardial revascularization reduce cognitive performance, especially in the field of attention. Thus, if a patient has myocardial ischemia, this cognitive deficit can impair description of the pain characteristics.

In conclusion, elderly patients with myocardial ischemia often have atypical clinical manifestations, due to comorbidities as diabetes mellitus, nociceptive changes, depression and dementia. Therefore, in elderly patients, atypical symptoms of coronary insufficiency should be valued, and to confirm or not diagnosis of myocardial ischemia, the search through additional tests should be more rigorous. Additionally, these research tests on myocardial ischemia also identify patients at higher risk that should be treated more intensively.

Referências

  • 1
    Galon MZ, Meireles GC, Kreimer S, Marchiori GG, Favarato D, Almeida JA, et al. Perfil clínico-angiográfico na doença arterial coronariana: desfecho hospitalar com ênfase nos muito idosos. Arq Bras Cardiol. 2010;95(4):422-9.
  • 2
    Fleg JL, Gerstenblith G, Zonderman AB, Becker LC, Weisfeldt ML, Costa Jr PT, et al. Prevalence and prognostic significance of exercise-induced silent myocardial ischemia detected by thallium scintigraphy and electrocardiography in asymptomatic volunteers. Circulation. 1990;81(2):428-36.
  • 3
    Rogers WJ, Bowlby LJ, Chandra NC, French WJ, Gore JM, Lambrew CT, et al. Treatment of myocardial infarction in the United States (1990 to 1993). Observations from the National Registry of Myocardial Infarction. Circulation. 1994;90(4):2103-14.
  • 4
    Aronow WS. Prevalence of presenting symptoms of recognized acute myocardial infarction and of unrecognized healed myocardial infarction in elderly patients. Am J Cardiol. 1987;60(14):1182.
  • 5
    Callaham PR, Frolicher VF, Klein J, Rish M, Dubach P, Friis R. Exercise-induced silent ischemia: age, diabetes mellitus, previous myocardial infarction and prognosis. J Am Coll Cardiol. 1989;14(5):1175-80.
  • 6
    Umachandran V, Ranjadayalan K, Ambepityia G, Marchant B, Kopelman PG, Timmis AD. Aging, autonomic function, and the perception of angina. Br Heart J. 1991;66(1):15-8.
  • 7
    Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol. 1987;59(7):23C-30C.
  • 8
    Falcone C, Specchia G, Rondanelli R, Guasti L, Corsico G, Codega S, et al. Correlation between beta-endorphin plasma levels and anginal symptoms in patients with coronary artery disease. J Am Coll Cardiol. 1988;11(4):719-23.
  • 9
    Kurita A, Takase B, Uehata A, Sugahara H, Nishioka T, Maruyama T, et al. Differences in plasma beta-endorphin and bradykinin levels between patients with painless or with painful myocardial ischemia. Am Heart J. 1992;123(2):304-9.
  • 10
    Heller GV, Garber CE, Connolly MJ, Allen-Rowlands CF, Siconolfi SF, Gann DS, et al. Plasma beta-endorphin levels in silent myocardial ischemia induced by exercise. Am J Cardiol. 1987;59(8):735-9.
  • 11
    Rosen SD, Paulesu E, Nihoyannopoulos P, Tousoulis D, Frackowiak RS, Frith CD, et al. Silent ischemia as a central problem: regional brain activation compared in silent and painful myocardial ischemia. Ann Intern Med. 1996;124(11):939-49.
  • 12
    Machado A. Neuroanatomia funcional. 2ª. ed. São Paulo: Atheneu; 2001.
  • 13
    Whang W, Kubzansky LD, Kawachi I, Rexrode KM, Kroenke CH, Glynn RJ, et al. Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses' Health Study. J Am Coll Cardiol. 2009;53(11):950-8.
  • 14
    Summers KM, Martin KE, Watson K. Impact and clinical management of depression in patients with coronary artery disease. Pharmacotherapy. 2010;30(3):304-22.
  • 15
    Ochiai ME, Franco LL, Gebara OC, Nussbacher A, Serro-Azul JB, Pierri H, et al. [Correlation between evolution of the cognitive function and mortality after hospital discharge in elderly patients with advanced heart failure]. Arq Bras Cardiol. 2004;82(3):251-4.
  • Sources of Funding
    There were no external funding sources for this study.
  • Study Association
    This study is not associated with any post-graduation program.

Publication Dates

  • Publication in this collection
    Mar 2014

History

  • Received
    13 May 2013
  • Reviewed
    22 Aug 2013
  • Accepted
    18 Oct 2013
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