Angina Pectoris in the Elderly

Systematic overview and clinical applications of pacing atrial stress echocardiography

Pacing atrial stress echocardiography (PASE) has been studied over the past 3 decades for the evaluation of myocardial ischemia. Published studies suggest that PASE may be used as an alternative to exercise or pharmacologic stress imaging. The recent introduction of improved pacing electrodes, together with use of accelerated and shortened pacing protocols and improvements in transthoracic echocardiographic imaging techniques, makes PASE an appealing stress imaging method. A critical analysis of the diagnostic accuracy of PASE shows equivalence with other imaging stress modalities. PASE has been found to be highly feasible and accurate technique that may expedite the diagnosis and risk stratification of patients with coronary artery disease. This review addresses the history, hemodynamics, protocols, accuracy, clinical utility, and cost-effectiveness of PASE as well as elucidating its place among other stress modalities.

Stress Echocardiography in Octogenarians: Transesophageal Atrial Pacing is Accurate, Safe, and Well Tolerated

The feasibility and diagnostic accuracy of transesophageal pacing stress echocardiography for detection of inducible myocardial ischemia were evaluated in 161 patients 80 years of age or older (mean 84 +/- 3.9, range 80-97). The pacing time was 5.5 +/- 2.5 minutes with a total test time of 37 +/- 7 minutes. The mean achieved heart rate was 96 +/- 7% (83%-121%) of maximum predicted with an average rate pressure product of 21,560 +/- 5175 beats/min x mm Hg. There were minor adverse events in 8% of cases and no major complications occurred. Patient acceptance was high. When compared with myocardial single photon emission computed tomography, pacing stress echocardiography had a sensitivity of 89% and a specificity of 93% for the detection of myocardial ischemia, and 91% agreement (kappa = 0.80, P < .001). We demonstrate that pacing stress echocardiography is safe and accurate for detection of myocardial ischemia and, thus, a reliable substitute to exercise and pharmacologic stress testing in octogenarians.

Stress echocardiography in elderly patients with coronary artery disease: applicability, safety and prognostic value of dobutamine and adenosine echocardiography in elderly patients

OBJECTIVES

Our aim was to determine the applicability, safety and prognostic value of adenosine and dobutamine stress echocardiography in patients > or = 70 years old.

BACKGROUND

These tests are sometimes mandatory because of difficulties and inaccuracies in interpreting traditional electrocardiographic stress tests. Furthermore, if these tests could be used to avoid coronary arteriography and cardiac catheterization, they would become essential in the care of the elderly, whose numbers are increasing.

METHODS

We performed coronary arteriography and dobutamine and adenosine stress echocardiographic tests in 120 patients (72 men) > or = 70 years old who entered the hospital because of chest pain and had known or suspected coronary artery disease. The stress tests were performed on separate days, within 2 weeks of coronary arteriography. Both the arteriograms and the echocardiograms were analyzed by two experts who had no knowledge of the patients' other data or the other interpreter's report. Tests were judged to have positive or negative results, and the patients were followed up for the development of cardiac events. Univariate and multivariate analyses and other statistical modalities were applied for comparisons.

RESULTS

Documented coronary artery disease was found in 89 patients. During the 14 +/- 7 of follow-up, cardiac events developed in 50 patients, including 3 (7.9%) of 38 patients with negative dobutamine and 12 (20.7%) of 58 patients with negative adenosine test results. Demonstration of any abnormality on stress echocardiography was an independent factor for cardiac events, both for dobutamine (relative risk 7.3) and for adenosine (relative risk 3.0). Both cessation of dobutamine or adenosine tests and diagnosis of disease in two or more coronary vessels were also independent predictors. ST segment depression > or = 1mm was related to future events only with the dobutamine test.

CONCLUSIONS

These echocardiographic stress tests proved safe and well tolerated. They successfully stratified this cohort of elderly patients with coronary artery disease to low or high risk subgroups for subsequent cardiac events.

Differential diagnosis of jaw pain in the elderly

While many diseases are marked by pain in the mandible or maxilla, a number of these conditions appear to be more prevalent in people 65 years and older. People in this age group often have a number of medical problems and take a variety of medications, so clear-cut diagnosis of jaw pain can be difficult. Memory deficits or concomitant somatic complaints can further complicate the diagnosis. This article presents a differential for jaw pain in the elderly and reports on a pertinent case.