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Heart Disease in Old Age F Postgrad Med J: first published as 10.1136/pgmj.39.453.408 on 1 July 1963. Downloaded from POSTGRAD. MED. J. (I963), 39, 408 HEART DISEASE IN OLD AGE F. I. CAIRD, D.M., M.R.C.P. Radcliffe Infirmary, Oxford IT is a truism that heart disease is one of the most the characteristic aortic ejection murmur of old important causes of morbidity and mortality in old age may give rise to difficulty. This murmur is age. Much of the morbidity and some of the discussed in connection with aortic stenosis. mortality can without doubt be prevented by The electrocardiogram is of great assistance in accurate diagnosis and correct treatment. It is diagnosis in the elderly, since any abnormality in upon these aspects of the cardiology of old age that it, other than positional changes and the occasional this paper will concentrate, rather than on the ectopic beat, is as abnormal as at any age, and problems of pathology and the natural history of carries an adverse prognosis (Fox, I944). Radio- heart disease, which will receive less attention than logy plays a less important part, since the quality of their intrinsic interest and importance merit. radiographs obtained in ill old people is often not high, and the interpretation of even technically The Diagnosis ofHeart Disease in the Elderly adequate films not easy. Alteration of the Two factors modify the cardinal symptoms of position of the heart associated with chest de- heart disease in old age. These are the mental formity is the most important cause of difficulty; manifestations of physical disease, which often it may give rise to prominence of the main pul- obstruct history-taking and make physical exami- monary artery, apparent left ventricular enlarge-by copyright. nation difficult, and the almost invariable co- ment, and obscuration of the costophrenic angles. existence of several pathological processes in the Curious appearances may result from calcification same patient. Thus one symptom may have more in costal cartilages, spinal ligaments, the annulus than one simultaneous possible cause: breathless- fibrosus, and the aorta. Nevertheless, in many ness may be due to chronic lung disease, to obesity, cases characteristic radiological appearances can or to anaemia, and ankle oedema to chronic venous be recognized, and are then of diagnostic value. insufficiency or hypoproteinaemia, rather than to Other investigations may be of assistance. A heart disease. Expected symptoms may also be low peak expiratory flow rate may help to identify absent, as when activity is limited by arthritis, cor pulmonale due to chronic and the bronchitis, http://pmj.bmj.com/ blindness, or hemiplegia. same diagnosis may be suggested by the finding By contrast, the majority of cardiovascular of a high serum bicarbonate, and proved by signs are little modified in old age. The arterial demonstration of an elevated arterial Pco2, either pulse is affected by the decreased elasticity of the by the rebreathing method (Campbell and Howell, large vessels so that the upstroke is more rapid and 1960) or by blood gas analysis. The appropriate the peak systolic pressure higher (Wiggers, I932). tests will be indicated if anaemia, uramia, thyro- The apex beat is frequently displaced by chest toxicosis, or bacterial endocarditis is suspected. deformity due to osteoporotic kyphoscoliosis, so on September 30, 2021 by guest. Protected that its site is not necessarily evidence of heart size. Disorders of Cardiac Rhythm But the interpretation of the venous pressure and The two important arrythmias in the elderly are pulse remains the same as in youth, except when atrial fibrillation and ventricular tachycardia, an elongated and unfolded aorta obstructs the left though the occurrence of paroxysmal atrial innominate vein and thus venous return from the tachycardia with block as a manifestation of left side of the neck (Shirley-Smith, 1960; Sleight, digitalis intoxication (Lown and Levine, 1955) 1962). The character of the apical impulse can must be remembered. usually be identified, and left ventricular hyper- Atrial fibrillation occurs in some 3 to 4% of trophy correctly diagnosed. In particular, otherwise 'normal' old people (Fisch, Genovese, auscultatory signs carry the same connotation Dyke, Laramore and Marvel, I957), and in o0 to at all ages, and should therefore receive especial I5% of old people in hospital (Wosika, Feldman, attention. Atrial and ventricular gallop sounds Chesrow, and Myers, 1950). It is not clear and respiratory variation in splitting of the second whether coronary artery disease should be con- heart sound can be recognized. Pansystolic and sidered as its real causes, since fibrillation is often all diastolic murmurs are abnormal at any age, but the only abnormality on the electrocardiogram. Postgrad Med J: first published as 10.1136/pgmj.39.453.408 on 1 July 1963. Downloaded from July I963 CAIRD: Heart Disease in Old Age 409 Atrial fibrillation is not infrequent in the course of companied by a steady decrease in the prepon- acute infections and in association with surgical derance of men. This is shown in all clinical and operations; it is then usually coterminous with autopsy studies, and is attributed to a protective its cause. It is also common in association with influence of the female sex hormones, a view, heart failure, especially in rheumatic heart disease supported by the high incidence of ischaemic (Bedford and Caird, 1956, I960), with thyro- heart disease in oophorectomized women (Oliver toxicosis and with pulmonary embolism, and may and Boyd, 1959). Pathologically a similar trend is complicate acute myocardial infarction. But it is seen in the incidence and sex ratio of large myo- often also an incidental finding, and then the cardial lesions, both necrotic and fibrotic, which ventricular rate is usually not raised. Digitalis may legitimately be termed infarcts (Mitchell and need only be given when there is tachycardia or Schwartz, 1962). These lesions are closely related heart failure, and intravenous digitalization should to the degree of coronary arterial stenosis. Other only rarely be used. When fibrillation outlasts an smaller myocardial lesions, which are usually acute cause, or when its onset has been associated thought to be ischaemic in origin, are more closely with the development of heart failure, considera- related to age than to coronary artery disease, and tion should be given to an attempt at conversion to show a more nearly equal sex ratio at all ages sinus rhythm with quinidine, after a preliminary (Schwartz and Mitchell, I962). The functional seven to ten days' course of anticoagulants to significance of these smaller lesions is not clear, lessen the risk of systemic embolism. but it is possible that they contribute more to the Ventricular tachycardia is probably the com- incidence of heart failure in old age than the larger monest regular tachycardia in the elderly. It is ones. Certainly congestive failure in the elderly usually associated with severe ischaemic heart is not much commoner in men than women disease or recent myocardial infarction, and (Bedford and Caird, 1956), and is poorly related results in hypotension and signs of a low cardiac to the severity of coronary artery disease (Rose and output. It is best terminated by procaine amide, Wilson, 1959). given slowly intravenously in a dose of up to i g., From the clinical standpoint, there are few under continuous electrocardiographic control. clear differences between ischaemic heart disease by copyright. To prevent recurrence, oral procaine amide should as it occurs in the elderly and the middle-aged. be given in doses up to 3 g. per day. The most definite is the lesser severity of cardiac Some 5 to 200/ of 'normal' old people show pain in old age, a phenomenon which cannot be prolongation of the P-R interval (Fisch and attributed to mental dulling. Angina pectoris may others, 1957). Complete heart block is compara- be described as mere tightness in the chest, and tively uncommon; it was found in six of 229 elderly the pain of cardiac infarction, though no different patients with congestive failure (Bedford and in distribution or character, is often surprisingly Caird, 1956), and may precipitate failure in some mild. Other manifestations such as breathless- cases. Steroids may be of benefit when complete ness or mental or neurological symptoms due to http://pmj.bmj.com/ heart block complicates acute myocardial infarc- cerebrovascular insufficiency may dominate the tion (Dall and Buchanan, 1962), but the conduc- picture. The clinical signs of cardiac ischaemia tion disturbance is then often transient (Penton, giving rise to angina are often slight at any age, and Miller and Levine, 1956). When heart failure is those of acute myocardial infarction may be intractable or Stokes-Adams attacks frequent and difficult to detect. Especial note must be made of uncontrolled by drugs, some form of cardiac slight elevation of the venous pressure with a pace-making should be considered whatever the positive hepatojugular reflux, of left atrial or on September 30, 2021 by guest. Protected age of the patient (Portal, Davies, Leatham and ventricular gallop rhythm, and of the sudden Siddons, I962). But it must be remembered that development of heart failure irn a patient with complete heart block may be present for many previously good exercise tolerance. Fever, leuco- years without symptoms and without treatment. cytosis, and elevation of the erythrocyte sedi- mentation rate and serum transaminase are as Ischaemic Heart Disease valuable in old age as earlier in life as indications Ischamic heart disease is undoubtedly the most of myocardial infarction, if other causes can be important single form of heart disease encountered excluded, but the electrocardiogram is the main- in the elderly, both by itself and as contributing stay of diagnosis. to the occurrence of cardiac symptoms in patients Few of the complications of myocardial with valvular and other forms of heart disease.
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