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Silent exertional myocardial ischemia in the elderly: a quantitative analysis of anginal perceptual threshold and the
G Ambepitiya1, M Roberts, K Ranjadayalan
1Hope Hospital, Salford, England, UK.
Insights
Elderly patients often have a delayed perception of angina, indicating a delayed warning of heart ischemia. Autonomic dysfunction may contribute to this impaired angina perception in older adults.
Area of Science:
- Cardiology
- Geriatrics
- Autonomic Neuroscience
Background:
- Angina perception is a crucial warning sign of myocardial ischemia.
- Age-related changes may affect the perception of anginal pain.
- Autonomic nervous system function plays a role in cardiovascular responses.
Purpose of the Study:
- To evaluate the perception of angina in elderly individuals.
- To investigate the relationship between angina perception and autonomic function in the elderly.
- To compare angina perception and autonomic function in older versus younger patients with ischemic heart disease.
Main Methods:
- Prospective cohort study involving patients with exertional ischemia.
- Measurement of Anginal Perception Threshold (APT) during treadmill stress tests.
- Assessment of cardiovascular autonomic function using Valsalva maneuver, deep breathing, and postural changes.
Main Results:
- Older patients exhibited a significantly prolonged APT compared to younger patients.
- A significant correlation was found between prolonged APT and impaired Valsalva response in a subgroup with high APT.
- Patients with no angina despite ischemia showed a higher prevalence of autonomic dysfunction compared to those with good angina perception.
Conclusions:
- Delayed perception of angina in the elderly may delay the warning of critical myocardial ischemia.
- Autonomic dysfunction is a potential underlying mechanism for impaired angina perception in older adults.
- These findings highlight the importance of considering autonomic function in elderly patients with ischemic heart disease.
Objective:
To assess the perception of angina in the elderly and its relationship to autonomic function.
Design:
Prospective cohort study of patients with exertional ischemia.
Setting:
Medical, geriatric and cardiac outpatient clinics in two centers.
Participants:
All subjects had ischemic heart disease as evidenced by positive treadmill stress tests and, in some, diagnostic angiography and/or documented Q wave infarction. In the first study (I), 37 older patients (range 70-82 years) and 39 younger patients (range 42-59 years) were studied. In a subsequent study (II), a further 49 patients were divided into 2 groups: those with good perception of angina (Anginal Perception Threshold < 15 seconds, group A, 26 patients) and those with no angina despite ischemia (group B, 23 patients).
Measurements:
Anginal perceptual threshold (APT), age, cardiovascular autonomic function, and blood pressure were measured. APT was defined as the time between onset of 1 mm ST depression to the onset of angina during treadmill stress testing. Autonomic function was studied using heart rate ratios before and after the valsalva maneuver, heart rate responses to deep breathing, and heart rate and blood pressure responses to standing.
Results:
In study I, APT in the older patients was delayed by a median value of 49 seconds [79 (range 15-188) versus 30 (-99 to 97) seconds in the younger patients, P < 0.001]. There was no significant correlation between prolonged APT and autonomic dysfunction when younger and older groups were analyzed independently or together. When, however, the high APT subgroup (APT > 30 seconds) was analyzed separately, there was a significant correlation between APT prolongation and impaired valsalva response (r = -0.4; P < 0.005). In study II, 21 of 23 patients (91.3%) with positive exercise test but with no angina (group B) had at least one abnormal autonomic function test compared with 5 of 26 (19%) patients with good anginal perception (group A). Of note, group A was significantly younger than group B [60 (53-63) years vs 66 (62-70 years, P < 0.001].
Conclusion:
Elevation of APT in the elderly suggests that warning of critical myocardial ischemia is delayed. Autonomic dysfunction may be one of the underlying mechanisms.