Feature Article
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Treatment of Older Persons After Myocardial Infarction Coronary risk factors should be modified in older persons after myocardial infarction (MI). Aspirin 160 mg to 325 mg daily and beta blockers should be administered indefinitely to older persons after MI. Nitrates, along with beta blockers, should be used to treat angina pectoris. Angiotensin-converting enzyme inhibitors should be given to persons after MI who have heart failure, an anterior MI, or a left ventricular ejection fraction of 40% or less. There are no Class I indications for the use of calcium channel blockers after MI. Complex ventricular arrhythmias should be treated with beta blockers. Persons with life-threatening ventricular tachycardia or ventricular fibrillation or who are at very high risk for sudden cardiac death after MI should have an automatic implantable cardioverter-defibrillator. There are no Class I indications for the use of hormonal therapy in postmenopausal women after MI. Indications for coronary revascularization in older persons after MI are prolongation of life and relief of unacceptable symptoms despite optimal medical management. (Annals of Long-Term Care 2000;8[2]:45-50)
Approximately 60% of hospital admissions for acute myocardial infarction (MI) are for persons older than 65 years of age, and persons older than 75 years of age account for nearly half of these admissions.1 After hospital discharge for MI, the 1-year cardiac mortality rate is 12% for persons aged 65 to 75 years and 17.6% for persons older than 75 years of age.2 About two-thirds of deaths after MI are sudden or related to a new MI.2 This review article discusses the appropriate treatment of the older person after MI.
Coronary Risk Factor Modification Coronary risk factors include cigarette smoking, hypertension, dyslipidemia, diabetes mellitus, obesity, and physical inactivity.
Cigarette Smoking Cigarette smoking is a risk factor for new coronary events in older men and women.2-9 At 4-year follow-up of 1488 older women in a nursing home, cigarette smoking increased the relative risk of new coronary events 2.0 times.9 At 40-month follow-up of 664 older men in a nursing home, cigarette smoking increased the relative risk of new coronary events 2.2 times.9 At 6-year follow-up of older men and women in the Coronary Artery Surgery Study registry, the relative risk of MI or death was 1.5 for persons aged 65 to 69 years and 2.9 for persons 70 years of age or older who continued smoking compared with persons who quit during the year before study enrollment.8 The author has also observed that cigarette smoking aggravates angina pectoris and precipitates silent myocardial ischemia in older persons after MI. On the basis of the available data, older men and women who smoke cigarettes should be strongly encouraged to undergo treatment for smoking cessation to reduce cardiovascular mortality and all-cause mortality after MI.
Hypertension Increased systolic blood pressure is a greater risk factor for cardiovascular morbidity and mortality in older persons than is increased diastolic blood pressure.10 The higher the systolic or diastolic blood pressure, the greater the morbidity and mortality from coronary artery disease (CAD) in older men and women.10 At 4-year follow-up of 1488 older women in a nursing home, systolic or diastolic hypertension increased the relative risk of new coronary events 1.6 times.9 At 40-month follow-up of 664 older men in a nursing home, systolic or diastolic hypertension increased the relative risk of coronary events 2.0 times.9
Older persons with hypertension should be treated with salt restriction; weight reduction, if necessary; avoidance of tobacco and alcohol; cessation of drugs that increase blood pressure; increase in physical activity; decrease of dietary saturated fat and cholesterol; and maintenance of adequate dietary potassium, calcium, and magnesium intake. Antihypertensive drugs decrease new coronary events in older men and women with hypertension.11-15 The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommends diuretics or beta blockers as initial drug therapy to reduce cardiovascular morbidity and mortality.16 The blood pressure should be lowered to less than 140/90 mm Hg.16 Older persons with diastolic hypertension should have their diastolic blood pressure lowered to between 80 mm Hg and 85 mm Hg.17 Older persons with hypertension who have had an MI should be treated initially with a beta blocker.
Dyslipidemia Serum total cholesterol is a risk factor for new coronary events in older men and women.4,9,18-22 Among persons aged 65 years or older with prior MI in the Framingham Study, serum total cholesterol was most strongly related to death from CAD and to all-cause mortality.19 At 40-month follow-up of 664 older men and at 4-year follow-up of 1488 older women in a nursing home, an increment of 10 mg/dL of serum total cholesterol increased the relative risk of new coronary events 1.12 times in men and 1.12 times in women.9
A low serum high-density lipoprotein (HDL) cholesterol level is a risk factor for new coronary events in older men and women.4,9,18, 23-26 At 40-month follow-up of 664 older men and at 4-year follow-up of 1488 older women in a nursing home, a decrement of 10 mg/dL of serum HDL cholesterol increased the relative risk of new coronary events 1.70 times in men and 1.95 times in women.9 Hypertriglyceridemia has been reported to be a risk factor for new coronary events in older women but not in older men.9,18
Drug treatment of hypercholesterolemia by statin drug therapy in older men and women with prior MI has been demonstrated to reduce all-cause mortality, CAD mortality, major coronary events, need for coronary artery revascularization, stroke, and any atherosclerosis-related event.27-31 On the basis of the available data, the American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend that men and women with prior MI and a serum low-density lipoprotein (LDL) cholesterol level greater than 125 mg/dL despite the AHA step II diet should be treated with drug therapy to decrease the serum LDL cholesterol level to less than 100 mg/dL.32 A statin drug is the lipid-lowering drug of choice for achieving this reduction.
Class IIa ACC/AHA guidelines recommend that men and women with prior MI and normal serum total cholesterol levels but serum HDL cholesterol levels less than 35 mg/dL despite diet and other nonpharmacologic therapy be treated with drug therapy to raise serum HDL cholesterol levels.32 Niacin or gemfibrozil may be used to treat low serum HDL cholesterol levels and hypertriglyceridemia.
Diabetes Mellitus Diabetes mellitus is a risk factor for new coronary events in older men and women.9,33 At 40-month follow-up of 664 older men and at 4-year follow-up of 1488 older women in a nursing home, diabetes mellitus increased the relative risk of new coronary events 1.9 times in men and 1.8 times in women.9
Older persons with diabetes mellitus and prior MI should be treated with dietary therapy, weight reduction if necessary, and appropriate drugs if necessary to control hyperglycemia. Other coronary risk factors should be controlled.
Obesity Obesity33 and disproportionate distribution of fat to the abdomen assessed by the waist-to-hip circumference ratio34,35 have been found to be risk factors for new coronary events in older men and women. At 40-month follow-up of 664 older men and at 4-year follow-up of 1488 older women in a nursing home, obesity was a risk factor for new coronary events in men and women by univariate analysis but not by multivariate analysis.9
Obese persons with prior MI must lose weight. Decrease of weight is also a first approach to controlling hyperglycemia, mild hypertension, and dyslipidemia before putting persons on long-term drug treatment. Regular aerobic exercise should be used in addition to diet in treating obesity.
Physical Inactivity Exercise training programs have been found to increase endurance and functional capacity in older persons after MI.36 Moderate exercise programs suitable for older persons after MI include walking, climbing stairs, swimming, and bicycling.
Aspirin Randomized trials involving 19,791 persons showed that aspirin and other antiplatelet drugs given to persons after MI decreased at 27-month follow-up the incidence of recurrent MI, stroke, or vascular death by 25%.37 The benefit of aspirin in reducing MI, stroke, or vascular death in persons after MI was irrespective of age, sex, blood pressure, and diabetes mellitus.37
At 23-month follow-up of persons after MI or with unstable angina pectoris, cardiac mortality was 1.6% for aspirin users and 5.4% for nonusers of aspirin.38 In persons who underwent thrombolytic therapy during acute MI, cardiac mortality was reduced 90% in aspirin users after MI compared with nonusers of aspirin after MI.38
On the basis of the available data, the ACC/AHA guidelines recommend that all persons should receive aspirin in a dose of 160 mg to 325 mg on day 1 of an acute MI and continue this dose of aspirin indefinitely unless there is a specific contraindication to its use.32
Anticoagulants The routine use of anticoagulants after MI is controversial.39 However, some studies have shown a decrease in mortality and/or morbidity in persons receiving long-term oral anticoagulant therapy after MI.40-42 On the basis of the available data, the ACC/AHA guidelines recommend long-term oral anticoagulant therapy after MI in persons unable to take daily aspirin, in persons with persistent atrial fibrillation, and in persons with left ventricular thrombus.32 Oral warfarin should be administered in a dose to maintain the international normalized ratio (INR) between 2.0 and 3.0.
Beta Blockers Beta blockers are effective antianginal and anti-ischemic drugs and should be administered to all persons with angina pectoris or silent myocardial ischemia caused by CAD, unless there are specific contraindications to their use. An analysis of 55 randomized controlled trials including 53,268 persons showed that beta blockers significantly reduced mortality by 19% after MI.43 Metoprolol,44 timolol,45,46 and propranolol47 caused a greater decrease in mortality after MI in older persons than in younger persons. The reduction in mortality after MI was due to both a decrease in sudden cardiac death and recurrent MI.45-47 A retrospective cohort study also found that persons aged 60 to 89 years treated with metoprolol after MI had an age-adjusted mortality decrease of 76%.48
Beta blockers have been shown to reduce mortality in persons after MI with abnormal left ventricular ejection fraction (LVEF)49 and in persons after MI with congestive heart failure (CHF) associated with abnormal or normal LVEF.50-53 Beta blockers have also been demonstrated to decrease mortality after MI in persons with complex ventricular arrhythmias associated with abnormal or normal LVEF.54,55
A retrospective analysis of the use of beta blockers after MI in a New Jersey Medicare population found that only 21% of older persons without contraindications to beta blockers were treated with beta blockers after MI.56 Older persons treated with beta blockers after MI had a 43% decrease in 2-year mortality and a 22% reduction in 2-year cardiac hospital readmissions compared with older persons not treated with beta blockers.56 Use of a calcium channel blocker instead of a beta blocker after MI doubled the risk of mortality.56
A meta-analysis also demonstrated that the use of beta blockers after non–Q-wave MI is likely to reduce mortality and recurrent MI by 25%.57 Therefore, older persons with Q-wave MI or with non–Q-wave MI without contraindications to beta blockers should be treated with beta blockers after MI. Beta blockers with intrinsic sympathomimetic activity should not be used.
On the basis of the available data, the ACC/AHA guidelines recommend that persons without a clear contraindication to beta blockers should receive them within a few days of MI (if not initiated at the time of the MI) and continue them indefinitely.32
Nitrates Long-acting nitrates are effective antianginal and anti-ischemic drugs.58 Nitrates should be administered after MI, along with beta blockers, to persons who have angina pectoris. To avoid nitrate tolerance, there should be a nitrate-free interval of 12 hours each day.59 Beta blockers should be used to prevent angina pectoris and rebound myocardial ischemia during the nitrate-free interval. The medical therapy of angina pectoris in older persons is discussed in detail elsewhere.60
Angiotensin-Converting Enzyme Inhibitors Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce mortality in older persons after MI.61-64 On the basis of the available data, the ACC/AHA guidelines recommend administering ACE inhibitors after MI to persons who have CHF, an anterior MI, or an LVEF of 40% or less unless there are specific contraindications to their use.32
Calcium Channel Blockers An analysis of randomized, controlled trials including 20,342 persons showed that mortality was insignificantly higher (relative risk = 1.04) in persons after MI treated with calcium channel blockers.43 A meta-analysis of randomized clinical trials of the use of calcium channel blockers in persons with MI, unstable angina pectoris, and stable angina pectoris found that the relative risk for mortality in the studies using dihydropyridines such as nifedipine, which increase heart rate, was significantly increased 1.16 times.65 The calcium channel blockers such as diltiazem and verapamil, which reduce heart rate, had no effect on survival.65
The Multicenter Diltiazem Postinfarction Trial showed at 25-month follow-up in persons after MI that diltiazem caused no significant effect on mortality or recurrent MI.66 However, diltiazem caused a significant 41% increase in new cardiac events in persons with pulmonary congestion at baseline and a significant 31% increase in new cardiac events in persons with an LVEF less than 40% at baseline.66 In this study, diltiazem also significantly increased the incidence of late-onset CHF in persons with an LVEF less than 40%.67
The ACC/AHA guidelines state that there are no Class I indications for the use of calcium channel blockers after MI.32 However, if persons with prior MI have persistent angina pectoris despite treatment with beta blockers and nitrates, the author would add verapamil or diltiazem to the therapeutic regimen if the LVEF is normal, and amlodipine or felodipine if the LVEF is abnormal.
Antiarrhythmic Therapy Class I antiarrhythmic drugs have been demonstrated to either increase mortality43,68 or not significantly affect mortality69 in persons after MI. The drug d,l-sotalol has not been found to reduce mortality in persons after MI.70 The drug d-sotalol has been shown to increase mortality after MI.71 Amiodarone has not been found to reduce mortality after MI.72,73 The incidence of adverse effects from amiodarone also approaches 90% after 5 years of treatment.74 On the basis of the available data, Class I antiarrhythmic drugs, sotalol, and amiodarone should not be used in the treatment of persons after MI.75
However, beta blockers have been demonstrated to reduce mortality in persons with nonsustained ventricular tachycardia or complex ventricular arrhythmias after MI in persons with normal or abnormal LVEF.54,55,75-77 On the basis of the available data, beta blockers should be used in the treatment of older persons after MI, especially if nonsustained ventricular tachycardia or complex ventricular arrhythmias are present, unless there are specific contraindications to their use.
Automatic Implantable Cardioverter-Defibrillator In the Antiarrhythmics Versus Implantable Defibrillator (AVID) trial, persons with a mean age of 65 years and with a history of ventricular fibrillation or serious sustained ventricular tachycardia were randomized to an automatic implantable cardioverter-defibrillator (AICD) or to drug therapy with amiodarone or d,l-sotalol.78 Persons treated with an AICD had a significant 39% reduction in mortality at 1 year, a significant 27% reduction in mortality at 2 years, and a significant 31% reduction in mortality at 3 years.78
If persons have life-threatening ventricular tachycardia or ventricular fibrillation after MI, an AICD should be implanted. The efficacy of the AICD implanted for ventricular fibrillation or recurrent sustained ventricular tachycardia on survival is similar in older and younger persons.79 Data from the Multicenter Automatic Defibrillator Implantation Trial80 also favor considering the prophylactic implantation of an AICD in post-MI persons at very high risk for sudden cardiac death.
Hormone Replacement Therapy The Heart Estrogen/progestin Replacement Study (HERS) investigated in 2763 women with documented CAD the effect of hormonal replacement therapy (HRT) versus double-blind placebo on coronary events.81 During the first year of therapy, HRT caused a significant 52% increase in nonfatal MI or CAD death.81 At 4.1-year follow-up, there was no significant difference in nonfatal MI or CAD death or in any of the secondary cardiovascular outcomes in women treated with HRT versus placebo.81 However, women randomized to HRT had at 4.1-year follow-up a significant 289% increase in venous thromboembolic events and a 38% significant increase in gallbladder disease over women prescribed placebo.81 The ACC/AHA guidelines state that there are no Class I indications for the use of estrogen replacement therapy or estrogen plus progestin in the treatment of postmenopausal women after MI.32
Revascularization Medical therapy alone is the preferred treatment in older persons after MI. The two indications for coronary revascularization in older persons after MI are prolongation of life and relief of unacceptable symptoms despite optimal medical management. In persons older than 80 years of age, the goal is less to prolong life than it is to improve the quality of life. If coronary revascularization is performed, aggressive medical therapy must be continued. Indications for preferring coronary artery bypass graft surgery or transluminal percutaneous coronary angioplasty in older persons after MI are discussed in detail elsewhere.82,83
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References 1. Weaver WD. Litwin PE, Martin JS, et al. Effect of age on the use of thrombolytic therapy and mortality in acute myocardial infarction. J Am Coll Cardiol 1991;18:657-662.
2. Smith SC Jr, Gilpin E, Ahnve S, et al. Outlook after acute myocardial infarction in the very elderly compared with that in patients aged 65 to 75 years. J Am Coll Cardiol 1990;16:784-792.
3. Jajich CL, Ostfield AM, Freeman DH Jr. Smoking and coronary heart disease mortality in the elderly. JAMA 1984;252:2831-2834.
4. Siegel D, Kuller L, Lazarus NB, et al. Predictors of cardiovascular events and mortality in the Systolic Hypertension in the Elderly Program pilot project. Am J Epidemiol 1987;126:385-399.
5. Kannel WB, Vokonas PS. Primary risk factors for coronary heart disease in the elderly: The Framingham Study. In: Wenger NK, Furberg CD, Pitt B, eds. Coronary Heart Disease in the Elderly. New York, NY: Elsevier Science Publishing Co Inc; 1986: 60-92.
6. Benfante R, Reed D, Frank J. Does cigarette smoking have an independent effect on coronary heart disease incidence in the elderly? Am J Public Health 1991;81:897-899.
7. LaCroix AZ, Lang J, Scherr P, et al. Smoking and mortality among older men and women in three communities. N Engl J Med 1991;324:1619-1625.
8. Hermanson B, Omenn GS, Kronmal RA, Gersh BJ. Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease: Results from the CASS registry. N Engl J Med 1988;319:1365-1369.
9. Aronow WS, Ahn C. Risk factors for new coronary events in a large cohort of very elderly patients with and without coronary artery disease. Am J Cardiol 1996;77:864- 866.
10. Applegate WB, Rutan GH. Advances in management of hypertension in older persons. J Am Geriatr Soc 1992;40:1164-1174.
11. Amery A, Birkenhager W, Brixko P, et al. Mortality and morbidity results from the European Working Party on Hypertension in the Elderly trial. Lancet 1985;1:1349-1354.
12. Dahlof B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991;338:1281- 1285.
13. MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: Principal results. BMJ 1992;304:405-412.
14. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:3255-3264.
15. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet 1997;350:757-764.
16. 1997 Joint National Committee. The Sixth Report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med 1997;157:2413-2444.
17. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: Principal result of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998;351:1755-1762.
18. Castelli WP, Wilson PWF, Levy D, Anderson K. Cardiovascular disease in the elderly. Am J Cardiol 1989;63:12H-19H.
19. Wong ND, Wilson PWF, Kannel WB. Serum cholesterol as a prognostic factor after myocardial infarction: The Framingham Study. Ann Intern Med 1991;115:687-693.
20. Benfante R, Reed D. Is elevated serum cholesterol level a factor for coronary heart disease in the elderly? JAMA 1990;263:393-396.
21. Barrett-Connor E, Suarez L, Khaw K-T, et al. Ischemic heart disease risk factors after age 50. Journal of Chronic Disease 1984;37:903-908.
22. Rubin SM, Sidney S, Black DM, et al. High blood cholesterol in elderly men and the excess risk for coronary heart disease. Ann Intern Med 1990;113:916-920.
23. Zimetbaum P, Frishman WH, Ooi WL, et al. Plasma lipids and lipoproteins and the incidence of cardiovascular disease in the very elderly: The Bronx Aging Study. Arteriosclerosis and Thrombosis 1992;12:416-423.
24. Corti M-C, Guralnik JM, Salive ME, et al. HDL cholesterol predicts coronary heart disease mortality in older persons. JAMA 1995;274:539-544.
25. Aronow WS, Ahn C. Correlation of serum lipids with the presence or absence of coronary artery disease in 1,793 men and women aged ³ 62 years. Am J Cardiol 1994;73:702-703.
26. Lavie CJ, Milani RV. National Cholesterol Education Program's recommendations, and implications of "missing" high-density lipoprotein cholesterol in cardiac rehabilitation programs. Am J Cardiol 1991;68:1087.
27. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383-1389.
28. Miettinen TA, Pyorala K, Olsson AG, et al. Cholesterol-lowering therapy in women and elderly patients with myocardial infarction or angina pectoris: Findings from the Scandinavian Simvastatin Survival Study (4S). Circulation 1997;96:4211-4218.
29. Pedersen TR, Kjekshus J, Pyorala K, et al. Effect of simvastatin on ischemic signs and symptoms in the Scandinavian Simvastatin Survival Study (4S). Am J Cardiol 1998;81:333-336.
30. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335:1001-1009.
31. The Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998;339:1349-1357.
32. Ryan TJ, Antman EM, Brooks NH, et al. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: Executive summary and recommendations: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation 1999;100:1016-1030.
33. Vokonas PS, Kannel WB. Epidemiology of coronary heart disease in the elderly. In: Tresch DD, Aronow WS, eds. Cardiovascular Disease in the Elderly Patient. 2nd ed, rev and expanded. New York, NY: Marcel Dekker; 1999: 139-164.
34. Kannel WB, Cupples LA, Ramaswami R, et al. Regional obesity and risk of cardiovascular disease: The Framingham Study. J Clin Epidemiol 1991;44:183-190.
35. Folsom AR, Kaye SA, Sellers TA, et al. Body fat distribution and 5-year risk of death in older women. JAMA 1993;269:483-487.
36. Williams MA, Maresh CM, Aronow WS, et al. The value of early out-patient cardiac exercise programmes for the elderly in comparison with other selected age groups. Eur Heart J 1984;5(suppl E):113-115.
37. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy—Pt. I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994;308:81-106.
38. Goldstein RE, Andrews M, Hall WJ, Moss AJ, for the Multicenter Myocardial Ischemia Research Group. Marked reduction in long-term cardiac deaths with aspirin after a coronary event. J Am Coll Cardiol 1996;28:326-330.
39. Chalmers TC, Malta RJ, Smith H Jr, et al. Evidence favoring the use of anticoagulants in the hospital phase of acute myocardial infarction. N Engl J Med 1977;297:1091-1096.
40. The Sixty Plus Reinfarction Study Group. A double-blind trial to assess long-term oral anticoagulant therapy in elderly patients after myocardial infarction. Lancet 1980;2:989-994.
41. Smith P, Arnesen H, Holme I. Effect of warfarin on mortality and reinfarction after myocardial infarction. N Engl J Med 1990;323:147-152.
42. Anticoagulants in the Secondary Prevention of Events in Coronary Thrombosis (ASPECT) Research Group. Effects of long-term oral anticoagulant treatment on mortality and cardiovascular morbidity after myocardial infarction. Lancet 1994;343:499- 503.
43. Teo KK, Yusuf S, Furberg CD. Effects of prophylactic antiarrhythmic drug therapy in acute myocardial infarction: An overview of results from randomized controlled trials. JAMA 1993;270:1589-1595.
44. Hjalmarson A, Herbiz J, Malek J, et al. Effect on mortality of metoprolol in acute myocardial infarction. Lancet 1981;2:823-827.
45. Gundersen T, Abrahamsen AM, Kjekshus J, et al. Timolol-related reduction in mortality and reinfarction in patients ages 65-75 years surviving acute myocardial infarction. Circulation 1982; 66:1179-1184.
46. Pedersen TR, for the Norwegian Multicenter Study Group. Six-year follow-up of the Norwegian Multicenter Study on Timolol after Acute Myocardial Infarction. N Engl J Med 1985;313:1055-1058.
47. Beta-Blocker Heart Attack Trial Research Group. A randomized trial of propranolol in patients with acute myocardial infarction, Pt. I: Mortality results. JAMA 1982; 247:1707-1714.
48. Park KC, Forman DE, Wei JY. Utility of beta-blockade treatment for older postinfarction patients. J Am Geriatr Soc 1995;43:751-755.
49. Lichstein E, Hager WD, Gregory JJ, et al. Relation between beta-adrenergic blocker use, various correlates of left ventricular function and the chance of developing congestive heart failure. J Am Coll Cardiol 1990;16:1327-1332.
50. Chadda K, Goldstein S, Byington R, Curb JD. Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. Circulation 1986;73:503- 510.
51. The Beta-Blocker Pooling Project Research Group. The Beta-Blocker Pooling Project (BBPP): Subgroup findings from randomised trials in post-infarction patients. Eur Heart J 1988;9:8-16.
52. Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996;334:1349-1355.
53. Aronow WS, Ahn C, Kronzon I. Effect of propranolol versus no propranolol on total mortality plus nonfatal myocardial infarction in older patients with prior myocardial infarction, congestive heart failure, and left ventricular ejection fraction 40% treated with diuretics plus angiotensin-converting enzyme inhibitors. Am J Cardiol 1997;80:207- 209.
54. Aronow WS, Ahn C, Mercando AD, et al. Effect of propranolol versus no antiarrhythmic drug on sudden cardiac death, total cardiac death, and total death in patients ³ 62 years of age with heart disease, complex ventricular arrhythmias, and left ventricular ejection fraction Æ 40%. Am J Cardiol 1994;74:267-270.
55. Kennedy HL, Brooks MM, Barker AH, et al. Beta-blocker therapy in the Cardiac Arrhythmia Suppression Trial. Am J Cardiol 1994;74:674-680.
56. Soumerai SB, McLaughlin TJ, Spiegelman D, et al. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA 1997;277:115- 121.
57. Yusuf S, Wittes J, Probstfield J. Evaluating effects of treatment subgroups of patients within a clinical trial: The case of non–Q-wave myocardial infarction and beta blockers. Am J Cardiol 1990;60:220-222.
58. Danahy DT, Aronow WS. Hemodynamics and antianginal effects of high dose oral isosorbide dinitrate after chronic use. Circulation 1977;56:205-212.
59. Parker JO, Farrell B, Lahey KA, et al. Effect of interval between doses on the development of tolerance to isosorbide dinitrate. N Engl J Med 1987;316:1440-1444.
60. Olson HG, Aronow WS. Medical therapy of stable and unstable angina in the elderly. In: Aronow WS, Stemmer EA, Wilson SE, eds. Vascular Disease in the Elderly. Armonk, NY: Futura; 1997: 267-292.
61. Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: Results of the Survival and Ventricular Enlargement Trial. N Engl J Med 1992;327:669-677.
62. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. Lancet 1993;342:821-828.
63. Ambrosioni E, Borghi C, Magnani B, for the Survival of Myocardial Infarction Long-Term Evaluation (SMILE) Study Investigators. The effect of the angiotensin-converting-enzyme inhibitor zofenopril on mortality and morbidity after anterior myocardial infarction. N Engl J Med 1995;332:80-85.
64. Kober L, Torp-Pedersen C, Carlsen JE, et al. A clinical trial of the angiotensin- converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 1995;333:1670-1676.
65. Yusuf S, Held P, Furberg C. Update of effects of calcium antagonists in myocardial infarction or angina in light of the second Danish Verapamil Infarction Trial (DAVIT-II) and other recent studies. Am J Cardiol 1991;67:1295-1297.
66. The Multicenter Diltiazem Postinfarction Trial Research Group. The effect of diltiazem on mortality and reinfarction after myocardial infarction. N Engl J Med 1988;319:385-392.
67. Goldstein RE, Boccuzzi SJ, Cruess D, et al. Diltiazem increases late-onset congestive heart failure in postinfarction patients with early reduction in ejection fraction. Circulation 1991;83:52-60.
68. Akiyama T, Pawitan Y, Campbell WB, et al. Effects of advancing age on the efficacy and side effects of antiarrhythmic drugs in post-myocardial infarction patients with ventricular arrhythmias. J Am Geriatr Soc 1992;40:666-672.
69. Aronow WS, Mercando AD, Epstein S, Kronzon I. Effect of quinidine or procainamide versus no antiarrhythmic drug on sudden cardiac death, total cardiac death, and total death in elderly patients with heart disease and complex ventricular arrhythmias. Am J Cardiol 1990;66:423-428.
70. Julian DJ, Prescott RJ, Jackson FS, Szekely P. Controlled trial of sotalol for one year after myocardial infarction. Lancet 1982;1:1142-1147.
71. Waldo AL, Camm AJ, deRuyter H, et al. Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. Lancet 1996;348:7-12.
72. Julian DG, Camm AJ, Frangin G, et al. Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. Lancet 1997;349:667-674.
73. Cairns JA, Connolly SJ, Roberts R, Gent M, for the Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators. Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Lancet 1997;349:675-682.
74. Herre J, Sauve M, Malone P, et al. Long-term results of amiodarone therapy in patients with recurrent sustained ventricular tachycardia or ventricular fibrillation. J Am Coll Cardiol 1989;13:442-449.
75. Aronow WS. Management of the older person with ventricular arrhythmias. J Am Geriatr Soc 1999;47:886-895.
76. Friedman LM, Byington RP, Capone RJ, et al. Effect of propranolol in patients with myocardial infarction and ventricular arrhythmia. J Am Coll Cardiol 1986;7:1-8.
77. Norris RM, Barnaby PF, Brown MA, et al. Prevention of ventricular fibrillation during acute myocardial infarction by intravenous propranolol. Lancet 1984;2:883-886.
78. The Antiarrhythmics Versus Implantable Defibrillators (AVID) Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med 1997;337:1576-1583.
79. Tresch DD, Troup PJ, Thakur RK, et al. Comparison of efficacy of automatic implantable cardioverter defibrillator in patients older and younger than 65 years of age. Am J Med 1991;90:717-724.
80. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. N Engl J Med 1996;335:1933-1940.
81. Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA 1998;280:605-613.
82. Aronow WS. Appropriate use of coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty in older patients. Clinical Geriatrics 1996;4(2)15-22.
83. Stemmer EA, Aronow WS. Surgical treatment of coronary artery disease in the elderly. In: Tresch DD, Aronow WS, eds. Cardiovascular Disease in the Elderly Patient. 2nd ed, rev and expanded. New York, NY: Marcel Dekker; 1999: 283-316.
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Dr. Aronow is Corporate Medical Director, Hebrew Hospital Home, Bronz and Westchester County, NY, and Adjunct Professor of Geriatrics and Adult Development in the Depoartment of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY. Address for correspondence: Wilbert S. Aronow, MD, Medical Director, Hebrew Hospital Home, 801 Co-op City Blvd, Bronx, NY 10475.
Annals of Long-Term Care - ISSN: 1524-7929 - Volume 8 - Issue 02 - February 2000 |