Faculty Bibliography

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults >/=75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged >/=75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.

Coronary artery embolism is an uncommon cause of acute myocardial infarction (MI). We present a patient with pulmonary atresia and severe right heart hypoplasia who underwent a lateral tunnel Fontan procedure in childhood and presented with an acute ST-segment elevation MI at 19 years of age. In addition to the known risk of thrombotic complications associated with a Fontan circulation, potential predisposing factors to thromboembolism in this patient included a right ventricle to left anterior descending coronary connection and a Fontan baffle leak. The patient was treated with device closure of the baffle leak and anticoagulation. This is one of the first reports of an embolic MI in a patient with a Fontan circulation. The optimal method of reducing thromboembolic risk in this patient, and those with a Fontan circulation in general, is complicated and no consensus exists.

A 55-year-old woman was diagnosed with endocarditis involving the aortic valve and resulting in moderate aortic insufficiency. Transesophageal and transthoracic echocardiography demonstrated an unusually accentuated diastolic anterior motion of the anterior mitral valve leaflet toward the interventricular septum. The anterior leaflet remained within a few millimeters of the septum throughout diastole, with a narrow jet of aortic insufficiency separating the anterior leaflet from the septum. We hypothesize that the particularly long anterior mitral leaflet was drawn toward the septum during diastole due to the Venturi effect of the aortic insufficiency jet within a narrow ventricular outflow tract. This accentuated diastolic anterior motion may be a diastolic correlate of systolic anterior motion of the mitral valve. (c) 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2012.

OBJECTIVE: This study sought to determine the relationship between vascular disease in different arterial territories and advanced age. BACKGROUND: Vascular disease in the peripheral circulation is associated with significant morbidity and mortality. There is little data to assess the prevalence of different phenotypes of vascular disease in the very elderly. METHODS: Over 3.6 million self-referred participants from 2003-2008 who completed a medical and lifestyle questionnaire in the United States were evaluated by screening ankle brachial indices <0.9 for peripheral artery disease (PAD), and ultrasound imaging for carotid artery stenosis (CAS) >50% and abdominal aortic aneurysm (AAA) >3cm. Participants were stratified by decade of life. Multivariate logistic regression analysis was used to estimate odds of disease in different age categories. RESULTS: Overall, the prevalence of PAD, CAS, and AAA, was 3.7%, 3.9%, and 0.9%, respectively. Prevalence of any vascular disease increased with age (40-50y: 2%; 51-60y: 3.5%; 61-70y: 7.1%; 71-80y: 13.0%; 81-90y: 22.3%; 91-100y: 32.5%; P<0.0001). Prevalence of disease in each vascular territory increased with age. After adjustment for sex, race/ethnicity, body mass index, family history of cardiovascular disease, smoking, diabetes, hypertension, hypercholesterolemia, and exercise, the odds of PAD (OR 2.14, 95% CI 2.12-2.15), CAS (OR 1.80, 95% CI 1.79-1.81), and AAA (OR 2.33, 95% CI 2.30-2.36]) increased with every decade of life. CONCLUSION: There is a dramatic increase in the prevalence of PAD, CAS, and AAA with advanced age. More than 20% and 30% of octo- and nonagenarians, respectively, have vascular disease in at least 1 arterial territory.