Cardiac conditions - ischaemic heart disease
Description
IHD in the older patient - the disease is the same; the presentation, the evidence base and the risk-benefit calculation are not.
- Spectrum: stable angina - unstable angina - NSTEMI - STEMI - ischaemic cardiomyopathy - sudden cardiac death
- Type 1 MI = plaque rupture/erosion with thrombus
- Type 2 MI = supply-demand mismatch without plaque rupture - the dominant mechanism in older inpatients
- Sepsis, anaemia, GI bleed, tachyarrhythmia, hypotension, hypoxia, severe AS
- *Treating the precipitant, not antiplatelets and angiography, is the treatment*
Presentation in the older patient - why it is missed
- Chest pain is frequently ABSENT (~1/3 of MIs over 75 are painless)
- Presents instead as: dyspnoea (the commonest anginal equivalent), delirium, falls, syncope, fatigue, nausea, epigastric pain, sudden functional decline, "off legs"
- Silent infarction is common in diabetes, dementia and the very old
- Functional limitation from arthritis, COPD or frailty masks exertional angina - the patient never walks far enough to get it
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