Peripheral arterial disease and abdominal aortic aneurysm in elderly people.

Patients with peripheral arterial disease (PAD) are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped and hypertension, dyslipidemia, diabetes mellitus, and hypothyroidism treated. Statins decrease the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in patients with PAD and hypercholesterolemia. The serum low-density lipoprotein cholesterol should be reduced to <70 mg/dL. Antiplatelet drugs such as aspirin or clopidogrel, angiotensin-converting enzyme (ACE) inhibitors, and statins should be given to patients with PAD. Beta blockers should be given if coronary artery disease is present. Cilostazol improves exercise time until intermittent claudication. Exercise rehabilitation programs should be used. Revascularization should be performed if indicated. Patients with an infrarenal or juxtarenal abdominal aortic aneurysm (AAA) measuring 5.5 cm or larger should undergo repair to eliminate the risk of rupture. Patients with an infrarenal or juxtarenal AAA measuring 4.0 to 5.4 cm in diameter should be monitored by ultrasound or computed tomographic scans every 6 to 12 months to detect expansion. Patients with an AAA should undergo intensive risk factor modification, be treated with ACE inhibitors, statins, and beta blockers, and undergo surgery if indicated.

Management of ventricular arrhythmias.

Underlying causes of ventricular tachycardia (VT) or complex ventricular arrhythmias (VA) should be treated if possible. Anti-arrhythmic drugs should not be used to treat asymptomatic patients with complex VA and no heart disease. Beta blockers are the only antiarrhythmic drugs that have been documented to reduce mortality in patients with VT or complex VA. Radiofrequency catheter ablation of VT has been beneficial in treating selected patients with arrhythmogenic foci of monomorphic VT. The automatic implantable cardioverter-defibrillator (AICD) is the most effective treatment for patients with life-threatening VT or ventricular fibrillation. The American College of Cardiology/American Heart Association class I indications for an AICD are discussed. Other indications for an AICD are discussed. Patients with AICDs should be treated with biventricular pacing, not with dual-chamber rate-responsive pacing at a rate of 70/minute. Patients with AICDs should be treated with beta blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin blockers.

Warfarin use and the risk of valvular calcification.

BACKGROUND: Warfarin affects the synthesis and function of the matrix Gla-protein, a vitamin K-dependent protein, which is a potent inhibitor of tissue calcification. OBJECTIVES: To investigate the incidence of mitral valve calcium (MVC), mitral annular calcium (MAC) and aortic valve calcium (AVC) in patients with non-valvular atrial fibrillation (AF) treated with warfarin vs. no warfarin. PATIENTS AND METHODS: Of 1155 patients, mean age 74 years, with AF, 725 (63%) were treated with warfarin and 430 (37%) without warfarin. The incidence of MVC, MAC and AVC was investigated in these 1155 patients with two-dimensional echocardiograms. Unadjusted logistic regression analysis was conducted to examine the association between the use of warfarin and the incidence of MVC, MAC or AVC. Logistic regression analyses were also conducted to investigate whether the relationship stands after adjustment for confounding risk factors such as age, sex, race, ejection fraction, smoking, hypertension, diabetes, dyslipidemia, coronary artery disease (CAD), glomerular filtration rate, calcium, phosphorus, calcium-phosphorus product, alkaline phosphatase, use of aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins. RESULTS: There was a significant association between the use of warfarin and the risk of calcification [unadjusted odds ratio = 1.71, 95% CI = (1.34-2.18)]. The association still stands after adjustment for confounding risk factors. MVC, MAC or AVC was present in 473 of 725 patients (65%) on warfarin vs. 225 of 430 patients (52%) not on warfarin (P < 0.0001). Whether this is a causal relationship remains unknown. CONCLUSIONS: Use of warfarin in patients with AF is associated with an increased prevalence of MVC, MAC or AVC.

Guidelines and the use of inferior vena cava filters: a review of an institutional experience.

BACKGROUND AND OBJECTIVES: Based on the American College of Chest Physicians 2004 antithrombotic therapy for venous thromboembolism (VTE) and the Eastern Association for the Surgery of Trauma 2002 guidelines, placement of an inferior vena cava (IVC) filter is indicated in patients who either have, or are at high risk for, VTE, but have a contraindication or failure of anticoagulation. Our aim is to compare clinical characteristics and outcomes of patients receiving IVC filters within-guidelines (WG) and outside-of-guidelines (OOG). METHODS: The 558 patients who received an IVC filter were divided into two groups called WG or OOG. The WG group met the criteria described above and the OOG group did not have a contraindication to or a failure of anticoagulation. RESULTS: The WG group had 362 patients and the OOG group had 196 patients. The OOG group had one (0.5%) patient with post-filter pulmonary embolism (PE), two (1%) with IVC thrombosis, and seven (3.6%) with deep vein thrombosis (DVT). The WG group had five (1.4%) patients with post-filter PE, 13 (3.6%) with IVC thrombosis, and 34 (9.4%) with DVT. All patients who developed post-filter PE had a DVT before filter placement, and patients who did not have a prior VTE event were at a significantly lower risk of developing post-filter IVC thrombosis and PE. CONCLUSION: Our data do not support the use of an IVC filter outside of guidelines in patients without prior VTE who can tolerate anticoagulation because of the low risk of developing PE.

Association of mitral annular calcium with prior thromboembolic stroke in older White, African-American, and Hispanic men and women.

Prior thromboembolic stroke was present in 57 of 188 white men (30%) with mitral annular calcium (MAC) and in 62 of 303 white men (20%) without MAC, in 42 of 65 African-American men (65%) with MAC and in 50 of 123 African-American men (41%) without MAC, and in 13 of 27 Hispanic men (48%) with MAC and in 21 of 58 Hispanic (36%) without MAC. Prior thromboembolic stroke was present in 164 of 614 white women (27%) with MAC and in 85 of 516 white women (16%) without MAC, in 111 of 193 African-American women (58%) with MAC and in 77 of 225 African-American women (34%) without MAC, and in 36 of 69 Hispanic women (52%) with MAC, and in 17 of 58 Hispanic women (29%) without MAC.

Increased plasma homocysteine is an independent predictor of new atherothrombotic brain infarction in older persons.

A prospective study investigated the association of plasma homocysteine and other risk factors with the incidence of atherothrombotic brain infarction (ABI) at 31 +/- 9 month follow-up in 153 men and 347 women (mean age 81 +/- 9 years, median age 82). The stepwise Cox regression model showed that significant independent predictors of new ABI in older persons were age (risk ratio 1.060 for each 1-year increase of age), plasma homocysteine (risk ratio 1.079 for each 1 micromol/L increase), prior ABI infarction (risk ratio 3.282), current cigarette smoking (risk ratio 2.687), hypertension (risk ratio 2.965), and diabetes mellitus (risk ratio 2.015).

Increased plasma homocysteine is an independent predictor of new coronary events in older persons.

A prospective study investigated the association of plasma homocysteine and other risk factors with the incidence of new coronary events at 31 +/- 9 month follow-up in 153 men and 347 women, mean age 81 +/- 9 years. The stepwise Cox regression model showed that significant independent predictors of new coronary events in older persons were age (risk ratio 1.041), plasma homocysteine (risk ratio 1.073), current cigarette smoking (risk ratio 2.524), hypertension (risk ratio 2.032), diabetes mellitus (risk ratio 2.022), serum total cholesterol (risk ratio 1.013), serum high-density lipoprotein cholesterol (risk ratio 0.925), and serum triglycerides (risk ratio 1.004).

Risk factors for coronary artery disease in old persons in an academic hospital-based geriatrics practice.

BACKGROUND: Risk factors for coronary artery disease (CAD) in old men and women include age, cigarette smoking, hypertension, diabetes mellitus, dyslipidemia, and obesity. OBJECTIVE: To investigate the association of risk factors with prevalence of CAD. METHODS: We performed a retrospective analysis of charts for all old persons seen during the period from 1 January 1998 through 15 June 1999 at an academic hospital-based geriatric practice to investigate associations of risk factors with prevalence of CAD among old persons. We studied 467 men, mean age 80 +/- 8 years, and 1444 women, mean age 81 +/- 8 years. RESULTS: CAD was present in 201 of 467 men (43%) and in 473 of 1444 women (33%; P < 0.0001). Risk factors for CAD according to univariate analysis were age (P < 0.0001 for women), cigarette smoking (P < 0.0001 for men and women), hypertension (P < 0.0001 for men and women), diabetes mellitus (P < 0.0001 for men and women), obesity (P < 0.0001 for men and women), and serum levels of total cholesterol (P < 0.0001 for men and P = 0.0001 for women), low-density lipoprotein (LDL) cholesterol (P < 0.0001 for men and P = 0.001 for women), and high-density lipoprotein (HDL) cholesterol (inverse association; P = 0.0001 for men and women). Stepwise logistic regression analysis showed that significant independent risk factors for CAD were cigarette smoking (odds ratio 6.7 for men), hypertension (odds ratios 3.3 for men and 2.7 for women), and serum levels of HDL cholesterol (odds ratio 0.83 for men and women) and LDL cholesterol (odds ratios 1.10 for men and 1.09 for women). CONCLUSIONS: Significant independent risk associations with prevalence of CAD among old persons were found for cigarette smoking by men, hypertension in men and women, and serum levels of HDL cholesterol (inverse association) in men and women, and of LDL cholesterol in men and women.

Risk factors for symptomatic peripheral arterial disease in older persons in an academic hospital-based geriatrics practice.

OBJECTIVE: To investigate risk factors for symptomatic peripheral arterial disease (PAD) in older persons. DESIGN: A retrospective analysis of charts from all older persons seen from January 1, 1998, through June 15, 1999, at an academic, hospital-based geriatrics practice. SETTING: An academic, hospital-based geriatrics practice staffed by fellows in a geriatrics training program and full-time faculty geriatricians. PATIENTS: A total of 467 men, mean age 80 +/- 8 years, and 1444 women, mean age 81 +/- 8 years, were included in the study. MEASUREMENTS AND MAIN RESULTS: Symptomatic PAD was present in 93 of 467 men (20%) and in 191 of 1444 women (13%) (P = .001). Significant risk factors for symptomatic PAD by univariate analysis were: age (P = .021 in women); cigarette smoking, hypertension, diabetes mellitus, serum total cholesterol, serum high-density lipoprotein (HDL) cholesterol (inverse association), and serum low-density lipoprotein (LDL) cholesterol (P < .001 in men and women); obesity (P = .013 in men and .002 in women); and serum triglycerides (P = .027 in women). Significant independent risk factors for symptomatic PAD by stepwise logistic regression analysis were: age (odds ratio = 1.052 in men and 1.025 in women); cigarette smoking (odds ratio = 2.552 in men and 4.634 in women); hypertension (odds ratio = 2.196 in men and 2.777 in women); diabetes mellitus (odds ratio = 6.054 in men and 3.594 in women); serum HDL cholesterol (odds ratio = .948 in men and .965 in women); and serum LDL cholesterol (odds ratio = 1.019 in men and women). CONCLUSIONS: Significant independent risk factors for symptomatic PAD in older men and women were age, cigarette smoking, hypertension, diabetes mellitus, serum HDL cholesterol (inverse association), and serum LDL cholesterol.

Clinical causes of death of 2372 older persons in a nursing home during 15-year follow-up.

OBJECTIVE: To investigate the causes of death in older persons in a nursing home. DESIGN: The major clinical cause of death of all persons aged 60 years older residing in a nursing home during a 15-year period was investigated in a prospective study. The author carefully reviewed the major cause of death with the physicians who took care of all persons who died either in the nursing home or after transfer to a general hospital. SETTING: A large nursing home in which 2372 of 3164 older persons (75%) died during a 15-year period. PATIENTS: The 2372 persons who died included 766 men and 1606 women, mean age 81 +/- 8 years. MEASUREMENTS AND MAIN RESULTS: A total of 2372 of 3164 persons (75%) died during the 15-year period,. Seven hundred sixty-six of 1023 men (75%) and 1606 of 2141 women (75%) died (P not significant). The major cause of death in these 2372 persons was sudden cardiac death in 25%, myocardial infarction in 18%, refractory congestive heart failure in 11%, thromboembolic stroke in 6%, cerebral hemorrhage in 1%, pulmonary embolism in 2%, mesenteric vascular infarction diagnosed at surgery in 1%, peripheral vascular disease, including dissecting aneurysm of aorta and ruptured abdominal aneurysm, in <1%, pneumonia in 15%, urosepsis in 4%, bacterial endocarditis in 1%, sepsis from abdominal abscess or gastrointestinal or biliary tract in 1%, sepsis from decubiti, gangrene of lower extremity, and osteomyelitis in <1%, cancer in 9%, renal failure in 3%, gastrointestinal or liver disease in 2%, hematologic disorders in 1%, and chronic obstructive pulmonary disease in 1% of persons. CONCLUSIONS: The major cause of death of persons in the nursing home was cardiovascular disease, which accounted for 63% of deaths. The second major cause of death was infectious disease, accounting for 21% of deaths. Cancer accounted for 9% of deaths, renal failure for 3% of deaths, gastrointestinal or liver disease for 2% of deaths, hematologic disorders for 1% of deaths, and chronic obstructive pulmonary disease for 1% of deaths.

Risk factors for ischemic stroke in older persons in an academic hospital based geriatrics practice.

We performed a retrospective analysis of charts investigating risk factors for ischemic stroke in 467 men (mean age 80±8 years) and 1444 women (mean age 81±8 years) seen in an academic geriatrics practice. Ischemic stroke was present in 126 of 467 men (27%) and in 296 of 1444 women (20%) (p=0.003). Stepwise logistic regression analysis showed that significant independent risk factors for ischemic stroke were age (p=0.005 in men and 0.010 in women, odds ratio=1.04 in men and 1.03 in women); cigarette smoking (p=0.006, odds ratio=1.7 in women); hypertension (p<0.001 in men and women, odds ratio=4.6 in men and 3.9 in women); diabetes mellitus (p=0.018 in men and <0.001 in women, odds ratio=1.9 in men and 2.0 in women); serum low-density lipoprotein cholesterol (p<0.001 in men and women, odds ratio=1.02 in men and 1.01 in women); and serum high-density lipoprotein cholesterol (p<0.001, odds ratio=0.97 in women). Significant independent risk factors for ischemic stroke in both sexes were: age, hypertension, diabetes mellitus, and serum low-density cholesterol; and in older women: cigarette smoking and serum high-density lipoprotein cholesterol (inverse association). (c) 2000 by CHF, Inc.

Prevalence of coronary artery disease, ischemic stroke, and symptomatic peripheral arterial disease and of associated risk factors in older men and women with and without diabetes mellitus.

The authors performed a retrospective analysis of the prevalence of coronary artery disease, ischemic stroke, and symptomatic peripheral arterial disease and of associated risk factors in 99 men (mean age 79±8 years) with diabetes mellitus vs. 368 men (mean age 81±8 years) without diabetes mellitus, and in 260 women (mean age 80±8 years) with diabetes mellitus vs. 1184 women (mean age 81±8 years) without diabetes mellitus. All patients were seen in an academic outpatient geriatrics practice. Diabetic men had a higher prevalence of coronary artery disease, ischemic stroke, and symptomatic peripheral arterial disease (p<0.0001); a higher prevalence of smoking (p=0.023), hypertension (p<0.0001), and obesity (p=0.0007); higher levels of serum total and low density lipoprotein cholesterol (p<0.0001) and triglycerides (p=0.003); and lower levels of serum high density lipoprotein cholesterol (p=0.0001) than men without diabetes mellitus. Diabetic women had a higher prevalence of coronary artery disease, ischemic stroke, and symptomatic peripheral arterial disease (p<0.0001); a higher prevalence of hypertension and obesity (p<0.0001); higher levels of serum total and low density lipoprotein cholesterol (p=0.0001) and triglycerides (p=0.005); and lower levels of serum high density lipoprotein cholesterol (p=0.0001) than women without diabetes mellitus. (c) 2000 by CHF, Inc.

Association of mitral annular calcium and of aortic cuspal calcium with coronary artery disease in older patients.

In a prospective study, mitral annular calcium (MAC) was present in 274 of 752 men (36%), mean age 80 years, and in 869 of 1,663 women (52%), mean age 82 years (p <0.0001); aortic cuspal calcium was present in 295 of 752 men (39%) and in 672 of 1,663 women (40%) without aortic cuspal calcium (p = NS). Coronary artery disease was present in 150 of 274 men (55%) with versus 192 of 478 men (40%) without MAC (p = 0.0001) and in 446 of 869 women (51%) with versus 276 of 794 women (35%) without MAC (p <0.0001); coronary artery disease was present in 167 of 295 men (57%) with versus 175 of 457 men (38%) without aortic cuspal calcium (p <0.0001), and in 360 of 672 women (54%) with versus 362 of 991 women (37%) without aortic cuspal calcium (p <0.0001).

The older man's heart and heart disease.

CAD is the most common cause of death in older men and was present in 44% of 664 men, mean age 80 years. Independent risk factors for new coronary events in older men include increasing age, prior CAD, cigarette smoking, hypertension, diabetes mellitus, high serum total cholesterol, and low serum HDL cholesterol. In older men with hypertension, echocardiographic LVH is a powerful independent predictor of new coronary events, atherothrombotic brain infarction, and CHF. In 554 older men with a mean age of 80 years, two-dimensional and Doppler echocardiography demonstrated that the prevalence of aortic stenosis was 14%, 1 + aortic regurgitation or greater was 31%, rheumatic mitral stenosis was 0.4, 1 mitral regurgitation or greater was 32%, mitral annular calcium was 35%, hypertrophic cardiomyopathy was 3%, idiopathic dilated cardiomyopathy was 1%, left atrial enlargement was 29%, LVH was 41%, and abnormal LVEF was 29%. The prevalence and incidence of CHF increase with age in older persons. The prevalence of a normal LVEF associated with CHF as a result of prior myocardial infarction or hypertension was 22% in men aged 60 to 69 years, 33% in men aged 70 to 79 years, 41% in men aged 80 to 89 years, and 47% in men aged 90 years or older.

Antiplatelet agents in the prevention of cardiovascular morbidity and mortality in older patients with vascular disease.

Antiplatelet drugs have been demonstrated to reduce the incidence of myocardial infarction (MI), stroke or vascular death in patients with vascular disease. There are no data suggesting that antiplatelet therapy acts differently in older people than in younger people and recommendations based on randomised clinical trials are probably generalisable to older people. Aspirin (acetylsalicylic acid) has been shown to reduce the incidence of non-fatal MI, nonfatal stroke and vascular death in patients with acute MI, a previous MI, angina pectoris or peripheral occlusive arterial disease (POAD), and to reduce cardiovascular morbidity and mortality in patients with a prior ischaemic stroke or transient ischaemic attack (TIA). It has also been shown to reduce the incidence of thrombus formation after coronary artery bypass graft surgery and percutaneous transluminal angioplasty, and in patients with atrial fibrillation and heart valve replacements. Deep vein thrombosis and pulmonary embolism after surgery are also prevented by aspirin. The available data allows the following recommendations to be made. Aspirin 160 to 325 mg daily should be administered to older men and women without contraindications to aspirin who have acute MI, prior MI, unstable or stable angina pectoris, ischaemic stroke, TIA or POAD, and continued indefinitely to reduce the risk of MI, stroke or vascular death. Aspirin should be started in patients before or immediately after revascularisation, and after heart valve replacement. Older men and women with nonvalvular atrial fibrillation who have contraindications to oral anticoagulant therapy but no contraindications to aspirin should be treated with aspirin 325 mg daily. It is reasonable to treat older men and women without contraindications to aspirin with aspirin 160 to 325 mg daily if they are at high risk for developing new coronary events. The incidence of stroke, MI or vascular death in patients after a stroke or TIA is reduced by ticlopidine. Therefore, ticlopidine 250 mg twice daily may be used in older men and women with a history of stroke or TIA who do not respond to or who cannot tolerate aspirin. Patients at high risk for coronary artery stent thrombosis benefit from combined therapy with aspirin plus ticlopidine. The annual incidence of ischaemic stroke, MI or vascular death was significantly reduced by clopidogrel in the Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial. Therefore, clopidogrel 75 mg daily may be used in older men and women with symptomatic atherosclerosis who do not respond to or who cannot tolerate aspirin to reduce the incidence of ischaemic stroke, MI or vascular death. It should be noted that the acquisition cost for either ticlopidine or clopidogrel is considerably greater than that for aspirin. Most data indicate that the combination of aspirin and dipyridamole is not more effective than aspirin alone in preventing vascular events, and available data do not support the use of sulfinpyrazone in patients with vascular disease.

Risk factors for new atherothrombotic brain infarction in older African-American men and women.

Independent risk factors for new atherothrombotic brain infarction (ABI) in older African-American men were hypertension (risk ratio 4.381), diabetes mellitus (risk ratio 2.872), and previous ABI (risk ratio 1.904). Independent risk factors for new coronary events in older African-American women were cigarette smoking (risk ratio 2.754), hypertension (risk ratio 5.914), diabetes mellitus (risk ratio 3.464), serum total cholesterol (risk ratio 1.008), serum high-density lipoprotein cholesterol (inverse association) (risk ratio 0.958), age (risk ratio 1.026), and previous ABI (risk ratio 2.601).

Prevalence of heart disease in older women in a nursing home.

The prevalence of coronary artery disease (CAD) and the incidence of new coronary events are similar in older men and women. Independent risk factors for new coronary events in older women include age, prior CAD, cigarette smoking, hypertension, diabetes mellitus, high serum total cholesterol and triglycerides, and low serum high-density lipoprotein cholesterol. Older women have a higher prevalence of hypertension than older men. In older women with hypertension, echocardiographic left ventricular hypertrophy is a powerful independent predictor of new coronary events, atherothrombotic brain infarction, and congestive heart failure (CHF). Older women have a higher prevalence of rheumatic mitral stenosis and of mitral annular calcium than older men. Older women and men have a similar prevalence of valvular aortic stenosis, aortic regurgitation, mitral regurgitation, hypertrophic cardiomyopathy, and idiopathic dilated cardiomyopathy. The prevalence and incidence of CHF increase with age. The prevalence of normal left ventricular ejection fraction associated with CHF increases with age and is higher in older women than in older men. The prevalence of chronic atrial fibrillation increases with age and is similar in older men and women. Atrial fibrillation is an independent predictor of new coronary events and thromboembolic stroke in older women. Older women with unexplained syncope should have 24-hour ambulatory electrocardiograms to determine whether pauses > 3 seconds are present, requiring permanent pacemaker implantation.

Management of older persons after myocardial infarction.

OBJECTIVE: To review the management of the older person after myocardial infarction (MI). DATA SOURCES: A computer-assisted search of the English language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles. STUDY SELECTION: Studies on the management of persons after MI were screened for review. Studies in persons older than 60 years and recent studies were emphasized. DATA EXTRACTION: Pertinent data were extracted from the reviewed articles. Emphasis was on studies involving older persons. Relevant articles were reviewed in depth. DATA SYNTHESIS: Available data about therapy of persons after MI, including control of risk factors, use of aspirin and beta-blockers, and indications for use of angiotensin-converting enzyme inhibitors, long-term anticoagulant therapy, nitrates, calcium channel blockers, hormone replacement therapy, antiarrhythmic drugs, the automatic implantable cardioverter-defibrillator, and revascularization, with emphasis on studies involving older persons, were summarized. CONCLUSIONS: Risk factors for coronary artery disease should be controlled after MI in older persons. A serum low-density lipoprotein (LDL) cholesterol >125 mg/dL after MI should be treated with lipid-lowering drug therapy to decrease the serum LDL cholesterol to <100 mg/dL. Aspirin in a dose of 160 mg to 325 mg daily should be given indefinitely. Indications for long-term anticoagulant therapy with warfarin after MI to maintain an international normalized ratio between 2.0 and 3.0 include secondary prevention of MI in persons unable to tolerate daily aspirin, persistent atrial fibrillation, and left ventricular thrombus. Beta-blockers should be given indefinitely. Angiotensin-converting enzyme inhibitors should be given to persons who have congestive heart failure, an anterior MI, or a left ventricular ejection fraction < or = 40%. Calcium channel blockers should not be used unless there is persistent angina pectoris despite beta-blockers and nitrates. Antiarrhythmic drugs other than beta-blockers should not be used. An automatic implantable cardioverter-defibrillator should be used in persons who have a history of ventricular fibrillation or serious sustained ventricular tachycardia or who are at very high risk for developing sudden cardiac death. Until data from the Heart Estrogen/ Progestin Replacement Study are available, use of an estrogen/progestin regimen is recommended in the treatment of postmenopausal women after MI unless they are at increased risk for developing breast cancer. The two indications for revascularization in older persons after MI are prolongation of life and relief of unacceptable symptoms despite optimal medical management.