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CHAPTER 19: HEART AND CIRCULATION CONDITIONS

Overview

Symptoms

    Chest Pain

    Swollen Ankles

Conditions

    High Blood Pressure

    Coronary Artery Disease

    Diseases of the Heart Valves

    Congestive Heart Failure

    Abdominal Aortic Aneurysm

    Poor Circulation

    Varicose Veins and Other Venous Disorders


Overview

The heart is a muscle pump that sends blood throughout the body. The heart has two main chambers: one that pumps blood through the lungs to receive oxygen and one that sends blood through the arteries. Valves in the heart keep the blood flowing in the proper direction. Coronary arteries supply energy and nutrients to the heart. If this supply of blood is reduced or stopped, chest pain or a heart attack can occur.

    Age-related changes in cardiovascular function probably occur but are hard to document because heart disease is so common. Most declines in cardiac function are due to diseases. Physical activity, nutrition, cigarette smoking, and socioeconomic status and other lifestyle factors contribute to the presence of heart disease in elderly people.

SYMPTOMS Chest Pain

Pain in the chest implies something ominous like a heart attack for most older people. Although chest pain may be preceded by a series of events that went unreported, most people will complain of chest pain out of concerns for underlying heart trouble.

Causes of Chest Pain

Chest pain can be produced by a number of conditions; sometimes a specific cause cannot be pinpointed. Chest pain can be divided into heart-related (cardiac) and nonheart-related causes. Pain from the heart is usually felt under the breastbone, but it can be felt anywhere in the chest, upper abdomen, in the jaw, or down the inner part of the arm. The discomfort ranges from minimal to severe and often provokes a feeling of squeezing, pressure, or burning in the chest (as if someone were standing on the chest). Cardiac pain that occurs during an activity usually causes the person to immediately stop until the pain subsides. If the pain is related to activity and immediately goes away when the person rests, it is called angina (from the Latin, meaning a choking or suffocating pain). Angina means that the heart muscle is not receiving enough blood, usually due to narrowing in the arteries that supply the heart (coronary arteries). The pain of a heart attack is similar to angina but usually lasts longer and is more severe. It is sometimes described as "crushing" or "viselike" and usually produces considerable shortness of breath.

    Nonheart-related chest pain can come from any of the numerous structures in the neck, chest, or upper abdomen. Pain in the chest wall (ribs, muscles, cartilage, and ligaments) can sometimes be produced or worsened by pressing on the site of the discomfort. Shingles (herpes zoster) is a skin disorder that can cause chest pain. Usually a rash is present. (Shingles is discussed on page 230).

Evaluation of Chest Pain

Any new chest pain warrants a complete medical evaluation. Chest pain and sweating, dizziness, fainting, shortness of breath, or an irregular pulse require urgent medical attention. The physician will want to determine whether the chest pain is due to a heart attack. A complete internal examination and electrocardiogram are essential parts of this evaluation.

Treatment of Chest Pain

The treatment of chest pain depends upon its underlying cause. However, the outlook is good even if the pain is due to a heart attack. The most important consideration is prompt medical attention.

Swollen Ankles

Ankle swelling results from fluid accumulation. It usually affects both ankles and occurs there because of the effects of gravity.

Causes of Swollen Ankles

Ankle swelling is caused by increased pressure in the veins or a low albumin in the blood. Increased venous pressure in the legs often results from problems in the leg vein valves that slow down the blood return to the heart. Blood tends to settle in the lower legs, and the pressure increases to the point that fluid leaks out and causes the ankle to swell. Heart failure, serious lung disease, and liver and kidney diseases can also produce leg swelling. Ankle swelling and chest pain, shortness of breath, or any ankle or leg pain need prompt medical evaluation.

Evaluation of Swollen Ankles

A physician's evaluation includes a complete examination of the heart and lungs to look for signs of heart failure and conditions that produce venous obstruction or a low albumin.

Treatment of Swollen Ankles

Mild swelling of the ankles with no other symptoms frequently does not require treatment. Elevating the legs can help the swelling by allowing blood to drain back toward the heart. Avoiding constricting garments and prolonged standing or sitting can reduce fluid accumulation. Support hose can be helpful. Sometimes a physician will prescribe medication to help reduce the amount of body fluid accumulation.

CONDITIONS High Blood Pressure

In industrialized societies, blood pressure progressively increases with aging; nearly half of people older than age 65 have mild elevated blood pressure.

    The risk of cardiovascular complications such as heart attacks and strokes increases as blood pressure rises, and there is no particular value that can be specified as too high. Definitions of blood pressure based on recommendations from the National Heart, Lung and Blood Institute will be used in this section. Blood pressure measurements are composed of two factors: the pressure when the heart muscle is contracting and pushing blood out, or the systolic pressure, and the pressure when the heart muscle is relaxing and letting blood into the heart, or diastolic pressure. Normal systolic pressure is about 120 to 130 mm Hg; normal diastolic pressure is around 70 to 80 mm Hg.

    Blood pressure is measured in terms of millimeters of mercury (mm Hg). Millimeters of mercury are used to measure atmospheric pressure and define the unit of pressure needed to support a one millimeter column of mercury. These technical units of measurement are called "torr," for the Italian scientist Evangelista Torricelli.

    According to the National Heart, Lung and Blood Institute systolic pressure equal to or greater than 160 mm Hg and diastolic pressures at 90 mm Hg or below present a condition called isolated systolic hypertension. When diastolic pressure rises above 90 mm Hg, the condition is called systolic-diastolic hypertension.

The Epidemiology of High Blood Pressure

Most people's average systolic blood pressure increases throughout their life, while the average diastolic blood pressure rises until about the age of 55 to 60 when it tends to level off. This age-related increase in blood pressure is not, however, a universal phenomenon. For example, the populations of nonindustrialized societies and people living their lives in mental institutions do not show a rise in average blood pressure with age.

    For older people, the systolic blood pressure is more predictive of future cardiovascular problems than is the diastolic blood pressure. However, both systolic and diastolic blood pressure are independently useful in predicting blood vessel problems. Approximately 40 percent of strokes in elderly men and 70 percent of strokes in elderly women are directly related to high blood pressure.

    Aside from age itself, an increased level of systolic blood pressure is the single greatest risk for cardiovascular disease in people over 65. In addition, increased blood pressure contributes to other cardiovascular risk factors, increasing the overall risk of heart diseases.

What Produces High Blood Pressure?

High blood pressure in elderly people is caused by increased resistance in the blood vessels of the body. This increased resistance results from an age-related decline in elastic tissue in the blood vessels and an increase in stiffness in the aorta and large blood vessel walls. The blood vessels also lose their ability to dilate, which increases the resistance in the small blood vessels. In addition, as people age, their blood vessels often become clogged with fatty tissue, a condition called atherosclerosis. Changes in the hormonal regulation of salt and water in the aging body may also play a role in the development of high blood pressure in the older person.

Treatment of High Blood Pressure

The goal of treatment in high blood pressure is to bring the pressure into a range where cardiovascular risks are lowered and drug side effects are minimized. Generally this means a systolic blood pressure of around 140 mm Hg and a diastolic blood pressure around 90 mm Hg. Nondrug therapy for high blood pressure may avoid the need for medications. This approach appears to be effective for some people with mild or borderline high blood pressure. Methods used include weight loss if overweight, sodium (salt) restriction, moderate and regular exercise, and a reduction of alcohol intake. The value of these measures has been inconsistent. It appears, however, that weight loss, provided it can be maintained, is effective in people who are overweight.

    If nondrug treatment fails, the alternative is medications. Moderate doses of diuretics are as good as other drugs in lowering blood pressure. Since diuretics are effective, inexpensive, and only need to be taken once a day, they are usually the first treatment for most older people with high blood pressure. Diuretics are not a good choice if a person has increased heart muscle mass or signs of heart stress or strain on the electrocardiogram. People with poorly controlled diabetes should also avoid certain types of diuretic medicines. Diuretics increase urine production, and people who have urinary difficulties can experience incontinence. Moreover, in some men diuretics can cause impotence. Many other medications for high blood pressure are available.

    The cost of antihypertensive medication over a long time can be substantial if several drugs are used. In effect, there can be a 20- to 30-fold difference in cost between the less expensive diuretics and the latest patented medications. The quality and effectiveness of antihypertensive drugs is not necessarily related to their cost. Once a person's blood pressure has been consistently controlled on a certain medication for over six months, dosage should be slowly tapered down. In some cases drug treatment can be replaced entirely by nondrug intervention.

How Beneficial Is the Treatment of High Blood Pressure?

A number of studies on assorted age groups indicate that high blood pressure is treatable. The problem in treating people with mild to moderate hypertension is that the benefits of treatment for each person are fairly low. For example, at least 300 people with mild to moderate high blood pressure need to be treated to prevent one of them from having a heart attack or a stroke (some studies suggest that over 800 people need to be treated to prevent one stroke or heart attack). This means that many people must be treated to benefit only a few. However, the benefits seem more obvious for people with severe high blood pressure.

    It is worth noting that the goal should be modest when lowering blood pressure. There may be a J-shaped relationship between the treated level of diastolic blood pressure and the likelihood of heart attack or death. This means that people whose diastolic blood pressure lowers most dramatically may have higher rates of death or heart attacks than people whose blood pressure is more modestly lowered. Therefore, modest lowering of the diastolic blood pressure to about 85 to 90 mm Hg and lowering of systolic blood pressure to around 150 mm Hg appear to be the most appropriate targets for most elderly people.

The Dangers of High Blood Pressure Treatment

Because of the concerns about the side effects of drug treatment for high blood pressure, some experts have advised restraint or even no treatment at all for high blood pressure in elderly people because they are particularly susceptible to many of the side effects. For example, they are more likely than younger people to develop a low sodium or a low potassium in the blood with the usual doses of diuretics. They are also more likely to develop depression and confusion when they are treated with antihypertensive medications that affect the central nervous system. The body reflexes that control posture and balance become less sensitive with age, which makes older people more susceptible to falls and fractures if they are given high blood pressure medicines.

    Some people have argued that older people with hypertension actually need the higher blood pressure to provide blood adequately to vital organs such as the brain or kidney. Despite this theoretical concern, judicious use of high blood pressure medications in older people does not adversely affect either the kidney or the brain. Long-standing high blood pressure should be lowered cautiously and slowly. A gradual, controlled reduction of high blood pressure will reset the blood flow in the brain to a more normal pattern without undue stress.

Coronary Artery Disease

Coronary artery disease is the progressive narrowing of the arteries supplying blood to the heart (see Figure 30). Although coronary artery disease remains the most common cause of death in people over the age of 65, the rate of coronary deaths has decreased by 28 percent for those older than 80 over the past 30 years and by more than 44 percent for those ages 65 to 70. During the same period, deaths due to stroke also decreased by 40 percent in older people. These findings suggest that even in the older age group the specter of cardiac disease does not loom as ominously as it used to: Lifestyle changes and possibly medical therapies have had an impact on the progression of vascular disease.

Risk Factors for Coronary Artery Disease

Smoking significantly increases the risk of cardiovascular deaths in older people. The mortality due to coronary artery disease increases with the number of cigarettes smoked. Smoking also accelerates the development of blood vessel disease. For all of these and for other health reasons, people who smoke should seriously consider giving it up immediately.

    High blood pressure is a risk factor for coronary artery disease. One large study showed a decrease in heart-related deaths as a result of treatment for high blood pressure. There was a decrease in deaths from heart attacks, but not a decrease in the number of heart attacks per se.

    The levels of different fatty substances in the body are predictive of heart disease. For instance, levels of high-density lipoprotein (HDL, which is considered healthy) and low-density lipoprotein (LDL, which is considered unhealthy) are related to the likelihood of having heart attacks. The total level of a person's cholesterol (yet another fatty substance) may be an independent risk factor for heart disease. There is not, however, a scientifically established exact level that can be considered the line between acceptable and too high cholesterol levels. Furthermore, maintaining a low cholesterol level may be at odds with a healthy diet. A diet that is restricted to 300 milligrams of cholesterol or less, for instance, may be deficient in calcium; people on such a diet would probably need to take calcium supplements to prevent loss of calcium in the bones. Drug treatment for elevated cholesterol in older people who have no history of heart disease is very controversial. Low-cholesterol diets are usually inappropriate for disabled older people.

    Older women with heart disease should discuss the question of estrogen replacement with a physician. Estrogen levels fall after menopause, causing HDL levels to decrease and LDL levels to increase in the blood. These changes can be reversed by estrogen replacement therapy; however, when estrogens are combined with progestins some of the beneficial effects are reduced. It does appear, however, that estrogen replacement therapy lowers the rate of subsequent cardiovascular events such as heart attacks.

Symptoms of Coronary Artery Disease

As people age, symptoms of heart disease can change. For example, the chest pain on exertion, called angina pectoris, may not be as intense; an older person may only experience significant shortness of breath on exertion. Nonetheless, chest pain remains the major symptom of a heart attack in people over the age of 65. Loss of consciousness, severe shortness of breath, nausea and vomiting, and changes in mental function become more common presenting symptoms of a heart attack. In people over the age of 80, shortness of breath is increasingly more common as an initial symptom of a heart attack. In disabled older people, changes in mental function may be the initial symptom. Despite these differences in initial symptoms, the physical examination and laboratory tests that physicians perform are the same for older people as they are for younger age groups.

Evaluation of Coronary Artery Disease

Various medical tests used to evaluate heart disease, such as the exercise electrocardiogram, are just as accurate in older people as they are in younger people. The accuracy of coronary angiography (cardiac catheterization) for detecting coronary heart disease in older people is also reliable. However, the decision to use these tests should be based on individual circumstances. Older people should drink plenty of fluids before and after the procedure to avoid kidney damage caused by the X ray dye given during the catheterization.

    During their stay in the hospital, the major difference between older people with a heart attack compared to their younger counterparts is a marked increase in mortality. For people in their fifties, the mortality rate for an acute heart attack is between 5 and 10 percent. In people past the age of 75 it is about 30 percent. In addition, the complication of congestive heart failure develops in about 60 percent of older people after a heart attack.

Treatment of Coronary Artery Disease

The medical treatment of heart disease is similar in both younger and older people. It is important to rest after eating, avoid vigorous activities in excessively cold weather, and avoid significant emotional stress. A regular exercise regimen and a good diet are also useful.

    The use of nitroglycerin is helpful for chest pain or pressure. It causes the blood vessels feeding the heart to dilate, reducing the work of the heart, which in turn helps relieve the pain. It also helps make breathing a little easier. Because fainting is a possible side effect of placing a nitroglycerin pill under the tongue, it is wise to take any nitroglycerin dose when seated. Nitroglycerin can also be given as a cream, in a patch worn like a bandage, or as an aerosol spray as directed by a physician.

    Chest pain on exertion (angina) is sometimes helped by medications called beta-blockers. These drugs can have a sedating effect and cause decreased mental function. Calcium channel-blocking drugs can also be helpful in controlling exertional chest pain and high blood pressure. These medications can cause constipation and difficulty urinating and may cause the blood pressure to drop when a person is standing. Calcium channel blockers can also cause the feet and ankles to swell uncomfortably.

    Treatment with drugs (called thrombolytic agents or clot busters) appears to present a major breakthrough in the treatment of acute heart attacks in older people. Because these drugs can cause significant bleeding complications, they should be used only after careful consideration of a patient's past history of bleeding disorders. Other medications, such as beta-blockers, may reduce by one-third the rate for having an additional heart attack.

Diseases of the Heart Valves

The heart valves keep the blood circulating in the appropriate direction (see Figure 31). Diseases of the heart valves due to wear and tear are more common in older people than problems due to rheumatic fever or congenital valve conditions.

    People with significant heart valve disease may be advised, with particular instruction, to use antibiotics prior to various procedures, such as dental care. The antibiotics will reduce the chance that bacteria released into the blood through such procedures will infest the damaged valve, thereby causing the very serious condition known as endocarditis.

Aortic Valve Narrowing

Narrowing of the aortic valve, called aortic stenosis, often results from wear and tear on a previously normal valve for people over age 70. Injurious changes on the valve are composed of scar tissue, calcium, and fat deposits. Scar tissue and calcium on the valve keeps it from opening normally, leading to obstruction of blood flow. People with diabetes mellitus have an increased risk of developing this form of aortic stenosis. In addition, nearly one-half of people with this disorder also have coronary artery disease.

Symptoms of Aortic Valve Narrowing. People with aortic stenosis often complain of exertional chest pain, shortness of breath, and loss of consciousness (fainting). Older people who are not very active may show weight loss, fluid buildup in the lungs, and kidney or liver failure. These symptoms may also be caused by a change in the normally regular heart rhythm (in addition to heart valve disease) leading to congestive heart failure.

Treatment of Aortic Valve Narrowing. If left untreated after the onset of symptoms, aortic stenosis leads to death within a year for 30 to 50 percent of older people. The older person without any symptoms does not require surgery unless there is very poor function on the left side of the heart, often determined by an echocardiogram. Valve repair is needed, however, when symptoms such as chest pain, congestive heart failure, or fainting occur.

    In the healthy older adult, the surgical procedure should be an aortic valve replacement, which, for people between the ages of 65 and 75, has a mortality rate of less than 5 percent. In people older than 80, a 10 percent mortality rate due to this operation is a realistic estimate. Replacement with specially treated valves from pig hearts is preferable to replacement with mechanical valves because they do not require as much blood-thinning medication afterward.

    Other procedures are available for people who cannot undergo heart surgery. One of these procedures is called balloon valvuloplasty. This enlarges the valve opening by passing a deflated balloon across the valve and then inflating it. The procedure carries a 2 to 3 percent mortality rate as well as a significant chance of stroke and other complications. In addition, the valve recloses in about half of the people within six months and in 70 percent within one year. The procedure may be helpful in the preoperative management of older people with aortic valve disease who are getting ready for nonheart surgeries such as the repair of a broken hip.

    The medical (i.e., nonsurgical) treatment of aortic stenosis consists of close observation and taking diuretics if heart failure is present. It is important to monitor any other medications a person may be taking for their effect on the heart in order to avoid heart failure or significant drops in blood pressure.

Aortic Valve Leaking

When an aortic valve leaks, the condition is called aortic valve insufficiency. In older people this may be due to rheumatic heart disease, but if it is, disease of the mitral valve (the valve controlling blood flow between the left atrium and left ventricle of the heart) must also be present (see Figure 31). Sometimes, the leaflets of the valves in people with high blood pressure and kidney disease develop holes that ultimately lead to leakage. Normal wear and tear on the aortic valve, however, is very rarely the cause of any major leakage.

Symptoms of Aortic Valve Leaking. People with aortic valve insufficiency usually tolerate it quite well. In some people, shortness of breath while lying flat, chest discomfort, and shortness of breath while at rest may be the early clues to this problem. Congestive heart failure is usually the prominent symptom of a leaky aortic valve. Physicians can identify the condition through careful listening to the heart.

Treatment of Aortic Valve Leaking. In older people, surgical replacement of the aortic valve is associated with a mortality rate of under 5 percent compared with 1 to 2 percent mortality for younger people undergoing the same surgery. These rates are doubled if other procedures, such as coronary artery bypass grafts, are performed during the same operation. The outlook for elderly people is excellent after a successful valve replacement and comparable to that for younger people who have had successful valve replacement.

The presence of coronary disease, however, worsens the postoperative outlook.

Mitral Valve Narrowing

Narrowing of the mitral valve, called mitral stenosis, sometimes occurs in older people.

Symptoms of Mitral Valve Narrowing. Often the person will feel tired and have congestive heart failure that gets worse because of a change in the heart rhythm. Blood clots can sometimes form in the heart and may lead to a stroke or other vascular trouble. Mitral stenosis can be determined through physical examination by a physician. Older people with mitral stenosis who have evidence of congestive heart failure or an irregular heart rhythm (or both) should be treated with anticoagulants (blood thinners) to reduce the likelihood of blood clots.

Treatment of Mitral Valve Narrowing. As with aortic valve replacement, mitral valve replacement is associated with a higher mortality in older people than in younger people. In people ages 65 to 75 the mortality rate may be as high as 5 percent; it exceeds 10 percent in people over age 80. The outlook for such surgery, however, is significantly worse if there is coronary artery disease present. With careful medical management, however, a reasonably comfortable lifestyle may be possible.

Mitral Valve Leaking

A leaking mitral valve, called mitral insufficiency, is fairly common in older people. This may be related to dysfunction of the heart muscles that control the valve, dilation of the heart, degeneration of the supporting tissues around the valve, or rupture of the delicate structures, called chordae tendineae, that help the valve stay in place. Sometimes the area around the valve has become calcified.

Symptoms of Mitral Valve Leaking. People with mitral valve leakage may have symptoms of congestive heart failure or irregular heart rhythms or both. Again, diagnosis is made through examination by a physician, who may want to include an echocardiogram as part of the examination to check the size of the heart muscle.

Table 26. The Causes of Heart Failure in Older People

INEFFECTIVE PUMPING

HIGH RESISTANCE TO BLOOD FLOW

Damaged heart muscle

High blood pressure

Drugs

Valve narrowing

TOO MUCH FLUID TO PUMP

PROBLEMS FILLING THE HEART

Increased blood volume

Ineffective heart relaxation

Increased body needs

Heart muscle enlargement

Leaking valves

Treatment of Mitral Valve Leaking. Replacement of the mitral valve is necessary for people suffering such symptoms as profound fatigue, severe shortness of breath, difficulty breathing when lying flat, and severe edema or swelling of body tissue due to fluid retention. Severe mitral valve disease can also lead to weight loss. Because the mortality rate associated with surgical treatment of mitral valve disease is related to the presence of coronary artery disease, medical management of a patient with both diseases before and after surgery requires particularly careful attention. In people whose mitral disease is not related to coronary artery disease, surgical replacement of the mitral valve is a less risky procedure. People who have an irregular heart rhythm as well as mitral insufficiency are often given blood thinners (anticoagulants).

Congestive Heart Failure

Congestive heart failure occurs when the heart cannot meet the body's demand for blood. Heart failure commonly occurs in older people. The main causes of heart failure are shown in Table 26. The symptoms of congestive heart failure are not very specific, such as shortness of breath, swelling of the ankles, fatigue, weakness, or confusion. Unusual or atypical symptoms can be seen, especially in extreme old age.

Types of Congestive Heart Failure

It is very important to distinguish between two types of congestive heart failure, systolic (when the heart beats) and diastolic (when the heart rests), because the treatment for each type may differ. (The characteristics of each type are shown in Table 27.) People with diastolic heart failure often have a history of high blood pressure; the walls of the heart are thickened, making it difficult for the heart to relax and fill with blood. In contrast, systolic heart failure commonly occurs after a person suffers a heart attack. People with systolic heart failure may have weight loss and low blood pressure. These people often have a history of coronary artery disease and multiple heart attacks. The heart is usually enlarged and its walls are thin. The heartbeats are often weak, thereby limiting the amount of blood flow out of the heart. Sometimes individuals will have elements of both diastolic and systolic heart failure.

Evaluation of Congestive Heart Failure

The physician's evaluation usually includes an interview, physical examination, electrocardiogram, echocardiogram, and a chest X ray. Other tests are ordered if it is the first episode of congestive heart failure.

Treatment of Congestive Heart Failure

Diuretics are medications that increase the amount of urine produced and therefore loss of fluid from the body. They are usually the first line of treatment in both systolic and diastolic forms of heart failure. People with significant heart failure may not absorb oral tablets fast enough into the bloodstream. Intravenous therapy may be required to get the medicine into the bloodstream more quickly.

Table 27. Clinical Characteristics of Systolic Versus Diastolic Congestive Heart Failure

          

SYSTOLIC

DIASTOLIC

History

Previous heart attack

Hypertension

Physical examination

No elevated blood pressure
Mitral valve leakage

Echocardiography

Dilated chambers with thin walls
Poor heart contractions

Chambers with thick walls
Vigorous heart contractions

Treatment

Diuretics, ACE inhibitors, digitalis

Diuretics, calcium channel blockers

ACE, angiotensin-converting enzyme.

    Digitalis is an important medication for treating systolic dysfunction. Long-term therapy with digitalis improves heart function. A third type of medication often considered for treating systolic heart failure is called ACE (angiotensin-converting enzyme) inhibitors.

    People started on any of these three medications need to have their blood pressures checked regularly and their kidney function carefully monitored. In older people, ACE inhibitors may produce a low blood pressure on standing and sometimes the loss of taste. A troubling cough has also been associated with their use.

    Anticoagulants (blood thinners) are sometimes used in people with very poor heart muscle contractions. However, anticoagulants are not indicated for frail older people who are at risk for falls and injury because of the greater chance they will have a serious bleeding complication.

    Diastolic dysfunction is present in 30 to 40 percent of older people who experience congestive heart failure. Initially these people are best treated with diuretics. People in this group may not be suited to treatment with digitalis or nitroglycerin. Digitalis is not necessary because the problem is not one of decreased contraction of the heart. Nitroglycerin preparations may cause fainting due to a sudden drop in the blood reaching the heart. ACE inhibitors and calcium channel blockers may decrease the size of the thickened heart muscle.

Abdominal Aortic Aneurysm

Abdominal aortic aneurysm is the widening or ballooning of the major blood vessel leading from the heart. About 2 percent of people over age 65 have aneurysm in the abdominal aorta. People with high blood pressure and atherosclerosis are at greatest risk for aortic aneurysm.

Symptoms and Evaluation of Abdominal Aortic Aneurysms

Such aneurysms are often not noticed but can be detected through physical examination by a physician. Aneurysms are sometimes discovered during an abdominal X ray performed for another reason or during surgery. If an aneurysm balloons to the point of rupture, it causes pain in the groin, lower back, or lower abdomen, along with symptoms of shock. An aneurysm that is smaller than 4.5 centimeters (about 1¾ inches) should be watched carefully. When an aneurysm is found to be more than that in diameter or if it increases in size every year by more than half a centimeter, it may be close to rupture. Fifty percent of people who have a ruptured aneurysm die, and those who survive are usually left with considerable disability. Because of this, a person usually elects to have the vessel repaired surgically. Aneurysms that are larger than 6 centimeters (about 2 inches) generally should be repaired in most older people. In people over 80, a more conservative approach may be useful, depending upon other medical conditions. The death rate from abdominal aortic aneurysm repair is between 5 and 15 percent, the greatest risk being due to heart disease.

Poor Circulation

Disease in the blood vessels of the limbs--particularly the legs and feet (peripheral vascular disease)--occurs in 2 percent of men and 1 percent of women who are older than 65. Peripheral vascular disease encompasses conditions that affect both arteries and veins. Poor circulation is due to peripheral arterial disease.

Causes of Poor Circulation

Peripheral arterial disease occurs with cigarette smoking, diabetes mellitus, and high levels of cholesterol and fat in the blood. Decreased physical activity can also cause poor circulation.

Symptoms of Poor Circulation

People with poor circulation often complain of calf, leg, or buttock pain when they exert themselves. Some elderly people have severe reduction in blood flow and even subsequent tissue death without feeling pain. The absence of pain may be because simultaneous or associated problems in the nervous system blunt the sensations. Signs of poor circulation such as changes in skin color or texture tend to occur in the extremities or the feet, and may not be seen by elderly people who have poor vision. The sudden onset of leg pain can indicate a blood clot (thrombosis) in a diseased vessel or a piece of such a clot or other undissolved material in a blood vessel (called an embolus) that has migrated downstream from a large vessel to a small vessel where it causes obstruction. The source of the embolus is often the heart or the aorta.

Treatment of Poor Circulation

A person being treated for poor circulation should stop smoking immediately, keep to a diet designed to lower fat and cholesterol in the blood, and, if possible, begin a regular walking program. A medication called pentoxifylline can help in severe cases of peripheral arterial disease, but its effectiveness for older people has not been specifically tested.

    Surgical procedures to improve the blood flow are controversial. Age does not seem to reduce success rates of surgery performed for the relief of symptoms or for the salvage of tissue.

Varicose Veins and Other Venous Disorders

Varicose veins result from leaky valves in the veins in the legs (see Figure 32). This disorder is usually caused by degeneration of the valves for which a person has a hereditary predisposition. Sometimes it is secondary to problems deep in the veins.

Symptoms of Varicose Veins

Aching in the legs that becomes worse when a person is standing is the chief symptom of varicose veins. Most older people with varicose veins will find that wearing elastic support stockings provides relief.

Treatment of Varicose Veins

Although treatment by injection of substances that burn and scar the veins is becoming more common, its purpose is primarily cosmetic, and the condition usually comes back. More invasive surgery such as stripping or tying off these veins should be avoided in older people, because the risk from anesthesia is not worth the essentially cosmetic results. In rare situations, ulcers or repeated bleeding from varicose veins or repeated blood clots may require surgical intervention.

Venous Insufficiency

Chronic problems of the deep venous circulation in the legs is usually the result of a previous blood clot in the deep veins called a deep venous thrombosis. Since this original clotting can occur without any symptoms, some people who develop chronic deep venous insufficiency have no history of deep vein thrombosis.

Symptoms of Venous Insufficiency. Individuals with this condition usually have swelling of the legs that becomes worse at the end of the day. This can evolve to a browning discoloration of the skin and can cause an ulcer above the ankle on the inside of the leg. The pain associated with this condition ranges from mild to severe.

Treatment of Venous Insufficiency. In addition to wearing elastic support stockings, which help prevent the progression of the disorder, the legs should be elevated intermittently throughout the day and long periods of standing avoided. Walking, however, should not be limited. If an ulcer occurs, antibiotic therapy and soaking the ulcer in warm solutions are recommended. Surgery is generally not indicated for deep venous insufficiency.




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