Myocardial infarction in the elderly

The concept of “ischemic heart disease” (IHD) currently includes a group of diseases and pathological conditions, the main cause of which is sclerosis of the coronary arteries.

Elderly people have various forms of manifestation of coronary heart disease - myocardial infarction in the elderly, angina pectoris, atherosclerotic cardiosclerosis, chronic circulatory failure, rhythm disturbances and intermediate forms of coronary insufficiency (small focal myocardial infarction in the elderly and focal myocardial dystrophy). In pathogenesis, it is necessary to take into account age-related changes predisposing to the development of coronary heart disease:

1. The adaptive function of the cardiovascular system decreases, its unconditional reflex reactions to various stimuli - muscle activity, stimulation of interoreceptors (change in body position, oculocardiac reflex), light, sound, pain irritation - in old people occur with a long patent period, are expressed much less. Relative sympathicotonia occurs, sensitivity to neurohumoral factors increases - this leads to the frequent development of spastic reactions of sclerotic vessels. The trophic influence of the nervous system is weakened.
2. The activity of humoral and cellular immunity decreases, and incomplete immune reactions lead to the circulation of immune complexes in the blood, which can damage the intima of the arteries.
3. The content of beta-lipoproteins, triglycerides, and cholesterol in the blood increases; the excretion of cholesterol by the liver and the activity of lipoprotein lipase (an enzyme that destroys lipoproteins) decrease.
4. Tolerance to carbohydrates decreases.
5. The functions of the thyroid gland and gonads decrease, the reactivity of the sympathetic-adrenal and renin-aldosterone systems increases, and the level of vasopressin in the blood increases.
6. Chronic activation of the blood coagulation system and functional insufficiency of anticoagulant mechanisms under stressful conditions.
7. Nutrition deteriorates, energy metabolism in the vascular stack decreases, the sodium content in it increases, which leads to activation of the atherosclerotic process, more pronounced vasoconstrictive reactions of the arteries. The need of the heart muscle for oxygen increases due to its age-related hypertrophy. Elimination of risk factors for coronary heart disease can increase the life expectancy of the elderly by 5-6 years, and of the elderly by 2-3 years.

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How does myocardial infarction manifest itself in older people?

Long-term clinical observations have shown that the most common form of coronary heart disease in patients over 60 years of age is stable angina, characterized by the constancy of clinical manifestations (nature, frequency, duration of pain syndrome).

Stable angina can become unstable, but this form is less common than in middle age. In old and senile age, spontaneous angina is extremely rare, the pathogenesis of which is based on spasm of the coronary vessels.

Pain syndrome in stable angina can be typical. Pain in the heart area in people over 50 years of age is mainly a symptom of coronary heart disease (CHD). Attacks of pain in the heart area can be a manifestation of chronic CHD and acute myocardial infarction, as well as a consequence of osteochondrosis of the cervical spine. With a thorough questioning of the patient, it is usually possible to establish the cause of the pain syndrome, which is extremely necessary for constructing rational therapy. It should be taken into account, however, that the diagnosis of pain in the heart area caused by osteochondrosis of the cervical spine does not exclude the diagnosis of angina caused by CHD. Both of these diseases are a manifestation of pathology, common in middle-aged, elderly and old people.

Myocardial infarction in elderly people has its own characteristics, which are manifested by the absence of its bright emotional coloring. Atypical signs of coronary circulatory failure become more frequent with increasing age (they occur in 1/3 of elderly people and in 2/3 of patients with coronary heart disease in old age).

Atypical angina may manifest itself in:

• Pain equivalents:
  • paroxysmal inspiratory or mixed dyspnea, sometimes accompanied by coughing or coughing;
  • interruptions in the work of the heart, palpitations, paroxysms of tachy- and bradyarrhythmia;
  • a low-intensity feeling of heaviness in the heart area during physical exertion, anxiety, disappearing at rest or after taking nitroglycerin.
• Change in pain localization:
  • peripheral equivalent without a retrosternal component: discomfort in the left arm (“left arm myth”), the scapular region, the lower jaw on the left, unpleasant sensations in the epigastric region;
  • provocation of exacerbation of diseases of other organs (for example, the gallbladder) - "reflex" angina.
• Changes in the time of onset and duration of pain:
  • "delayed manifest (pain) syndrome" - from several tens of minutes to several hours.
• The presence of non-specific symptoms:
  • attacks of dizziness, fainting, general weakness, feeling of nausea, sweating, nausea.

In elderly and senile people, the incidence of silent myocardial ischemia (SMI) increases. This is facilitated by taking drugs that reduce pain sensitivity, such as nifedipine, verapamil, and prolonged nitrates.

IAC is a transient disturbance of blood supply to the heart muscle, of any severity, without a typical angina attack or its clinical equivalents. IAC is detected by ECG monitoring (Holter), continuous recording of left ventricular function indicators, and a physical exercise test. Coronary angiography in such individuals often reveals stenosis of the coronary arteries.

In many people of the "third age", exacerbation of coronary insufficiency is associated with an increase in blood pressure. In some cases, neurological symptoms come to the fore, caused by insufficient cerebral circulation in the basin of a particular vessel, most often in the vertebrobasilar region.

Myocardial infarction in older people can be triggered by meteorological factors, such as significant changes in atmospheric pressure, temperature or humidity.

A large meal, causing overflow and bloating, is also often a provoking factor for angina. The fat load, which causes alimentary hyperlipemia, activates the blood coagulation system in elderly and old people, so after eating even a small amount of fatty food, attacks of angina may occur (especially at night).

In case of an angina attack lasting more than 15 minutes, one should think about such an emergency as myocardial infarction in the elderly. With age, atypical forms of the disease develop more often: asthmatic, arrhythmic, collaptoid, cerebral, abdominal and other variants of MI. In 10-15% of cases, myocardial infarction in the elderly is asymptomatic. A feature of MI in elderly and senile patients is the more frequent development of subendocardial necrosis with the occurrence of recurrent forms.

The prognosis of the disease in geriatric patients is significantly worse than in middle age, since acute myocardial infarction in the elderly is almost always accompanied by rhythm disturbances, often dynamic cerebrovascular accidents, cardiogenic shock with the development of renal failure, thromboembolism, and acute left ventricular failure.

It is more difficult to recognize myocardial infarction in elderly people than in middle-aged people, not only due to its more frequent atypical course, the erasure of many clinical symptoms and the appearance of new signs caused by the multiplicity of pathological lesions of the body, but also due to electrocardiographic features.

Myocardial infarction in the elderly with ST-segment elevation (subepicardial) usually has a relatively benign course, although it is more often recurrent. This is the only variant of MI without pathological Q-wave, when thrombolytic therapy is indicated.

Myocardial infarction in elderly people with a decrease in the ST segment relative to the isoline (subendocardial), affects a relatively thin layer of the heart muscle, often significant in area, and is relatively severe. ST segment depression persists for several weeks. This type of MI often develops in elderly and senile people with severe atherosclerosis of the coronary arteries, suffering from diabetes mellitus, arterial hypertension with heart failure. It is often repeated, can be widespread, circular, with a recurrent course, and can transform into MI with a wave 3. Sudden death is observed more often.

However, ST segment shift is not always observed in the acute period; changes more often concern the T wave. It becomes negative in several leads and acquires a pointed appearance. A negative T wave in the chest leads often persists for many years, being a sign of a previous MI.

Echocardiographic signs of MI in elderly patients differ from those in middle-aged individuals by a larger area of hypokinesia zones of the cardiac muscle, more frequent registration of myocardial dyskinesia, a greater increase in the size of the heart chambers and a decrease in the contractility of the cardiac muscle.

When diagnosing myocardial infarction, it is necessary to take into account a weaker temperature reaction, and often its complete absence in elderly and especially senile people. Blood changes (increased number of leukocytes, accelerated ESR) are expressed in them much weaker than in young people. If the blood was tested shortly before the onset of myocardial infarction, the obtained data must be compared dynamically. It should be remembered that an increased ESR is often observed in practically healthy people and is due to a change in the protein composition of the blood, not going beyond the physiological age-related shifts. In patients with suspected acute coronary heart disease, it is necessary to determine dynamically (after 6-12 hours) such markers of damage to the heart muscle as troponins T or I, myoglobin or creatinine phosphokinase (CPK).

How is myocardial infarction treated in the elderly?

Treatment of patients with coronary heart disease should be complex and differentiated depending on the stage of the disease and the presence of complications. Its main principles in elderly and senile people are:

• continuity of drug treatment, including anti-ischemic, antithrombin and antiplatelet agents, fibrinolytics;
• early hospitalization with continuous ECG monitoring at the first signs of risk of developing acute coronary syndrome (prolonged! Discomfort or pain in the chest, presence of ECG changes, etc.);
• coronary revascularization (restoring the patency of the damaged artery) using thrombolytic therapy, balloon angioplasty or coronary artery bypass grafting;
• improvement of metabolic processes in the myocardium, limitation of the area of ischemic damage and necrosis;
• prevention of arrhythmias and other complications of acute coronary syndrome;
• remodeling of the left ventricle and vessels.

The basis of drug therapy for angina is nitrates. These drugs improve the ratio between oxygen delivery to the heart muscle and its consumption by unloading the heart (by dilating the veins, they reduce the blood flow to the heart and, on the other hand, by dilating the arteries, they reduce the afterload). In addition, nitrates dilate normal and atherosclerotic coronary arteries, increase collateral coronary blood flow and inhibit platelet aggregation. Nitroglycerin, due to its rapid destruction in the body, can be taken during an ongoing attack of angina after 4-5 minutes, and during a repeated attack - after 15-20 minutes.

When prescribing the drug for the first time, it is necessary to study its effect on the blood pressure level: the appearance of weakness and dizziness in the patient usually indicates a significant decrease in it, which is important for people suffering from severe coronary sclerosis. At first, nitroglycerin is prescribed in small doses (1/2 tablet containing 0.5 mg of nitroglycerin). If there is no effect, this dose is repeated 1-2 times. It is possible to recommend the combination proposed by B. E. Votchal: 9 ml of 3% menthol alcohol and 1 ml of 1% alcohol solution of nitroglycerin (5 drops of the solution contain half a drop of 1% nitroglycerin). Patients with attacks of angina pectoris and low blood pressure are simultaneously injected with nitroglycerin subcutaneously cordiamine or mesaton in a small dose.

Prolonged-action nitrates are most indicated for patients with angina pectoris with left ventricular dysfunction, bronchial asthma, and peripheral arterial diseases. To maintain effectiveness, repeated administration of the drug is recommended no earlier than 10-12 hours later. Prolonged-action nitrates can increase intraocular and intracranial pressure, so they are not used in patients with glaucoma.

Beta-blockers have an antianginal effect due to their effect on blood circulation and energy metabolism in the heart muscle. They slow down the heart rate, reduce blood pressure and myocardial contractility. Drugs in this group reduce the frequency of angina attacks and can prevent the development of myocardial infarction and sudden death.

In geriatrics, selective beta-blockers are most often used: atenolol (atenoben) 25 mg once a day, betaxolol (lacren) 5 mg per day, etc., which have selective action and are easy to use. Less commonly used are non-selective beta-blockers: propranolol (acaprilin, obzidan) 1-10 mg 2-3 times a day, pindolol (visken) 10 mg 2-3 times a day.

Limitations to the use of beta-adrenergic blockers are: severe heart failure, atrioventricular blocks, bradycardia, peripheral arterial circulatory failure, obstructive bronchitis and asthma, diabetes mellitus, dyslipidemia, depression.

Calcium antagonists are strong dilators of coronary and peripheral arteries. Drugs of this group cause the reverse development of left ventricular hypertrophy, improve the rheological properties of blood (reduce platelet aggregation and blood viscosity, increase the fibrinolytic activity of plasma). These drugs are indicated for patients with ischemic brain disease, hyperlipidemia, diabetes mellitus, chronic obstructive pulmonary diseases, mental disorders. Verapamil is often used for tachyarrhythmias and diastolic heart failure (daily dose of 120 mg in 1-2 doses).

ACE inhibitors have a vasodilatory effect, leading to remodeling of not only the heart, but also blood vessels. This effect is extremely important, since by reducing myocardial hypertrophy, it is possible to increase the coronary reserve and reduce the risk of developing such cardiovascular diseases as sudden death (by 3-6 times), stroke (by 6 times). Restoration of the vascular wall slows down the development of arterial hypertension and ischemic heart disease. ACE inhibitors help to reduce the secretion of aldosterone, increase the excretion of sodium and water, reduce pulmonary capillary pressure and end-diastolic pressure in the left ventricle. They increase life expectancy and physical performance.

The drugs in this group include: prestarium at a dose of 2-4-6 mg once a day, captopril (capoten) at a dose of 6.25 mg once a day; enalaprip (enap) at a dose of 2.5 mg once a day.

Special indications for the use of ACE inhibitors include: manifestations of heart failure, previous myocardial infarction, diabetes mellitus, high plasma renin activity.

Peripheral vasodilators used for coronary heart disease in elderly people include molsidomine, which reduces venular tone and, thus, preload on the heart. The drug improves collateral blood flow and reduces platelet aggregation. It can be used to relieve (sublingually) and prevent angina attacks (orally 1-2-3 times a day).

In patients with coronary insufficiency who suffer from diabetes, blood sugar levels should not be reduced sharply. Particular caution is required in reducing the amount of carbohydrates in food and in prescribing insulin; otherwise, hypoglycemia may occur, which has a negative effect on metabolic processes in the heart.

For the prevention and treatment of coronary insufficiency in geriatric practice, rational organization of work, physical activity in an appropriate volume, diet and nutrition regimen, rest, etc. are of great importance. Therapeutic gymnastics, walks and other types of active recreation are recommended. These measures are indicated even in cases where their implementation is possible only with the condition of preliminary intake of antianginal drugs.

The general principles of treating patients in the acute period of myocardial infarction are: limiting the work of the heart, alleviating and removing pain or suffocation, mental stress, conducting therapy to maintain the function of the cardiovascular system and eliminate oxygen starvation of the body; prevention and treatment of complications (cardiogenic shock, cardiac arrhythmia, pulmonary edema, etc.).

When administering pain relief therapy to elderly patients, it is necessary to take into account the increased sensitivity to narcotic analgesics (morphine, omnopon, promedol), which in large doses can cause depression of the respiratory center, muscle hypotension. To enhance the analgesic effect and reduce side effects, they are combined with antihistamines. If there is a risk of depression of the respiratory center, cordiamine is administered. It is advisable to combine analgesics (fentanyl) with neuroleptic drugs (droperidop). In myocardial infarction, anesthesia with a mixture of nitrous oxide (60%) and oxygen (40%) is effective. Its effect is potentiated by small doses of morphine, promedol, omnopon, haloperidol (1 mg of 0.5% solution intramuscularly).

It is advisable to use heparin and fibrinolytic agents in complex therapy for myocardial infarction in elderly and senile people with some reduction in their doses and with particularly careful monitoring of the level of the prothrombin index of the blood, clotting time and urine analysis (the presence of hematuria).

The use of cardiac glycosides in the acute period of myocardial infarction is controversial. However, clinicians believe that they are indicated for elderly and senile patients with acute myocardial infarction even without clinical manifestations of heart failure.

Myocardial infarction in the elderly and care

In the first days of acute myocardial infarction, the patient must certainly adhere to strict bed rest. On the doctor's instructions, the nurse can turn the patient on his side. Urination and defecation are performed in bed. It is necessary to explain to the patient the danger of actively changing position, the inadmissibility of using the toilet. It is necessary to monitor bowel function, since constipation is often observed during bed rest. To prevent stool retention, it is necessary to include in the diet fruit juices with pulp (apricot, peach), dried apricot and raisin compotes, baked apples, beets and other vegetables and fruits that stimulate intestinal peristalsis. Taking mild laxatives of plant origin (buckthorn, senna preparations), slightly alkaline mineral waters can be used to combat constipation.

An important role belongs to medical personnel in providing mental peace to the patient. In each individual case, the issue of visits, sending letters and telegrams, the possibility of taking those foods that are brought to the patient is decided.

In the first days of acute myocardial infarction, especially if there is pain in the heart, the patient is given several small portions (1/4-1/3 cup) of easily digestible food. Limit the consumption of table salt (up to 7 g) and liquid. The patient should not be forced to eat.

In the following days, prescribe mashed cottage cheese, steamed cutlets, vegetables and fruits in the form of puree with a sharply reduced energy value and limited fluid (600-800 ml). Do not give sweets and dishes that cause bloating, which negatively affects the function of the heart. Meals should be fractional. The energy value is increased as the patient's condition improves: gradually, due to products containing complete proteins (meat, boiled fish) and carbohydrates (porridge, black bread, raw mashed fruits, etc.).

With a favorable course of the disease, from the 2nd week the necrotic area of the heart is replaced by connective tissue - scarring. The duration of this period is 4-5 weeks.

By the end of the second week, a period of clinical stabilization with relative restoration of blood circulation occurs. Signs of severe cardiac and vascular (sharp hypotension) insufficiency disappear, angina attacks decrease or disappear, tachycardia and arrhythmia cease, body temperature normalizes, and positive dynamics are observed on the ECG.

In cases of mild myocardial infarction, strict bed rest is gradually discontinued to eliminate the possibility of collapse or heart failure when the patient moves from a horizontal to a vertical position. Partial change of bed rest (allowing the patient to sit in a comfortable chair), however, does not mean that the patient can get up and walk around the room.

With the abolition of strict bed rest, elements of physical activity and therapeutic exercise (exercise therapy) are gradually introduced.

At the same time, it is necessary to exercise great caution in determining the volume of physical exercise, starting, as a rule, with small loads and gradually increasing the intensity of physical exercise under the control of the functional indicators of the cardiovascular system.

Physical exercise should be stopped immediately if discomfort or fatigue occurs.

Heart rhythm disturbance (arrhythmia) is a common manifestation of cardiosclerosis in the elderly and old age. A distinction is made between arrhythmia: extrasystolic, atrial and heart block. In most cases, these types of arrhythmia can be determined by palpating the pulse and listening to the heart. For a more complete diagnosis, an electrocardiographic examination is always necessary. However, it is necessary to take into account that arrhythmia is a common symptom of myocardial infarction. In this regard, the occurrence of arrhythmia in people over 50 years of age, especially after an attack of pain or other unpleasant sensations in the heart area or behind the breastbone, shortness of breath - should always be considered as a possible manifestation of severe heart damage, in many cases requiring urgent hospitalization, strict bed rest.

When monitoring an elderly patient, it should be remembered that arrhythmia can be provoked by the following factors:

• acute hypoxia, ischemia and myocardial damage;
• electrolyte disturbances (hypokalemia, hypercalcemia, hypomagnesemia);
• congestive heart failure, cardiomegaly (enlarged heart);
• transient metabolic disorders (for example, diabetes mellitus);
• nervous excitement (isolated and in neuroses);
• acidosis, respiratory disorders;
• a sharp increase or decrease in blood pressure;
• alcohol consumption, smoking, abuse; coffee or tea;
• imbalance of sympathetic and parasympathetic activity;
• polypharmacy, arrhythmogenic action of antiarrhythmic drugs, cardiac glycosides
• volume overload of the myocardium, arrhythmogenic changes in the myocardium of the left ventricle.

The most severe disturbances of cardiac function are observed in atrial fibrillation (with an irregular pulse, when the number of heartbeats exceeds 100 per 1 min). In this type of arrhythmia, which especially often accompanies myocardial infarction, it is often difficult to judge the heart rate (HR) by the pulse, since many of them, arising from incomplete filling of the ventricles of the heart with blood, do not produce a pulse wave of sufficient power to reach the peripheral sections of the vessels. In these cases, they speak of a pulse deficit. The magnitude of the deficit, that is, the difference in the number of heart contractions determined by listening to it and palpating the pulse, is greater, the more pronounced the disturbance of cardiac function.

Having detected arrhythmia in a patient, a nurse should put him to bed, and for a bedridden patient prescribe a strict regimen and ensure an urgent examination by a doctor. Recording an electrocardiogram, treatment is prescribed strictly individually. It is necessary to treat the underlying and concomitant diseases, eliminate factors that provoke and aggravate arrhythmia (ischemia, hypoxia, electrolyte disturbances, etc.), special antiarrhythmic treatment - suppression of cardiac rhythm disturbances and their secondary prevention: use of antiarrhythmic drugs, electropulse therapy, electrical cardiac stimulation and/or surgical methods of treatment.