Myocardial infarction in the elderly

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

In elderly people there are different forms of manifestation of IHD - 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 elderly people and focal dystrophy of the myocardium). In pathogenesis it is necessary to take into account the age-related changes predisposing to the development of IHD:

1. The adaptive function of the cardiovascular system decreases, its unconditioned reflex reactions to stimuli of various kinds-muscular activity, stimulation of interoceptors (change in body position, eye-heart reflex), light, sound, pain stimulation-old people have a large patent period, are much less pronounced. Relative sympathicotonia arises, sensitivity to neurohumoral factors increases - this leads to frequent development of spastic reactions of sclerosed vessels. The trophic influence of the nervous system is weakened.
2. The activity of humoral and cellular immunity decreases, incompleteness of immune reactions leads to circulating in the blood of immune complexes, which can damage the intima of the arteries.
3. Increased blood levels of beta-lipoproteins, triglycerides, cholesterol; decrease in cholesterol release by the liver, lipoprotein lipase activity (enzyme that destroys lipoproteins).
4. Decreased tolerance to carbohydrates.
5. The functions of the thyroid gland, gonads decrease, the reactivity of sympathic-adrenal and renin-aldosterone systems increases, the level of vasopressin increases in blood.
6. Chronic activation of the blood clotting system and functional deficiency of anticoagulant mechanisms under stress conditions.
7. The diet 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 for cardiac muscle in oxygen increases because of its age-related hypertrophy. Elimination of risk factors IHD can increase the life expectancy of the elderly by 5-6 years, the elderly for 2-3 years.

[1], [2], [3], [4]

How is myocardial infarction manifested in the elderly?

Long-term clinical observations have shown that stable angina characterized by persistence of clinical manifestations (character, frequency, duration of pain syndrome) is the most frequent form of IHD in patients over 60 years old.

Stable angina may turn into unstable angina, but this form is less common than in middle age. In the elderly and senile age, spontaneous angina is rarely observed, the pathogenesis of which is caused by spasm of the coronary vessels.

Pain syndrome with stable angina may be typical. Pain in the heart area in people over 50 is mainly a symptom of coronary heart disease (CHD). Attacks of pain in the heart can be a manifestation of chronic coronary artery disease 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 the construction of rational therapy. It should be taken into account, however, that the diagnosis of pain in the region of the heart due to osteochondrosis of the cervical spine does not exclude the diagnosis of angina caused by ischemic heart disease. Both these diseases are a manifestation of pathology, frequent for people of middle age, elderly and senile age.

Myocardial infarction in the elderly has its own peculiarities, which are manifested by the absence of its bright emotional coloration. Progressively, with increasing age, atypical signs of coronary artery insufficiency increase (they occur in 1/3 of elderly people and in 2/3 patients with IHD in old age).

Atypical angina may manifest itself:

• Equivalents of pain:
  • paroxysmal inspiratory or mixed dyspnea, sometimes accompanied by coughing or coughing;
  • interruptions in the work of the heart, palpitation, paroxysms of tachy- and bradyarrhythmias;
  • a low-intensity feeling of heaviness in the region of the heart with physical exertion, excitement disappearing at rest or after taking nitroglycerin.
• Change in the localization of pain:
  • peripheral equivalent without a retrosternal component: discomfort in the left arm ("left hand myth"), scapula area, 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.
•  Changing the time of appearance and duration of pain:
  • "Delayed manifest (pain) syndrome" - from several tens of minutes to several hours.
• Presence of nonspecific symptoms:
  • attacks of dizziness, fainting, general weakness, a feeling of faintness, sweating, nausea.

In elderly and senile people, the incidence of painless myocardial ischemia (BIM) is increasing. . This is facilitated by the use of drugs that reduce pain sensitivity - such, for example, as nifedipine, verapamil and prolonged nitrates.

BIM is a transient impairment of the blood supply to the heart muscle, of any degree, without a typical stenocardic attack or its clinical equivalents. BIM is detected during ECG monitoring (Holter), constant recording of left ventricular function and exercise test. On coronarography, these individuals often have narrowing of the coronary arteries.

In many people of the "third age" the aggravation of coronary insufficiency is associated with an increase in blood pressure. In a number of cases, the neurological symptomatology due to the insufficiency of cerebral circulation in the basin of a vessel, to the fore in the vertebrobasilar region, comes to the fore.

To provoke a myocardial infarction in the elderly can meteorological factors, for example, significant changes in the atmospheric pressure of temperature or humidity.

Abundant food, causing overflow and swelling of the intestines, is also often a provoking factor in angina pectoris. The fat load that causes alimentary hyperlipitemia in elderly and old people activates the blood coagulation system, so after taking even a small amount of fatty foods, angina pectoris may occur (especially at night).

With an angina attack lasting more than 15 minutes, one should think about such an urgent condition 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. The peculiarity of MI in elderly and senile patients is more frequent development of subendocardial necrosis with the emergence of recurrent forms.

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

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

Myocardial infarction in elderly people with ST segment elevation (subepicardial), as a rule, is relatively favorable, although more often there is a recurrent course. This is the only variant of myocardial infarction without a pathological Q wave, when thrombolytic therapy is indicated.

Myocardial infarction in the elderly with a decrease in the relative segment ST (subendocardial), covers a relatively thin layer of the heart muscle, more often significant in area, proceeds relatively hard. Depression of the ST segment persists for several weeks. This variant of MI often develops in elderly and senile patients with severe atherosclerosis of the coronary arteries, suffering from diabetes mellitus, arterial hypertension with heart failure. It is more often repeated, can be widespread, circular, with a recurrent course, can be transformed into an infarction with a tooth 3. More often sudden death is noted.

However, the ST segment does not always appear in the acute period; changes often affect the T wave. It becomes negative in several leads, acquiring a pointed appearance. The negative T wave in the thoracic leads is often retained for many years, being a sign of transferred MI.

Echocardiographic signs of myocardial infarction in elderly patients differ from those of middle-aged people with a larger area of hypochkiniasis of the heart muscle, more frequent registration of myocardial dyskinesia, a large increase in the size of the heart chambers and a decrease in the cardiac muscle contractility.

In the diagnosis of myocardial infarction, a weaker temperature response, and often its complete absence in elderly and especially senile patients, should be taken into account. Changes in blood (an increase in the number of leukocytes, acceleration of ESR) in them are expressed) is much weaker than in young people. If the blood was examined shortly before the onset of myocardial infarction, then the obtained data should be compared in dynamics. It should be remembered that elevated ESR is often observed in almost healthy individuals and is due to a change in the protein composition of the blood that does not go beyond physiological age-related changes. In patients with suspected acute coronary heart disease, it is necessary to determine in the dynamics (after 6-12 hours) such markers of damage to the heart muscle as troponins T or I, myoglobin or creatinine phosphokinase (CKF).

How is myocardial infarction treated in the elderly?

Treatment of patients with IHD should be complex differentiated depending on the stage of the disease, the presence of complications. Its main principles for people of elderly and senile age are:

• continuity of drug treatment, including anti-ischemic, antithrombin and antiplatelet agents, fibrinolytics;
• early hospitalization with continuous ECG monitoring at the first sign of risk of developing acute coronary syndrome (prolonged discomfort or pain in the chest, presence of ECG changes, etc.);
• coronary revascularization (restoration of patency of the damaged artery) with the help of thrombolytic therapy, balloon angioplasty or coronary artery bypass grafting;
• improvement of metabolic processes in the myocardium, restriction of the zone 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 pectoris is nitrates. These drugs improve the relationship between the delivery of oxygen to the heart muscle and its consumption by discharging the heart (expanding the veins, reducing the flow of blood to the heart and, on the other hand, expanding the arteries, reduce afterload). In addition, nitrates expand normal and amazed atherosclerosis coronary arteries, increase collateral coronary blood flow and inhibit platelet aggregation. Nitroglycerin, due to rapid destruction in the body, can be taken with an ongoing attack of angina in 4-5 minutes, and when repeated - in 15-20 minutes.

Assigning the drug for the first time, you need to study its effect on the level of blood pressure: the appearance of weakness in the patient, dizziness usually punctures a significant decrease in it, which is not indifferent to persons suffering from severe coronary sclerosis. In the beginning, nitroglycerin is prescribed in small doses (1/2 tablet containing 0.5 mg of nitroglycerin). In the absence of effect, this dose is repeated 1-2 times. We can recommend a combination proposed by BE Votchal: 9 ml of 3% menthol alcohol and 1 ml of 1% alcohol solution of nitroglycerin (in 5 drops of solution contains half a drop of 1% nitroglycerin). Patients with angina attacks and low blood pressure simultaneously with nitroglycerin subcutaneously administered cordiamine or mezaton in a small dose.

Nitrates of prolonged action are most often shown by patients with angina pectoris with dysfunction of the left ventricle, bronchial asthma, diseases of peripheral arteries. To maintain the effectiveness of repeated use of the drug is recommended not earlier than 10-12 hours. Nitrates of prolonged action can increase intraocular and intracranial pressure, so they are not used in patients with glaucoma.

Antianginal action has beta-adrenoblockers due to the influence on blood circulation and energy metabolism in the heart muscle. They slow down the heart rate, reduce blood pressure and contractility of the myocardium. Drugs in this group reduce the incidence of angina attacks, can prevent development! Myocardial infarction and sudden death.

In geriatrics, selective beta-blockers are more often used: atenolol (atenoben) 25 mg once a day, betaxolol (lacrine) but 5 mg per day, etc., with selective action and ease of use. Less commonly used non-selective beta-blockers: propranolol (akaprilin, obzidan) 1 10 mg 2-3 times a day, pindolol (vecin) 10 mg 2 - 3 times a day.

Limitations to the use of beta adrenoblockers are: severe heart failure, atrioventricular blockade, bradycardia, peripheral arterial blood circulation insufficiency, obstructive bronchitis and asthma, diabetes mellitus, dyslipidemia, depression.

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

ACE inhibitors have a vasodilating effect, lead to remodeling of not only the heart, but also the vessels. This effect is extremely important, as reducing myocardial hypertrophy, you can increase the coronary reserve and reduce the risk of developing cardiovascular diseases like sudden death (3-6 times), stroke (6 times). Restoration of the vascular wall slows the development of arterial hypertension and coronary heart disease. ACE inhibitors reduce the secretion of aldosterone, increase the release 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 of this group are; Prestarium in a dose of 2-4-6 mg once a day, captopril (kapoten) in a dose of 6.25 mg once a day; enalaprip (enap) in a dose of 2.5 mg once a day.

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

The peripheral vasodilators used in IHD in the elderly include molsidomine, which reduces venous tone and, thus, preload on the heart. The drug improves collateral blood flow and reduces platelet aggregation. It can be used for cupping (sublingually) and for preventing angina attacks (inside 1-2-3 times a day).

In patients with coronary insufficiency, who suffer from diabetes mellitus, blood sugar levels can not be sharply reduced. Special care is needed in reducing the amount of carbohydrates in food and in the appointment of insulin; otherwise, hypoglycemia may occur, which adversely affects the metabolic processes in the heart.

For the prevention and treatment of coronary insufficiency in geriatric practice, the rational organization of labor, motor activity in an appropriate volume, the regimen and diet, rest, etc. Are of great importance. Therapeutic gymnastics, walks and other types of outdoor activities. These measures are shown even in cases when they are possible only if the antianginal drugs are taken beforehand.

The general principles of treatment of patients in acute myocardial infarction are: limitation of heart function, relief and relief of pain or suffocation, mental stress, therapy for the maintenance of cardiovascular function and elimination of oxygen starvation of the body; prevention and treatment of complications (cardiogenic shock, cardiac arrhythmia, pulmonary edema, etc.).

When carrying out analgesic therapy in elderly patients, it is necessary to take into account the increased sensitivity to narcotic analgesics (morphine, omnopon, promedol), capable in large doses to cause depression of the respiratory center, hypotension of muscles. To enhance the analgesic effect and reduce side effects, they are combined with antihistamines. When the threat of oppression of the respiratory center is resorted to the introduction of cordiamine. It is advisable to combine analgesics (fentanyl) with neuroleptic drugs (droperidop). With myocardial infarction, anesthesia is effective with a mixture of nitrous oxide (60%) and oxygen (40%). Its action is potentiated by small doses of morphine, promedola, omnopone, haloperidol (1 mp 0.5% solution intramuscularly).

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

The use of cardiac glycosides in the acute period of myocardial infarction causes discussion. However, clinicians believe that they are shown to patients of elderly and senile age 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, of course, must comply with strict bed rest. At the direction of the doctor, the nurse can turn it on its side. Urination and act of defecation are performed in bed. It is necessary to explain to the patient the danger of active change of position, inadmissibility of using the toilet. It is necessary to monitor the function of the intestine, since during bed rest, constipation is often observed. To prevent stool delay, it is necessary to include fruit juices in the food ration with pulp (apricot, pepper), compotes from dried apricots and raisins, baked apples, beets and other vegetables and fruits that stimulate intestinal peristalsis. Acceptance of light laxatives of vegetable origin (preparations of buckthorn, senna), weakly alkaline mineral water can be used to fight constipation.

An important role belongs to medical personnel in providing mental rest to the patient. In each individual case, the question of visits, the transfer of letters and telegrams, the possibility of receiving those foods that bring the patient.

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

In the days that follow, you designate the grated cottage cheese, steam cutlets, vegetables and fruits in the form of puree with a sharply reduced energy value and a restriction of the liquid (600-800 ml). Do not give sweets and dishes that cause bloating, which adversely affects the function of the heart. The food should be a fraction. The energy value is increased as the patient's condition improves: gradually, due to products containing high-grade proteins (meat, fish in boiled form) and carbohydrates (porridges, black bread, raw mashed fruits, etc.).

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

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

In cases of mild myocardial infarction, severe bed rest is abolished gradually to exclude the possibility of developing collapse or heart failure when the patient moves from a horizontal position to a vertical one. Partial change in bed rest (allowed 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 gradually introduced elements of motor activity, therapeutic exercise (LFK).

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

Physical exercises should be stopped immediately if discomfort or feeling tired.

Violation of the heart rhythm (arrhythmia) is a frequent manifestation of cardiosclerosis in the elderly and senile years. Distinguish arrhythmia: extrasystolic, ciliary and cardiac blockade. In most cases, these types of arrhythmia can be determined by palpation of the pulse and listening to the heart. For more complete diagnosis, an electrocardiographic study is always necessary. However, it must be taken into account that arrhythmia is a frequent symptom of myocardial infarction. In this regard, the appearance of arrhythmia in people over 50 years, especially after a bout of pain or other unpleasant sensations in the heart or behind the sternum, shortness of breath - should always be considered as a possible manifestation of severe heart damage, in many cases requiring urgent hospitalization, strict bed rest mode.

When observing an elderly patient, remember that arrhythmia can be triggered by the following factors:

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

The most severe violations of the heart are observed with atrial fibrillation (with a random pulse, when the number of heartbeats exceeds 100 per 1 minute). In this form of arrhythmia, which is often accompanied by myocardial infarction, it is often difficult to judge the heart rate (heart rate) by pulse, since many of them, arising from incomplete filling of the ventricles of the heart with blood, do not give a pulse wave of sufficient power reaching the peripheral parts of the vessels . In these cases, there is a lack of pulse. The magnitude of the deficit, that is, the difference in the number of contractions of the heart, determined when listening to and probing the pulse, is greater than the greater violation of the function of the heart.

Having found out the patient's arrhythmia, the nurse must put him to bed, and the lying patient should be prescribed a strict regime and provide an urgent examination of the doctor. Recording electrocardiograms, treatment is prescribed strictly individually. Therapy of the main and accompanying diseases, elimination of the triggers and aggravating factors (ischemia, hypoxia, electrolyte disturbances, etc.), special antiarrhythmic treatment - suppression of cardiac arrhythmias and their secondary prevention: the use of antiarrhythmics, electroimpulse therapy, electrical pacing and / or ipypsy surgical methods of treatment.