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Underlying causes of ventricular tachycardia (VT) or complex ventricular arrhythmias (VA) should be treated if possible. Antiarrhythmic drugs should not be used to treat asymptomatic persons with complex VA and no heart disease. Beta blockers are the only antiarrhythmic drugs that have been demonstrated 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 therapy 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.

After an MI, elderly persons should have their modifiable coronary artery risk factors--such as hypertension, dyslipidemia, and diabetes--intensively treated. Aspirin or clopidogrel, beta-blockers, and ACE inhibitors should be given indefinitely, unless contraindications exist. Long-acting nitrates are effective antianginal and anti-ischemic drugs. There are no Class I indications for the use of calcium channel blockers after MI. Postinfarction patients should not receive Class I antiarrhythmic drugs, sotalol, or amiodarone. Those at very high risk for sudden cardiac death should have an implantable cardioverter-defibrillator. Hormonal therapy should not be used in postmenopausal women after MI. The indications for coronary revascularization are prolongation of life and relief of unacceptable symptoms despite optimal medical management.

Peripheral arterial disease (PAD) in the elderly can be: 1) asymptomatic, 2) associated with intermittent claudication, or 3) cause critical limb ischemia. Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease (CAD). Hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism should be treated, and smoking should be stopped. Statins reduce the incidence of intermittent claudication and increase exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs (eg, aspirin, clopidogrel, angiotensin-converting enzyme [ACE] inhibitors, statins) should be given to all persons with PAD. Beta blockers should be given if CAD is present. Exercise rehabilitation programs and cilostazol lengthen exercise time until leg pain develops. Chelation therapy has no scientific basis and should be avoided. Revascularization or amputation may be indicated in some cases.

Using statins to treat older men and women with coronary artery disease (CAD) and hypercholesterolemia reduces the risk of all-cause mortality, cardiovascular mortality, coronary events, coronary revascularization, stroke, Intermittent claudication, and congestive heart failure. The target serum low-density lipoprotein (LDL) cholesterol level is < 100 mg in older patients with CAD, prior stroke, peripheral arterial disease, extracranial carotid arterial disease, abdominal aortic aneurysm, diabetes meilitus, and the metabolic syndrome. Statins are also effective in reducing cardiovascular events in older persons with hypercholesterolemia without cardiovascular disease. Consider using statins in older persons without cardiovascular disease but with a serum LDL cholesterol > or = 130 mg/dL, or a serum high-density lipoprotein cholesterol < 50 mg/dL. Data from the Heart Protection Study favor treating patients at high risk for vascular events with statins regardless of age or initial serum lipids.

Hormone replacement therapy (HRT) has long been a staple of management of the postmenopausal life phase. Over time, and after estrogen therapy was modified to include progestin, an increasing number of observational reports suggested that HRT conferred benefits well beyond those of managing or minimizing not flashes, mood swings, and vaginal dryness. In short, HRT was believed to improve women's health and even extend life. One of the most significant theorized benefits was protection against cardio- and cerebrovascular events. Other benefits--protection against osteoporosis, reduction in incontinence symptoms, and improved cognition--have also been linked with HRT. The validity of these theories depended largely on observational studies and anecdotal reports, and only lightly (or not at all) on randomized clinical trial data. Nevertheless, significant clinical data refuting HRT's proposed benefits has been available for several years. Findings from these investigations, including new results from two very large trials, show that beyond managing traditional menopause symptoms, HRT has little or no role in protection against certain diseases or conditions associated with aging. Indeed, long-term use of HRT may be contraindicated in most older women with intact uteruses.

Mitral annular calcification (MAC) is a degenerative process which commonly occurs in the elderly and has multiple etiologies. Patients with MAC have a higher prevalence of left atrial enlargement, left ventricular enlargement, atrial fibrillation, conduction defects, mitral regurgitation, mitral stenosis, hypertrophic cardiomyopathy, and bacterial endocarditis than those without it. In addition, patients with the disorder have a higher incidence of cardiovascular events, thromboembolic cerebrovascular events, permanent pacemaker implantation, and valve replacement. This review discusses the significance of these warning signs, explores updated diagnostic procedures for MAC, and recommends some therapeutic strategies.

Systolic or diastolic hypertension, cigarette smoking, diabetes mellitus, left ventricular hypertrophy, age, prior stroke, transient cerebral ischemic attack, extracranial arterial disease, and coronary heart disease are risk factors for the most common type of geriatric stroke, atherothrombotic brain infarction (ABI). Also, by contributing to hypertension and diabetes mellitus, obesity predisposes to ABI. The relationship of abnormal serum lipids and of physical inactivity to ABI is unclear. Antihypertensive treatment decreases the incidence of fatal and nonfatal stroke in patients with systolic and diastolic hypertension. Cessation of smoking also decreases risk.

Shown to be associated with new coronary events in elderly men and women are cigarette smoking, systolic or diastolic hypertension, hypercholesterolemia, low serum HDL cholesterol, increased ratio of serum total cholesterol to serum HDL cholesterol, hypertriglyceridemia, diabetes mellitus, obesity, physical inactivity, increased age, prior coronary artery disease, and electrocardiographic and echocardiographic left ventricular hypertrophy. The greater the number of major coronary risk factors, the higher the incidence of new coronary events. Risk factor modification should therefore be considered in elderly persons.