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Coronary heart disease is a common and serious condition in patients aged over 80 years. The presenting clinical symptoms are all the more atypical and the prognosis poorer when it occurs in patients with multiple comorbid diseases. The presence of comorbidities dictates the need for a standardized geriatric assessment to screen for the existence of underlying frailty. The available scientific data were obtained during studies that included few subjects aged over 80 years. These recommendations are therefore mainly extrapolated from results obtained in younger populations. The pharmacological management and revascularization strategy for coronary heart disease in octogenarians is basically the same as in younger subjects. Epidemiological studies all concur that available therapies are underutilized despite the fact that this population has a high cardiovascular risk. Specific precautions for use must be respected because of the comorbidities and age-related changes in pharmacokinetics or pharmacodynamics. Generally, the therapeutic strategy in coronary heart disease is based not on the patient's real age, but rather on an individual analysis taking into account the severity of the coronary disease, comorbidities, the risk of drug misadventures, patient life expectancy and quality of life.

Hypertension constitutes a recognized risk factor of vascular dementia but also of Alzheimer-type dementia. Various longitudinal studies showed that midlife blood pressure level is one of the factors conditioning the onset of dementia syndrome in late life. The high risk of dementia is linked to leukoaraiosis, vascular rigidity, microcirculation disorders, oxidative stress, blood pressure fluctuations including orthostatic hypotension and strokes, all of those being associated with hypertension. Numerous clinical trials showed the positive effect of effective treatment of hypertension on the prevention of cognitive disorders and dementias. Thus, screening and early management of dementia and cognitive decline, in particular in the hypertensive subject, are essential. The Mini-Mental State Examination (MMSE) is a major first-intention screening test because it allows a full assessment of cognitive aptitudes. If cognitive decline is suspected and the MMSE score is considered to be abnormal, the elderly subject must be sent to a specialist or a referent memory centre; the MMSE is only a first stage in the diagnostic reasoning. MMSE should be included in the follow-up of all hypertensive elderly subjects and should be performed once a year by the general practitioner.

Objective: The aim of this review of the literature is to report the factors which both contribute to the frailty syndrome and increase hip fracture risk in the elderly. This work is the fruit of common reflection by geriatricians, endocrinologists, gynecologists and rheumatologists, and seeks to stress the importance of detection and management of the various components of frailty in elderly subjects who are followed and treated for osteoporosis. It also sets out to heighten awareness of the need for management of osteoporosis in the frail elderly., Design: The current literature on frailty and its links with hip fracture was reviewed and discussed by the group., Results: The factors and mechanisms which are common to both osteoporosis and frailty (falls, weight loss, sarcopenia, low physical activity, cognitive decline, depression, hormones such as testosterone, estrogens, insulin-like growth factor-I (IGF-I), growth hormone (GH), vitamin D and pro-inflammatory cytokines) were identified. The obstacles to access to diagnosis and treatment of osteoporosis in the frail elderly population and common therapeutic pathways for osteoporosis and frailty were discussed., Conclusion: Future research including frail subjects would improve our understanding of how management of frailty can can contribute to lower the incidence of fractures. In parallel, more systematic management of osteoporosis should reduce the risk of becoming frail in the elderly population.

Unstable angina and acute coronary syndromes (ACS) without ST-segment elevation are frequent in the elderly and is associated to a very poor prognosis. The cause of mortality excess in the elderly has not yet been fully elucidated, even though the numerous comorbidities present in this age range play a non-negligible role. In every case, age is the most powerful prognostic factor for ACS without ST-segment elevation. The presentation and clinical characteristics of coronary disease in the elderly are particular and are essential to be recognized. Patients are mostly women with history of heart failure and myocardial infarction, and risk factors are predominantly diabetes and hypertension. The usual presentation is a "silent" MI or with atypical symptoms. Instead of typical chest pain, the coronary artery disease will be presented by dyspnea, neurological symptoms such as confusion, cognitive disorders aggravation, digestive disorders. This atypical presentation will have direct consequences on the therapeutic management of ACS, and sometimes it will even remain undiagnosed, and these explain also why complications will be more severe than in younger counterparts. Due to this atypical presentation, the physician should be careful and suspect an ACS in case of any non-explicated modification of physical and behavioral change in the elderly.

Purpose: The prevalence or hypertension increases with aging, reaching more than 50% in people aged 60 years and older. The increase of systolic blood pressure is a major risk of cardiovascular event., Methods: With the aim of assessing risk factors in old people "in apparent good health", we analysed blood pressure and treatments in people aged 60 years and older who had a periodic check-up that was adapted to older people., Results: This check-up concerned, between April and December 2003, 1638 people with a mean age of 68 years (SD 5.7): 815 men and 823 women. Fourty percent had a systolic blood pressure (SBP) >or=140 mmHg (44% of men, 36% of women); 6% (8% of men, 4% of women) had a diastolic blood pressure (DBP) >or=90 mmHg. A treatment for hypertension was followed by 473 people: 31% of men and 26% of women. Fifty percent were controlled for the SBP and the DBP. Fourty-two percent were not controlled for the SBP, but were controlled for the DBP. Seven percent were not controlled for the SBP nor the DBP. Only 3 subjects (<1%) were not controlled for the DBP, whereas they were controlled for SBP., Conclusion: These results, combined with data of literature on the predominant role of SBP in cardio-vascular risk, as compared with DBP, underline the need for a better treatment of systolic hypertension in older people.

We evaluated the prevalence, risk factors and impact on all-cause mortality of the metabolic syndrome (MetS) and its components in a large French population. The study population consisted of subjects aged 40 years or more who volunteered for a free health check-up at the IPC Center (Investigations Préventives et Cliniques, Paris) between 1999 and 2002. There were 40 977 men (53.2 +/- 9.1 years) and 21 277 women (55.9 +/- 10.3 years). The cutoff date for mortality data was March 2004. The mean follow-up period was 3.57 +/- 1.12 years. During this period, 271 men and 87 women died. MetS was defined according to NCEP-ATP III criteria. Cox regression models were used to evaluate the risk of death [hazards ratio (95% CI)]. MetS was present at baseline in 11.8% of men and 7.6% of women. The prevalence of MetS increased from 9% in men aged 40 to 49 years to 12.5% in men aged 70 years. In women, the prevalence rose from 4.9% to 11.3%, respectively. From 1999 to 2002, the prevalence of MetS increased from 11.0% to 12.8% in men and from 7.2% to 8.8% in women. The following clinical and biological parameters were significantly associated with MetS in men and women, after adjustment for age: lower physical activity, lower vital capacity ratio, higher pulse pressure and heart rate, higher gamma-glutamyl transpeptidase, ASA and ALA transaminase and alkaline phosphatase levels, higher uricemia, leukocyte and globulin levels, dental and gingival inflammation, and higher stress and depression scores. After adjustment for age, the excess risk of all-cause mortality in subjects with MetS compared to subjects without MetS was 1.82 (1.35-2.43) in men and 1.80 (1.01-3.19) in women. After adjustment for age, gender, smoking, cholesterol, physical activity, socioeconomic status and prior cardiovascular disease, the risk of all-cause mortality was 1.69 (1.28-2.22) in the entire population. In order to evaluate the impact of each Mets component, and combinations of three MetS components, on all-cause mortality, a control group of subjects with no MetS components was used. After adjustment for age and gender, the risk of death associated with each MetS component was 2.36 (1.65-3.37) for high waist circumference, 2.08 (1.44-3.01) for elevated triglyceride levels, 1.71 (1.07-2.72) for low HDL-cholesterol levels, 1.75 (1.29-2.38) for elevated arterial pressure, and 2.93 (2.04-4.22) for elevated glucose levels. Waist circumference + elevated triglycerides + elevated glucose was the three-component combination with the strongest impact [HR = 4.95 (2.92-8.37)]. In this large French population, in which MetS was moderate, MetS was associated with other hemodynamic, hepatic, inflammatory and psychological risk factors, and with a 70% increase in all-cause mortality. The three-component combination most strongly associated with mortality was high waist circumference + elevated glucose + elevated triglycerides.

Background: Epidemiological studies have shown that increased arterial stiffness and wave reflections, major determinants of systolic and pulse pressure, are associated with morbidity and mortality. Therapeutic trials based on cardiovascular mortality have recently shown that reduction of systolic blood pressure (SBP) requires normalization of both large-artery stiffness and wave reflections., Aims: To compare the antihypertensive effects of the very-low-dose combination of perindopril (2 mg) and indapamide (0.625 mg) (one or two tablets per day) with the beta-blocking agent atenolol (50 mg; one or two tablets per day) in order to determine whether the combination decreased SBP and pulse pressure more than did atenolol, and whether this decrease occurred in relation to a reduction in arterial stiffness [aortic pulse wave velocity (PWV)] or a decrease in the intensity of, or delay in, wave reflections (augmentation index, measured by applanation tonometry) or a combination of both., Material and Methods: This was a double-blind randomized study in 471 individuals with essential hypertension followed for 12 months. Arterial pressure was measured in the brachial artery (mercury sphygmomanometer) and in the carotid artery (applanation tonometry)., Results: For the same reduction in diastolic blood pressure (DBP), the combination of perindopril and indapamide decreased brachial SBP and pulse pressure significantly more than did atenolol (adjusted differences between groups -6.2 +/- 1.5 and -5.5 +/- 1.0 mmHg, respectively; P < 0.001). This difference was even more pronounced for the carotid than for the brachial artery. Whereas both antihypertensive agents similarly decreased PWV, only the combination significantly attenuated wave reflections., Conclusion: Normalization of SBP, pulse pressure and arterial function--a haemodynamic profile known to improve survival significantly in hypertensive populations at high cardiovascular risk--was achieved to a greater extent with a very-low-dose combination of perindopril and indapamide than with atenolol.

Several studies have attempted to assess the effect of the heart rate on cardiovascular and non-cardiovascular mortality. The best known of these, the Framingham study, showed that an increased heart rate was associated with an increased frequency of sudden death. This study also demonstrated that the rôle of the heart rate in cardiovascular complications, especially coronary artery disease, was even greater in hypertensive patients. Nevertheless, in the other studies, when the results are corrected for other cardiovascular risk factors, the heart rate becomes insignificant. The patients with the highest heart rates often have other risk factors, especially hypertension and hypercholesterolaemia. The first large scale French trial was carried out on the data base of the Centre of Preventive and Clinical Investigations. This Centre, recognised by the Ministry of Health and Social Security, carries out 25,000 check-ups each year and has been working for the last 25 years. The check-up includes clinical, biological and radiological investigations. A significant relationship was observed between the heart rate and most of the classical cardiovascular risk factors in both sexes. Subjects with the highest heart rates (> 85 beats/min) compared with those with the lowest heart rates (< 65 beats/min) had higher systolic blood pressures by 12 mmHg and diastolic blood pressures by 7 mmHg. Similarly, most of the patients with tachycardia had higher plasma cholesterol, triglyceride and sugar levels. It was also demonstrated that rapid heart rates in men were associated with increased cardiovascular and non-cardiovascular mortality. In women, a relationship between the heart rate and cardiovascular mortality was not demonstrated. On the other hand, the heart rate was associated with non-cardiovascular mortality. The association between heart rate and cardiovascular mortality in men was mainly explained by a large increase in coronary mortality in those with the fastest heart rates. After adjustment for the other known risk factors, the increase in risk corresponding to a heart rate 20 beats/min faster was 40% for cardiovascular mortality. These epidemiological findings may be explained by at least two mechanisms: a) the increase in the number of heart beats increases the myocardial oxygen requirements, accelerate arterial fatigue and may provoke rupture of constituted atheromatous plaques; b) the increase in heart rate is a sign of increased sympathetic activation which may have negative effects on the cardiovascular system, especially the coronary circulation. In the light of these epidemiological and physiopathological data, the value of lowering the heart rate in high risk patients, especially hypertensive patients with rapid heart rates, remains to be demonstrated.

In a randomized double blind study, the arterial changes produced either by hydrochlorothiazide plus amiloride (Group I), or by hydrochlorothiazide plus captopril (Group II) were investigated in two territories of the arterial tree, the common carotid artery and the terminal aorta. Arterial echo-tracking techniques of high resolution and applanation tonometry were used to evaluate non-invasively the indices of arterial stiffness and carotid wave reflections. In Group I and II, there was a similar significant decrease in brachial blood pressure (BP) and carotid diastolic diameter and an increase in aortic compliance and distensibility. Groups I and II differed significantly in aortic diastolic diameter which decreased in Group I but not in Group II, and in carotid wave reflections which were modified in Group II but not in Group I. Thus, captopril associated with hydrochlorothiazide resulted in a shift in the carotid arterial reflection wave from systole to diastole with no reduction in the aortic diastolic dimension. For similar BP reduction, the combination of hydrochlorothiazide and amiloride had no significant effect on the carotid reflection wave, but caused a significant reduction in the aortic diastolic diameter. These intergroup differences were related to the presence or absence of converting enzyme inhibition.