What is the management approach for elderly patients with angina, as informed by the Senior RITA (RITA: Randomized Intervention Treatment of Angina) trial?

Management of Angina in Elderly Patients: Insights from the Senior RITA Trial

Elderly patients with angina benefit equally from medical therapy, angioplasty, and bypass surgery as younger patients, but treatment should begin with optimal medical management and progress to interventional strategies when symptoms persist. 1

Assessment and Diagnostic Approach in Elderly Patients

• Exercise electrocardiographic testing should remain the initial diagnostic test in elderly patients with suspected coronary artery disease (CAD), unless they cannot exercise, in which case pharmacological stress imaging is appropriate 1
• The evaluation of chest pain in the elderly can be challenging due to atypical presentations, comorbidities, and reduced activity levels that may mask symptoms 1
• Elderly patients (≥65 years) with atypical symptoms and those with typical angina have similar 3-year cardiac mortality rates, highlighting the importance of thorough evaluation regardless of presentation 1
• Functional capacity is often compromised in elderly patients due to muscle weakness and deconditioning, requiring modified exercise protocols 1

Medical Therapy for Elderly Patients with Angina

• Anti-anginal medications are as efficacious in reducing symptoms in elderly patients as they are in younger patients 1
• Beta-blockers should be strongly considered as initial therapy for chronic stable angina in elderly patients due to their beneficial effects on morbidity and mortality 1
• Nitrates are effective for symptom relief in elderly patients with exertional angina 1
• Calcium channel blockers (such as nifedipine, nicardipine, felodipine) are appropriate alternatives when beta-blockers are contraindicated or not tolerated 1
• Ranolazine may be considered for elderly patients with persistent symptoms, with dose selection starting at the low end of the dosing range 2
• Aspirin (75-325 mg daily) should be used routinely in all elderly patients with stable angina without contraindications 1

Special Considerations for Medication in the Elderly

• Prescribing for elderly patients requires careful attention to drug interactions, polypharmacy, and compliance problems 1
• Patients ≥75 years of age on certain medications may have a higher incidence of adverse events, serious adverse events, and drug discontinuations due to adverse events 2
• Dose selection for elderly patients should usually start at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and concomitant disease or other drug therapy 2
• Monitor renal function periodically in elderly patients with moderate to severe renal impairment 2

Revascularization Strategies in Elderly Patients

• Elderly patients with objective evidence of moderate to severe ischemia on non-invasive testing should have similar access to coronary arteriography as younger patients 1
• Diagnostic coronary arteriography has relatively little increased risk in older patients undergoing elective evaluation compared to younger patients 1
• The RITA trials demonstrated that elderly patients have the same benefit from medical therapy, angioplasty, and bypass surgery as younger patients in terms of mortality and symptom relief 1
• In the RITA-3 trial, an interventional strategy showed benefit over a conservative strategy in unstable coronary artery disease, with a halving of refractory or severe angina 3
• The RITA-2 trial showed that an initial strategy of PTCA (percutaneous transluminal coronary angioplasty) did not influence the risk of death or MI but improved angina and exercise tolerance compared to medical therapy 4, 5

Algorithm for Management of Angina in Elderly Patients

1. Initial Assessment:

   • Confirm diagnosis with exercise ECG testing (or pharmacological stress imaging if unable to exercise) 1
   • Assess severity of symptoms and impact on quality of life 1
   • Evaluate comorbidities that may affect treatment decisions 1, 6

2. First-Line Approach:

   • Optimize medical therapy with antiplatelet agents, beta-blockers, and nitrates 1
   • Address modifiable risk factors (hypertension, diabetes, dyslipidemia) 1
   • Recommend lifestyle modifications (smoking cessation, appropriate diet, and exercise) 1

3. If Symptoms Persist Despite Optimal Medical Therapy:

   • Consider coronary angiography for patients with moderate to severe ischemia on non-invasive testing 1
   • Proceed with revascularization (PCI or CABG) if anatomy is suitable 1
   • For refractory angina not amenable to standard revascularization, consider specialized treatment approaches 1

Common Pitfalls and Caveats

• Underuse of diagnostic tests and therapeutic interventions in elderly patients due to age bias should be avoided 1
• Age >75 years is an important predictor of contrast-induced nephropathy during angiography, requiring appropriate preventive measures 1
• Elderly patients may have atypical presentations of angina, making diagnosis challenging and potentially leading to undertreatment 1, 7
• The higher prevalence of disease in elderly patients means that more exercise test results may be false-negative, requiring careful interpretation 1

By following this evidence-based approach, clinicians can effectively manage angina in elderly patients, improving both symptoms and outcomes while minimizing risks associated with treatment.