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The heart is a muscular pump that sends blood throughout the body. Blood enters the heart through veins and leaves through two major arteries:
The right side of the heart pumps blood through the pulmonary artery to the lungs, where it picks up oxygen. The left side of the heart pumps blood through the aorta to the rest of the body. The upper part of the heart consists of the right and left atria. The lower part of the heart consists of the right and left ventricles. Valves between the atria and the ventricles on both sides of the heart keep the blood flowing in the proper direction. As we age, our heart muscle thickens and becomes less elastic, which means it has to work harder to pump the blood. Similarly, the arteries become stiffer, which makes it harder for blood to flow through them—again making the heart work harder. We can make up for some of these changes by modifying our diet and exercising, which can allow the heart to continue to pump the blood efficiently around our body, although perhaps not as efficiently as when we were younger. Note: The abbreviation CAD, for coronary artery disease, is used throughout this chapter.
Coronary Artery Disease and Heart Attacks The heart does not get the oxygen and nutrients it needs directly from the blood flowing through it. Instead, the heart muscle has its own blood supply—the coronary arteries. Over time, fatty deposits called plaque can build up within the coronary arteries and restrict or block blood flow. This condition is called atherosclerosis. Blood clots can also form and further restrict blood flow. If atherosclerosis or a blood clot reduces or blocks the blood supply to a part of the heart, it can cause a heart attack. In a heart attack, the part of the heart muscle that is supplied by the blocked coronary artery doesn’t get enough oxygen. This is called “ischemia,” which can cause chest pain. If the blockage lasts too long and the heart muscle continues to have too little oxygen, it becomes permanently damaged. If the damaged area is small, the heart can repair itself and continue to operate, although it may be weaker. If too much heart tissue is damaged, the heart cannot continue to function, resulting in death. The problems caused by atherosclerosis, including heart attack, are referred to generally as coronary artery disease (CAD). About three quarters of adults older than 70 years have some degree of CAD, and in about half, one or more coronary artery(ies) is blocked. Cigarette smoking significantly increases the risk of CAD and the risk of dying from CAD. Smoking speeds up the development of arterial problems, such as atherosclerosis. The risk has a direct relationship to the number of cigarettes smoked, so that someone who smokes two packs a day is at greater risk than someone who smokes one pack a day. For these and many other health reasons, people who smoke should give it up immediately. Results of studies show that it is never too late to gain benefits from not smoking. High blood pressure is also a risk factor for CAD. Having high blood pressure especially increases the risk of death from a heart attack. In general, blood pressure should be less than 140/90 mmHg (see also High Blood Pressure). If you have diabetes, your blood pressure should be less than 130/80. Fatty substances in the blood can also affect the risk of CAD. For instance, high levels of blood cholesterol increase the risk of heart disease. Specifically, high levels of low-density lipoproteins (LDL), or the “bad” cholesterol, increase the risk of CAD. On the other hand, high levels of high-density lipoproteins (HDL), or the “good” cholesterol, decrease the risk of CAD. In general, lowering high cholesterol and keeping LDL levels low in comparison with HDL levels are helpful. Eating a diet low in fat and taking certain medications (eg, statins) can help us manage cholesterol levels. However, because cholesterol is a building block for hormones, it is an important part of a balanced diet. Diets that are too low in cholesterol may also be too low in other important nutrients, such as calcium (see also Nutrition). Your healthcare provider or nutritionist can give you advice on a diet that is both balanced and helps control high cholesterol. Up to the age of 75 years, men are at higher risk of CAD than women. After that, the risk is similar in both men and women. Other risk factors for CAD include obesity, low levels of physical activity, and menopause. Physical fitness lowers body weight, increases heart strength, and has other health benefits as well (see Physical Activity). Most heart attacks in women happen after menopause. Menopause increases the risk in older women because of a loss of estrogen, followed by an increase in LDL levels. We used to believe that estrogen replacement therapy could lessen the risk of CAD in women after menopause. However, recent research found that estrogen combined with progesterone was linked to an increased risk of cardiovascular disease and stroke in certain women. It is also linked to increased risk of some kinds of cancer. Your healthcare provider can help you decide if estrogen replacement therapy is right for you. Chest pain is one of the most common symptoms of CAD, although chest pain can be caused by conditions other than heart disease (eg, injuries to the neck, chest, or upper abdomen). Pain from the heart usually causes a feeling of squeezing, pressure, or burning in the chest (as if someone were standing on your chest). This pain is usually felt under the breastbone, but it can be felt anywhere in the chest, upper abdomen, jaw, back, shoulders, or inner part of the arm. The pain can be mild to severe, depending on the degree of blockage. Heart pain typically happens during some type of physical activity and is usually strong enough to cause you to immediately stop what you are doing. The medical term for this heart pain is angina, which means that the heart muscle is not receiving enough blood. This is usually because the coronary arteries that supply the heart are narrowed. The pain of a heart attack is similar to that of angina, but it usually lasts longer and is more severe. It is sometimes described as “crushing” or “viselike.” A heart attack is a medical emergency that should prompt a call to 911 and a trip to the emergency room. The first minutes to hours after the attack are crucial, so don’t delay. While you are waiting for the ambulance, it is a good idea to chew a non-coated aspirin tablet, which thins the blood and prevents clots. Getting treatment early can greatly decrease the damage and may mean the difference between life and death. Shortness of breath on physical activity is also a common symptom of CAD or heart attack. Many older adults with CAD experience only shortness of breath and no angina, and it is important to recognize that this can also be a symptom of a heart attack. Other signs and symptoms of CAD in older adults may include fainting (see also Fainting), nausea and vomiting, palpitations, sweating, restlessness, changes in mental function, or buildup of fluid in the lungs. Unfortunately, the first sign of CAD may be sudden death, especially as we grow older. Decreasing your risk factors and having regular medical checkups are important to prevent CAD as much as possible. Any new chest pain calls for a complete medical evaluation. Chest pain along with sweating, dizziness, fainting, shortness of breath, or an irregular pulse requires urgent medical attention. A complete evaluation, including an electrocardiogram (ECG), is essential to determine whether the chest pain is due to a heart attack. An ECG done while you are at rest can sometimes diagnose CAD. Often, you will be asked to exercise on a treadmill or bicycle before the ECG, or while the ECG is being run. This puts the heart under some stress (making it work harder), so that if the blood supply to the heart is restricted, it will show up on the ECG. Of course, this is done only in people healthy enough to safely perform the exercise. If someone can’t exercise, medication may be used to make the heart work harder and evaluate the blood supply. The ideal way to diagnose CAD is with a procedure called coronary angiography. A dye is injected through a catheter that is placed directly into an artery in the chest. The dye shows up on x-rays as it travels through the coronary arteries, so that the point where the flow is blocked can be identified. This procedure has some risks. For example, some people are allergic to the dye and can have a serious reaction. Also, the dye can potentially cause kidney damage, so older adults should drink plenty of fluids before and after the procedure. Echocardiography may also be helpful in some cases. Echocardiograms bounce sound waves off the heart to get a picture of its internal structure. Echocardiograms are sometimes combined with a stress test, just like in an ECG. In general, the medical treatment of CAD includes resting after eating, avoiding vigorous activities in cold weather, and avoiding emotional stress. Risk factors such as high blood pressure, high cholesterol, and obesity should be corrected. A regular exercise program and a good diet are also helpful. Limiting salt or fat in the diet may be needed if cholesterol or blood pressure is high. Again, a heart attack is a medical emergency that should prompt a call to 911 and a trip to the emergency room. The first minutes to hours after the attack are crucial, so don’t delay. While you are waiting for the ambulance, it is a good idea to chew a non-coated aspirin tablet, which thins the blood and prevents clots. Getting treatment early can greatly decrease the damage and may mean the difference between life and death. Drugs: Several types of drugs are commonly used in the treatment of CAD. The dosage and types of drugs used depend in large part on how severe the problem is. For example, stable angina, which is chest pain that occurs fairly predictably with specific types of activity, and a heart attack are not treated the same way. Nitroglycerin can help relieve chest pain or pressure. It causes the blood vessels to relax and widen, so the heart doesn’t have to work as hard, which in turn helps relieve the pain. It also helps make breathing easier. Fainting is a possible side effect of placing a nitroglycerin pill under the tongue, so it is best to sit down before taking nitroglycerin. Nitroglycerin can also be given as a cream, in a patch worn like a bandage, or as an aerosol spray. Several other types of drugs, such as beta-blockers or calcium-channel blockers, can also ease angina and decrease the risk of heart attack. Side effects from beta-blockers include sleepiness or decreased mental function. However, if you are taking a beta blocker, you should never stop it suddenly, because this can potentially worsen your condition. Be sure to talk to your healthcare provider about your concerns. Calcium-channel blockers may cause constipation, difficult urination, a sudden drop in blood pressure, or swelling of the feet and ankles. A mainstay in the treatment of CAD and heart attack is aspirin. Aspirin thins the blood so that clots are less likely to form in a narrowed coronary artery. The typical dosage varies from one quarter to one whole, regular-strength (325 mg) tablet per day, depending on the problem. If a heart attack is in progress or imminent, the first dose of aspirin should be non-coated and chewed, so it gets into the blood faster. Potential side effects of long-term aspirin therapy include stomach upset, ulcers, and bleeding problems. Other blood thinners used to treat CAD include clopidogrel and heparin. Heparin is often injected intravenously or subcutaneously (under the skin). “Clot-busting” drugs such as TPA or TNK can be injected during or shortly after a heart attack to break up any blood clots that have formed. Surgery: Surgery is often needed for severely narrowed arteries that could cause a fatal heart attack. The simplest surgery is angioplasty, in which a collapsed “balloon” is passed into the narrowed area of the artery. When the balloon is inflated, it pushes aside the blockage. A small wire stent (like a stiff mesh cloth used to cover the wall of the artery and help keep it open) can also be placed inside the blood vessel to keep it open. Blood thinners are usually given in conjunction with angioplasty or stents, so that clots do not form again. A severe blockage may require coronary bypass surgery. In this procedure, a new artery is grafted or attached to the old one, traveling from just before the blockage to just after it. This allows the blood to flow around, or bypass, the blockage. The graft itself is often a vein taken from another part of the body, such as the leg. Because the graft is from the person’s own body, there is no risk of rejection. Heart failure develops when the heart cannot pump enough blood to meet the body’s demand. This can be caused by several conditions, including the following:
The two main types of heart failure are diastolic and systolic. It is important to distinguish between these two types, because the causes and treatments are usually different. Some people have features of both diastolic and systolic heart failure. Common Characteristics of Systolic and Diastolic Heart Failure
In diastolic heart failure, the heart is primarily affected when it is at rest. The walls of the heart are thickened, making it difficult for the heart to relax and fill with blood. The most common cause is chronic high blood pressure. In systolic heart failure, the heart is affected when it beats. The heart is usually enlarged and has thin walls. The heartbeats are often weakened, limiting the amount of blood flow out of the heart. This type of heart failure commonly develops after a person has suffered one or more heart attacks. In fact, people with systolic heart failure often have a history of CAD and multiple heart attacks. Symptoms vary, depending on the type and severity of the heart failure. As blood flow weakens, fluid backs up in various parts of the body. For example, fluid build up in the lungs leads to coughing, wheezing, or difficult breathing. This may progress from wheezing during exertion, to congestion and coughing at night, to difficult breathing at rest. An overall feeling of weakness or fatigue is common. Fluid can build up in the limbs, causing ankles to swell and the legs to feel heavy. Fluid build up in the liver can cause abdominal problems, including discomfort in the upper right part of the abdomen, a sense of fullness after eating, loss of appetite, nausea, or vomiting. Some people with heart failure have to urinate often during the night as the body tries to get rid of excess fluid. Others may not urinate much because the weakened blood flow decreases kidney function. Other possible symptoms include confusion, insomnia, headache, anxiety, memory loss, or bad dreams or nightmares. Sometimes, heart failure can be diagnosed based on your symptoms and physical examination. Your healthcare provider may be able to tell if your heart is not pumping efficiently or if you have fluid build up by listening to your heart and lungs, feeling your liver, or looking at the veins in your neck. Additional tests are needed to confirm whether or not you have heart failure and to assess how severe it is. Chest x-rays, an ECG, and an echocardiogram are usually vital parts of the evaluation. Other tests may also be ordered, especially if this is your first episode of heart failure. The first step in managing heart failure is to identify and correct any underlying causes. This may involve lowering blood pressure (eg, decreasing salt intake, losing weight, etc), or treating infection or problems with the heart’s rhythm or your thyroid gland. Underlying CAD should also be diagnosed and treated. Certain medications can aggravate heart failure (eg, nonsteroidal anti-inflammatory drugs, calcium-channel blockers, drugs for problems with heart rhythm), and these may need to be stopped or adjusted. People with heart failure usually need to make lifestyle changes such as eating a low-salt diet and watching their weight. They should weigh themselves daily and call their healthcare provider if they gain more than two pounds (usually from fluid) in one day. They need to be careful about taking any non-prescription medicines, because some can cause fluid buildup and aggravate heart failure. Over-the-counter medicines and preparations that should be avoided include the following:
See also Complementary and Alternative Medicine. Drug treatment: Diuretics and ACE inhibitors are the mainstay of treatment for heart failure. Diuretics (ie, “water pills”) increase urine production and fluid loss. They decrease both the amount of fluid backup and the amount of work the heart must do. They are useful in both the systolic and diastolic forms of heart failure. Usually, diuretics can be taken orally. However, if heart failure is severe, an intravenous form may be used to get the medicine into the blood faster. The ACE (angiotensin-converting enzyme) inhibitors are especially useful for people with systolic heart failure. Treatment with ACE inhibitors can improve quality of life and reduce symptoms, allowing someone to participate in more physical activity and exercise. Potential side effects of the above drugs include very low blood pressure or changes in the blood’s chemical makeup. People started on any of these three medications need to have their blood pressure and kidney function checked regularly. In older adults, ACE inhibitors may sometimes also result in a loss of taste or a troubling cough. Other standard medications sometimes used to treat heart failure include beta-blockers, nitroglycerin, and blood thinners. Blood thinners are generally not prescribed for frail older adults who are at risk of falls and injury because of the potential for serious bleeding problems. Several newer products are also available and are often used as replacement drugs for people who cannot take standard therapies. The heart valves keep the blood circulating in the right direction (see Figure: Heart Valves). In younger people, valve problems are usually due to congenital disorders or rheumatic fever. In older adults, valve problems are often caused by years of wear and tear. Treatment for valve problems depends on the specific valve and how it is affected. Valve problems include the following:
All people with significant heart valve disease are usually advised to take antibiotics before certain procedures (such as routine dental cleanings) to lessen the chances of bacteria that are released into the blood during the procedure infecting the damaged valve. Narrowing of the aortic valve (aortic stenosis) The aortic valve controls the flow of blood from the left side of the heart into the aorta, which is the main artery in the chest. Narrowing of the aortic valve is called aortic stenosis, and it often results from wear and tear. Years of pumping blood can cause scarring of the valve, or calcium or fat to be deposited on the valve. These changes keep the valve from opening normally, which blocks the flow of blood. Risk factors for aortic stenosis include diabetes and CAD. In fact, about half of the people with aortic stenosis also have CAD and an increased risk of heart attack. Sometimes, there are no symptoms. However, if symptoms develop, people with stenosis should tell their healthcare provider immediately. Common symptoms include the following:
Older adults may also lose weight, build up fluid in their lungs, or have kidney or liver failure. Diagnosis and treatment: The most common way to diagnose aortic stenosis is with an echocardiogram. Like sonar, the echogram bounces sound waves off the heart to produce a picture of its internal structure. Your healthcare provider will also check for other underlying heart problems (eg, CAD or heart failure) or other illnesses (eg, diabetes or liver failure) that are often seen along with aortic stenosis. Unless symptoms develop, generally no treatment is needed. If symptoms are mild, treatment consists of close observation and appropriate medications for heart disease, such as diuretics (ie, “water pills”). People taking these medications should be monitored closely because of the risk of heart failure or a large drop in blood pressure. If symptoms are severe, such as chest pain, fainting, or heart failure, then surgery to repair the aortic valve is usually needed. In healthy older adults, the aortic valve is usually replaced with an artificial valve. People who are not healthy enough for heart surgery can have “balloon valvuloplasty” instead. In this procedure, the valve opening is enlarged by passing a deflated balloon across the valve and then inflating it. Unfortunately, the valve closes again in about half of the people who undergo this procedure in about 6 months, and in about three quarters of the people within 1 year. However, this procedure may be helpful for people who are initially too ill for heart surgery or who need other treatment first, such as repair of a broken hip. When the aortic valve leaks, some blood rushes back into the heart between beats instead of going to the rest of the body. This condition is called aortic valve insufficiency or regurgitation. Common causes include infection of the heart lining (see Infectious Illness), rheumatic heart disease, problems with the aorta, or complications after valve replacement surgery. In some people, the leaking comes from holes that develop in the valve from high blood pressure or kidney disease. However, normal wear and tear on the aortic valve is rarely the cause of major leakage. People with aortic valve insufficiency usually do not have symptoms initially. Shortness of breath while at rest and chest discomfort may be early clues. However, aortic insufficiency can cause heart failure, which is usually the first major sign of a problem. People may not have symptoms for years, and then symptoms of heart failure can develop suddenly. This situation requires emergency surgery. Diagnosis and treatment: A history of sudden heart failure and the presence of a characteristic high-pitched heart murmur suggest aortic insufficiency. Echocardiography is needed to confirm the diagnosis. Older people with aortic insufficiency who do not have symptoms can be treated with ACE inhibitors and monitored closely, including routine echocardiograms. Emergency surgery to replace the aortic valve is required if heart failure develops. The prognosis is often excellent after successful valve replacement unless the person also has CAD or heart failure is severe. Narrowing of the mitral valve (mitral stenosis) The mitral valve controls the flow of blood from the left atrium (upper chamber) into the left ventricle (lower chamber) of the heart. Narrowing of the mitral valve is called mitral stenosis. This condition is not common in older adults but can occur. The most common cause is a buildup of calcium, so that the valve can no longer open properly. Symptoms of mitral stenosis include fatigue and signs of heart failure. Heart failure tends to worsen over time if there are changes in the heart rhythm. Blood clots can sometimes form in the heart and may lead to a stroke or other problems with the circulation. Diagnosis and treatment: A history of heart failure and an irregular heart rhythm, along with the presence of a characteristic low-pitched heart murmur suggest mitral stenosis. Echocardiography is needed to confirm the diagnosis. Older people with both mitral stenosis and either heart failure or an irregular heart rhythm are treated with blood thinners to reduce the chance of blood clots and stroke. In some cases, balloon valvuloplasty can be used to open up the narrowed valve (see aortic stenosis). However, many older adults need valve replacement. Having CAD complicates surgery and worsens the prognosis. Leaking of the mitral valve is called mitral insufficiency or regurgitation. This condition develops in about one third of people over the age of 65. The most common cause is buildup of calcium on the mitral valve. Other causes include CAD, degeneration or rupture of the supporting tissues around the valve, and rheumatic heart disease. Diagnosis and treatment: People with mitral valve leakage may have symptoms of heart failure, irregular heart rhythms, or both. Severe mitral valve insufficiency can also lead to weight loss. As with other valve problems, the history and physical examination provide clues, but an echocardiogram is needed to confirm the diagnosis. Surgical replacement of the valve is necessary for people with severe mitral insufficiency, especially if they have severe fatigue, shortness of breath, or swelling of body tissues caused by retaining fluid. Drug treatment before and after surgery can improve the result. People who also have an irregular heart rhythm are often given blood thinners (ie, anticoagulants). CAD complicates surgery and worsens the prognosis. Irregular Heart Rhythms (Arrhythmias) Arrhythmias are usually categorized according to the affected part of the heart—the upper (atrial) part, or the lower (ventricular) part of the heart—as well as by the change in rhythm. One particular rhythm problem is called “fibrillation,” in which the affected part of the heart quivers instead of beating normally. Fibrillation of the upper (atrial) part of the heart is the most common type of irregular heart rhythm, or arrhythmia, in adults. Atrial fibrillation causes the heart to speed up, because the upper part of the heart is sending too many electrical impulses to the lower part. The electrical impulses signal the lower part of the heart to beat or contract. Common symptoms include irregular rapid beats and lightheadedness. However, many older adults have only vague symptoms (eg, listlessness) or no symptoms at all. An ECG is needed for diagnosis. Men are usually affected more often than women. Other risk factors for atrial fibrillation include high blood pressure, rheumatic heart disease, CAD, heart failure, high thyroid levels, some lung conditions, previous surgery, and alcohol intoxication. The problems with blood flow caused by atrial fibrillation can also result in clots, which increase the risk of stroke or other diseases linked with clots and emboli (see also Diseases of the Nervous System). Treatment: A first step in treating atrial fibrillation is to identify and treat underlying illnesses (eg, heart disease, high blood pressure, or an overactive thyroid). The atrial fibrillation itself can usually be managed with medication. In most cases, blood thinners (eg, warfarin) are used to decrease the risk of stroke, while other drugs (eg, varapamil or digitalis) are used to slow the heart. These drugs do not stop the fibrillation but manage the symptoms and risks. Long-term therapy with antiarrhythmic drugs is usually not recommended for atrial fibrillation, because the risks outweigh the benefits. Getting the heart back into a normal rhythm is possible in some cases by using drugs or by passing an electrical current through the heart. However, this does not always work and may have risks. Permanent pacemakers are sometimes used to control symptoms of dizziness or fainting. Ventricular arrhythmias and ventricular fibrillation Arrhythmias of the lower part of the heart, made up of the ventricles, are the most serious irregular heart rhythms. These arrhythmias show up as premature (or early) beats on an ECG. Occasional premature beats in a healthy person may not be a serious problem. However, frequent premature beats or premature beats along with underlying heart disease (eg, CAD) are serious and need to be treated. Ventricular arrhythmias are often associated with underlying heart disease, so a complete cardiac evaluation, including an ECG, is usually done. Treatment involves dealing with the underlying heart condition and sometimes using antiarrhythmic drugs. Many people respond well to treatment with drugs known as beta-blockers. Ventricular arrhythmias can lead to ventricular fibrillation, which is a life-threatening emergency. In ventricular fibrillation, the heart does not beat correctly, and blood stops circulating. CPR should be performed while emergency personnel are called. Defibrillation needs to be done immediately by delivering an electric shock to the chest to convert the heart back into a normal rhythm. Traditionally, this lifesaving procedure (often demonstrated in television shows) required trained medical professionals. However, automated defibrillators that can be easily handled by lay people with some training are now available in many locations. There are also small cardioverter-defibrillators that can be implanted in the chest, like a pacemaker, to automatically convert ventricular arrhythmias. These automatic devices are the most effective treatment for improving survival in older adults with life-threatening ventricular arrhythmias. Problems with the conduction of electrical impulses, or signals, through the heart can cause a slower than normal heart rhythm. A slow heart rhythm can be caused by drugs or by low levels of oxygen, potassium, or thyroid hormone in the blood. A slow heart rhythm can also be caused by problems in the upper (atrial) part of the heart, so that electrical impulses are not sent effectively to the lower (ventricular) part of the heart. Common symptoms include difficult breathing, weakness, fatigue, dizziness, fainting spells, falls, and chest pain. Slow heart rhythm can also cause heart failure or fluid buildup in the lungs. Other signs or symptoms may include slurred speech, personality changes, partial paralysis, or seizures. Diagnosis and treatment: The ECG is the most important diagnostic tool. Your healthcare provider may send you home with a portable ECG unit, so that you can take readings at home. Portable units are especially useful for diagnosing problems that come and go, such as unexplained fainting spells in people without obvious heart disease. Treatment involves addressing underlying problems (eg, changing drugs or adjusting blood chemistry levels) or surgically installing a pacemaker. An electronic pacemaker sets the rhythm for the heart, permanently taking over this normal function of the upper part of the heart. Data from the pacemaker can be sent by telephone to the laboratory or physician’s office for evaluation. The pacemaker can then be adjusted to better control the heart rhythm. An aneurysm is a widening or ballooning of a major artery leading from the heart. Aneurysms usually develop in the aorta or one of the other major arteries in the chest or abdomen. Aneurysms are common in older adults, especially those with underlying high blood pressure or CAD. Often, aneurysms do not cause any symptoms and cannot be found during a physical examination. However, they are sometimes discovered during surgery or when an x-ray, CAT scan, MRI, or echocardiogram is performed for another reason. Older people who smoke or have a history of smoking are at high risk and should talk to their healthcare provider about being screened for an aneurysm. If an aneurysm is found, it should be watched closely for signs of enlargement, which might suggest that it could burst. Ruptured aneurysms often result in serious disability or death. As aneurysms get bigger, they can cause pain in the groin, lower back, lower abdomen, or chest, depending on their location. They can also lead to fainting spells, stroke, paralysis, loss of pulse, or heart failure. Pain or other symptoms suggest that rupture may be about to happen. This is a medical emergency, and surgery is needed immediately to repair the weakened vessel. Aneurysms can also be repaired as elective procedures, especially if they appear to be growing too large or too rapidly. Poor circulation in the blood vessels of the limbs, particularly the legs and feet, is called peripheral vascular disease and includes disorders of both the veins and arteries. Disease of the arteries is more serious and increases the risk of early death from heart disease or other problems. Important risk factors for arterial problems include the following:
Lack of physical activity can also aggravate poor circulation. Peripheral vascular disease is often associated with underlying CAD. People with arterial problems often have pain in the calves, legs, or buttocks when they exert themselves. There may also be signs of poor circulation, such as changes in skin color or texture in the feet. Some older adults may have substantially decreased blood flow and even severe tissue damage, without necessarily being aware of it. Associated problems with the nervous system may blunt pain sensations, and poor vision may make it difficult to see characteristic changes. This is especially a problem for older adults with diabetes, because of the nerve and vision damage often seen in diabetes (see Diabetes). Leg pain may come and go. However, if leg pain comes on suddenly, a blood clot (or thrombus) may have lodged in an artery, blocking the flow of blood. This condition is called an embolus. The source of the blood clot is often the heart or the aorta. Diagnosis and treatment: Often, problems with the arteries can be diagnosed based on a thorough history and physical examination. Additional, more sophisticated tests (eg, ultrasound) are sometimes needed. A person being treated for poor circulation should do the following:
Regular exercise is the most effective medical treatment for leg pain that comes and goes. Aspirin and drugs to lower cholesterol may help. Aspirin also reduces the risk of stroke, heart attack, or other conditions that block the flow of blood. Foot care is very important. People with poor circulation must wear properly fitted shoes and should avoid injury from nail clipping or walking barefoot. Socks should be made of thick fabrics to help protect the feet. Padding or shoe inserts may be used to prevent pressure ulcers. Feet should be washed daily, and the skin kept moist with topical emollients. This prevents cracks and fissures that may act as doorways to bacterial or fungal infection. However, moisturizers should not be put between the toes, because these areas tend to retain moisture, so the skin can become softened and wear away. Athlete’s foot should be treated. Ulcers or other foot injuries should be treated carefully and may require special dressings, casts, or another form of protection. Angioplasty or bypass surgery can be used to remove the arterial blockage and improve blood flow. However, this is usually reserved for severe disease that interferes substantially with quality of life or threatens loss of the limb. Varicose Veins and Other Venous Disorders Varicose veins result from leaky valves in the veins in the legs (Figure: Varicose Veins). The cause is usually deterioration of the valves among people with a hereditary tendency. The chief symptom of varicose veins is aching in the legs that becomes worse when standing. Treatment for varicose veins consists of raising the legs, wearing elastic supportive stockings, and exercising to increase muscle tone. Elastic stockings may be contraindicated in people who have problems with the arteries as well as the veins. Cosmetic surgery can remove varicose veins temporarily, but they usually come back. More invasive surgery, such as stripping or tying off these veins, is usually avoided in older adults, because the risk of anesthesia is not worth the cosmetic results. In rare situations, ulcers, repeated bleeding, repeated blood clots, or phlebitis may require surgery. Varicose veins involve the veins in the legs that are close to the skin surface. However, deeper veins in the legs can become blocked by blood clots, leading to swelling of the lower legs. This condition is called deep venous thrombosis. It usually becomes worse at the end of the day and may resolve temporarily after lying down at night. Deep venous thrombosis can also cause a browning discoloration of the skin and ulcers on the inside of the leg (usually above the ankle). The pain ranges from mild to severe. Treatment is very similar to that for varicose veins, including support hose and raising the legs. Long periods of standing should be avoided, but walking is encouraged. Ulcers can be treated with antibiotics, foot soaks, and surgical or chemical cleansing. More extensive surgery is usually not needed. Blood thinners may be used to prevent blood clots from forming. Guidelines on the use of prophylactic antibiotics are available from the American Heart Association. |
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Published: 10/31/2005