Age-related changes in the cardiovascular system in the elderly. Diseases of the cardiovascular system in the elderly

The heart has two sides - the atria. The right atrium pumps blood to the lungs to take in oxygen and get rid of carbon dioxide. The left atrium delivers oxygen-rich blood to the body.

Blood flows from the heart through arteries, which branch and become smaller and smaller as they travel through the tissues. In tissues, they become small capillaries.

Capillaries are where the blood gives oxygen and nutrients to the tissues and receives carbon dioxide and waste products back from the tissues. The vessels then begin to come together into large veins, which return blood to the heart.

Age-related changes in the heart

The heart has a natural pacing system that controls the heartbeat. Some of the pathways in this system may develop fibrous tissue and fatty deposits (cholesterol). The heart muscle loses some of its cells.

These changes can cause your heart rate to slow down.

A slight increase in the size of the heart, especially the left ventricle, is not uncommon. The wall of the heart thickens, so the amount of blood the chamber can hold may actually decrease despite the overall size of the heart increasing. The heart may fill with blood more slowly.

Cardiac changes cause, as a rule, a change in the ECG. The ECG of a normal, healthy elderly person will be slightly different from the ECG of a healthy young adult. Rhythm abnormalities (arrhythmias), such as atrial fibrillation, are more common in older people. They may be caused by heart disease.

Normal changes in the heart also relate to the accumulation of the “aging pigment” lipofuscin in it. The heart muscle cells degenerate slightly. The valves inside the heart that control the direction of blood flow thicken and become stiffer. Heart murmurs are caused by stiffness of the valves quite often in old age.

Age-related changes in blood vessels

Receptors called baroreceptors monitor blood pressure and make changes to help the body keep blood pressure essentially the same when a person changes position or pace of activity. Baroreceptors become less sensitive with aging. This may explain why many older people suffer from orthostatic hypotension, a condition in which blood pressure drops when a person moves from lying or sitting to standing. This leads to dizziness because blood flow to the brain is reduced.

The walls of the capillaries thicken slightly. This may result in slightly slower rates of metabolism and waste.

The main artery of the heart (aorta) becomes thicker, stiffer, and less flexible. This is probably due to changes in the connective tissue of the walls of blood vessels. This raises blood pressure and causes the heart to pump harder, which can cause the heart muscle to thicken (hypertrophy). Other arteries also thicken and become stiffer. In general, most older people experience a mild increase in blood pressure.

Age-related changes in blood

The blood itself changes slightly with age. Normal aging leads to a decrease in the total amount of water in the body. As part of this, the fluid participating in the blood flow is reduced, so the blood volume is slightly reduced.

The number of red blood cells in the blood (and, accordingly, hemoglobin and hematocrit) decreases. This contributes to rapid fatigue. Most white blood cells remain the same, although some white blood cells responsible for immunity (lymphocytes) decrease in number, reducing their ability to fight bacteria. This reduces the body's ability to resist infection.

Impact of age-related changes

Under normal circumstances, the heart continues to supply sufficient blood to all parts of the body. However, aging of the heart may somewhat reduce the ability to tolerate increased stress, since age-related changes have reduced the ability to pump additional blood into the heart, thus reducing the reserve functions of the heart.

Some factors that can increase the workload of the heart:

Angina (chest pain caused by a temporary decrease in blood flow to the heart muscle), shortness of breath on exertion, and heart attacks can lead to coronary artery disease.

Various types of abnormal heart rhythms (arrhythmia) may occur.

Anemia is also possible due to malnutrition, chronic infections, loss of blood from the gastrointestinal tract, or complications of other diseases or side effects of various medications.

Atherosclerosis (hardening of the arteries) is a very common phenomenon. Fatty deposits (cholesterol plaques) inside blood vessels cause them to narrow and can completely block the blood vessels.

Heart failure is also very common among older people. In people over 75 years of age, congestive heart failure is 10 times more common than in younger adults.

Coronary heart disease is quite common, very often resulting from atherosclerosis.

Diseases of the heart and blood vessels are also quite common in older people. Common disorders include high blood pressure and orthostatic hypotension.

Heart valve diseases are quite common. Aortic stenosis, or narrowing of the aortic valve, is the most common valve disease in old age.

A transient ischemic attack (TIA) or stroke can occur if blood flow to the brain is disrupted.

Other heart and blood vessel problems include the following:

Deep vein thrombosis

Peripheral vascular disease resulting in intermittent pain in the legs when walking (claudication)

Prevention of age-related changes in the cardiovascular system

You can help your circulatory system (heart and blood vessels). Cardiovascular disease has risk factors that you should monitor and try to reduce:

High blood pressure,

Eat heart-healthy foods that are low in saturated fat and cholesterol, and control your weight. Follow your doctor's recommendations for treating high blood pressure, high cholesterol, or diabetes. Reduce your tobacco consumption or quit smoking altogether.

Exercise can help prevent obesity, and it helps people with diabetes control their blood sugar levels. Exercise can help you maintain your abilities for as long as possible and reduce stress.

Regular examinations and examinations of your heart are necessary:

Check your blood pressure. If you have diabetes, heart disease, kidney disease, or other medical conditions, your blood pressure should be checked more closely.

If your cholesterol levels are normal, you should have them checked every 5 years or more often. If you have diabetes, heart disease, kidney disease, or other medical conditions, your cholesterol levels should be checked more closely.

Moderate exercise is one of the best things you can do to keep your heart and the rest of your body healthy for as long as possible. Check with your healthcare provider before starting a new exercise program.

Exercise moderately and within your capabilities, but do it regularly.

People who eat less fat and smoke less tend to have fewer blood pressure problems and less heart disease than fatty food eaters who smoke.

Age-related changes in the circulatory system

Age-related changes in the circulatory system largely determine the nature and pace of aging. They limit the body's adaptive capabilities, worsen the functional state of organs, and create preconditions for the development of diseases. With aging, the structure of the vascular wall changes. Large arteries are the first to change. The inner lining of the vessel becomes denser, sclerosed, the muscle layer atrophies, and the elasticity of the vascular wall decreases. A decrease in vascular elasticity and an increase in peripheral resistance cause an increase in blood pressure (BP), mainly systolic. Usually it is moderately expressed.

Pulse tension increases. Venous pressure (VP) decreases with age. In older people, the number of functioning capillaries decreases, which contributes to a deterioration in the blood supply to organs and a decrease in metabolic rate. The blood supply to the heart is also disrupted. As a result, dystrophic changes appear in the heart muscle, and then the connective tissue grows, and progressive cardiosclerosis develops - “senile heart”.

The neurohumoral regulation of the cardiovascular system is disrupted. All this leads to rhythm disturbances, deterioration of myocardial contractile function, and circulatory disorders. Hemodynamics are rearranged, the speed of blood flow slows down in various parts of the cardiovascular system, and local blood circulation is redistributed.

Age-related changes in blood flow

Age-related changes in the cardiovascular system largely characterize the nature and pace of human aging. As a person ages, significant changes in the cardiovascular system occur.

Elastic arteries (aorta, coronary, renal, cerebral arteries) and the arterial wall change significantly due to compaction of the inner lining, deposition of calcium salts and lipids in the middle lining, atrophy of the muscle layer, and decreased elasticity.

This leads to thickening of the arterial walls and a constant increase in peripheral vascular resistance, an increase in systolic blood pressure, and an increase in the load on the ventricular myocardium; the blood supply to the organs becomes less than adequate.

In old and senile age, a number of hemodynamic features are formed: mainly systolic blood pressure (blood pressure) increases, venous pressure, cardiac output, and later cardiac output decrease. As a person ages, systolic blood pressure can increase throughout life, but diastolic blood pressure can only increase up to 50 years of age.

In men, the increase in blood pressure with age is often gradual, and in women, especially after menopause, it is more dramatic. Reduced aortic elasticity is an independent predictor of cardiovascular mortality.

In the arteries, endothelial dysfunction is noted, its production of vasodilator factors decreases, and the ability to produce vasoconstrictor factors is retained. Tortuosity and aneurysmal dilatation of capillaries and arterioles, their fibrosis, and hyaline degeneration develop, which leads to obliteration of the vessels of the capillary network, worsening transmembrane metabolism, and insufficiency of blood supply to the main organs, especially the heart.

Veins also change as a result of sclerosis of the walls and valves, atrophy of the muscle layer. The volume of venous vessels increases.

As a result of coronary circulatory insufficiency, dystrophy of myocardial muscle fibers, their atrophy and replacement with connective tissue develops. The heart exhibits degeneration of collagen, which is the main structural component. Collagen becomes more rigid, therefore the extensibility and contractility of the myocardium decreases. Cardiomyocytes die and are replaced with connective tissue, which progresses with age.

Developing sclerosis of the heart muscle in the elderly contributes to a decrease in its contractility and expansion of the cavities of the heart. Atherosclerotic cardiosclerosis is formed, leading to heart failure and heart rhythm disturbances. A “senile heart” is formed, which is one of the main factors in the development of heart failure due to changes in neurohumoral regulation and prolonged myocardial hypoxia.

Aortic stenosis with calcification is most often observed in old age.

In the sinus node, the number of pacemaker cells, the number of fibers in the left bundle branch and Purkinje fibers decreases, they are replaced by connective tissue.

A shift in the electrolyte balance in the muscle cells of the myocardium aggravates the decrease in its contractility, helps reduce excitability, and this causes a high frequency of arrhythmias in old age, increasing the tendency to develop bradycardia, weakness of the sinus node, and various heart blocks. With aging, systole lengthens and diastole shortens.

Structural and functional changes in the body, hormonal and metabolic disorders form the features of the clinical picture of cardiovascular diseases in elderly and senile people. With age, the neurohumoral regulation of microcirculation changes, the sensitivity of capillaries to adrenaline and norepinephrine increases. The effect on the cardiovascular system of the autonomic nervous system weakens with age, but sensitivity to catecholamines, angiotensin and other hormones increases.

In old age, the blood coagulation system is activated, functional insufficiency of anticoagulant mechanisms develops, the concentration of fibrinogen and antihemophilic globulin increases, the aggregation properties of platelets increase - this promotes thrombus formation, which plays a significant role in the pathogenesis of atherosclerosis, coronary heart disease and arterial hypertension.

When lipid metabolism is disturbed during the aging process of the body, there is a general increase in fat and cholesterol, i.e. atherosclerosis begins to develop. Impaired carbohydrate metabolism is associated with the fact that with age, glucose tolerance decreases, insulin deficiency develops, and this leads to a more frequent development of diabetes mellitus.

In addition, due to disruption of the metabolism of vitamins C, B and B 6, E, polyhypovitaminosis develops, which contributes to the development of atherosclerosis. Functional and morphological changes in the nervous, endocrine, and immune systems lead to the development of cardiovascular diseases, which is why diseases of the cardiovascular system occur so often in elderly and elderly people.

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/ Age-related features of blood circulation

Age-related features of blood circulation.

What changes does the circulatory system undergo during the growth and development of the body?

To answer this question, let us turn to the characteristics of blood circulation in the fetus. The main distinguishing feature of the development of blood circulation in the latter is the presence of placental circulation and the absence of pulmonary respiration, as well as the parallel connection of both halves of the heart. The transition to placental circulation is accompanied by serious functional changes in the fetal cardiovascular system.

Modern ideas about fetal blood circulation have been formulated since the time of the discoverer of the systemic circulation, Harvey.

Blood, saturated with nutrients and oxygen, enters the fetus through the umbilical vein from the placental villi, where gas exchange occurs. The continuation of the umbilical vein is the so-called duct of Arantius. Before or after anastomoses with the portal vein, it gives several branches into the liver parenchyma and then flows into the inferior vena cava. In the inferior vena cava, arterial blood from the placenta mixes with venous blood from the lower extremities, intestines, and pelvis. Due to the presence of a valve-shaped fold in the right atrium, about 60% of all blood from the inferior vena cava is directed through the foramen ovale to the left atrium, left ventricle and the aorta. The remaining blood from the inferior and superior vena cava enters the right ventricle and pulmonary artery. Only 25% of all blood circulating in the body flows through the fetal lungs, which is explained by the high resistance in the pulmonary artery system. The pulmonary arteries have a pronounced muscular layer and are in a spasmodic state. In the fetus, the pulmonary artery is connected to the aorta by a wide arterial duct through which blood enters the descending aortic arch below the origin of the vessels that deliver blood to the head and upper extremities of the fetus. The descending aorta carries blood to the lower parts of the body. In this regard, the liver, heart, organs located in the head, and upper limbs are in the most favorable conditions for supplying oxygen to the fetus, which contributes to their rapid development.

After the birth of a child, a sharp restructuring of the circulatory system occurs. Cutting the umbilical cord at the time of birth disrupts the connection between the fetus and the mother's body. When a newborn takes his first breath, a reflex expansion of the lungs occurs, and the pulmonary circulation begins to function. Blood is sent through the pulmonary artery to the lungs, bypassing the ductus arteriosus, which also contracts reflexively and soon turns into a connecting cord. Increased pulmonary blood flow increases pressure in the left atrium, and cessation of placental circulation reduces pressure in the right atrium, which leads to closure of the foramen ovale.

The most active functioning and morphological improvement of the cardiovascular system occurs during the first three years of a child’s life, but in the future the continuous, albeit uneven, development of the circulatory organs continues.

After the birth, the heart of the child grows and enlarges, the processes of shaping take place in it. The heart of a newborn has a transverse position and a spherical shape, this is due to the fact that the relatively large liver makes the arch of the diaphragm high, so the heart of the newborn is at the level of the 4th left intercostal space. Under the influence of sitting and standing, by the end of the first year of life, the diaphragm descends, and the heart takes an oblique position. By the age of 2-3, the apex of the heart reaches the level of the 5th rib, and in 10-year-old children, the borders of the heart are the same as in adults.

Height during the first year of life, the growth of the ventricles outstrips the growth of the ventricles, and only after 10 years the growth of the ventricles begins to exceed the growth of the atria.

The heart mass grows most intensively in the first year of life, by eight months the mass of the heart doubles, by the age of three it triples, by the age of 5 it increases by 4 times, and by the age of 16 - by 11 times.

At the same time, the mass of the heart in boys exceeds this indicator in girls in the first years of life, and in flight, on the contrary, due to the onset of a period of increased growth in girls, its mass becomes larger than in boys. By the age of 16, girls’ hearts again begin to lag behind boys’ hearts in mass.

Heart rate (HR) in the fetus it ranges from 120 to 150 per minute. In the first 2 days after birth, heart rate is slightly lower than intrauterine, which is explained by an increase in intracranial pressure, a change in heat production due to the transition to an environment with a lower temperature, and finally, inhibition of sympathetic influences. In the following week, heart rate increases slightly per beat per minute. Subsequently, heart rate decreases with age. For example, in preschool children at 6 years old it is 95 beats/min, in schoolchildren 7-15 years old it varies within minutes, in adults it is beats/min.

A slowdown in heart rate is the result of a change in the lability of the sinus node and the development of more advanced forms of neurohumoral regulation of the heart. An increase in the tonic influence of the vagus nerve leads not only to a current decrease in heart rate, but also changes the metabolism of the sinus node, leading to a persistent decrease in its lability with age.

To assess the functional state of the heart, determining the systolic (stroke) and cardiac output is crucial.

Amount of blood ejected by the heart of a newborn with one contraction, 2.5 cubic meters. cm. By 1 year it increases 4 times and amounts to 10.2 cubic cm, by seven years - already 9 times, and by 12 years - 16.4 times. The minute volume of blood flow (MVF) also increases, mainly due to an increase in systolic volume. However, the deviation of the IOC value from mass (weight), which characterizes the body’s need for blood, is greater the younger the child’s age.

It is generally accepted that both systolic and diastolic blood pressure increase with age. In newborns, blood pressure is significantly lower than in adults. This is explained by the fact that in children of this age the arteries have a larger lumen width in relation to the mass of the heart, the total weight and height of the child. Venous vessels, on the contrary, are somewhat narrowed. The ratio of the diameters of venous and arterial vessels at this age is 1:1, while in adults it is 1:2.

Having reached a value of 70-72 mmHg. Art., the pressure then remains unchanged for a long period and only increases slightly in old age due to the loss of elastic properties of the walls of blood vessels and an increase in peripheral resistance.

It should be noted that the data presented are contradictory. These values, obtained in different countries, in different regions of our country, are different and depend on living conditions - for example, the physical development of a person. Thus, the blood pressure of natives of the south is lower than that of children from the northern regions (residents of Armenia and Kyrgyzstan have lower blood pressure than Muscovites).

Age-related characteristics of the cardiovascular system's response to physical activity.

Of particular interest may be the peculiarities of changes in the response of the cardiovascular system in ontogenesis under various conditions of the body, in particular under the influence of physical activity. In this case, increasing cardiac output is crucial in ensuring the required level of blood circulation. The younger the child, the more often the increase in minute blood volume occurs due to an increase in heart rate. The heart rate during exercise in children can reach, and in 8-year-old children the heart rate increases by 50%, in 17-year-olds by 70% relative to the initial level. The maximum increase in blood pressure in 8-year-olds is 14 mmHg. Art., and summer ones by 30 mm Hg. Art.

In older children, during physical work the work-in period is shortened, that is, the time to achieve the maximum change in hemodynamics. The older the child, the more significant changes in blood circulation can occur under the influence of physical activity. The duration of the recovery period also shortens with the age of the child.

With the growth and development of the body, its total energy expenditure increases and the need for oxygen increases. Body size increases, and the increasing oxygen demand is ensured by the development of systems that deliver and transport oxygen in the lungs and blood. Metabolic processes are improved in tissues. As the body further develops individually, neurohumoral regulation and coordination of the mechanisms that serve the exchange of gases between the external environment and tissues improve.

Age-related changes in the circulatory system

Age-related changes in blood vessels and the heart significantly limit their adaptive capabilities and create preconditions for the development of diseases.

Changes in blood vessels

The structure of the vascular wall changes with age in each person. The muscle layer of each vessel gradually atrophies and decreases, its elasticity is lost, and sclerotic compactions of the inner wall appear. This greatly limits the ability of blood vessels to expand and narrow, which is already a pathology.

First of all, large arterial trunks, especially the aorta, suffer. In older and older people, the number of active capillaries per unit area decreases significantly. Tissues and organs cease to receive the amount of nutrients and oxygen they need, and this leads to their starvation and the development of various diseases.

Features of hemodynamics in old age

With age, with the loss of elasticity of large vessels and an increase in the peripheral resistance of small vessels, the

blood pressure (especially systolic). Venous

pressure decreases. This is due to a weakening of tone, a decrease in the elasticity of the venous walls, which leads to an expansion of the total lumen of the venous bed.

In old and senile age, the cardiac output decreases (minute volume is the amount of blood ejected by the heart in one minute). This decrease is mainly due to a slower heart rate and a decrease in stroke volume. Since basal metabolism decreases with age, a decrease in cardiac output can be considered as a natural reaction of the body to a decrease in tissue demand for oxygen.

In elderly and elderly people, against the background of reduced cardiac output, an active redistribution of regional blood circulation is observed. At the same time, cerebral and coronary circulation remains almost unchanged, while renal and hepatic circulation are significantly reduced.

This restructuring of the hemodynamic system partially compensates for the increase in energy consumption during cardiac operation in conditions of increased resistance to cardiac output associated with increased peripheral vascular resistance.

Decreased contractility of the heart muscle

The older a person gets, the more muscle fibers of the heart muscle atrophy. The so-called “senile heart” develops. Progressive myocardial sclerosis occurs, and in place of the atrophied muscle fibers of the cardiac tissue, fibers of non-working connective tissue develop. The strength of heart contractions gradually decreases, an increasing disturbance of metabolic processes occurs, which creates conditions for energetic-dynamic heart failure in conditions of intense activity,

As a result of all of the above processes, the physical performance of the heart decreases with age. This leads to a limitation of the range of reserve capabilities of the body and to a decrease in the efficiency of its work.

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Age-related changes in the blood supply to the kidneys in people over 40 years old

The kidneys in the process of aging undergo changes in accordance with shifts in the circulatory system.

Due to sclerotic changes in the vessels, significant areas of the kidneys in old age are ischemic, and in an 80-year-old person from 30 to 40% of the nephrons are sclerotic.

In the elderly, the volume of glomerular filtration, plasma renal blood flow, and the concentration ability of the kidneys are reduced to almost 50%. For example,

the decrease in effective renal blood flow after 40 years is expressed as follows:

effective renal blood flow = 840-6.44 number of years;

decrease in glomerular filtration after 40 years:

glomerular filtration = 153.2-0.96-number of years.

However, the threshold of plasma glucose concentration for excretion in the kidneys may even be increased, so that in elderly people with diabetes, glycosuria may not be sufficiently pronounced. Drugs that are excreted in the urine in young people can accumulate in the body of old people due to insufficient excretory function of the kidneys. Of the 185 metabolic products determined in human urine, at least 60 change concentration with aging.

Many old people suffer from nocturia (excretion of a large part of the daily amount of urine at night), which correlates with the above-mentioned insufficiency of the concentrating ability of the kidneys.

The decrease in the ability of the kidneys to concentrate urine is due to the fact that sclerosis of the arteries and vessels of the glomeruli in the renal cortex is accompanied by increased blood flow in the medulla, in the straight arterioles and the network of capillaries they form.

The increase in blood flow in the renal medulla increases the leaching of osmotically active substances from the interstitial space of the medulla, reducing water reabsorption and the effectiveness of the counterflow-rotation system.

The decrease in the ability of the kidneys to retain water in the body is compensated by the increasing secretion of ADH by the hypothalamic-pituitary system.

Increased secretion of ADH is associated with an increasing sensitivity of osmoreceptors to osmotically active substances in the blood and tissue fluid in humans after 50 years.

Thanks to these compensatory mechanisms, the intravascular and extracellular volumes of body fluids and their composition in the elderly are little changed.

Compatibility of the development of motor and mental activity of a child in the first half of life. Joint development of motor and mental activity of a child in the second half of life. Simultaneous formation of the first and second signaling systems of a child under 3 years old.

Physiologists N.A. Bernstein and G. Shepherd believe that “motor activity is a kinetic factor that largely determines the development of the body and nervous system, along with the genetic factor and the influence of sensory multimodal information. Full physical development, the formation of correct posture, motor qualities, optimal motor stereotype through developmental movement is inextricably linked with the harmonious consistent organization of the nervous system, its sensitive and motor centers, analyzers." Thus, according to scientists, the preschool education program "Physical Development and Health" should be equally aimed at the physical (physical) and neuropsychic development of the child.

V.A. Shishkina notes the extremely important role of movements for the development of the psyche and intelligence. “Impulses from working muscles constantly enter the brain, stimulating the central nervous system and thereby promoting its development. The more subtle movements a child has to perform and the higher level of coordination of movements he achieves, the more successful the process of his mental development is. A child’s motor activity not only contributes to the development of muscle strength as such, but also increases the body’s energy reserves.” Scientists have established a direct relationship between the level of motor activity and their vocabulary, speech development, and thinking. They note that under the influence of physical exercise and physical activity in the body, the synthesis of biologically active compounds increases, which improve sleep, have a beneficial effect on the mood of children, and increase their mental and physical performance. “In a state of reduced motor activity, metabolism and the amount of information entering the brain from muscle receptors decrease. This worsens metabolic processes in brain tissue, which leads to disruption of its regulatory function. A decrease in the flow of impulses from working muscles leads to disruption of the functioning of all internal organs, primarily the heart, and affects the manifestations of mental functions and metabolic processes at the cellular level

Speaking about motor activity as the basis for the life support of a child’s body, E.Ya. Stepanenkova points out that it is she who influences the growth and development of the neuropsychic state, functionality and performance of the child. “During muscular work, not only the executive (neuromuscular) apparatus is activated, but also the mechanism of motor-visceral reflexes (i.e. reflexes from muscles to internal organs) of the work of internal organs, nervous and humoral regulation (coordination of physiological and biochemical processes in body). Therefore, a decrease in physical activity worsens the condition of the body as a whole: both the neuromuscular system and the functions of internal organs suffer.”

T.I. Osokina and E.A. Timofeeva also note in their studies that in the process of muscular activity the work of the heart improves: it becomes stronger, its volume increases. Even a diseased heart, they note, is significantly strengthened under the influence of physical exercise.

“The blood is cleared of carbon dioxide and saturated with oxygen in the lungs. The more clean air the lungs can hold, the more oxygen the blood will carry to the tissues. When performing physical exercises, children breathe much deeper than in a calm state, as a result of which the mobility of the chest and lung capacity will increase.”

The authors note that physical exercise in the fresh air especially activates gas exchange processes. A child, being systematically exposed to air for a long time, hardens, as a result of which the child’s body’s resistance to infectious diseases increases. Thus, summarizing all of the above, we can note physical activity as a biological need of the body, the degree of satisfaction of which determines the health of children, their physical and general development. “Movements and physical exercises will provide an effective solution to the problems of physical education if they act in the form of a holistic motor regime that meets the age and individual characteristics of the motor activity of each child.”

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Age-related changes in the cardiovascular system, while not themselves the primary mechanism of aging, largely determine the intensity of its development.

They, firstly, significantly limit the adaptive capabilities of an aging organism, and secondly, they create the preconditions for the development of pathology, which is the main cause of human death - atherosclerosis, hypertension, coronary heart disease and brain disease.

Blood pressure

Most researchers agree that it is mainly the systolic level that increases with age. blood pressure (BP) blood (Fig. 29), while the diastolic changes slightly.

Rice. 29. Age dynamics of blood pressure on the right radial (A) and right femoral (B) arteries (arterial oscillography technique).
On the ordinate - maximum (1), minimum (2) and average dynamic (3) blood pressure, mm Hg. Art.; The abscissa axis is age, years.

With age, the average dynamic blood pressure, lateral, shock and pulse pressure also increases. Blood pressure is a complex parameter determined by vascular resistance and cardiac output. As can be seen from table. 27, the same level of blood pressure can be maintained at different age periods due to unequal shifts in general peripheral vascular resistance and cardiac output (Frolkis et al., 1977a, 1979).

Table 27. Indicators of hemodynamics and myocardial contractility in animals of different ages

It is of interest to compare hemodynamic parameters in phylogenetic terms, comparing them in organisms with different life expectancies. It is noteworthy that in short-lived species (rats, rabbits) blood pressure does not change significantly, while in longer-lived species (people, dogs) it increases.

It was noted that the increase in blood pressure is mainly associated with age-related changes in the vascular system - loss of elasticity of large arterial trunks, increase in peripheral vascular resistance. A decrease in cardiac output against the background of an increase in vascular resistance protects against a sharp increase in blood pressure.

There are differences in age-related changes in human blood pressure in different countries and in different regions of the Russian Federation. Thus, the lowest level of systolic pressure in old men and women is in Abkhazia, and then in Ukraine, Moldova; higher among residents of Belarus and Lithuania. Residents of Armenia and Kyrgyzstan have lower blood pressure than Muscovites and Leningrad residents (Avakyan et al., 1977).

With age, there is a decrease in venous blood pressure. According to Korkushko (1968b), when it is measured in a bloody manner using a Waldmann apparatus in the median vein in the area of ​​the elbow with a horizontal body position in the age group of 20-40 years, the level of venous pressure is on average 95 ± 4.4 mm water. Art., in the seventh decade - 71 ± 4, in the eighth - 59 ± 2.5, in the ninth - 56 ± 4.4, in the tenth - 54 ± 4.3 mm water. Art. (R
Expansion of the venous bed, decrease in tone, elasticity of the venous wall are the determining factors in the decrease in venous blood pressure with age. A decrease in muscle tone and a decrease in the suction effect of the chest are also known to have an effect.

Rhythmic activity of the heart and its electrical activity

Aging is characterized by a slowdown in the rhythmic activity of the heart. It should be noted that there are significant individual differences. The slowdown in cardiac rhythm in old age is associated to a certain extent with a decrease in sinus automatism.

Bear (1979), by removing electrical potentials from pacemaker cells located at the mouth of the right vena cava, showed that their frequency decreases significantly with old age. However, a decrease in sinus automatism alone cannot explain the slowing of heart rate in old age. The fact is that the heart rate in the myocardial strips is much lower than in the heart in situ.

In slowing down the heart rate, the weakening of sympathetic extracardiac influences is of great importance. Thus, after the administration of beta-blockers in old animals, the slowdown in heart rate is less pronounced than in young animals. Certain changes also occur in the electrical activity of cardiocytes (Shevchuk, 1973).

Thus, the membrane potential of the myocardial fibers of the isolated right atrium was 78.6 ± 1.1 mV in adult animals, 81.9 ± 2.9 mV in old animals, PP - 96.9 ± 1.3 and 93.0 ± 0.7 mV, respectively. Noteworthy is the pronounced decrease in overshoot in old age, which was 18.3 ± 0.9 mV in adult rats and 12.1 ± 1.3 mV in old rats (p
A change in the repolarization process is also indicated by the results of electrocardiographic studies - a decrease in the main vector of the G loop, a discrepancy between the main vector of the ventricular complex loop (QRS) and the T loop.

With age, the process of depolarization also changes, and the QRS complex widens. Despite the development of age-related pulmonary emphysema, the electrical axis of the heart is deviated to the left, which indicates predominant changes in the myocardium of the left ventricle.

Noteworthy is the fact that the overall bioelectrical activity of the myocardium, according to vectorcardiography, changes unevenly in different age groups. It reaches its greatest increase in the sixth and seventh decades, after which it declines.

Partial analysis of the vectorcardiogram shows uneven changes in the right and left parts of the heart. Starting from the fifth decade, the activity of the left ventricle of the heart predominates. These conclusions coincide with morphological data on the development of left ventricular hypertrophy.

With age, the electrical systole of the heart lengthens. For example, according to our data, at the age of 20-40 years its duration is 0.368 ± 0.0067 s, in the tenth decade - 0.396 ± 0.008 s with the due 0.358 ± 0.0056 s (p
The conditions for the propagation of excitation in the atria worsen (expansion, flattening, deformation of the P wave). Atrioventricular conduction and the spread of excitation throughout the ventricular myocardium slow down somewhat.

These changes can be made depending on the age-related characteristics of the structure and metabolic processes in the conduction system of the heart. However, it should be emphasized that in comparison with other parts of the heart, the conduction system of the heart changes to a lesser extent.

Cardiac output

There is a close relationship between cardiac output and basal metabolic rate. Savitsky (1974) considers the connection between minute blood volume (MBV) and general metabolism is so close that, based on the basal metabolism, they derived formulas for calculating the proper IOC values. Most researchers come to the conclusion that cardiac output decreases in old and senile age (Fig. 30).

Rice. 30. Changes in basic hemodynamic parameters with age (study with T-1824 dye dilution).
Along the ordinate - SV, ml (A), SV, ml/m2 (B), minute blood volume, l/min (C) and SI, l*min-1*m-2 (D); along the abscissa - age, years.

According to Brandfonbrener et al. (Brandfonbrener et al., 1955), a decrease in cardiac output has been observed since the third decade, and from 50 years of age and older, cardiac output decreases by 1% per year due to systolic volume and a slight decrease in the number of heart contractions (the dye dilution method was used - Evans blue ).

It was noted that the decrease in cardiac output was more pronounced than the decrease in oxygen consumption and CO2 emissions (oxygen consumption decreased by 0.6% per year). Strandell (1976) believes that the decline in cardiac output with age is associated with a decrease in oxygen consumption.

Tokar (1977) also observed a decrease in cardiac output in elderly people (dye dilution technique). In young people cardiac index (SI) was equal to 3.16 ± 0.19 l*min-1*m-2, in the elderly - 2.53 ± 0.11, in the old - 2.46 ± 0.09 l*min-1*m-2, the shock index - respectively 46.5 ± 2.6, 42.2 ± 1.8 and 39.6 ± 1.4 ml/m2.

Moreover, in older people compared to young people, a decrease in IOC was associated with a decrease number of heartbeats (HR), while in the old ones there was a significant decrease in SV.

In table 27 presents data on changes in hemodynamic parameters during aging in rats, rabbits and dogs (Frolkis et al., 1977b). They showed a significant decrease in minute blood volume and cardiac index. It is important that these animals do not suffer from spontaneous atherosclerosis, whereas it is known that people over 60 years of age almost always have atherosclerosis to one degree or another.

The decrease in cardiac output in old animals suggests that this is an age-related rather than a pathological phenomenon. It is also noteworthy that in different species of animals the participation of changes in the rhythm of heart contractions in the mechanism of the fall in cardiac output varies.

It has been found that with age, the functional reserve of cardiac output decreases above the basal level during submaximal physical activity (Korkushko, 1978; Strandell, 1976). Experimental data also indicate a limitation in the ability to adapt to loads (Frolkis et al., 1977b).

With experimental coarctation of the aorta in old animals, acute heart failure often develops, in 48% of cases. As can be seen from Fig. 31, 4-6 days after coarctation of the aorta in the so-called emergency phase in old animals, IOC, SV, and the maximum rate of increase in intraventricular pressure drop significantly.

Rice. 31. Systolic pressure in the left ventricle of the heart (L), the maximum rate of increase in intraventricular pressure (B) and the index of myocardial contractility (C) in% of the initial values ​​in adult (I) and old (II) rats on the 4th-6th ( 1) and 14-16 (2) days after experimental coarctation of the aorta.

With age, basal metabolism decreases. That is why a decrease in minute blood volume in elderly and old people is considered by some to be a natural reaction of the cardiovascular system to a decrease in tissue demands for oxygen delivery (Burger, 1960; Korkushko, 1968a, 1968b, 1978; Strandell, 1976; Tokar, 1977).

However, the decrease in oxygen consumption falls less than cardiac output, and this contributes to the occurrence of circulatory hypoxia. Compensatory mechanisms aimed at optimal tissue oxygen supply with reduced cardiac output are an increase in the arteriovenous oxygen difference and a change in the oxyhemoglobin dissociation curve (shift to the right).

In elderly and elderly people, against the background of reduced cardiac output, active regional redistribution of organ fractions of cardiac output is observed. Despite the decrease in IOC, the cerebral and coronary fractions of cardiac output are quite high (Mankovsky, Lizogub, 1976), while the renal (Kalinovskaya, 1978) and hepatic (Landowne et al., 1955; Kolosov, Balashov, 1965) are significantly reduced.

Absolute values central blood volume (CCV) do not change with age. However, his attitude towards mass of circulating blood (MCB) indicates a relative increase. At the same time, an increase in SV in relation to the CTC was noted (Korkushko, 1978).

All this indicates a change in the conditions of blood flow to the heart and its deposition in the intrathoracic area. The relative increase in central blood volume in elderly and senile people is associated with an increase in the residual blood volume in the cavities of the heart. It is also important to increase the capacity (volume) of the aorta, its ascending part and arch.

MCC practically does not change with age. The ratio of the mass of circulating blood to the minute volume of blood gives an idea of ​​the time of complete blood circulation. This figure increases with age. At the same time, a slowdown in blood flow time was also noted in other areas of the vascular system: hand-ear, hand-lungs, lungs-ear; the time characterizing the central volume (intrathoracic) of blood circulation increases (Fig. 32).

Rice. 32. Age-related changes in blood flow speed.
On the ordinate axis - the time of intrathoracic (A) and complete (B) blood circulation and blood flow in the arm-lung (C), lung-ear (D) and arm-ear (E) section, s; The abscissa axis is age, years.

N.I. Arinchin, I.A. Arshavsky, G.D. Berdyshev, N.S. Verkhratsky, V.M. Dilman, A.I. Zotin, N.B. Mankovsky, V.N. Nikitin, B.V. Pugach, V.V. Frolkis, D.F. Chebotarev, N.M. Emanuel

To a large extent characterize the nature and pace of human aging. As a person ages, significant changes in the cardiovascular system occur.

Elastic arteries (aorta, coronary, renal, cerebral arteries) and the arterial wall change significantly due to compaction of the inner lining, deposition of calcium salts and lipids in the middle lining, atrophy of the muscle layer, and decreased elasticity.

This leads to thickening of the arterial walls and a constant increase in peripheral vascular resistance, an increase in systolic blood pressure, and an increase in the load on the ventricular myocardium; the blood supply to the organs becomes less than adequate.

In old and senile age, a number of hemodynamic features are formed: systolic blood pressure increases mainly arterial pressure), venous pressure, cardiac output, and later cardiac output decrease. As a person ages, systolic blood pressure can increase up to 60-80 years, diastolic blood pressure - only up to 50 years.

In men, the increase in blood pressure with age is often gradual, but in men, especially after menopause, it is more dramatic. Reduced aortic elasticity is an independent predictor of cardiovascular mortality.

In the arteries, endothelial dysfunction is noted, its production of vasodilator factors decreases, and the ability to produce vasoconstrictor factors is retained.

Tortuosity and aneurysmal dilatation of capillaries and arterioles, their fibrosis, and hyaline degeneration develop, which leads to obliteration of the vessels of the capillary network, worsening transmembrane metabolism, and insufficiency of blood supply to the main organs, especially the heart.

Veins also change as a result of sclerosis of the walls and valves, atrophy of the muscle layer. The volume of venous vessels increases.

As a result of coronary circulatory insufficiency, dystrophy of myocardial muscle fibers, their atrophy and replacement with connective tissue develops. There is degeneration of collagen, which is the main structural component.

Collagen becomes more rigid, therefore the extensibility and contractility of the myocardium decreases. Cardiomyocytes die and are replaced with connective tissue, which progresses with age.

Developing sclerosis of the heart muscle in the elderly contributes to a decrease in its contractility and expansion of the cavities of the heart. Atherosclerotic cardiosclerosis is formed, leading to heart failure and heart rhythm disturbances.

A “senile heart” is formed, which is one of the main factors in the development of heart failure due to changes in neurohumoral regulation and prolonged myocardial hypoxia.

Aortic stenosis with calcification is most often observed in old age.

In the sinus node, the number of pacemaker cells, the number of fibers in the left bundle branch and Purkinje fibers decreases, they are replaced by connective tissue.

A shift in the electrolyte balance in the muscle cells of the myocardium aggravates the decrease in its contractility, helps reduce excitability, and this causes a high frequency of arrhythmias in old age, increasing the tendency to develop bradycardia, weakness of the sinus node, and various heart blocks. With aging, systole lengthens and diastole shortens.

Structural and functional changes in the body, hormonal and metabolic disorders form the features of the clinical picture of cardiovascular diseases in elderly and senile people. With age, the neurohumoral regulation of microcirculation changes, the sensitivity of capillaries to adrenaline and norepinephrine increases.

Effect on the cardiovascular system of the autonomic nervous system weakens with age, but sensitivity to catecholamines, angiotensin and other hormones increases.

In old age, the blood coagulation system is activated , functional insufficiency of anticoagulant mechanisms develops, the concentration of fibrinogen and antihemophilic globulin increases, the aggregation properties of platelets increase - this contributes to thrombus formation, which plays a significant role in the pathogenesis

Abstract on the topic:

Features of CVS in older people.

Made by: Mingazheva Elvira 401g

Checked by: Evdokimov V.V.

Arterial hypertension in old age

Increasing life expectancy entails an increase in the elderly population.
The prevalence of arterial hypertension (AH) increases with age, affecting approximately 60% of older people. Blood pressure level is a risk factor, the elimination of which significantly reduces the risk of developing cardiovascular diseases and death, the frequency of which among older people is significantly higher than among young people.
With age, blood pressure increases: SBP - up to 70-80 years, DBP - up to 50-60 years; subsequently, stabilization or even a decrease in DBP is noted. Increasing SBP in older people significantly increases the risk of developing cardiovascular complications, such as coronary heart disease (CHD), cerebrovascular disease, heart and kidney failure, and death from them. In accordance with the results of recent studies, pulse blood pressure (the difference between systolic and diastolic blood pressure) is considered as the most accurate predictor of cardiovascular complications in patients over 60 years of age due to the fact that it reflects the pathological stiffness of the arterial walls. The most convincing results are from a meta-analysis based on three studies: EWPНE, SYST-EUR and SYST-CHINA. They provided evidence that the higher the level of systolic BP and the lower the level of diastolic BP, i.e., the higher the pulse BP, the worse the prognosis for cardiovascular morbidity and mortality.
Currently, normal values ​​for pulse BP are not clearly defined, although most studies have shown a significant increase in cardiovascular risk with pulse BP above 65 mm Hg. Art.

Pathogenetic mechanisms of hypertension in old age
The following structural and functional changes in the cardiovascular system during aging should be noted.
Anatomical changes
Heart:
enlargement of the cavities of the left atrium and left ventricle;
calcification of the mitral and aortic valve rings.
Vessels:
increase in the diameter and length of the aorta;
thickening of the aortic wall.
Physiological changes
Heart:
decreased compliance of the left ventricle;
violation of diastolic filling of the left ventricle (decrease in early filling and increase in filling during atrial systole).
Vessels:
decreased elasticity;
increase in pulse wave speed;
increase in SBP.

Histophysiological changes
Increased content of lipids, collagen, lipofuscin, amyloid in tissues.
A decrease in the number of myocytes with an increase in their size.
Decreased rate of myocyte relaxation.
Decreased sensitivity of β-adrenergic receptors.
Increased duration of myocyte contraction.

Features of examination of elderly patients with hypertension
In addition to the routine diagnosis that is performed in all hypertensive patients, patients over 60 years of age should be screened for pseudohypertension, white coat hypertension, orthostatic hypotension, and secondary hypertension.
Great attention should be paid to the correct measurement of blood pressure. It should be carried out in a sitting position after a 5-10 minute rest. Blood pressure is defined as the average of two or more measurements.
Sometimes, when measuring blood pressure in elderly people, false results can be obtained due to an “auscultatory failure” - the absence of tones for a certain period after the first sound characterizing SBP appears. This can lead to a decrease in systolic blood pressure by 40-50 mm Hg. Art. To avoid errors and register a tone that appears before the “auscultatory dip,” it is recommended to inflate the cuff to 250 mm Hg. Art. and slowly release the air. The diagnosis of hypertension is established if SBP is >140 mmHg. Art. or DBP >90 mm Hg. Art. during several examinations.
Hypertension in the elderly is often accompanied by increased stiffness of the arterial wall due to its thickening and calcification. In some cases, this contributes to an overestimation of blood pressure readings, since the cuff cannot compress the stiff artery. In such a situation, the blood pressure level when measured using a cuff (indirect method) may be 10-50 mm Hg. Art. higher than using an intra-arterial catheter (direct method). This phenomenon is called pseudohypertension. The Osler test sometimes helps to diagnose it: determining the pulsation on a. radialis or a. brachialis distal to the cuff after inflating approximately to the patient's SBP level. If the pulse is palpable despite strong compression of the brachial artery, this indicates the presence of pseudohypertension. It should be suspected in cases where, against the background of high blood pressure numbers, there are no other signs of target organ damage. If an elderly person with pseudohypertension is prescribed antihypertensive therapy, he or she may have clinical signs of an excessive decrease in blood pressure, although hypotension is not measured when measured.
High blood pressure variability is another sign of increased stiffness of large arteries.

Clinical manifestations of increased blood pressure variability may include:
orthostatic decrease in blood pressure;
decreased blood pressure after eating;
enhanced hypotensive response to antihypertensive therapy;
increased hypertensive response to isometric and other types of stress;
"White coat hypertension"
Patients with complaints of severe changes in blood pressure, a history of dizziness and fainting, or patients with high blood pressure at a doctor's appointment and no signs of target organ damage are advised to undergo ambulatory 24-hour blood pressure monitoring or measure blood pressure at home 4-5 times a day. In addition, elderly patients with hypertension often experience disturbances in the circadian rhythm of blood pressure, which require identification and correction, as they can cause cardiovascular complications.
To diagnose orthostatic hypotension, all patients over 50 years of age are recommended to measure blood pressure while lying down, and after 1 and 5 minutes - while standing. The normal response of blood pressure to the transition from a lying position to a standing position is a slight increase in DBP and a decrease in SBP. Orthostatic hypotension occurs when SBP decreases by more than 20 mmHg. Art. or DBP increases by more than 10 mmHg. Art. The causes of orthostatic hypotension, as mentioned above, are a decrease in blood volume, baroreceptor dysfunction, disruption of the autonomic nervous system, as well as the use of antihypertensive drugs with a pronounced vasodilating effect (a-blockers and combined a- and b-blockers). Diuretics, nitrates, tricyclic antidepressants, sedatives and levodopa can also worsen orthostatic hypotension.
To reduce the severity of orthostatic hypotension, it is recommended to adhere to the following rules:
lie on a high pillow or raise the head of the bed;
rise from a lying position slowly;
before moving, if possible, perform isometric exercises, for example, squeezing a rubber ball in your hand, and drink at least a glass of liquid;
eat food in small portions.
Another important point in the examination of elderly patients with hypertension is the exclusion of secondary hypertension. The most common causes of secondary hypertension in elderly patients are renal failure and renovascular hypertension. The latter, as a possible cause of increased blood pressure, is recorded in 6.5% of hypertensive patients aged 60-69 years and in less than 2% of patients aged 18-39 years.

Treatment of elderly people with arterial hypertension
The goal of treating elderly patients with hypertension is to reduce blood pressure below 140/90 mmHg. Art.
Non-drug therapy is a mandatory component of the treatment of elderly patients with hypertension. In patients with mild hypertension, it can lead to normalization of blood pressure; in patients with more severe hypertension, it can reduce the number of antihypertensive drugs taken and their dosage. Non-drug treatment consists of lifestyle changes.
Reducing body weight in case of excess and obesity helps reduce blood pressure and improves the metabolic profile in these patients.
Reducing table salt intake to 100 mEq Na, or 6 g of table salt per day, can have a significant effect on BP in older adults. Overall, controlled studies show a small but consistent reduction in BP in response to limiting salt intake to 4-6 g/day
An increase in physical activity (35-40 minutes per day of dynamic exercise, for example, brisk walking) also has an antihypertensive effect and has a number of other positive effects, in particular metabolic ones.
Reducing alcohol consumption per day to 30 ml of pure ethanol (maximum 60 ml of vodka, 300 ml of wine or 720 ml of beer) for men and 15 ml for women and men with low body weight also helps reduce blood pressure.
Inclusion in the diet of foods high in potassium (approximately 90 mmol/day). The effect of potassium on blood pressure levels has not been conclusively proven, however, given its effect on the prevention of strokes and the course of arrhythmias, elderly patients with hypertension are recommended to consume vegetables and fruits rich in this element.
Enriching the diet with calcium and magnesium has a beneficial effect on the general condition of the body, and calcium also slows down the progression of osteoporosis.
Quitting smoking and reducing the proportion of saturated fats and cholesterol in the diet help improve the condition of the cardiovascular system.
It must be remembered that one of the reasons for increased blood pressure in old age may be the treatment of concomitant diseases with non-steroidal anti-inflammatory drugs, so it is necessary to reduce their use.

Drug therapy
In cases where non-drug treatment does not normalize blood pressure, it is necessary to consider prescribing antihypertensive drug therapy.
Patients with SBP levels above 140 mm Hg. Art. and concomitant diabetes mellitus, angina pectoris, cardiac, renal failure or left ventricular hypertrophy, treatment of hypertension should begin with pharmacotherapy along with lifestyle changes.
The medication regimen should be simple and understandable for the patient; treatment should begin with low doses (half as much as in young people), gradually increasing them until the target blood pressure is reached - 140/90 mm Hg. Art. This approach helps prevent orthostatic and postprandial (after eating) hypotension.
A forced decrease in blood pressure can worsen cerebral and coronary blood flow against the background of obliterating atherosclerotic vascular lesions.
Pharmacotherapy used in elderly patients with hypertension does not differ from that prescribed for young patients. Diuretics and long-acting dihydropyridine calcium antagonists are drugs effective in preventing stroke and major cardiovascular complications.
Thus, the algorithm for managing elderly patients with hypertension is as follows:
establishing a diagnosis (excluding the secondary nature of hypertension, “white coat hypertension” and pseudohypertension);
risk assessment taking into account the presence of concomitant diseases;
non-drug treatment;
drug therapy.
However, it must be remembered that only an individual approach to the examination and treatment of elderly patients can improve their quality of life and the prognosis of a particular patient.

Cardiac ischemia

Coronary heart disease is myocardial damage caused by impaired blood flow in the coronary arteries. That is why in medical practice the term coronary heart disease is often used.

Typically, in people suffering from coronary artery disease, symptoms appear after 50 years of age. They only occur during physical activity. Typical manifestations of the disease are:

pain in the middle of the chest (angina);

feeling of shortness of breath and difficulty breathing;

circulatory arrest due to too frequent heart contractions (300 or more per minute). This is often the first and last manifestation of the disease.

Some patients suffering from coronary heart disease do not experience any pain or lack of air even during a myocardial infarction.

The more risk factors a person has, the more likely they are to have the disease. The influence of most risk factors can be reduced, thereby preventing the development of the disease and the occurrence of its complications. Such risk factors include smoking, high cholesterol and blood pressure, and diabetes.

Diagnostic methods: recording an electrocardiogram at rest and during a stepwise increase in physical activity (stress test), chest x-ray, biochemical blood test (with determination of cholesterol and blood glucose levels). If there is severe damage to the coronary arteries requiring surgery, then coronary angiography. Depending on the condition of the coronary arteries and the number of affected vessels, the treatment, in addition to medications, is angioplasty or coronary artery bypass surgery. If you consult a doctor on time, they will prescribe medications that help reduce the impact of risk factors, improve quality of life and prevent the development of myocardial infarction and other complications:

• statins to lower cholesterol;
• beta blockers and angiotensin-converting enzyme inhibitors to lower blood pressure;
• aspirin to prevent blood clots;
• nitrates to help relieve pain during an angina attack
• do not smoke. It's the most important. Nonsmokers have a significantly lower risk of myocardial infarction and death than smokers;
• eat foods low in cholesterol;
• Do physical activity regularly, every day for 30 minutes (walking at an average pace);
• reduce your stress levels.

Atherosclerosis

Atherosclerosis (from the Greek athera - gruel and sclerosis), a chronic disease characterized by hardening and loss of elasticity of the walls of the arteries, narrowing of their lumen with subsequent disruption of the blood supply to the organs; The entire arterial system of the body is usually affected (albeit unevenly). A. older people get sick more often. External manifestations of the disease are usually preceded by a many-year asymptomatic period; To some extent, many young people have atherosclerotic changes. Men are 3-5 times more likely to suffer from A. than women. In the development of the disease, hereditary predisposition, as well as the individual characteristics of the body, play a role. Diabetes mellitus, obesity, gout, cholelithiasis, etc. contribute to the development of A. A diet with an excess amount of animal fat plays a significant role as a factor predisposing to A., but not as the root cause of A. Low physical activity is known to be important in the origin of A. An important reason should be considered psycho-emotional stress, traumatic to the nervous system, the influence of a busy pace of life, noise, some specific working conditions, etc.

The mechanism of development of the disease is a disturbance in the metabolism of lipids (fat-like substances), especially cholesterol, changes in the structure and function of the vascular wall, and the state of the blood coagulation and anticoagulation systems. When cholesterol metabolism is disrupted, the cholesterol content in the blood increases, which over time becomes an important (albeit optional) link in the development of the disease. Apparently, with A. not only is the degree of utilization and elimination of excess dietary cholesterol reduced, but its synthesis in the body is also increased. Metabolic disorders are associated with a disorder of its regulation - the nervous and endocrine systems.

With A., atherosclerotic plaques form in the vascular wall - more or less dense thickenings of the inner lining of the artery. First, the protein substance of the inner lining of the artery swells. Subsequently, its permeability increases: cholesterol penetrates the vessel wall. Accumulations of cholesterol in the walls of arteries cause secondary changes in the vessels, expressed in the proliferation of connective tissue. Subsequently, atherosclerotic plaques undergo a number of changes: they can disintegrate with the formation of a mushy mass (hence the name A.), lime is deposited in them (calcification) or a translucent homogeneous substance (hyaline) is formed. The process is progressive. The lumens of blood vessels narrow. Due to the circular arrangement of plaques, the vessels lose their ability to expand, which, in turn, disrupts the regulation of blood supply to organs during intense work. Irregularities inside the vessels in A. contribute to the formation of blood clots and thrombi, which aggravate circulatory disorders until they completely stop. The development of blood clots is also facilitated by a decrease in the intensity of anti-clotting processes observed in A. Some researchers associate the onset of A. development with a violation of blood clotting, the accumulation of thrombotic masses in the walls of the vessel, followed by their obesity, loss of cholesterol and connective tissue reaction.

With the predominance of atherosclerotic changes in the vessels of the heart, brain, kidneys, lower extremities, in the organ that experiences a lack of blood supply as a result of A., disturbances occur that determine the clinical picture of the disease. A. heart vessels is expressed by coronary insufficiency or myocardial infarction. A. cerebral vessels leads to disorders of mental activity, and in severe degrees - to various types of paralysis. A. renal arteries usually manifests as persistent hypertension. A. blood vessels of the legs can be the cause of intermittent claudication (see Endarteritis obliterans), the development of ulcers, gangrene, etc.

Treatment and prevention of A. are aimed at regulating general and cholesterol metabolism. At the same time, measures to normalize working and living conditions (observance of work and rest schedules, physical education, etc.) are important. Nutrition should not be excessive, especially in relation to animal fats and carbohydrates. The diet includes foods containing vitamins and vegetable oils. Of the medicinal preparations, some vitamins, hormonal agents, drugs that inhibit the synthesis of cholesterol, promote its excretion, and other drugs that prevent blood clotting - anticoagulants, as well as vasodilators, are used. Treatment is carried out in a strictly individual order with mandatory medical supervision.

N The steady aging of the population of developed countries increases the share of cardiovascular diseases in the overall structure of morbidity, and consequently leads to an increase in the number of elderly patients in the practice of doctors of many specialties. Therefore, knowledge of geriatric aspects of cardiology is an important element of knowledge not only of a modern cardiologist, but also of a geriatrician, family doctor and general practitioner.

Until recently, there was an opinion about the need for only symptomatic treatment of cardiovascular diseases (CVD) in the elderly and the elderly and about the insignificant impact of drug intervention on the prognosis of life at this age. Meanwhile, large clinical studies convincingly show that the patient’s age is not an obstacle to active medical and surgical treatment of many cardiovascular diseases - coronary artery disease, arterial hypertension, stenotic atherosclerosis of the great arteries, heart rhythm disturbances. Moreover, since the absolute risk of cardiovascular complications is higher in the elderly, treatment of CVD in the elderly is even more effective than in young and middle-aged people.

Treatment goals for cardiovascular disease in the elderly

As in other age groups, the main goals of treatment in the elderly are to improve the quality and increase life expectancy. For a doctor familiar with the basics of geriatrics and the specifics of clinical pharmacology in the elderly, both of these goals are achievable in most cases.

What is important to know when prescribing treatment for older people?

Within the framework of this article, the features of treatment in elderly patients with the most common cardiovascular diseases are considered:

• Arterial hypertension, incl. isolated systolic hypertension
• Heart failure

Arterial hypertension in the elderly

Arterial hypertension (AH), according to various estimates, occurs in 30-50% of people over 60 years of age. Diagnosis and treatment of this disease have a number of important features (Table 4). The elderly need to measure blood pressure (BP) especially carefully, since they often have “pseudohypertension”. The reasons for this are both the rigidity of the main arteries of the extremities and the large variability in systolic blood pressure. In addition, orthostatic reactions are typical for elderly patients (due to violations of the baroreceptor apparatus), therefore, it is strongly recommended to compare blood pressure in the patient's supine position and immediately after moving to a vertical position.

Due to the high prevalence of hypertension, especially the isolated increase in systolic blood pressure among the elderly, this disease has long been considered as a kind of relatively benign age-related change, the active treatment of which could worsen well-being due to an excessive decrease in blood pressure. Also feared more than at a young age, the number of side effects of drug therapy. Therefore, doctors resorted to lowering blood pressure in the elderly only in the presence of clinical symptoms (complaints) associated with high blood pressure. However, by the beginning of the 90s of the 20th century it was shown that regular long-term antihypertensive therapy significantly reduces the risk of developing major cardiovascular complications of hypertension - cerebral stroke, myocardial infarction and cardiovascular mortality. A meta-analysis of 5 randomized clinical trials, including more than 12 thousand elderly patients (aged >60 years), showed that active reduction of blood pressure was accompanied by a reduction in cardiovascular mortality by 23%, cases of coronary artery disease - by 19%, cases of heart failure - by 48%, stroke rates - by 34%.

A review of the main prospective randomized trials showed that in elderly patients with hypertension, drug lowering of blood pressure for 3-5 years significantly reduces the incidence of heart failure by 48%.

Thus, today there is no doubt that elderly patients with hypertension receive a real benefit from lowering blood pressure. However, after making a diagnosis and making a decision on treatment for an elderly patient with hypertension, it is necessary to take into account a number of circumstances.

Older people respond very well by reducing blood pressure to limiting salt intake and reducing body weight. Starting doses of antihypertensive drugs are half the usual starting dose. Dose titration occurs more slowly than in other patients. You should strive to gradually reduce blood pressure to 140/90 mmHg. (with concomitant diabetes mellitus and renal failure, the target blood pressure level is 130/80 mm Hg). It is necessary to take into account the initial level of blood pressure, duration of hypertension, and individual tolerance to lowering blood pressure. A concomitant decrease in diastolic blood pressure in patients with isolated systolic hypertension is not an obstacle to continuing therapy. In the study SHEP the average level of diastolic blood pressure in the group of treated patients was 77 mm Hg, and this corresponded to an improvement in prognosis.

Thiazide diuretics, beta-blockers and their combinations were effective in reducing the risk of cardiovascular complications and mortality in elderly patients with hypertension, and diuretics (hydrochlorothiazide, amiloride) had an advantage over beta-blockers. Recently completed large study ALLHAT clearly confirmed the benefit of diuretics in the treatment of hypertension in all age groups. In the 7th Report of the United States Joint National Committee on the Detection, Prevention and Treatment of Arterial Hypertension (2003), diuretics play a leading role in both monotherapy and combination treatment of hypertension. Clinical trial currently underway HYVET involving 2100 patients with arterial hypertension aged 80 years and older. Patients will be randomized to treatment groups with placebo and the diuretic indapamide (including in combination with the ACE inhibitor perindopril). The target blood pressure level in this study is 150/80 mm Hg, the primary end point is cerebral stroke, the secondary end point is total mortality and mortality from cardiovascular diseases.

Studies have shown the effectiveness of a calcium antagonist amlodipine (Amlovas) . The advantage of using amlodipine in lowering blood pressure compared with another calcium antagonist, diltiazem, has been shown. The duration of action of amlodipine is 24 hours, which facilitates a single dose per day and ensures ease of use. In the study THOMS a decrease in the left ventricular myocardial mass index was noted in the group of patients taking amlodipine.

ACE inhibitors are the drugs of choice for at least two categories of elderly patients with hypertension - 1) with left ventricular dysfunction and/or heart failure; 2) with concomitant diabetes mellitus. This is based on a proven reduction in cardiovascular mortality in the first case and a slowdown in the development of renal failure in the second. If intolerant, ACE inhibitors can be replaced with angiotensin receptor antagonists.

a-blockers (prazosin, doxazosin) are not recommended for the treatment of hypertension in the elderly due to the frequent development of orthostatic reactions. Moreover, in a large clinical trial ALLHAT an increase in the risk of heart failure during treatment of hypertension with a-blockers has been shown.

Heart failure in the elderly

Currently, chronic heart failure (CHF) affects 1-2% of the population of developed countries. Every year, chronic heart failure develops in 1% of people over 60 years of age and in 10% of people aged >75 years.

Despite the significant progress achieved in the last decades in the development of therapeutic algorithms for the treatment of CHF using various drugs and their combinations, the specifics of treatment of elderly and geriatric patients remain poorly understood. The main reason for this turned out to be the deliberate exclusion from most prospective clinical trials on the treatment of CHF of persons over 75 years of age - primarily women (who make up more than half of all elderly people with CHF), as well as people with concomitant diseases (also, as a rule, the elderly). Therefore, before obtaining data from clinical studies specifically designed for the population of elderly and elderly people with CHF, one should be guided by proven principles for the treatment of CHF in middle-aged people - taking into account the above-mentioned age-related characteristics of the elderly and individual contraindications. Elderly patients with CHF are prescribed ACE inhibitors, diuretics, b-blockers, spironolactone , as drugs proven to improve survival and quality of life. For supraventricular tachyarrhythmias due to CHF, digoxin is very effective. If it is necessary to treat ventricular arrhythmias against the background of CHF, preference should be given to amiodarone, since it has a minimal effect on myocardial contractility. In case of severe bradyarrhythmias due to CHF (sick sinus syndrome, intracardiac blockade), the possibility of implanting a pacemaker should be actively considered, which often significantly facilitates the possibilities of pharmacotherapy.

Of utmost importance for the successful treatment of CHF in the elderly is the timely identification and elimination/correction of concomitant diseases, often hidden and asymptomatic (exhaustion, anemia, thyroid dysfunction, liver and kidney diseases, metabolic disorders, etc.).

Stable ischemic heart disease in the elderly

Elderly people make up the majority of patients with coronary artery disease. Almost 3/4 of deaths from coronary heart disease occur among people over 65 years of age, and almost 80% of people who die from myocardial infarction belong to this age group. However, in more than 50% of cases, the death of persons over 65 years of age occurs from complications of coronary artery disease. The prevalence of coronary heart disease (and, in particular, angina) in young and middle age is higher among men than among women, but by the age of 70-75 years, the frequency of coronary heart disease among men and women is comparable (25-33%). The annual mortality rate among patients in this category is 2-3%, in addition, another 2-3% of patients may develop non-fatal myocardial infarction.

Features of IHD in old age:

• Atherosclerosis of several coronary arteries at once
• Stenosis of the left main coronary artery is common
• Decreased left ventricular function is common
• Atypical angina pectoris, silent myocardial ischemia (up to silent MI) are common.

The risk of complications during planned invasive studies in the elderly is slightly increased, so old age should not be an obstacle to referring a patient for a coronary angiographic study.

Features of treatment of stable ischemic heart disease in the elderly

When selecting drug therapy for elderly patients, it should be remembered that treatment of IHD in the elderly is carried out according to the same principles as in young and middle age, but taking into account some of the features of pharmacotherapy (Tables 5,6).

The effectiveness of medications prescribed for ischemic heart disease, as a rule, does not change with age. Active antianginal, anitischemic, antiplatelet and lipid-lowering therapy can significantly reduce the incidence of complications of coronary artery disease in elderly people. According to indications, all groups of drugs are used - nitrates, b-blockers, antiplatelet agents, statins. However, evidence-based studies specifically devoted to the treatment of coronary artery disease in older and older people are still insufficient. At the same time, the proven benefits of a calcium channel blocker amlodipine at a dose of 5-10 mg/day to reduce the frequency of episodes of myocardial ischemia (Holter monitoring data). The reduction in the frequency of painful attacks compared to placebo makes the use of the drug promising in this category of patients, especially in those who suffer from hypertension. In recent years, clinical studies have been conducted specifically on the effectiveness of drug treatment for coronary artery disease in the elderly.

Generalized data from studies on secondary lipid-lowering prevention with statins LIPID , CARE And 4S indicate that with a comparable reduction in the relative risk of cardiovascular complications among young and elderly patients, the absolute benefit of treatment with statins (simvastatin and pravastatin) is higher among the elderly. Effective treatment of 1000 elderly (aged<75 лет) пациентов в течение 6 лет предотвращает 45 смертельных случаев, 33 случая инфаркта миокарда, 32 эпизода нестабильной стенокардии, 33 процедуры реваскуляризации миокарда и 13 мозговых инсультов. Клинические испытания с участием больных старше 75 лет продолжаются. До получения результатов этих исследований вопросы профилактического назначения статинов больным с ИБС самого старшего возраста следует решать индивидуально.

In a large multicenter randomized trial PROSPER studied the effect of long-term use of pravastatin (40 mg/day) on the course and outcomes of coronary artery disease and the incidence of strokes in elderly people (age of participants 70-82 years) with proven coronary artery disease or risk factors for its development. Over 3.2 years of treatment, pravastatin reduced plasma LDL-C levels by 34% and reduced the combined risk of death from coronary artery disease and nonfatal myocardial infarction by 19% (RR 0.81, 95% CI 0.69–0.94). The relative risk of stroke in the active treatment group did not change significantly (RR 1.03, 95% CI 0.81-1.31), while the total relative risk of death from ischemic heart disease and stroke, as well as non-fatal myocardial infarction and non-fatal stroke decreased by 15% (HR 0.85 with 95% CI 0.74-0.97, p=0.0014). Mortality from coronary artery disease among those receiving pravastatin decreased by 24% (HR 0.76, 95% CI 0.58-0.99, p=0.043). The study noted good tolerability of long-term use of pravastatin as part of combination therapy in elderly people - there were no cases of myopathy, liver dysfunction, or statistically significant memory impairment. Among those taking statins, there was a higher incidence of detection (but not an increase in mortality!) of concomitant cancer diseases (OR 1.25 with 95% CI 1.04-1.51, p = 0.02). The authors attribute this finding to more careful diagnostic testing of the older adults included in the study.

Thus, the PROSPER clinical trial at a high methodological level proved the effectiveness and good tolerability of long-term use of pravastatin in elderly people with coronary artery disease, other cardiovascular diseases and cardiovascular risk factors.

Efficiency coronary bypass surgery and stenting of the coronary arteries in the elderly is comparable to the effectiveness of these interventions in younger patients, so age, in itself, is not an obstacle to invasive treatment. Limitations may be caused by concomitant diseases. Considering that complications after bypass surgery are more common in the elderly, as well as symptomatic improvement as the most frequent desired goal of intervention in the elderly, it is necessary to take into account all comorbidities during preoperative preparation and, if possible, give preference to balloon coronary angioplasty and coronary artery stenting .

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