History and Physical Examination

When taking the history, a physician should remember that age-related changes in lifestyle may mask important symptoms; for example, exertional angina pectoris and dyspnea may not occur if a patient no longer walks far or fast enough to experience them. Other symptoms may be atypical; for example, the age-related decrease in left ventricular compliance may produce exertional dyspnea rather than angina in patients with myocardial ischemia. Memory or attention deficits may prevent a patient from accurately recalling or describing a cardiac symptom. Drugs commonly used by the elderly may affect cardiac function. For example, a nonsteroidal anti-inflammatory drug may cause sodium retention, which may exacerbate heart failure.

Elderly patients should be asked about cardiovascular risk factors, including smoking, hypertension, hyperlipidemia, and diabetes mellitus. In the elderly, aggressive risk factor modification is well tolerated and is accompanied by a reduction in risk of coronary events. Whether arterial pulse wave velocity and carotid artery intimal-medial thickness are useful markers of cardiovascular risk is unclear; therefore, tests to determine these parameters should not be routinely performed.

Blood pressure measurement is essential because hypertension (systolic blood pressure >= 140 mm Hg or diastolic pressure >= 90 mm Hg, regardless of age) is the most common treatable cardiovascular risk factor in the elderly. Blood pressure is measured with the patient supine, sitting, and standing (after 2 minutes). In about 20% of persons > 65 years, standing causes blood pressure to decrease by > 20 mm Hg. Absence of compensatory tachycardia suggests autonomic insufficiency, sinus node dysfunction, or a drug adverse effect.

Arterial blood pressure is measured in both arms to exclude significant stenosis distal to the origin of the subclavian artery. Systolic blood pressure is first estimated by palpation, because an auscultatory gap (disappearance and later reappearance of the Korotkoff sounds) is more prevalent among the elderly than among younger patients and may lead to systolic blood pressure's being greatly underestimated. Measurements of systolic blood pressure in the peripheral arteries cannot be used to accurately estimate central systolic blood pressure because such measurements do not consider the exaggeration of late systolic peak pressure in central arteries that occurs with age. A sclerotic noncompressible brachial or radial arterial wall that remains palpable at suprasystolic cuff pressure suggests generalized arteriosclerosis. Generalized arteriosclerosis may result in falsely high systolic blood pressure--a condition called pseudohypertension. Pseudohypertension is suspected when cuff pressure is very high but no target-organ damage is apparent. The diagnosis can be confirmed by measuring intra-arterial pressure. (Osler's sign--the ability to palpate the radial artery when the sphygmomanometric cuff is inflated to suprasystolic pressure--was thought to suggest pseudohypertension, but this sign is neither sensitive nor specific for pseudohypertension.)

Central venous pressure is best estimated by observing the right internal jugular vein because the left brachiocephalic (innominate) vein is often compressed by the aortic arch and the left external jugular vein.

Heart sounds are usually softer in the elderly, probably because the distance between the heart and the chest wall increases with age. Splitting of the second heart sound (S₂) can be heard in only about 30 to 40% of elderly patients. Wide splitting that increases with inspiration suggests right bundle branch block. In the elderly, the heart relies on atrial contraction to compensate for diminished early left ventricular filling. Consequently, a fourth heart sound (S₄) is normal, but a third heart sound (S₃) is always abnormal. In younger persons, the reverse is true. Kyphoscoliosis and other deformities of the chest wall complicate interpretation of the apical impulse and other precordial movements.

Systolic ejection murmurs (most often aortic) are detected in about half of elderly patients. These benign murmurs are distinguished from murmurs due to significant aortic valve stenosis or hypertrophic obstructive cardiomyopathy by their short duration, low intensity (usually grade 1 or 2), and failure to radiate. Age-related stiffening of the arterial tree may result in an apparently normal, brisk upstroke of the carotid artery pulse tracing, even in patients with severe aortic stenosis. Pulmonary valve murmurs are much less common among the elderly.

A bruit in the neck, abdomen, or groin strongly suggests carotid, aortorenal, or peripheral vascular disease, respectively. A prominent midline abdominal pulse with bruit suggests an abdominal aortic aneurysm.

Pulmonary rales are more likely to represent atelectasis, pulmonary fibrosis, or an acute inflammatory process (and not pulmonary edema) in elderly patients than in younger ones. Emphysematous lungs can produce factitious hepatomegaly by displacing the liver inferiorly.

Peripheral edema may be secondary to right-sided heart failure or to venous varicosities, lymphatic obstruction, or low serum albumin.