Atherosclerosis in the elderly: a heavy burden to bear

The World Health Organization estimates there are over thirty-two million major atherothrombotic events oc-cur worldwide each year with nearly seventeen million di-rectly attributable deaths.' Atherothrombosis as the name refers to blood clot formation within an arterial vessel. It may occur de novo, usually over an atherosclerotic seg-ment of the vessel, or embolised from a proximal source." These clots cause the blood vessel lumen to be-come totally or sub-totally occluded and, depending on the site and supply, lead clinically to unstable angina and myocardial infarction, ischemic strokes or leg claudica-tion. Acute myocardial infarction ( AMI) alone account for 25% of all deaths in the United States and is the leading cause of death in the world including many of the developing countries.3 It is of little suiprise therefore that from the cardiologists' standpoint, the bulk of our work whether as researchers or clinicians have been channeled towards the prevention, regression or at least delaying the process of atherothrombosis and minimizing its risk of re-currence. Yet we must be mindful that atherothrombosis is a generalized and progressive disease. Indeed over a quarter of patients with vascular disease would involve 2 or more vascular beds in their lifetime.4 For example, patients with a first stroke or peripheral arterial disease (PAD) has a 2 to 4-fold increased risk of AMI. Patients who have had an AMI are themselves at 5-fold increased risk of a further heart attack. The life-expectancy of pa-tients with a history of stroke, PAD or myocardial infarc-tion is also reduced.4'5 But to screen all patients with suspected cardiovascular disease for concomitant peripher-al disease would lead to unnecessary risks from longer ra-diation exposure, higher amount of contrast used and costs. Hence the original article by Rigatelli et al in this issue addresses an important issue on which patient scheduled for coronary angiogram should also undergo aorto-iliac studies.6 Indeed the clinical issue of whether it is justified to perform additional scans is also highlighted here.