Individuals over 65 years of age account for 12 % of the total population in the USA, twice the proportion 20 years ago. This group is expected to increase by 20 % in the next decade and is predicted to constitute more than 20 % of the population by the year 2030. Moreover, the proportion of individuals aged 80 and over in EU Member States currently represents 4.7 % of the total population and is projected to increase to 12.1 % in 2060 . As the prevalence and severity of coronary artery disease (CAD) show a striking growth with age [2, 3], the assessment of risk in elderly and very old (>80 years) is and will be increasingly important in the next future. Unfortunately, in these patients, the predictive value of a test may be negatively affected by reduced life expectancy. On the other hand, due to the high prevalence of CAD in this subset, a negative test result may likely be a false-negative one . Exercise electrocardiography shows limited feasibility in very old patients, mainly due to neuromuscular weakness; physical deconditioning; or neurologic, orthopedic, peripheral vascular, or respiratory limitations. In addition, test specificity declines as age increases  because of repolarization abnormalities on resting electrocardiogram due to hypertension , left ventricular hypertrophy [4, 5], or digoxin intake . Stress echocardiography has been found to confer effective prognostic contribution in elderly individuals [7–16]. Pharmacologic stress echocardiography provides useful prognostic information in patients >65 years of age. However, its prognostic value decreases with increasing age  (Fig. 29.1). In particular, ischemia failed to add prognostic information in subjects >80 years of age, and in this subset it does not predict mortality  (Fig. 29.2). The stratification strategy should be tailored and designed on patients' profile. In patients older than 80 years, stress echocardiography does not provide additive information on outcome. Elderly patients with positive stress echocardiography test results tended to receive less coronary angiography and fewer revascularization procedures when compared to the overall population . Advanced age often directs physician's decision on therapeutic strategy, but this policy in time may adversely affect outcome, since a dramatic change in the natural history can be achieved by properly targeted interventions oriented by physiologic testing results. With current advances in surgical techniques and intraoperative myocardial protection, elderly patients with multivessel disease and even significant baseline dysfunction can undergo coronary artery bypass surgery with a low in-hospital mortality rate and an excellent short-term survival rate. Stress echocardiography is a suitable and effective tool for risk stratification in this setting.
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