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Background: Increasing time and resource constraints, and the potential for patient complications, has led to an emphasis on finding innovative ways to teach catheter-based procedures outside of the laboratory. Virtual reality (VR) simulator training has been proposed as a potential training solution. We report on the initial validation of a full procedural VR simulator for carotid angiography (CA) using the Vascular Interventional System Trainer (VIST)., Methods: In all, 100 experienced physicians, currently performing endovascular procedures (71 cardiologists, 29 surgeons, and one radiologist), underwent simulator based training in CA. Each operator completed three VR simulated CAs, and assessed the VIST VR simulator for both its face and content validity., Results: Assessment involved how the carotid procedure simulation looked and felt as well as how catheters behaved during the completion of the CA. Assessment was rated on a five-point Likert scale. Anatomically, physicians reported that the aortic arch and carotid vasculature were well simulated (mean = 4.4). However, the bony structures and intra-cranial vasculature correlated poorly with actual anatomic structures (means = 2.3 and 1.1, respectively). One-to-one haptic correspondence of catheters during psychomotor movements were felt to be strongly representative of live procedures. The simulated sequence of using guidewires and catheters was rated to be nearly identical to actual CA (means = 4.8)., Conclusions: VIST represents one of the most sophisticated VR simulators in medicine. Physicians reported that it looked, felt, and behaved similar to working on an actual patient. Future work is required to validate whether this simulator will improve catheter performance on actual patients.

During the past 3 years, the treatment of dyslipidemia has evolved significantly. The impact of recent trial data on management strategies in older patients is especially important, because the elderly segment of the US population continues to grow. Several clinical trials have been completed since the publication of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III guidelines were published in 2001. Recent trial data strongly support the use of lipid-lowering therapy in the elderly population. Although therapeutic lifestyle changes remain highly important, supplementation with lipid-lowering therapy has been shown to reduce the risk of cardiovascular events in both primary and secondary prevention models. Compelling data noted from recent clinical trials have prompted the NCEP to publish an updated report that addresses the significant interim developments.

Cardiovascular disease accounts for significant morbidity and mortality in the elderly. The clinical trial data available to guide therapy in this growing population subset are relatively limited. This review will focus on treatment approaches and recommendations obtained from subgroup analyses of elderly patients from major clinical trials for the management of chronic stable angina, acute coronary syndromes (unstable angina and non-ST-segment elevation myocardial infarction), and coronary revascularization. Recent advances in the treatment of stable angina have shown that use of angiotensin-converting enzyme inhibitors and lipid-lowering therapy as adjunctive measures show benefit in the elderly by reducing the occurrence of death, nonfatal myocardial infarction, and unstable angina. However, if patients experience disabling or unstable anginal symptoms despite effective medical therapy, coronary revascularization must be considered. Several clinical trials have shown a significant reduction in major adverse cardiac events when using intravenous glycoprotein receptor antagonists periprocedurally during percutaneous revascularization approaches in elderly patients with unstable angina or non-ST-segment elevation myocardial infarction, especially when these measures are performed as soon as possible. However, the success of myocardial revascularization by a percutaneous or surgical approach is highly dependent on the patient's associated comorbidities, especially in patients over age 80 years.

Cardiovascular disease accounts for significant morbidity and mortality in the elderly. Despite several, large cardiovascular clinical trials, data to guide therapy in this growing population subset are relatively limited. This review focuses on treatment approaches and recommendations for the management of elderly patients with acute myocardial infarction (MI) obtained from subgroup analyses from major clinical trials.Treatment options for acute MI in the elderly have changed dramatically since the 1990s. Reperfusion therapy by primary percutaneous coronary intervention has superseded the use of thrombolytic therapy for the treatment of acute ST-elevation myocardial infarction (STEMI). Clinical trial data have demonstrated that even transferring patients to facilities that have primary angioplasty capabilities is better than thrombolytic therapy, if the anticipated transfer time is of acceptable duration. Additionally, adjunctive use of the intravenous glycoprotein (GP) receptor antagonist, abciximab, during primary angioplasty affords a reduction in the composite primary end point of death, reinfarction, and target vessel revascularization, with much of the benefit derived from the latter. Thrombolytic therapy, barring any contraindication, must be used when mechanical revascularization is not available; however, the risk for complications in the elderly is higher, especially for those 75 years and older. Studies investigating the use of thrombolytics plus GP receptor antagonists with and without percutaneous coronary intervention show questionable benefit in the elderly.