The Prevention of Cardiovascular Disease in Older Adults

Patrick P. Coll, MD, AGSF; Vivyenne Roche, MD, AGSF; Jaclyn S. Olsen, DO; Jessica H. Voit, MD; Emily Bowen, MD; Manish Kumar, MD

Disclosures

J Am Geriatr Soc. 2020;68(5):1098-1106. 

In This Article

Coronary Artery Disease

The Epidemiology of CAD in Older Adults

CAD, defined as coronary artery insufficiency, myocardial infarction (MI), and angina pectoris, is a major cause of morbidity and mortality in older adults. Age, sex, family history, hyperlipidemia, diabetes mellitus, and smoking cigarettes are all risk factors for CAD. To determine a patient's risk of experiencing a cardiac event, the American College of Cardiology (ACC)/AHA guidelines recommend assessing 10-year atherosclerotic CVD (ASCVD) risk in patients aged 40 to 75 years using the ASCVD risk calculator and designating patients as low risk (<5%), borderline risk (5%-7.5%), intermediate risk (>7.5%-20%), and high risk (>20%).[74] The ASCVD is not validated for patients older than 75 years.

Preventing a First Coronary Artery Event in Older Adults

Hypertension. As described above, there is extensive evidence that the treatment of hypertension in older adults reduces overall CVD. It is not clear to what extent BP reduction in older adults impacts the incidence of CAD.[75]

Lifestyle Modification. Cigarette smoking is strongly associated with CAD and MI.[38] Because of the many benefits of not smoking cigarettes, patients who smoke cigarettes or use other forms of tobacco, regardless of age, should be advised at every medical visit to quit.

There continues to be considerable confusion regarding the benefit of specific diets on preventing CAD. Available evidence from a randomized controlled trial (mean age = 52 years) showed that the replacement of saturated fat with vegetable oils rich in linoleic acid effectively lowered serum cholesterol, but did not demonstrate a lower risk of death from coronary heart disease or all-cause mortality.[76] However a prospective cohort study of almost 4000 adults older than 65 years, who did not have evidence of CVD, reported that consumption of fish twice a week did reduce the incidence of CAD-related death.[39]

Physical activity reduces CAD risk for older adults. A study of older adults in the Netherlands, with a mean age of approximately 68 years, showed that domestic work or cycling reduced coronary events and deaths related to CAD.[40] There was a dose-response reduction for both types of physical activity.

Lipid-lowering Agent. There is uncertainty regarding the use of lipid-lowering agents to prevent a first CAD event in older adults. In an analysis of data collected as a part of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, no benefit was found when pravastatin, 40 mg/d, was given for primary prevention to older adults, aged 65 to 74 years, with moderate hyperlipidemia and hypertension, and there was a nonsignificant direction toward increased all-cause mortality with pravastatin among adults 75 years and older.[77] In a meta-analysis of nine primary prevention trials that enrolled patients 65 years or older, though statins reduced the incidence of CAD events for those 65 years or older, there was no significant reduction for those 75 years and older.[66] However, in a meta-analysis of the JUPITER and HOPE-3 trials, the authors concluded that the results support the use of statins to prevent CVD for older adults with low to intermediate CVD risk, up to at least 80 years of age. The recommendation is based on a reduction in the composite measure of nonfatal MI, nonfatal stroke, and CVD death.[26] The AHA/ACC recommend that adults up to 75 years of age be evaluated for primary ASCVD prevention, and that the clinician should have a discussion with the patient before starting statin therapy.[78] Trials, including the Statins in Reducing Events in the Elderly trial, are currently being conducted in an attempt to clarify the appropriate use of statins to prevent initial CVD events in older adults.

Clinicians frequently encounter patients 75 years or older on a statin, who do not have a known history of CVD. There are no clear guidelines regarding the best approach to these patients. Recent data from France showed that the discontinuation at age 75 years of statins used for primary prevention resulted in increased hospitalizations for CAD events.[79]

Antiplatelet Therapy. Antiplatelet therapy is not recommended to prevent a first coronary event in older adults.[27] The ACC/AHA recommend against aspirin for primary prevention of CAD in adults older than 70 years.[74]

Screening for CAD in Older Adults

The US Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise electrocardiography to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events.[41] There are no specific guidelines with regard to the screening of asymptomatic older adults. Screening for CAD may be indicated for patients who have been identified with carotid stenosis or PAD. The USPSTF also concludes that the current evidence is insufficient to assess the balance of benefits and harms of adding high-sensitivity C-reactive protein level or a coronary artery calcium score to traditional risk assessment for CVD in asymptomatic adults to prevent CVD events.[42]

Preventing a Subsequent Coronary Artery Event in Older Adults

Hypertension. Though there are no data for older adults regarding the benefits of BP reduction on the prevention of a subsequent CAD event, based on the fact that BP reduction in older adults has been demonstrated to have a positive impact on overall cardiovascular risk and stroke, older adults with CAD should be treated for hypertension.

Lifestyle Modification. There is strong evidence that stopping cigarette smoking reduces the risk of a subsequent coronary artery event for younger adults. For adults with a median age of 60 years, smoking cessation following an MI reduced the risk of future CAD events to the rate for nonsmokers, after approximately 3 years.[43] Though these data do not pertain specifically to older adults, it is advisable to recommend that older adults who have CAD and continue to smoke cigarettes should stop.

Though exercise following incident CAD events has been demonstrated to improve overall health status, and reduce subsequent CVD and hospitalizations, exercise has not been demonstrated to reduce the incidence of subsequent CAD events.[44] There are few data regarding changes in diet and the prevention of a subsequent CAD event in an older adult. In spite of these limitations, older adults with known CAD should be encouraged to exercise and follow a heart healthy diet.

Lipid-lowering Agents. A subanalysis of the Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis in Myocardial Infarction 22 trial involving 730 persons aged 70 years or older who had a recent acute CAD event showed that the achievement of the low-density lipoprotein cholesterol target (<70 mg/dL) was associated with an 8% absolute and a 40% relative lower risk of events (death, MI, or unstable angina) in older, vs corresponding benefits of 2.3% and 26% in 3150 younger, subjects.[45] The choice of high-intensity vs. low-intensity statin therapy for the prevention of a subsequent CAD event in older adults is not clear. There are data indicating that high-intensity therapy may provide additional benefit.[46] Though the correlation between total cholesterol and CAD is poor in older adults, statins have been shown to reduce all-cause mortality when given to older adults with existing CAD.[47]

Antiplatelet Agents. Huynh et al. analyzed the effectiveness of aspirin, warfarin, and the combination of aspirin and warfarin in participants with prior coronary bypass surgery.[48] The primary end point was all-cause mortality, MI, or unstable angina requiring a new hospitalization. Those older than 65 years and on aspirin monotherapy had the lowest event rate. Based on this and other data, low-dose aspirin is recommended for secondary prevention in patients with known CAD.[49] Limited indications for dual-antiplatelet therapy (DAPT) include a history of acute coronary syndrome, coronary stent, or recent CABG. A shorter duration of DAPT should be considered in older adults because of the increased bleeding risk.[80]

β Blockers. The ACC/AHA guidelines on the management of ST-segment–elevation MI (STEMI) recommend early and continuous β-blocker therapy in all STEMI patients if no contraindications are present.[50] Treatment duration is recommended to be at least 3 years after an MI in patients with preserved ejection fraction and lifelong in patients with a reduced ejection fraction. There are no data to specifically guide therapy for those 75 years or older.

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