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

Peripheral Artery Disease

Epidemiology of PAD in Older Adults

PAD occurs when there is a decrease in the size of the lumen of an artery, which results in decreased blood supply to organs and tissues perfused by the artery. This can lead to acute and/or chronic symptoms of ischemia, including pain, decreased function, and tissue necrosis.[81,82] Arterial aneurysm, including abdominal aortic aneurysm (AAA), though much less common than PAD, can result in serious life-threatening complications. The incidence of PAD increases with increasing age, with a peak incidence of over 20% in those 80 years and older.[83] Many patients with PAD are unaware of their disease. There is a strong association between PAD and other CVDs. Risk factors for PAD include tobacco use, diabetes mellitus, hypertension, and hypercholesterolemia.[84–86]

Preventing Incident PAD in Older Adults

Hypertension. As described above, though 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 PAD.[87]

Lifestyle Modification. Despite the strong correlation between cigarette smoking and PAD, there are few randomized controlled data that show that avoiding or ceasing to smoke cigarettes reduces the risk of developing PAD. Data from the Women's Health Study in the United States, where all participants were 45 years or older, showed both the strong correlation between cigarette smoking and PAD and the positive impact of smoking cessation on PAD incidence.[51] Because of the many benefits to never smoking or stopping smoking, healthcare providers should educate all their patients about the healthcare risks of smoking cigarettes, including the strong association between smoking and PAD. They should also provide guidance, support, and treatment regarding smoking cessation for patients who are current smokers, regardless of their age.

There are limited data indicating that diet has an impact on incident PAD.[88] There are no data indicating that diet has an impact on incident PAD in older adults.

Though exercise has been demonstrated to have a positive impact on the incidence of overall CVD, there is no compelling evidence that exercise prevents PAD.

Lipid-lowering Agents. There are insufficient data to support the use of lipid-lowering medications to reduce incident PAD. However, as noted above, there are data that support the use of statins to prevent overall CVD for older adults with low to intermediate CVD risk, up to at least 80 years of age.[26]

Antiplatelet Agents. Antiplatelet agents are not indicated for the primary prevention of PAD.

Screening for PAD and AAAs in Older Adults

Peripheral Artery Disease. Asymptomatic PAD is common, especially in patients with diabetes mellitus.[89] The ACC and the AHA have released a joint practice guideline recommending screening with the measurement of an ankle-brachial index (ABI) in patients at increased risk for PAD, including all adults 65 years or older.[53] However the USPSTF did not find that there was convincing evidence to support the use of screening ABI in asymptomatic patients, including those with diabetes mellitus.[54]

Abdominal Arterial Aneurysm. The USPSTF recommends one-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked.[55] Because of the strong association between PAD and AAA, patients with symptomatic PAD, including women, should be screened for AAA.[56] Patients found to have an AAA on screening should be tested for concomitant PAD and CAD, if either condition has not previously been diagnosed.[57]

Preventing the Progression of PAD in Older Adults

Hypertension. There is evidence that good BP control in patients with PAD reduces the incidence of major cardiovascular events.[58] AHA guidelines recommend a BP target of lower than 130/80 mm Hg for adults with increased cardiovascular risk, including patients with PAD.[90] Data from a meta-analysis of patients with a mean age of 58 to 66 years, diagnosed with PAD, showed that the use of angiotensin-converting enzyme inhibitors for the treatment of hypertension in these patients reduced claudication symptoms and improved walking distance.[91]

Lifestyle Modification. Those with PAD who smoke cigarettes or use other forms of tobacco should be advised at every medical visit to quit.

Though there is no proven benefit on the progression of PAD from dietary interventions, a heart healthy diet is recommended for patients with PAD.

Exercise can improve walking distance for patients with PAD.[59] Patients with PAD should be advised and supported to exercise to reduce claudication and improve function.[92] Those recently diagnosed with PAD should have a cardiac evaluation to rule out asymptomatic CAD before beginning an exercise program.

Lipid-lowering Agents. The use of high-intensity statin therapy has been shown to improve symptoms and improve both PAD- and other CVD-related outcomes for patients with PAD.[60] Patients with PAD should be prescribed a high-intensity statin medication.

Antiplatelet Therapy. Antiplatelet therapy with aspirin, 75 to 325 mg/d, or clopidogrel, 75 mg/d, is recommended to prevent MI, stroke, and cardiovascular death in patients with symptomatic PAD.[61] In symptomatic PAD, DAPT with clopidogrel and aspirin does not provide benefit over treatment with aspirin alone and is associated with increased risk of major bleeding.

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