About a decade ago, the American Heart Association (AHA) released an initial scientific statement on secondary prevention of atherosclerotic cardiovascular disease (ASCVD) for older patients, but there has been an explosion of studies addressing the treatment of hypertension, hyperlipidemia, diabetes, and antithrombotic therapy since that publication. AHA updated this scientific statement in 2013 to further clarify risks and benefits of secondary prevention in older adults. The statement, published in Circulation, is also intended to stimulate greater use of proven therapies for these patients.
“Secondary prevention lifestyle changes may seem inappropriate in the context of advanced age, but they have the potential to improve function, quality of life, and functional independence,” explains Jerome L. Fleg, MD, who co-chaired the writing group that developed the AHA update. “Therefore, these changes should be actively considered for many older patients with ASCVD.”
The proportion of adults older than 75 in most cardio-vascular trials is low, according to the AHA update. Furthermore, the patients enrolled are often healthier than elders in the community due to the desire of investigators to avoid the potential effects of comorbidities on trial outcomes. Consequently, generalizing the results of these trials to typical older patients is challenging. In addition, many older patients are not receiving evidence-based secondary prevention care. Comorbidities, polypharmacy, socioeconomic stresses, and cognitive limitations can also complicate how secondary prevention for ASCVD is utilized in older adults.
Per the recommendations, secondary preventive care for ASCVD should be personalized in patients aged 75 and older, given their wide range of comorbidities, lifestyles, and functional status. When not contraindicated, b-blockers, aspirin, and statins are recommended to curb mortality and morbidity. ACE inhibitors are recommended for individuals with a left ventricular ejection fraction below 40%. “The scientific statement provides guidance on the selection of antihypertensive therapy for older adults based on comorbidities,” says Dr. Fleg (Table 1). He adds that data supporting use of statins and antihypertensives for older patients to prolong life and to reduce cardiovascular morbidity are relatively clear-cut up to around age 80.
“Secondary prevention lifestyle changes may seem inappropriate in the context
of advanced age, but they have the potential to improve function, quality of life,
and functional independence.”
Physical inactivity is a well-documented risk factor for ASCVD, including peripheral arterial disease (PAD). The risk of PAD increases with age; up to half of people older than 65 with the disease will be asymptomatic. This is likely due in part to their low physical activity levels. In addition, about two-thirds of seniors are overweight or obese. “It’s important to encourage physical activity and consider weight loss interventions in selected older patients to improve functional status,” says Dr. Fleg. However, the potential harm from muscle loss in older weight-loss patients requires specific strategies for long-term maintenance of muscle mass.
The AHA statement also includes information on the value of cardiac rehabilitation, revascularization techniques, and implantable cardioverter defibrillators (ICDs). “Despite its unequivocal utility in older adults, cardiac rehabilitation remains vastly underused among older patients,” says Dr. Fleg (Table 2). In addition, he notes that coronary revascularization of patients in their 70s and 80s can potentially improve quality of life by reducing pain and reliance on medications while enhancing physical function. However, the effects of ICD placement in this age group are less clear and deserve further study.
Older adults with CVD are recommended to be screened for clinical depression because it can worsen outcomes. “Depression and mood instability are common among older adults and mandate appropriate therapy,” adds Dr. Fleg. “Clinicians should also inquire about patients’ social support.” Drug interactions, adherence, medication costs, and other consequences should be considered for older patients who take multiple medications for heart-related and other conditions. Efforts are also needed to take into account patient preferences. Some older adults may prefer to live with an increased risk of a cardiovascular event rather than make lifestyle changes or undergo more invasive procedures late in life.
The AHA is calling for more research to clarify which senior patients with ASCVD are likely to derive the most benefit from secondary prevention therapy. “Greater attention is needed on determining the strategies that yield the greatest benefit–risk profiles in older patients regarding medication regimens, lifestyle modifications, revascularization, and ICDs,” Dr. Fleg says. “Older and very elderly patients need to be included in clinical trials and national registries, and educational programs should be designed specifically for these patients and their families. These efforts for minimizing risks and promoting physical, mental, and emotional well-being are the foundation for moderating the effects of
ASCVD in old age.”
Readings & Resources (click to view)
Fleg JL, Forman DE, Berra K, et al. Secondary prevention of atherosclerotic cardiovascular disease in older adults: a scientific statement from the American Heart Association. Circulation. 2013 Oct 28 [Epub ahead of print]. Available at: http://circ.ahajournals.org/content/early/2013/10/28/01.cir.0000436752.99896.22.full.pdf+html.
Fleg JL, Forman DE, Berra K, et al. Executive summary: secondary prevention of atherosclerotic cardiovascular disease in older adults: a scientific statement from the American Heart Association. Circulation. 2013 Nov 26 [Epub ahead of print]. Available at: http://circ.ahajournals.org/content/suppl/2013/10/23/01.cir.0000436752.99896.22.DC1/Executive_Summary.pdf.
Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458-2473.
Odden MC, Coxson PG, Moran A, Lightwood JM, Goldman L, Bibbins-Domingo K. The impact of the aging population on coronary heart disease in the United States. Am J Med. 2011;124:827-833.
Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology. Circulation. 2007;115:2549-2569.