Preventing cardiovascular disease in older adults: One size does not fit all

Recommendations on hypertension

Managing hypertension in frail patients at risk of cardiovascular disease requires balancing the benefits vs the risks of treatment, such as polypharmacy, falls, and orthostatic hypotension.

The Eighth Joint National Committee suggests a blood pressure goal of less than 150/90 mm Hg for all adults over age 60, and less than 140/90 mm Hg for those with a history of cardiovascular disease or diabetes.²⁹

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on hypertension, recently released, recommend a new blood pressure target of <120/<80 as normal, with 120–129/<80 considered elevated, 130–139/80–89 stage 1 hypertension, and ≥140/≥90 as stage 2 hypertension.³⁰ An important caveat to these guidelines is the recommendation to measure blood pressure accurately and with accurate technique, which is often not possible in many busy clinics. These guidelines are intended to apply to older adults as well, with a note that those with multiple morbidities and limited life expectancy will benefit from a shared decision that incorporates patient preferences and clinical judgment. Little guidance is given on how to incorporate frailty, although note is made that older adults who reside in assisted living facilities and nursing homes have not been represented in randomized controlled trials.³⁰

American Diabetes Association guidelines on hypertension in patients with diabetes recommend considering functional status, frailty, and life expectancy to decide on a blood pressure goal of either 140/90 mm Hg (if fit) or 150/90 mm Hg (if frail). They do not specify how to diagnose frailty.³¹

Canadian guidelines say that in those with advanced frailty (ie, entirely dependent for personal care and activities of daily living) and short life expectancy (months), it is reasonable to liberalize the systolic blood pressure goal to 160 to 190 mm Hg.³²

Our recommendations. In both frail and nonfrail individuals without a limited life expectancy, it is reasonable to aim for a blood pressure of at least less than 140/90 mm Hg. For those at increased risk of cardiovascular disease and able to tolerate treatment, careful lowering to 130/80 mm Hg may be considered, with close attention to side effects.

Treatment should start with the lowest possible dose, be titrated slowly, and may need to be tailored to standing blood pressure to avoid orthostatic hypotension.

Home blood pressure measurements may be beneficial in monitoring treatment.

MANAGING LIPIDS

For those over age 75, data on efficacy of statins are mixed due to the small number of older adults enrolled in randomized controlled trials of these drugs. To our knowledge, no statin trial has examined the role of frailty.

The PROSPER trial (Prospective Study of Pravastatin in the Elderly at Risk)³³ randomized 5,804 patients ages 70 to 82 to receive either pravastatin or placebo. Overall, the incidence of a composite end point of major cardiovascular events was 15% lower with active treatment (P = .014). However, the mean age was 75, which does little to address the paucity of evidence for those over age 75; follow-up time was only 3 years, and subgroup analysis did not show benefit in those who did not have a history of cardiovascular disease or in women.

The JUPITER trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin)³⁴ randomized 5,695 people over age 70 without cardiovascular disease to receive either rosuvastatin or placebo. Exploratory analysis showed a significant 39% reduction in all-cause mortality and major cardiovascular events with active treatment (HR 0.61, 95% CI 0.46–0.82). Over 5 years of treatment, this translates to a number needed to treat of 19 to prevent 1 major cardiovascular event and 29 to prevent 1 cardiovascular death.

The benefit of statins for primary prevention in these trials began to be apparent 2 years after treatment was initiated.

The Women’s Health Initiative,³⁵ an observational study, found no difference in incident frailty in women older than 65 taking statins for 3 years compared with those who did not take statins

Odden et al³⁶ found that although statin use is generally well tolerated, the risks of statin-associated functional and cognitive decline may outweigh the benefits in those older than 75. The ongoing Statin in Reducing Events in the Elderly (STAREE) trial may shed light on this issue.

Recommendations on lipid management

The ACC/AHA,³ in their 2013 guidelines, do not recommend routine statin treatment for primary prevention in those over age 75, given a lack of evidence from randomized controlled trials. For secondary prevention, ie, for those who have a history of atherosclerotic cardiovascular disease, they recommend moderate-intensity statin therapy in this age group.

Our recommendations. For patients over age 75 without cardiovascular disease or frailty and with a life expectancy of at least 2 years, consider offering a statin for primary prevention of cardiovascular disease as part of shared decision-making.

In those with known cardiovascular disease, it is reasonable to continue statin therapy except in situations where the life expectancy is less than 6 months.³⁷

Although moderate- or high-intensity statin therapy is recommended in current guidelines, for many older adults it is prudent to consider the lowest tolerable dose to improve adherence, with close monitoring for side effects such as myalgia and weakness.

TYPE 2 DIABETES

Evidence suggests that tight glycemic control in type 2 diabetes is harmful for adults ages 55 to 79 and does not provide clear benefits for cardiovascular risk reduction, and controlling hemoglobin A_1c to less than 6.0% is associated with increased mortality in older adults.³⁸

The American Diabetes Association³¹ and the American Geriatrics Society³⁹ recommend hemoglobin A_1c goals of:

• 7.5% or less for older adults with 3 or more coexisting chronic illnesses requiring medical intervention (eg, arthritis, hypertension, and heart failure) and with intact cognition and function
• 8.0% or less for those identified as frail, or with multiple chronic illnesses or moderate cognitive or functional impairment
• 8.5% or 9.0% or less for those with very complex comorbidities, in long-term care, or with end-stage chronic illnesses (eg, end-stage heart failure), or with moderate to severe cognitive or functional limitation.

These guidelines do not endorse a specific frailty assessment, although the references allude to the Fried phenotype criteria, which include gait speed. An update from the American Diabetes Association provides a patient-centered approach to tailoring treatment regimens, taking into consideration the risk of hypoglycemia for each class of drugs, side effects, and cost.⁴⁰

Our recommendations. Hyperglycemia remains a risk factor for cardiovascular disease in older adults and increases the risk of many geriatric conditions including delirium, dementia, frailty, and functional decline. The goal in individualizing hemoglobin A_1c goals should be to avoid both hyper- and hypoglycemia.

Sulfonylureas and insulins should be used with caution, as they have the highest associated incidence of hypoglycemia of the diabetes medications.