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

ASPIRIN

For secondary prevention in older adults with a history of cardiovascular disease, pooled trials have consistently demonstrated a long-term benefit for aspirin use that exceeds bleeding risks, although age and frailty status were not considered.⁴¹

Aspirin for primary prevention?

The evidence for aspirin for primary prevention in older adults is mixed. Meta-analysis suggests a modest decrease in risk of nonfatal myocardial infarction but no appreciable effects on nonfatal stroke and cardiovascular death.⁴²

The Japanese Primary Prevention Project,⁴³ a randomized trial of low-dose aspirin for primary prevention of cardiovascular disease in adults ages 60 to 85, showed no reduction in major cardiovascular events. However, the event rate was lower than expected, the crossover rates were high, the incidence of hemorrhagic strokes was higher than in Western studies, and the trial may have been underpowered to detect the benefits of aspirin.

The US Preventive Services Task Force⁴⁴ in 2016 noted that among individuals with a 10-year cardiovascular disease risk of 10% or higher based on the ACC/AHA pooled cohort equation,³ the greatest benefit of aspirin was in those ages 50 to 59. In this age group, 225 nonfatal myocardial infarctions and 84 nonfatal strokes were prevented per 10,000 men treated, with a net gain of 333 life-years. Similar findings were noted in women.

However, in those ages 60 to 69, the risks of harm begin to rise and the benefit of starting daily aspirin necessitates individualized clinical decision-making, with particular attention to bleeding risk and life expectancy.⁴⁴

In those age 70 and older, data on benefit and harm are mixed. The bleeding risk of aspirin increases with age, predominantly due to gastrointestinal bleeding.⁴⁴

The ongoing Aspirin in Reducing Events in Elderly trial will add to the evidence.

Aspirin recommendations for primary prevention

The American Geriatrics Society Beers Criteria do not routinely recommend aspirin use for primary prevention in those over age 80, even in those with diabetes.⁴⁵

Our recommendations. In adults over age 75 who are not frail but are identified as being at moderate to high risk of cardiovascular disease using either the ACC/AHA calculator or any other risk estimator, and without a limited life expectancy, we believe it is reasonable to consider low-dose aspirin (75–100 mg daily) for primary prevention. However, there must be careful consideration particularly for those at risk of major bleeding. One approach to consider would be the addition of a proton pump inhibitor along with aspirin, though this requires further study.⁴⁶

For those who have been on aspirin for primary prevention and are now older than age 80 without an adverse bleeding event, it is reasonable to stop aspirin, although risks and benefits of discontinuing aspirin should be discussed with the patient as part of shared decision-making.

In frail individuals the risks of aspirin therapy likely outweigh any benefit for primary prevention, and aspirin cannot be routinely recommended.

EXERCISE AND WEIGHT MANAGEMENT

A low body mass index is often associated with frailty, and weight loss may be a marker of underlying illness, which increases the risk of poor outcomes. However, those with an elevated body mass index and increased adiposity are in fact more likely to be frail (using the Fried physical phenotype definition) than those with a low body mass index,⁴⁷ due in part to unrecognized sarcopenic obesity, ie, replacement of lean muscle with fat.

Physical activity is currently the only intervention known to improve frailty.⁵

Physical activity and a balanced diet are just as important in older adults, including those with reduced functional ability and multiple comorbid conditions, as in younger individuals.

A trial in frail long-term care residents (mean age 87) found that high-intensity resistance training improved muscle strength and mobility.⁴⁸ The addition of a nutritional supplement with or without exercise did not affect frailty status. In community-dwelling older adults, physical activity has also been shown to improve sarcopenia and reduce falls and hip fractures.⁴⁹

Progressive resistance training has been shown to improve strength and gait speed even in those with dementia.⁵⁰

Tai chi has shown promising results in reducing falls and improving balance and function in both community-dwelling older adults and those in assisted living.^51,52

Exercise recommendations

The US Department of Health and Human Services⁵³ issued physical activity guidelines in 2008 with specific recommendations for older adults that include flexibility and balance training, which have been shown to reduce falls, in addition to aerobic activities and strength training.

Our recommendations. For all older adults, particularly those who are frail, we recommend a regimen of general daily activity, balance training such as tai chi, moderate-intensity aerobics such as cycling, resistance training such as using light weights, and stretching. Sessions lasting as little as 10 minutes are beneficial.

Gait speed can be monitored in the clinic to assess improvement in function over time.

SMOKING CESSATION

Although rates of smoking are decreasing, smoking remains one of the most important cardiovascular risk factors. Smoking has been associated with increased risk of frailty and significantly increased risk of death compared with never smoking.⁵⁴ Smoking cessation is beneficial even for those who quit later in life.

The US Department of Health and Human Services in 2008 released an update on tobacco use and dependence,⁵⁵ with specific attention to the benefit of smoking cessation for older adults.

All counseling interventions have been shown to be effective in older adults, as has nicotine replacement. Newer medications such as varenicline should be used with caution, as the risk of side effects is higher in older patients.