Top 10 things to know about secondary prevention of atherosclerotic CVD in older adults

ByRoger S. Blumenthal, MD

by Oluseyi “Shay” Ojeifo, MD; and Roger S. Blumenthal, MD

With an aging population to care for and rising rates of CVD, Oluseyi “Shay” Ojeifo, MD, and Roger S. Blumenthal, MD, from The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, have compiled a top 10 list of important points for the public and health care providers to know about secondary prevention of atherosclerotic CVD in the elderly.

In 2010, there were 18.6 million Americans aged 75 years and older, representing 6% of the population. This number is expected to double by 2050. Patients in this age group tend to have more extensive coronary atherosclerosis, peripheral arterial disease and cerebrovascular disease due to advanced hardening of the arteries vs. younger patients. The economic costs of atherosclerotic CVD (ASCVD) are projected to increase from $84.8 billion to $202 billion between 2015 and 2030.

Oluseyi Ojeifo

Secondary prevention — better lifestyle habits and use of CV medications — has the potential to increase longevity, improve quality of life and decrease annual health care costs related to CVD.
Physicians should manage traditional CV risk factors, such as aiming for better BP, cholesterol and blood glucose values and improving lifestyle habits, in patients of advanced age according to existing guidelines while being aware of other health problems that the patient may have, the number of medications they are already taking (polypharmacy), and patient preferences.
Nonpharmacological approaches to risk factor modification, including weight loss, exercise and smoking cessation, are key components of secondary prevention of ASCVD. Because there is potential for harm, weight-loss interventions in seniors should include attention to muscle preservation and specific strategies for long-term weight maintenance.
Aggressive BP control can lead to significant decreases in stroke, HF and risk for all-cause mortality. Lifestyle changes are recommended as initial therapy, especially for patients with milder hypertension. In approximately two-thirds of seniors with hypertension, two or more drugs will be required to achieve target BP levels.
Lipid-lowering therapy with a statin also is an essential element of secondary prevention of ASCVD. The benefits and risks of treatment should be discussed with patients. If a lipid-altering agent is initiated, the dose may need to be lower than when treating a middle-aged patient, and adverse effects should be monitored carefully.
Although managing diabetes and its complications is important, preventing hypoglycemia is especially important in older patients. A less-intensive target HbA1c of 7% to 7.9% is recommended for older adults, as compared with <7% in adults younger than 65 years.

Roger S. Blumenthal

Depression is a psychosocial risk factor that is common in older patients with ASCVD and is associated with increased adverse cardiac events. Therefore, each patient should be routinely screened and treated with counseling and possibly a medication when indicated.
The risks and benefits of other secondary prevention interventions such as coronary revascularization and implantable cardioverter defibrillator placement should be weighed for each patient.
Secondary prevention of ASCVD has the potential to improve CV medical outcomes and greatly reduce health care costs. Physicians should be as aggressive about following the existing guidelines in their older patients as in their younger patients.

Oluseyi “Shay” Ojeifo, MD, is a fellow at The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. Roger S. Blumenthal, MD, is director of The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and Section Editor of CHD and Prevention for Cardiology Today. He can be reached at rblument@jhmi.edu.
Disclosure: Blumenthal and Ojeifo report no relevant financial disclosures.