Required Reading: Secondary Prevention of CVD in Older Adults

Despite successful efforts aimed at primary and secondary prevention of cardiovascular disease (CVD) and a resultant decline in mortality in the US and developed nations, CVD will remain the leading cause of death throughout the world for the foreseeable future.¹ The burden of CVD, as well as type 2 diabetes, an important contributor to CVD, is substantial in developing countries, even as these nations are simultaneously confronted with the continuing challenge of communicable diseases. Therefore, the recently released guideline, Secondary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults, which focuses not only on pharmacological management, but on lifestyle interventions, has wide global applicability.²

An important contributor to the global burden of CVD is population aging. Over the next century the number of individuals aged 60 or older will triple from 841 million (2013) to 2 billion (2050) and then to almost 3 billion by 2100.³ The population of those 80 and older will increase seven-fold from 120 million (2013) to 32 million in 2050 to 830 million in 2100.³ While currently approximately half of this population lives in developing countries, by 2050, 68% of those aged 80 and older will live in developing countries.³ Therefore, global efforts are needed to prevent CVD and its complications.

The increasing prevalence of obesity and type 2 diabetes in combination with increased longevity will contribute to an increased prevalence of CVD through 2030, despite a continued decline in smoking and improvements in secondary prevention.⁴ Mortality is not the only outcome of interest, however, as the higher prevalence of CVD, particularly in the wake of population aging will contribute to disability, lower quality of life, and higher health care expenditures.³ The authors suggest that urgent measures are needed to successfully treat hypertension and elevated cholesterol levels, as well as to decrease the prevalence of obesity.

While risk reduction efforts should target all age segments of the population, it is critical that interventions also be aimed at older adults and that risk reduction efforts are targeted broadly at atherosclerotic CVD. It is important, therefore, that the initial scientific statement, Secondary Prevention of Coronary Heart Disease in the Elderly,⁵ has not only been revised, but expanded to include peripheral arterial disease and stroke. The updated statement, Secondary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults, not only provides a synthesis of data from recent randomized trials, but aims to highlight the risks and benefits of treatment and to provide guidance for the utilization of secondary prevention in older adults. Evidence is provided on the control of obesity, hypertension, hyperlipidemia, diabetes, smoking, and psychosocial risk factors, along with dietary considerations, physical inactivity and cardiac rehabilitation, and the use of coronary revascularization and implantable cardioverter defibrillator therapy is reviewed. The authors have sought to interpret these recommendations considering age-related physiological changes seen in older adults, as well as in the presence of polypharmacy, socioeconomic considerations, and cognitive limitations. The importance of co-morbidities and risk-benefit also receive special consideration, providing practitioners with guidance on how to apply these findings to their older adult patients.

The problem of multiple (i.e., two or more) chronic conditions (MCC) cannot be underestimated. Population aging will have a significant effect on the burden of MCC, with 81 million persons expected to be living with MCC by 2020, as compared to 63 million in 2005, a 30% increase.⁶ One in 5 Americans suffer from MCC with the prevalence being substantially higher in older adults and racial and ethnic minority individuals, and the prevalence is increasing.⁷ MCC accounts for 95% of Medicare spending and two thirds is spent to care for those with more than 5 conditions.⁶ The most prevalent combination of MCC is that of CVD, including hypertension, type 2 diabetes and depression, and this cluster is associated with significant morbidity and mortality.⁸ In addition, the presence of MCC increases the likelihood of disability and adverse drug events (ADEs), hampers self-management, and contributes to poor health-related quality of life.^7,9 The complexity of MCC prevention and self-management is further complicated by lifestyle behaviors such as tobacco, lack of physical exercise, and treatment nonadherence. In the context of MCC, these factors contribute to poor health outcomes and exacerbate health disparities, often disproportionately experienced by vulnerable groups, such as ethnic minorities, women, individuals with low socioeconomic status, and older adults.¹⁰

The task to present the evidence for secondary prevention in older adults is not an easy one. Exclusion of older adults, particularly those 80 and older, from randomized trials in CVD^11,12 and type 2 diabetes¹³ continues. Given the age-related physiological changes that occur with aging, co-morbidities, and special social circumstances of older adults, one cannot generalize from trials conducted in younger adults. In addition, even when older adults are included, they are often not representative of the older adult population, who often suffer from MCC or have cognitive or functional limitations. Data in ethnic minority older adults, who make up a substantial proportion of the US population, are further lacking, as they are in women. In addition, the authors highlight the importance of considering outcomes other than mortality as important endpoints in older adults. Quality of life, functional and cognitive ability, maintenance of independence, hospitalizations, use of long-term care, caregiver burden, and costs may be more relevant endpoints upon which decisions should be based.

A second theme throughout the statement and one that deserves attention is that pharmacological and non-pharmacological therapies for all major risk factors are underutilized in older adults. The problem of underuse of evidence-based therapies in all populations is widespread, but especially so in older adults, as well as in those with MCC. Innovative strategies should be developed and employed to facilitate older adults receiving evidence-based care.¹³ The authors assist clinician decision-making by highlighting the need to consider MCC, polypharmacy, logistics, costs, and management complexity when deciding treatment options. They further recognize the need to improve health literacy and for effective provider communication, which is particularly important in older adults with cognitive and visual and hearing impairments. Others have stressed the need for shared decision-making and the use of a framework for considering treatment goals.¹³ In order to assist in attaining these preventive goals, all health care providers should have the opportunity to function within their full scope of practice.¹⁵

The authors conclude that older adults are as likely to benefit from secondary prevention strategies as younger-aged individuals and that while these interventions are feasible, the associated risks may be higher. In addition to inclusion of representative, older adults they suggest that future research should be aimed at identifying which interventions will provide the greatest risk-benefit ratio and that outcomes be pertinent to this population. This updated statement reminds us all of the necessity and feasibility of secondary prevention in older adults, as well as the further work needed in the area. It should be required reading for all healthcare providers and researchers.