THE ELDERLY

Although cardiovascular events can occur at any age, the absolute risk increases incrementally as the population ages and is greatest in the elderly population (65 years and older); approximately two thirds of cardiovascular deaths occur after age 65. In the United States alone, more than 25 million people are 65 years or older. In 2000, elderly individuals represented 12.7% of the population. By 2020, the elderly population will increase to 16.5%. The 31% increase in this group of individuals with a high prevalence of CVD will further increase the demands on the health care system, underscoring the importance of treatment strategies for elderly individuals (Fig. 71-2, upper).

Clinically, CHD in elderly individuals often presents in an atypical manner, with dyspnea, decreased exercise tolerance, fatigue, or heart failure as the initial symptom. Though not always the case, CHD in elderly individuals is frequently asymptomatic. When symptoms are present, their atypical nature often delays diagnosis and treatment. This delay combined with an increase in comorbidities and the underuse of proven beneficial therapies (pharmacologic and interventional) contributes to increased rates of morbidity and mortality among post-MI elderly patients. The increased incidence of comorbid conditions contributes to polypharmacy in elderly patients— with the attendant risk of adverse effects—and prevents the addition of medications that would probably lower cardiac risk. Despite the need for multiple medical therapies, risk factor modification in elderly patients translates into decreased cardiovascular events.

Elevated LDL-C has an important role in the pathogenesis and lifelong risk of CHD, and reduction of LDL-C levels decreases risk of cardiovascular events. Despite widespread information indicating a therapeutic benefit, underdiagnosis and undertreatment of dyslipidemia continue among elderly individuals. In fact, preventive therapies (pharmacologic and nonpharmacologic) in elderly individuals may decrease cardiovascular events even more dramatically than in younger cohorts, probably because of the increased risk and incidence of CHD in elderly individuals. Age should not exclude patients from treatment for LDL-C lowering, especially as a therapeutic strategy for secondary prevention. In primary prevention, treatment of elevated LDL-C has been more controversial. However, benefits of preventive treatment in this population are substantiated by several smaller trials and by the Heart Protection Study, which included patients up to the age of 80. The ATP III recommends therapeutic lifestyle changes as an important component of therapy to reduce LDL-C.

Hypertension (blood pressure of 140/90 or higher) occurs in more than 50% of the population aged 65 years and older. In 2004, 63.6% of men and 73.9% of women ages 65 years or older had high blood pressure. Hypertension is a major risk factor for stroke, heart failure, and CHD. Although hypertension was once considered part of “normal aging,” the benefit of treating elderly patients with elevated systolic and/or diastolic blood pressure is clear. Intensive treatment of isolated systolic hypertension can provide a 30% reduction in the combined fatal and nonfatal stroke rate, a 26% reduction in the rates of fatal and nonfatal cardiovascular events, and a 13% reduction in the total mortality rate.

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