Primary prevention of CVD in older adults
Overall, there is uncertainty in the trade-off between benefits and risks for drug therapy in the primary prevention of cardiovascular disease in older adults.
This is further confounded by researchers not adjusting for a person’s ‘biological’ age (i.e. their general physical health) and only their ‘chronological’ age.
QRISK 3 does not estimate risk beyond age 84y. However, by 61y (if male) or 68y (if female), a person has acquired a QRISK 3 score of least 10%.
Guidance in this area is being continually updated.
Lifestyle interventions
Continue to emphasise:
Smoking cessation
Weight loss if overweight or obese
Appropriate physical activity
Healthy ‘Mediterranean diet’ - high in fruits and vegetables, low salt, low saturated fat, low processed and red meats
Hypertension
Check: BP in both arms (record, use higher one),
Check for: sinus rhythm, resting heart rate and test for hypertension-mediated organ damage (HMOD)
Consider biological age (frailty, comorbidities, risk of falling, tolerability of BP-lowering medications) as well as chronological age and patient preference
Treat all older adults (>65y, including group >80y) with antihypertensives if SBP ≥ 160
Treat all older adults (>65y, but not >80y) with antihypertensives if Stage 1 (BP 140-159)
If aged 65-80y, aim for SBP 130-139
If aged>80y, aim for SBP 130-139, only if tolerated
If frail, age>80y, use mono therapy
Start drug treatment at lowest available doses and monitor closely for adverse effects, especially hypotension, postural hypotension and falls
Two drug combination for drug therapy: ACEi/AEB + CCB/Diuretic
Avoid loop diuretics and alpha-blockers as higher risk of falls
There is evidence that antihypertensive treatment with lower targets in fitter older adults, even once >75y, reduces morbidity and mortality related to CVD.
Evidence from SPRINT suggests intensive (target SBP <120 instead of <140) BP treatment in adults>75yr lowers rates of adverse CVD events without significantly increased risks of hypotension, syncope, electrolyte abnormalities, acute kidney injury or injurious falls.
Statins
In a meta-analysis (CTTC) incorporating primary and second prevention usage of statins in older adults, statins were found to reduce adverse CVD events.
However, there is less direct evidence of benefit among adults>75yr who do not have occlusive vascular disease.
Moreover, primary care based research has shown no benefit of statins in adults>74y without type 2 diabetes, but some benefit when used in adults with type 2 diabetes up to age 85y.
Current NICE UK guidance suggests recommends statins if QRISK 3 score ≥ 10%, which in practical terms means all men> 61y and women> 68y.
Consequently, treatment decisions need to be individualised, evidence of research uncertainty shared, and patient preference should be prioritised.
Aspirin
DO NOT routinely prescribe aspirin for primary prevention of CVD.
The recent ASPREE trial which showed older people on low dose aspirin had a significantly higher risk of haemorrhage and did not lower their CVD risk.