What is the limit? Between preventive cardiovascular
treatment and reverse epidemiology in older adults
CARLOS RICARDO SECOTARO, ROXANA LOURDES IANARDI
Centro Médico Palmares - Ministerio de Salud de Mendoza.
(5519) Mendoza, Argentina. E-mail
Recibido 21-JUN-2018 – ACEPTADO el 19-Agosto de 2018.
There are no conflicts of interest to disclose.
In our country, as in the rest of the Western World, there will be a significant increase in people over 60 years, especially those over 80 years of age. As in the rest of the adult population, the main cause of mortality will be cardiovascular disease.
For this reason, institutions like WHO focus on this topic and ask us to achieve a “Healthy Ageing”.
Thus, we must incorporate into daily practice some particularities such as: Diversity in older age. Fragility-Comorbidity-Disability, different concepts that sometimes converge in the patient. Polymedication. Prevalence of Cardiovascular Disease in elderly people. Presence of gaps in the evidence in these population groups and the so-called Reverse Epidemiology; and social environment.
With these concepts in mind, we will review the most common therapeutic decisions in the field of Prevention such as: High Blood Pressure, Dyslipidemia, Diabetes, Smoking, Sedentarism, Cognitive Impairment and Anticoagulation.
Key words: Healthy Ageing. Diversity in older age. Fragility.
The population of elderly people in the world is constantly growing. According to the WHO, by year 2050 the number of people older than 60 years will double . This increase in the Western world will occur mainly in ages >80 years. In our country, more than 16% of the population is >60 years. In the projections of growth in the population pyramid, in Argentina, a similar phenomenon will be observed, but not so marked.
As currently, cardiovascular disease will continue to be the main cause of mortality in the Western world, so that cardiologists should be prepared to achieve, as the WHO requests, a healthy ageing .
On this issue, we should emphasize, widening the range of knowledge, acknowledging limitations, adding gerontologists, family doctors, general practitioners, and public health specialists, the new issues to achieve the desired healthy ageing.
A very common error in daily practice is to ignore the particular aspects of the population of elderly patients, and to extrapolate to this population the results form clinical studies that to a large extent, exclude this part of the population.
The diversity of old age refers to the wide dispersion of physical and mental capacities of this age group, mainly in those older than 70 years, with people with a physical capacity comparable to that of a young person, and others with an evident deterioration in spite of having the same age .
This diversity influences on life expectancy and should be taken into account in old age, as in the previous stages, to attempt to reach this stage of life with positive capacities. We should add to this concept, the wide dispersion of ages in the population of elderly people.
Fragility: Phenotypically, defined by the presence of slowing down, weakness, thinning, inactivity and tiredness. This phenotype is reached by two ways, not necessary mutually exclusive. A process of inflammatory activation, deficiency of androgens and insulin resistance that will mainly lead to sarcopenia. A subclinical multiple organ failure due to chronic cardiovascular diseases, a fatigue proper of the age or genetic predisposition. This fragility should be assessed, so there are numerous tools like the Freid, Rockwood or SOF tests .
Co-morbidity: Its formal definition is the concurrent presence of two or more medically diagnosed diseases in the same individual. A very frequent situation in elderly people, for instance, in USA after 65 years of age, 35% of the population present co-morbidities; while in those older than 80 years, the percentage involves more than 70% of the population . Many of this co-morbidities are cardiovascular risk factors and their consequences.
Disability: It is defined as the difficulty or dependence to conduct daily essential activities for an independent life.
These three conditions should be considered separately to make decisions, although to a large extent they overlap.
Polypharmacy: It deserves a special consideration due to its importance and frequency. In general, it is the consequence of what has been mentioned above. It is very important to bear in mind the known medications interactions, loss of adherence, lack of knowledge, appropriate management of posology, and the possibility of de-prescription of medications.
Prevalence of cardiovascular disease (CVD) in the elderly: It is well known by everyone, that CVD have a high prevalence in the elderly, as the main cause of mortality >60 years of age, regardless of social status (per capita income); although it occurs more frequently in individuals with medium-to-high incomes .
Evidence gap: Due to the particular aspects proper of older adults, as we mentioned above, and others like different ethnicities, a gap in knowledge is generated, both in primary and secondary prevention, and in the established treatments for CVD .
Reverse epidemiology: This is a concept that starts in nephrology at the beginning of the century based on epidemiological studies in patients in chronic hemodialysis, in whom it was observed that they had a worse prognosis in relation to those presenting a lower body mass index, systolic blood pressure and lipid levels in blood in comparison to the general population . This concept was later extended to patients with heart failure, <75 years and AIDS. Obesity paradox is also known.
As observed in Figure 1, the same pathophysiological mechanisms that determine body mass index, blood pressure and lipid levels in blood, are those decreasing quality of life, increasing the rate of hospital admissions and finally, increasing overall and cardiovascular mortality . A better yearly prognosis in older patients admitted due to heart failure when they have a history of isolated systolic hypertension stands out .
Figure 1. Pathophysiological mechanisms proposed that determine Reverse Epidemiology and their consequences on morbidity and mortality, and quality of life. Modified from Kalantar-Zadeh K, et al. Blood Purif 2005; 23 (1): 57-63.
Social environment: Finally, we should consider the social environment around the individual, and how this environment supports him/her or not, from the family to health insurance.
When making therapeutic decisions in the elderly, we should consider a constellation of circumstances. Figure 2.
Figure 2. Constellation of situations to consider in elderly patients.
The most common therapeutic decisions to adopt in the elderly, in the field of prevention, are linked to:
Hypertension: It may constitute the paradigm of the previous items. There is no total consensus on the recommendations to manage it in older people in the different guidelines (NICE , European Society of Cardiology , JNC 8 ). The most significant coincidence is that hypertension should be treated both at >65 years and at >80 years, both if it is isolated systolic hypertension (the most frequent variant in the elderly) or systolic-diastolic hypertension. Non-pharmacological treatment is recommended for all age groups.
Most differences are related to the objective value to reach, in spite of the results of the HYVET  study, that showed a decrease in mortality by treating 80-year-old patients up to levels of 150/80, although we should question whether these were healthy people; and we cannot forget to mention the SPRINT study , that showed a greater reduction in mortality in patients older than 75 years. In recent years, evidence emerged on the existence of a J curve in the INVEST study, and more recently in the VALISH study, a J curve was described for isolated systolic hypertension . The 2016 guidelines of the European Society of Hypertension for the management of hypertension in the elderly, with a more holistic criterion, with a different level of evidence, suggest: those older than 65 years with systolic pressure should be taken to levels of 140-150 when the patients are not frail. In frail patients, we should be more careful and consider co-morbidities and a close follow-up. If the treatment is properly tolerated and the patients reach 80 years, the above levels should be kept, and preferably use diuretics and calcium blockers for their management .
A special consideration in this age group is the presence of orthostatic hypotension and for this consider co-morbidities as neurological, central and peripheral, as well as polypharmacy in this population. Orthostatism should be evaluated in all patients and if this condition is present, the objective level of blood pressure should be the balance between the minimum tolerable blood pressure and symptomatic hypotension.
Dyslipidemia: As with the other risk factors, its management should be considered within their global scenario, paying special attention to the presence of reverse epidemiology. If it is secondary prevention, there is consensus about the treatment with statins being indicated, in spite of the evidence coming from the analysis of subgroups and meta-analyses. Nevertheless, they should be recommended as guidelines for adults indicate, in the case of non-frail older patients, with the relevant care for side effects. In primary prevention, the evidence available is poorer, even though the more advanced the age, the greater the cardiovascular mortality, so the risk-benefit should be properly evaluated.
Diabetes: A highly prevalent disease, very frequently associated to other risk factors. The American Diabetes Association (ADA) considers a different goal for HbA1c, depending on the general health of the patient. Thus, for healthy individuals, HbA1c <7.5% is recommended, and in those with impaired health, HbA1c <8.5% . In 2017, the recommendations for targets of different risk factors in elderly diabetic patients were published .
Smoking: There are interventions that regardless of age, have a positive effect on cardiovascular morbidity and mortality, and one of them is to stop smoking. A meta-analysis of more than 500,000 patients >60 years, showed that smokers had twice the chance of developing cardiovascular events than non-smokers, and that to stop smoking has a clear beneficial effect on reducing cardiovascular morbidity and mortality. The earlier, the better .
Sedentarism: Another intervention where age is not taken into account, is physical activity, according to the health state. The sooner it is implemented, the better, helping to control the rest of the risk factors and to decrease the “gerontology triad”.
Cognitive impairment: It is known as the relationship between cardiovascular disease and cognitive deterioration (heart-brain unity). Also, the early management of risk factors decrease cognitive deterioration. It is also important to stimulate cognitive functions from the environment and the family. For instance, the participation in social activities, book discussion clubs, occupational therapy, etc.
Prevention of stroke in the presence of atrial fibrillation: The convenience of anticoagulation in individuals >75 years with AF is substantiated on the greater possibility of thromboembolic events and in turn, the risk of bleeding should be taken into account. In this regard, it is key to make a good selection of patients to be anticoagulated through thromboembolism (CHADVASC) and bleeding (HASBLED) risk scores. We should remember that in the elderly, the possibility of falls, of confusing medications, so it is necessary to conduct a thorough monitoring INR with vitamin K antagonists. Direct action anticoagulants (DAC) are another issue entirely, as these would not require monitoring, except in some specific subgroups .
Randomized clinical trials, from which the guidelines emerge that later Scientific Societies adopt and recommend, in general exclude the population of elderly patients.
The age group of the “elderly” is quite varied, and in them we should evaluate with precision, the vulnerability of each patient to adopt the decision of a preventive therapeutic intervention.
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