Challenges in the prevention, treatment and management of cardiovascular disease among older adults

Summary

The ageing population in Europe is contributing to a growing proportion of older people affected by cardiovascular disease (CVD). Older adults account for most of the CVD burden and face unique challenges, complicated by age-related physiological changes and comorbidities. Older patients are underrepresented in clinical trials, leading to scientific and clinical equipoise, and inequities in care. Managing CVD in this age group is complex. Despite the availability of guideline-directed therapies, older adults often do not receive optimal treatment due to the complexity of their conditions and are at higher risk of complications. Strategies for the treatment and management of CVD in older individuals should be driven by patient centred outcomes relating to functional capacity and quality of life. Social and economic factors, such as financial limitations and isolation, further exacerbate age-related CVD inequalities and highlight the need for a holistic approach to care. To address this challenge, The Lancet Regional Health–Europe convened experts to evaluate the current state of knowledge on inequalities and disparities in cardiovascular health among older adults and propose recommendations to address these disparities. This Series paper aims to explore inequalities in, and the escalating burden of, CVD for older adults, with a focus on treatment, prevention, and strategies to support their physical and mental well-being.

Introduction

The United Nations (UN) decade of healthy ageing (2021–2030) arose in response to the unprecedented global ageing, with predictions that the proportion of people aged >60 years will nearly double by 2050.¹ As we approach the midpoint of this decade it is pertinent to consider the inequalities that exist for older adults in receiving timely and effective treatment for cardiovascular disease (CVD). Although CVD remains the leading cause of death globally, with increases in the proportion of total deaths attributed to CVD with increasing age,² the UN healthy ageing action plan states that health services are not set up to address conditions of older age, including CVD.¹

Correspondingly, the recent COVID-19 pandemic highlighted the vulnerability of older individuals with pre-existing cardiovascular conditions and brought attention to the need for better management of CVD in this group. Cardiac injury has been recognised as one of the most frequent complications of COVID, with higher mortality rates amongst older patients.³ This has driven renewed interest in improving cardiovascular health in older populations to prepare better for future public health crises.

Demography and CVD epidemiology in Europe

Europe has undergone major changes in age distribution in recent decades. The proportion of older age individuals has grown, while that of younger age groups has declined. This has led to a transformation in the structure of Europe's population pyramid from a broad base of younger individuals to one in which each age group accounts for a more equal share of the population.⁴ UN Population Division data for Europe demonstrate an increase in the proportion of individuals >75 years, from 1990 (males = 1.8%, females = 3.8%) to 2024 (males = 3.6%, females = 5.8%). Corresponding to an increase in the number of people aged >75 between 1990 and 2024, from 12.7 million to 26.4 million for males and from 27.4 million to 42.9 million for females (Fig. 1).

Fig. 1.

Population pyramid, percentage of population, by sex and five-year age bands, Europe, 1990 and 2024.

Source: United Nations, Department of Economic and Social Affairs, Population Division (2024). Data Portal, custom data acquired via website. United Nations: New York. Available from https://population.un.org/DataPortal/ (accessed 16 July 2024).

These population shifts have been driven by increased longevity and declining birth rates, with longer life expectancies attributed to several key factors including economic development, advancement in healthcare, improved living conditions, and healthier lifestyles resulting from sustained public health approaches. As CVD has been the most common cause of death within Europe over the last few decades, during which these population shifts occurred,⁵ substantial decreases in mortality from CVD, resulting from advances in management, treatment and enhanced public health initiatives,⁶ have played a major role in increasing longevity. Reductions in premature mortality from CVD have resulted in a shift towards individuals dying from CVD at older ages,⁶ with data demonstrating that more than 80% of all CVD deaths in women and approximately 54% of all CVD deaths in men, occur in ages ≥75 years (Fig. 2).

Fig. 2.

Number of deaths from cardiovascular disease, by age and sex, Europe, latest available year of data. Data presented are the sum of individual country level data. Most recent year of data available differs by country, ranging from 2010 in Albania to 2022 in nine out of the 36 countries included. Albania is the only country for which data are older than 2018.

Source: WHO Mortality Database https://platform.who.int/mortality (accessed 24 July 2024).

Greater decreases in CVD mortality than morbidity, mean that individuals live longer with CVD, with a noticeable increase in CVD prevalence among older adults. Data indicate an increase in the number of prevalent CVD cases between 1990 and 2021 of more than 87% in males aged ≥75 years and of more than 45% for women of the same age, with even larger increases found for older individuals (Fig. 3).

Fig. 3.

Number of cardiovascular disease prevalent cases, by sex and age bands, Europe, 1990 to 2021.

Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2021 (GBD 2021) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2022. Available from https://vizhub.healthdata.org/gbd-results/ (accessed 5 August 2024).

Such population and disease demographic changes underscore the need for effective prevention and treatment strategies to address the challenges posed by CVD in older adults. In particular, there have been consistent findings of inequities in treatment approaches and outcomes for the main CVDs amongst older individuals.

Inequities in types of CVD

The incidence of atrial fibrillation (AF) increases with increasing age, and has been found to be substantially greater in those >70 years compared to those <50, with high risks of stroke incidence and total mortality in older individuals with AF.⁷ However, a recent study from the GARFIELD-AF registry found that older AF patients on anticoagulants had reduced mortality and stroke risks without a corresponding increase in major bleeding incidents.⁸ Decreases in mortality among patients with heart failure (HF) have been less prominent in patients >80 years, despite them being at greatest mortality risk, with little progress in survival seen for HF patients in this age group over the past 25 years.⁹ Correspondingly, increased disease complexity in older HF patients often results in altered treatment responses.¹⁰

Case fatality rates are substantially higher in older adults following myocardial infarction (MI), with mortality increasing three-fold for each decade for women and two-fold for each decade for men.¹¹ Older patients are also less likely to receive recommended treatments, including invasive procedural and pharmacological interventions.¹² Older individuals have a higher risk of stroke incidence, severity, and mortality.¹³ Older stroke patients are less likely to receive intravenous thrombolysis or mechanical thrombectomy and have poorer outcomes following these.¹⁴ Older stroke survivors are more prone to cognitive impairment, such as post-stroke dementia and experience a greater reduction in quality of life.¹⁵

Underrepresentation in randomised clinical trials

Tailoring approaches to the complexities of CVD in older adults is challenging, not least because current prevention and management approaches have largely been developed from research involving younger populations, with an obvious underrepresentation of older people, particularly those >75 years, in randomised clinical trials (RCTs), despite them being the most likely to require treatment.¹⁶ CVD RCTs have an increasing age cap percentage as trial phase progresses, with cancer trials setting fewer upper age limits.¹⁷ This has led to a lack of evidence-based recommendations for the diagnosis and treatment of CVD in older individuals,¹⁸ with current clinical practice guidelines not including specific recommendations for older adults.¹⁹ This leaves clinical and scientific equipoise and propels uncertainties regarding the intensity of treatments and therapeutic targets for this age group. The underrepresentation in RCTs has arisen because older adults are often multimorbid, frail, have functional impairments, and may live in long-term care, finding participation in research studies difficult. Given that this is a reality for many older people, it is important that such factors are considered within study design and delivery to provide data on the effectiveness and safety, as well as to inform adjustments, for treating CVD in this population. Careful consideration of drug dosages and potential side effects are required, given the high prevalence of comorbidity (having two or more diseases at the same time) and polypharmacy (concurrent use of multiple medications) in older adults. Without this, diagnostic and treatment processes will remain informed by evidence from younger populations and older patients will continue to receive less aggressive, less evidence-based, and less effective care. Although there are no legal or regulatory requirements mandating recruitment of a specific percentage of participants based on age, practical steps should be undertaken to recruit older individuals for trials. This can be supported by broad recruitment strategies and site selection criteria that reflect the patient population, alongside limiting unjustified exclusion criteria and adopting pragmatic trial designs such as embedded and decentralised approaches that reduce research burden on participants.²⁰ In addition, results should be reported for subgroups to enhance informed approaches to the diagnosis, management, treatment, and prevention of CVD.²¹

Diagnostic challenges

Basic assumptions about the use and efficacy of CVD diagnostic tests cannot always be extrapolated to older adults. The use and interpretation of many tests are altered when applied to older individuals, due to physiological changes, atypical symptoms, and greater risk of some diagnostic tests, in older patients. Among the key limitations is the lack of age-based normative ranges for many metrics, including commonly used risk scores.²²

Risk scores

Identification of older people with increased risk of major adverse cardiovascular events (MACE) is important. However, prediction algorithms for this population are lacking.²² Most established CVD risk prediction models exclude older individuals, with many only recommended for those below a certain age,²³ as they perform substantially worse in older individuals.²⁴ Although there are some risk models designed for use with older adults, with the SCORE2 Older Persons (SCORE2-OP) risk model the most recognised,²³ most older people have high calculated risk on account of their age alone and risk factors, such as cholesterol, blood pressure and body-mass index (BMI), might have weakened predictive power in old age as a result of reverse epidemiology.²⁵

There have been calls to integrate other conditions associated with CVD risk for older adults into risk assessments. For example, renal function is a graded, independent predictor of MI risk in older populations, and early detection of reduced renal function can help identify individuals at higher risk for coronary heart disease (CHD).²⁶ Lower-income groups also experience higher rates of CVD, incorporating socioeconomic status (SES) into CVD risk assessments would provide a more comprehensive view of population-level risk, as socioeconomic vulnerabilities contribute significantly to cardiovascular risk.²⁷ Omitting SES factors may obscure important disparities, particularly as individuals in high-deprivation areas are often the least likely to attend CVD screenings.²⁸

Physiological changes

The limitations of CVD diagnostic tests in older patients are multifaceted and can lead to underdiagnosis and inadequate treatment. Physiological changes due to ageing impact the recognition of CVD, leading to variability in diagnostic parameters.²⁹ Unique cardiovascular characteristics such as increased arterial stiffness, diastolic dysfunction, and reduced coronary reserve, heighten sensitivity to and complicate the diagnosis of a range of cardiovascular conditions, impacting the diagnostic accuracy of tests such as echocardiography or electrocardiograms (ECGs).²⁹

Symptoms

Older patients often present with cardiovascular symptoms that diverge from classic presentations.²⁹ This group commonly experience complex symptomatology that can mask the underlying cardiovascular issue, making clinical assessment challenging. Symptoms such as chest pain may be less pronounced or absent due to reduced pain sensitivity or cognitive impairment.³⁰ Older patients with HF often present with non-specific symptoms such as fatigue and breathlessness, potentially attributable to other conditions, whilst older patients with MI may present with atypical symptoms such as fatigue, confusion, or gastrointestinal discomfort. Such complex symptomatology can impede the diagnosis of CVD, leading to higher risks of misdiagnosis and delayed treatment, which can further complicate the condition of the patient.^29,30 Older patients admitted to emergency departments with non-classical cardiovascular symptoms have been found to wait longer before attending hospital and wait longer to be examined following arrival, with a higher one-month mortality than those presenting with more typical symptoms.³¹

Diagnostic procedures

Greater risks associated with invasive procedures for older patients present additional challenges, with older adults less likely to receive comprehensive diagnostic testing, leading to inadequate management and poorer prognosis.³² Older patients are less likely to undergo procedures such as exercise testing, radionuclide ventriculography, pulmonary artery catheterisation, and coronary arteriography, due to concerns over the higher risks of such approaches in older individuals.³³ In addition, cognitive decline may prevent older patients from effectively communicating symptoms, following pre-test instructions, or understanding the risks of certain diagnostic procedures. Whilst a lack of available data to inform decision making can impact the use of many diagnostic tests with this age group.¹⁸

Treatment

Older CVD patients are less likely to receive guideline-directed treatment due to disease complexity, age-related changes, comorbidities, and higher risk of complications, with low usage of therapies known to reduce morbidity and mortality in this population and dose adjustment of therapies necessary to improve outcomes.³⁰

Physiological changes

Age-related cardiovascular system changes, along with changes to body composition, organ function, and comorbidities, affect how drugs are absorbed, distributed, metabolised, and excreted, resulting in altered end-organ responsiveness and different clinical effects of drug concentrations by age.³⁴ These changes necessitate careful consideration when prescribing cardiovascular medications to older adults, due to impacts on pharmacodynamics (the effects of drugs on the body) and pharmacokinetics (how the body absorbs, distributes, metabolises, and eliminates drugs), increasing sensitivity and affecting treatment efficacy and safety. A higher risk of adverse effects and drug toxicity is found in older adults, something that is particularly problematic for those with comorbidities.³⁴

Comorbidities

Older individuals often present with complex health profiles, including multiple cardiovascular risk factors, necessitating thorough and careful screening to manage and mitigate risks of cardiovascular events, complicating diagnostic and treatment approaches. Multimorbidity affects more than two thirds of older individuals and the vast majority of patients with chronic CVD, with comorbidities impacting the health outcomes of older CVD patients.³⁵ Those with multiple chronic conditions are at higher risk of unintentional medication discrepancies upon admission, due to comorbidities and the necessity for numerous medications,³⁶ with individuals with higher comorbidity burdens also less likely to receive invasive diagnostic and treatment approaches.³⁷

Polypharmacy

Polypharmacy among older adults with CVD is common, with one study reporting that 95% of older patients experience polypharmacy, 69% hyper-polypharmacy, and 78% have at least one severe potential drug–drug interaction.³⁸ Polypharmacy can lead to an increased risk of serious side effects, lower adherence to prescribed medication regimes, negative effects on quality of life, and increased risk of hospitalisation and death.³⁹ Adverse drug reactions (ADRs) are more common in older patients, with those using five or more drugs having an approximate 88% ADR risk, including an increased risk of malnutrition, renal insufficiency, metabolic disorders, bleeding, geriatric syndromes, and further decreased quality of life.⁴⁰ Correspondingly, overmedication in older patients with CVD is a concern. Studies of older individuals in long-term care found that the majority are using potentially inappropriate medications.⁴¹

Cognitive impairment

The intersection between cognitive impairment and CVD requires careful consideration in clinical settings. Both have a higher incidence in older populations, with clear interaction between the two. A meta-analysis examining age-stratified prevalence of mild cognitive impairment and dementia in European populations found that the predicted pooled prevalence of dementia increased with every five-year increase in age. The prevalence was estimated at 0.15% for individuals aged 60–65 years, rising to 21.31% at 85–90 years, and 44.70% for those >95 years.⁴²

Cognitive impairment influences the progression and self-management of CVDs and increases event risk, whilst CVDs aggravate impairment. Hypertension, CHD, AF, and HF, can contribute to cognitive impairment, with CVDs found to be a strong predictor of dementia before its onset.⁴³

Impaired cognition can present barriers to complex medication regimens and lifestyle modifications necessary for CVD prevention and treatment, which can further complicate treatment efficacy. Underlining the need for comprehensive health management strategies that ensure that older patients understand their treatment plans and can follow them accurately.

Invasive treatment

Cardiovascular surgery (including coronary artery bypass grafting, aortic valve, mitral valve and aortic surgery) in older patients can result in good outcomes for reasonable-risk candidates.⁴⁴ Early mobilisation post-surgery can improve outcomes and reduce hospital stays, although this is more challenging with older patients who are more likely to be frail and at a higher risk of complications,⁴⁵ with higher postoperative mortality⁴⁶ and treatment costs.⁴⁷

Studies on interventional therapy in older patients have mixed results, although recent research has shown that older patients may benefit from complex procedures. In the FIRE trial, complete revascularisation in patients >75 years with ST- or Non-ST-elevation MI (NSTEMI) and multivessel disease, led to better outcomes than culprit-only revascularisation.⁴⁸ However, the SENIOR-RITA trial found that in older adults with NSTEMI, an invasive coronary strategy did not result in a significantly lower risk of a composite primary outcome of cardiovascular death or nonfatal MI than a conservative strategy, although nonfatal MI did occur at a lower rate in patients randomised to the invasive arm.⁴⁹ Similarly, an RCT of NSTEMI patients with a Clinical Frailty Scale score ≥4 who were stable upon admission, found that a routine invasive approach did not increase the number of days alive out of the hospital up to one year after discharge. These findings supporting conservative management with close monitoring for older frail patients.⁵⁰

The After Eighty study found reductions in MI and the need for urgent revascularisation in patients aged >80 years with non-ST segment elevation acute coronary syndrome (NSTE-ACS), who received an invasive compared to a conservative strategy.⁵¹ Although no significant differences were found, stroke and death from any cause were lower in those receiving invasive treatment, with no differences in major bleeding occurrence between groups and small but non-significant higher levels of minor bleeding found in the invasive group.⁵¹ This finding was partly supported by a recent meta-analysis that reported that for older NSTE-ACS patients, routine invasive treatment was found to not reduce the combined risk of all-cause mortality and MI within one year when compared to a conservative approach. However, it did significantly decrease the risk of recurrent MI or the need for urgent revascularization.⁵²

Prevention

The prevention of CVD in older individuals, particularly those with comorbidities, presents several challenges. The intersection of ageing, comorbidities, and complexities of treatment regimens create a unique set of obstacles. Effective prevention strategies must account for the complex health profiles and specific needs of older adults. Primary prevention interventions such as antihypertensive agents, statins, and lifestyle modifications apply across all age groups, as they show similar effects on cardiovascular health in all ages.⁵³ However, cardiovascular risk stratification and treatment approaches differ based on age, with recommendations highlighting the need to avoid overtreatment in older individuals.⁵⁴

Atherosclerotic cardiovascular disease (ASCVD) often develops silently over many years before presenting as clinical events. Recent advances in genomics and imaging technology are enhancing early detection and prevention strategies for ASCVD.⁵⁵ Genomics can now reveal individual susceptibility to ASCVD by identifying genetic risk factors that influence processes such as cholesterol metabolism, inflammation, and other cardiovascular functions.⁵⁶ Imaging technologies allow the detection of plaque buildup or calcifications in the arteries of asymptomatic individuals, particularly valuable in older adults as it provides a more direct assessment of cardiovascular health beyond traditional risk factors.⁵⁷ Together, these advances enable targeted preventive measures, potentially reducing the likelihood of ASCVD symptoms or severe events.

The use of medications such as statins and aspirin by older patients requires further evaluation. Whilst prescribing statins for older patients have proven cost-effective, as they reduce MACE⁵⁸ and help mitigate heightened health risks and reduce prolonged hospital stays,⁵⁹ side effects of the treatment are more likely to occur in older individuals.⁵⁸ Similarly, although aspirin has been found to be efficacious for the secondary prevention of CVD, the benefits of aspirin for primary prevention have been questioned, due to increased risks of bleeding and mortality, when used in healthy older adults.⁶⁰ In particular, the Aspirin in Reducing Events in the Elderly (ASPREE) trial reported a significantly higher risk of major haemorrhage in older adults using low-dose aspirin as a primary prevention strategy, with no significant decrease in the risk of CVD, when compared to those taking a placebo.⁶⁰

Lifestyle modifications

Lifestyle changes play a key role in promoting cardiovascular health in older adults with the aim of maintaining functional independence, which also enhances overall quality of life, as people age. Modifications such as quitting smoking, eating a balanced diet, and engaging in regular exercise can slow the age-related decline in cardiovascular function.

Older adults who stop smoking experience reduced cardiovascular mortality, improved cognitive function, and a higher quality of life.⁶¹ Research shows that smoking cessation around 65 years can extend life expectancy by 1.4–2 years for men and 2.7–3.7 years for women.⁶²

A nutritious diet that addresses common age-related issues like hypertension and diabetes is important, as it lowers cardiovascular risk and improves quality of life in older adults, with higher levels of malnutrition found in this population. A meta-analysis examining malnutrition in community-dwelling adults >60 years, using the Mini Nutritional Assessment (MNA) tool, found a malnutrition prevalence of 3.1% overall, whilst 26.5% were identified as being at risk of malnutrition and in need of nutritional support. Malnutrition prevalence was found to rise with increasing levels of functional dependency, with a 3.1% prevalence of malnutrition in community-dwelling older adults, 6.0% in outpatients, 8.7% in those receiving home-care services, 17.5% amongst those in nursing homes, 22.0% in hospitalised individuals, 28.7% in long-term care facilities, and 29.4% in rehabilitation or sub-acute care settings. Notably, Europe had a relatively low malnutrition prevalence (2.1%) compared to other global regions.⁶³ A further meta-analysis focusing on protein-energy malnutrition risk in adults >65 years across Europe reported pooled prevalence rates of 28.0% in hospitals, 17.5% in residential care, and 8.5% in community settings, based on data from various malnutrition screening tools.⁶⁴ Meta-regression found that prevalence rates were significantly higher in individuals aged >80 years, in women, and in those with comorbidities. Variability in prevalence rates across countries and screening tools underscores the importance of adopting a standardised malnutrition screening tool tailored to this population.⁶⁴

The World Health Organization (WHO) highlight that older adults have unique dietary needs due to reduced calorie requirements, slower metabolism, and age-related muscle and bone loss. They recommend a balanced diet rich in fruits, vegetables, and dairy, with an emphasis on higher protein intake. Hydration is also essential, as the sense of thirst diminishes with age.⁶⁵ Older individuals should prioritise key nutrients such as potassium, calcium, vitamin D, fibre, and vitamin B12, whilst limiting added sugars, saturated fats, and sodium can help lower the risk of chronic diseases.⁶⁵ Socioeconomic factors, social support, social interaction, and oral health also impact the health, well-being, and eating habits of older adults.⁶⁵

Regular physical activity supports cardiovascular performance and resilience. The WHO physical activity guidelines offer tailored recommendations for older adults (≥65 years), emphasising exercises that enhance balance and strength, designed to boost functional capacity and reduce fall risk, on at least three days per week.⁶⁶ Older adults are also encouraged to follow the general physical activity guidance for all adults (18–64 years), which advises at least 150 min of moderate-intensity, or 75 min of vigorous-intensity, aerobic activity per week, along with muscle-strengthening exercises on two or more days per week. The guidelines further recommend minimising sedentary time for all older adults,⁶⁶ with evidence demonstrating that exercise interventions can improve physical function among those in residential care settings.⁶⁷ Self-reported participation in health-enhancing aerobic and muscle-strengthening activities from the third wave (2019) of the European Health Interview Survey (EHIS), conducted across all 27 EU Member States, along with Iceland, Norway, Serbia, and Turkey, found adherence to recommendations declined steadily with age, with only 7.4% of EU residents aged ≥65 meeting weekly recommended levels of physical activity and muscle strengthening.⁶⁸

Initiating preventive measures early and maintaining them throughout life, including later years, is important due to the cumulative effect of risk factors, with shared decision-making crucial to balance benefits and risks.⁶⁹ Aiming to improve self-efficacy levels, in particular through social network support, are seen to be valuable when developing lifestyle interventions for low SES older adults.⁷⁰

Gerotherapeutics aim to enhance resilience against ageing to prevent chronic diseases, extend health span, and reduce disability. Geroscience posits that chronic diseases such as CVD arise from the gradual breakdown of homeostatic mechanisms due to ageing-related molecular damage.⁷¹ Interventions target ageing processes and can be both pharmacologic (e.g., nicotinamide adenine dinucleotide (NAD+) boosters, senolytic drugs, metformin, mammalian target of rapamycin (mTOR) inhibitors) and nonpharmacologic (exercise, diet). Although a number of geroscience approaches are currently being used, the development of new and novel approaches, in particular drug therapies, require large-scale clinical trials to validate their effectiveness and inform their use.⁷¹

Frailty

Frailty is an age-related condition marked by declining physiological function, reducing resilience and increasing vulnerability to health deterioration from minor illnesses or stressors.⁷² An analysis of Survey of Health, Ageing and Retirement in Europe (SHARE) Wave 6 data, covering 18 European countries, revealed an increasing prevalence of frailty, as defined by the Fried phenotype, with advancing age. Among individuals aged 50–64 years, the prevalence of pre-frailty and frailty was 38.7% and 3.0%, respectively. These rates rose to 41.7% and 6.0% for those aged 65–74 years, 50.5% and 16.0% for ages 75–84 years, and 52.3% and 32.8% for individuals >85.⁷³ A larger study across 42 European countries, using relevant cases from waves 1 to 8 of the SHARE dataset, found similar frailty prevalence at younger ages (e.g., 50–54 years) across all countries, but reported frailty rates two to three times higher in countries with lower compared to higher GDP per capita, at older age groups (e.g., ≥85 years).⁷²

A growing body of evidence highlights the utility of frailty assessment in patients with CVD due to the link between the two⁷⁴ as well its association with other adverse health outcomes including dementia and diabetes.⁷⁵ Frailty and sarcopenia, both of which are more common in older adults, are associated with faster CVD progression, higher risk of mortality and falls, and reduced quality of life.^76,77

The impact of frailty has been observed across a broad spectrum of cardiovascular conditions, including stable and subclinical CVD, HF, coronary syndromes, cardiac surgery, and transcatheter aortic valve replacement (TAVR).⁷⁴ Furthermore, frailty⁷⁴ and prefrailty⁷⁸ have been found to be associated with elevated risk of cardiovascular mortality, with frailty independently associated with increased mortality within one year of follow-up in patients with CVD.⁷⁹

Identifying frailty or pre-frailty is therefore essential in the comprehensive management of older CVD patients, particularly given its potential reversibility.⁷⁹ Frailty assessment provides valuable prognostic information, and facilitates a patient-centred approach to care, serving as a guide for tailoring treatment rather than as a justification to withhold care.⁷⁴ Systematic efforts to incorporate frailty assessment into cardiovascular practice are essential in improving the health and well-being of older patients. Clinical trials evaluating frailty interventions in specific cardiac populations are also needed to further optimise cardiovascular care.⁸⁰ However, the lack of consensus on the best tool for routine clinical use presents challenges, including in the translation of research findings into clinical practice.⁷⁴

Rehabilitation

Despite the known benefits on both frailty and CVD, participation rates in cardiac rehabilitation programmes among older adults have traditionally been low, with markers of frailty leading to more conservative management.⁸¹ Rehabilitation programmes can improve physical function and overall quality of life, as well as enhancing cardiovascular health, reducing the risk of future cardiovascular events, and addressing both physical and psychological needs. Those who participate in rehabilitation report benefits in survival, lifestyle, functional capacity, and quality of life. It is concerning, therefore, that older adults are more likely to withdraw from rehabilitation programmes and understanding their reasons for doing so may help guide the development of programmes that fulfil the requirements of older patients.⁸²

Clinical and personal outcomes

Some argue that the risk-treatment paradox of older patients being less likely than younger counterparts to receive evidence-based therapies for CVD treatment, despite a higher prevalence of CVD in this population, may not actually be paradoxical and could be a reflection of appropriate management.⁸³ Suggesting that a conservative approach to the treatment of CVD within frail older patients may be appropriate when basing such a decision on biological, rather than chronological, age and when considering principles of beneficence and autonomy related to quality of the patient's life before intervention and their likely improvement following it.⁸⁴

Physicians can make decisions to withhold treatment or diagnostic procedures due to the condition of the patient, considering such factors as age, life expectancy after treatment, decreased physical condition or quality of life, and comorbidity. Treatment to prolong life may be seen to be inappropriate in some older patients and clinicians should carefully consider whether to expose them to invasive procedures that might prolong the process of dying without influencing quality of life.⁸³ In particular, all-cause mortality, a common outcome in trials and treatment aims, may not be as relevant to some older patients as other endpoints including quality of life, symptom status, tolerance to medication, disability, repeated hospitalisation, and return to independent living.^83,84

Targeted outcome measures when treating older patients may be different to those for younger patients. Although preventing acute cardiovascular events is key and prolonging life is a goal for many patients, there should be greater consideration given to achieving a balance between longevity and the quality of remaining life in older individuals.⁸⁵ There should also be aims to preserve cognitive function, manage comorbidities, minimise polypharmacy risks, and reduce hospital admissions.⁸⁶ Decision-making on this is complicated by wide gaps in the evidence base, for example, current risk scores take no account of factors such as functional capacity and cognitive status that are important to the older patient.⁸³ However, newer biomarkers such as frailty are being increasingly used by clinicians for evaluating the appropriateness of more intensive care in older patients with CVD.⁷⁴

A collaborative, interdisciplinary approach—uniting cardiologist, geriatrician, and primary care provider expertise—is essential to deliver holistic, patient-centred care tailored to the complex needs of ageing patients. Such a model integrates cardiovascular care within a broader focus on geriatric health, addressing key issues such as multimorbidity, frailty, and cognitive decline. By balancing cardiovascular treatment goals with overall quality of life and functional independence, interdisciplinary frameworks help align healthcare with each patient's health priorities.⁸⁶

Where management of older adults with CVD is deferred to specialist geriatricians, guidance on evidence-based strategies and how these might be modified to meet the needs of older frail patients with comorbidities should be made available. In addition, both patients and their family may decide to target comfort over cure. A person-centred approach, should provide comprehensive care that addresses physical, mental, and emotional health, including the management of cognitive decline, depression, and social isolation.⁸³ Advanced Care Planning and End-of-Life Care can also be appropriate in ensuring that care aligns with the patient's values and wishes.⁸⁶ However, planning for a decline in decision-making capacity can be difficult to conceive for individuals and support should be given to enable patients and their families to understand the nature of the disease and the care required, such that they can make decisions on it.⁸⁴ Older patients often prefer options that prioritise stability and comfort over aggressive interventions and many value open discussions with healthcare providers to express their treatment preferences and risk tolerance.⁸⁵

Home-based palliative services, such as hospice and in–home care, better align with patients' goals and reduce hospital-based deaths. These services not only support patients' desires to remain at home in the comfort and familiarity of home, where they can retain a sense of control over their care,⁸⁷ but are also cost-effective in achieving this outcome.⁸⁸

Wider social inequalities

Social and economic factors play a major role in CVD related inequalities experienced by older adults. Many older individuals have limited financial resources, making it difficult to afford medications, healthy food, and other necessities. Moreover, social isolation can reduce access to healthcare services and support systems, further complicating disease treatment and management efforts.

Healthcare access

Older adults with CVD face systemic and individual challenges in accessing healthcare. Personal economic, social, and cultural circumstances can impact healthcare access for older adults, with affordability and accessibility key. Older patients, especially those in rural areas, face substantial barriers related to the geographic availability of healthcare providers, with long travel distances to healthcare facilities delaying care.⁸⁹ Economic stability can impact healthcare access, with poverty a major factor in limiting healthcare access in older individuals.⁹⁰

Inequalities in cardiovascular care for older adults show regional variations across Europe, influenced largely by socioeconomic factors, healthcare access, and national healthcare policies.⁵ In Southern European nations older adults face barriers in accessing cardiovascular care due to limited healthcare resources and the impact of austerity measures, which have led to disparities in care services.⁹¹ In contrast, Western European countries generally have more robust healthcare infrastructures, contributing to improved outcomes and reduced cardiovascular mortality among older adults.⁹² Whilst inequalities in healthcare services and CVD mortality remain high in Eastern and Central European countries.⁹²

Social isolation

Social isolation, more common in older adults, impacts those with CVD, exacerbating both physical and mental health outcomes. Longitudinal studies have shown that loneliness and social isolation are correlated with cardiovascular events and increased mortality risk among older individuals.⁹³

Social support has been found to influence patient activation through self-efficacy in older adults living with CVDs with older individuals often dependent on family caregiver networks and home-based clinical services for this. These caregivers provide essential physical, social, and emotional assistance, particularly after hospital discharge.⁹⁴ Informal caregivers, typically family members, play a crucial role and often need support themselves to manage the physical, emotional, and financial toll of caregiving. Older caregivers, especially those >65 years, face substantial health and financial burdens, with interventions such as community health workers and respite care recommended to help alleviate these strains.⁹⁵

Conclusions

The management of CVD in older adults is complicated by an array of challenges, primarily due to unique physiological, psychological, and social factors that characterise this population. The greatest challenges are multimorbidity and the associated risk of polypharmacy which complicate CVD treatment and can increase risk of adverse drug reactions, drug–drug interactions, and overall medication burden. The high prevalence of frailty and cognitive decline in older individuals further complicate treatment, necessitating a personalised therapeutic approach that balances the risks and benefits of interventions tailored to the individual's specific health status. However, these challenges are compounded by a lack of robust randomised clinical trial data specifically addressing this age group and these conditions (Fig. 4).

Fig. 4.

Challenges and solutions in the prevention, treatment and management of cardiovascular disease among older adults.

As the proportion of older people is projected to rise further within Europe, steps should be taken to overcome the challenges of treating and managing CVD in them (Panel 1). Practical steps should be undertaken to recruit older individuals for trials with results reported for subgroups and supported by real-world studies assessing long-term outcomes. Whilst treating older patients, decisions should be made in consultation with them and their families, considering age-related physiological changes, comorbidities, and overall patient health status. Approaches to manage and treat CVD in older adults requires an interdisciplinary and coordinated care plan approach, involving cardiologists, geriatricians, and other healthcare professionals, that may occur across multiple sectors and settings. These approaches should involve individualised treatment plans, be patient-centred, and prioritise functionality, independence, quality of life, prognoses, and feasibility, along with individual preferences. Such interventions should be multidomain, including pharmacological management, preventive measures, lifestyle, education and self-management.

Panel 1. Recommendations on the management and treatment of CVD in the older adults.

• 1.Decision making: The treatment and management of CVD in older individuals should be interdisciplinary and based around a coordinated care approach that is individualised to the patient. This should include considerations around frailty, estimated life expectancy, time to benefit, comorbidities, quality of life, and patient preference.
• 2.Pharmacotherapy: Pharmacotherapy is critical in managing CVD within older patients, with recommendations to base decision on its initiation on the SCORE2-OP risk score and to consider comorbidities and other factors related to quality of life that are common in older adults.
• 3.Interventional cardiology: For older patients with AMI, thrombolytic therapy, coronary angioplasty, and surgical interventions are viable options, even for those over 80 years old. Although, conservative management with close monitoring is recommended for older frail patients with comorbidities.
• 4.Preventive Measures: Lifestyle modifications and preventive vaccinations, such as the influenza vaccine, are recommended to lower the risk of heart failure and other CVDs in older patients. Additionally, the management of comorbidities and the adoption of healthy behaviours are emphasised, focusing on the importance of healthy diet, reduction in sedentary behaviour, and support to quit smoking in those of older age.
• 5.Emerging Therapies: Exploration of novel approaches, such as geroscience, should be supported, to enhance resilience mechanisms and target age-related cellular senescence, as they have the potential to transform CVD treatment and prevention in older adults.

Implementing these strategies in order to tackle CVD inequalities in the older population requires collaborative efforts between healthcare providers, patients, caregivers, and policymakers. It is essential for governments and healthcare funders to support and invest in health systems that address the unique needs of older adults. The integration of long-term care with medical services offers significant benefits by coordinating resources across health and social sectors, ensuring continuous, tailored care for older individuals and reducing caregiving burdens on families.⁹⁶ By adopting integrated and preventive strategies, healthcare systems can balance cost and quality of care, enhancing the well-being of older adults while alleviating financial and operational pressures.⁹⁷ Recommendations summarised from this Series paper can be found in Panel 1.

Key messages.

• -Socioeconomic changes and advances in healthcare have contributed to increased longevity and ageing populations. This has resulted in a higher prevalence of cardiovascular disease (CVD) among older adults, as well as more individuals living longer with CVD.
• -Managing CVD in older adults presents unique challenges, as current diagnostic and treatment approaches are largely based on clinical trials and research that often underrepresent older populations.
• -Older patients face multiple challenges in diagnosis and treatment, including inappropriate risk scores, physiological changes, atypical and complex symptomology, frailty, cognitive impairment, comorbidities, polypharmacy, and the risks posed by invasive procedures.
• -These challenges are exacerbated by broader social inequalities, such as limited financial resources, social isolation, and reduced access to healthcare services.
• -A holistic and interdisciplinary approach to care is essential. This includes integrating related conditions into risk assessment, leveraging advancements in genomics and imaging technology, recruiting older individuals for clinical trials, and conducting real-world studies.
• -Care strategies should prioritise outcomes meaningful to older patients, including person-centred, patient-led approaches that focus on quality of life, functionality, and independence. Goals should encompass reducing hospital stays, promoting lifestyle modifications and rehabilitation, and balancing treatment with side effects and risks.

Search strategy and selection criteria.

A full systematic review was not undertaken. Literature was identified predominantly from the databases PubMed, Embase, and Web of Science with final searches conducted during December 2024. Search terms included “cardiovascular disease” or “CVD”, along with CVD subtypes (e.g., myocardial infarction, cerebrovascular disease etc.), with the population identified as “older adults” or using synonyms such as “elderly” or “ageing”. The United Nations defines older adults as individuals aged >60 years, although definitions may vary. In many developed countries there are distinctions between young-old (65–74 years), middle-old (75–84), and oldest-old (>85), reflecting the diversity within the older population. For this review, we did not impose strict age limits, allowing each study to define “older adults” individually. However, given that life expectancy in European countries averages 81 years for women and 75 years for men, our primary focus was on those aged more than 70–75 years of age.

Factors to be included in the search, such as treatment and diagnosis, were pre-defined by the authors, although some were identified inductively from the literature. Population, factors, and diseases were combined using Boolean operators (i.e., AND, OR, NOT) to focus searches. Database searches were limited to articles from Europe and North America–reflecting the cultural similarities and shared health system structures between the two regions–and those written in English or for which an English translation was available. Initial searches identified articles published between 1/1/2014 and 31/12/2024 to prioritise studies published in the last ten years. These were complemented with manual review of reference lists and snowballing of relevant articles, along with author recommendation.

Contributors

NT, CPG, and AT conceived the topic. AE, DM, PPF, FW, and TG contributed to the identification and interpretation of the literature. NT drafted the Series paper, with initial input from CPG and AT. All authors contributed to editing and critically revised the manuscript.

Declaration of interests

AT declaration include receiving an annual honorarium to edit the European Heart Journal: Quality of Care and Clinical Outcomes, sitting on the Trial Steering Committees of SCOT HEART 2 and DUAL ACS and owning shares in RE-COGNITION Health Ltd–Dementia care unit, no income has been received from this investment. GC reports funding from Alan Turing Institute, British Heart Foundation, National Institute for Health Research, Horizon 2020, Abbott Diabetes, Bristol Myers Squibb, and European Society of Cardiology; consulting fees from AI Nexus, AstraZeneca, Amgen, Bayer, Bristol Myers Squibb, Boehrinher-Ingleheim, CardioMatics, Chiesi, Daiichi Sankyo, GPRI Research B.V., Menarini, Novartis, iRhythm, Organon, The Phoenix Group; fees from AstraZeneca, Boston Scientific, Menarini, Novartis, Raisio Group, Wondr Medical, Zydus; support for attending meetings and/or travel from AstraZeneca; participation on a Data Safety Monitoring Board or Advisory Board for DANBLCOK trial and TARGET CTCA trial; Leadership or fiduciary role as Deputy Editor for EHJ Quality of Care and Clinical Outcomes, NICE Indicator Advisory Committee, Chair ESC Quality Indicator Committee; stock or stock potions CardioMatics; and receipt of other services from Kosmos device. TG reports consulting fees from Moderna. NT, AE, DM, PPF, and FW, report no disclosures relevant to this manuscript.