Table 2.

Potential benefits, harms and knowledge gaps of different CVD risk management strategies (primary prevention) for older people as mentioned in the CPGs (n = 47)

	Potential benefits	Potential harms	Knowledge gaps
CVD risk assessment	Provides an estimate of CVD* risk in older people	Risk models underestimate CVD risk for older people	Risk models not rigorously tested/reliable in older people
			Disagreement about the efficacy of risk assessment in older people (75+)
		Most CVD risk models focus on short term risk, and are therefore inevitably more likely to classify older people as at high risk and the young as at low risk
	Beneficial in older patients with multiple risk factors and good quality of life
	Repeated screening of cholesterol is less important as lipid levels are less likely to increase after age 65
		Older people could be considered at high CVD risk based on their age while other risk factors are relatively low
		Disease labeling healthy older people
CVD risk management overall	CVD risk reduction	Risk of adverse effects is higher in older people	Limited available evidence for older people esp. older people with comorbidities and ‘oldest of old’ (age definitions are variable)
	Part of lifetime approach to CVD prevention
		Resources are likely to be concentrated on older people, who may not be able to benefit in their remaining life (time needed to treat to benefit)
	Similar relative benefit but greater absolute benefit for older people due to higher pre-treatment risk
			Lack of generalizability of RCTs† to older people in the community
	Similar benefit in old people as in young people (when taking into account higher case fatality rates after a CVD event in older people and temporal discounting of life years gained)
			Disagreement about the efficacy of risk management in older people (75+)
		Costs associated with inappropriate prescribing in older people
			Implication of knowledge gaps is that patient preferences and potential harms must be taken into account more, not just treatment benefits
	Improved quality of life
Both BP and cholesterol medication	Morbidity/mortality benefit in older people	Risk of adverse effects is higher in older people, esp. frail and very old; risk is acceptable as long as the patient is carefully monitored	Limited available evidence for older people esp. frail old and older people with comorbidities; age definitions are variable
	Choice of drug should not be age dependent and is less important than degree of BP/cholesterol reduction
			Lack of generalizability of RCTs to older people in the community
	Benefit for different treatment threshold/dosages in older people provided
	Benefits provided for specific drugs
	Benefits provided for different older age groups, age definitions are variable
Blood pressure medication	No upper age limit to benefit	Risk of diabetes onset with thiazide diuretics	Limited available evidence on the benefits/harms of lowering SBP§ below certain threshold in older people
	Pre-existing very high risk might set a ceiling effect to the benefits of treatment; incl. in older patients
		Risk of postural hypotension especially with alpha blockers
			Older people are under-represented in trials vs. incentive to recruit more elderly to get enough high risk patients and CVD events for adequate power
	Morbidity but not mortality benefit in very old patients
	Reducing BP‡ has benefits for other conditions beyond CVD (cognitive decline, dementia)		Unknown whether certain medication classes are superior to others in preventing cognitive decline
Cholesterol medication	Stronger evidence for the benefits of cholesterol medication for secondary prevention than primary prevention in older people	Small increase in all-cause mortality in older people	Association between high cholesterol and mortality weaker in older people
		Higher risk muscle toxicity in older people
		Frailty is an additional risk factor for myopathy
	Benefit for older people with risk factors other than age	Increased risk of cancer in older people
	Benefit continuing well tolerated medication vs. starting medication	Very small risk of new-onset diabetes in older people but does not outweigh benefit
Lifestyle	Benefit of healthy diet, physical activity, smoking, moderate alcohol intake	Not discussed	Not discussed
	Benefits of physical activity in older people include mortality benefit, improved quality of life and CVD risk reduction.
	Weight loss and reduction of salt intake lowers blood pressure
Aspirin	Reduced risk of CVD events/myocardial infarctions but older people need to have higher baseline risk for benefits to outweigh harms	Risk of adverse effects increases with age in particular gastrointestinal bleeding and hemorrhagic strokes	Not discussed

*CVD: cardiovascular disease; ^†RCT: randomized controlled trial; ^‡BP: blood pressure; ^§SBP: systolic blood pressure