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1.
CVD prevention recommendations vary among different guidelines regarding individuals over 65 years of age. CVD treatment decisions for older individuals are best based upon the individual presentation utilizing a patient-centered approach.
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2.
General principles of CVD prevention in older individuals include: (a) Blood pressure goal of< 140/90 mmHg, and perhaps lower depending upon the patient’s clinical presentation (e.g., CVD, other CVD risk factors), or perhaps higher among those with poor life expectancy and risk for orthostatic hypotension and other side effects of lower blood pressure; (b) Unless accompanied by unacceptable side effects, statin therapy should be continued in older individuals, recommended to older individuals who experience CVD events or who are at high CVD risk, and offered as primary prevention to patients 75 years of age as primary prevention as part of patient centered, shared decision-making; (c) The degree of glucose control in older individuals should be based upon the underlying health and risks to the patient, with a priority to avoid hypoglycemia and hyperglycemia (i.e., hemoglobin A1c 7.5% or less in patients with 3 or more chronic illnesses and intact cognition, 8.0% or less in patients who are frail, with multiple chronic illnesses and/or moderate cognitive or functional impairment, and 9.0% or less in patients with very complex comorbidities, undergoing long-term assisted care, end-stage chronic illness, and/or moderate to severe cognitive or functional limitations; (d) Older individuals should avoid cigarette smoking that not only increases the risk of cancer, lung disease, and frailty, but also increases the risk of CVD and thrombosis. In patients with CVD treated with aspirin for anti-thrombotic effects, the benefits of continuing aspirin in older patients with CVD often exceed the risk of bleeding. Regarding primary prevention, the risk of bleeding in frail individuals over 80 years of age may exceed the potential benefits of preventing the first CVD event; and (e) Appropriate, patient-centered nutritional intervention and physical activity/exercise may not only have CVD benefits, but other CVD risk factor and anti-frailty health benefits in older individuals [50,97].
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3.
Compared to Caucasians, many Asian individuals are at increased CVD risk. Compared with Caucasians at the same statin dose, Asian individuals may have increased statin bioavailability, similar LDL-C lowering at lower statin doses, and thus lower approved statin doses among Asians [115].
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4.
In addition to healthful nutrition and physical activity generally applicable to all races, African Americans may be especially “salt sensitive” with regard to high blood pressure; with general recommendations that sodium be limited to less than 2300 mg per day in adults, and specifically less than 1500 mg per day among African Americans [116]. Guidelines for pharmacologic CVD prevention in African Americans are generally similar to other racial/ethnic groups, except regarding heart failure and hypertension. In African Americans, diuretics and calcium channel blockers may be preferred over angiotensin converting enzyme inhibitors and beta-blockers [99].
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5.
Recommendations to reduce CVD risk in Hispanics is like other races, with a substantial barrier often being effective CVD prevention communication to non-English speaking Hispanics [101].
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6.
Women typically have same rate of CVD onset 10 years later than men. However, this favorable cardioprotective effect diminishes among women with polycystic ovary syndrome and women entering the menopause. Women over 60 years of age often have less well controlled blood pressure, and higher prevalence of hypertension compared to men [106]. Any cardioprotective effect is mostly lost among women with type 2 diabetes mellitus (T2DM). Women with T2DM increase their risk of CVD three-fold, have higher risk of heart failure, stroke, claudication, and CVD mortality compared to men with T2DM [106]. While supporting CVD outcome data is more limited than men, statins appear to be equally effective for secondary CVD prevention in women, although women may have a greater likelihood of developing statin-associated diabetes mellitus and myalgias [106].
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7.
Chest pain is the most common symptom of acute coronary syndrome among both men and women. However, compared to men, women are more likely to present without chest pain (e.g. weakness, fatigue, nausea, dyspnea, and pain to neck, jaw, and back) [106].
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8.
Polycystic ovary syndrome (PCOS) often occurs in premenopausal women with overweight or obesity and is clinically characterized by androgen excess (hirsutism), amenorrhea or oligomenorrhea, and infertility [3]. PCOS increases CVD risk, largely because of accompanying cardiometabolic abnormalities such as insulin resistance, glucose intolerance, diabetes mellitus, hypertension, dyslipidemia (increased triglycerides and decreased high density lipoprotein cholesterol), metabolic syndrome, increased C-reactive protein, increased coronary artery calcium scores, increased carotid intima-medial thickness, and endothelial dysfunction [117]. As with other patients having increased CVD risk, women with PCOS should be aggressively treated with healthful nutrition and physical activity. Statin therapy may be indicated in many women with PCOS; however, statins may worsen insulin sensitivity in women with PCOS [118]. Conversely, statin therapy may lower testosterone in women with PCOS, with variable reports regarding effects on menstrual regularity, spontaneous ovulation, hirsutism, or acne [119,120]. Statin therapy combined with metformin therapy in women with PCOS may not only lower cholesterol, triglyceride, and testosterone levels, but may also improve insulin resistance with improvement in menstrual regularity, hirsutism, acne, and spontaneous ovulation [121]. While the degree of possible teratogenic effects are unclear, statins are contraindicated in women who are pregnant, or who may become pregnant [122].
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9.
Regarding menopause, while premenopausal women may have some “protection” against CVD compared to men, this protection gap narrows after menopause. This increased CVD risk is partially because women entering the menopause are mostly older than premenopausal women. While perhaps more so in men than women, advancing age is also usually associated with an increase in percent body fat [123]. In women undergoing menopause, the loss of estrogens may have systemic effects such as worsening circulating lipids and lipoproteins and reduced central nervous system satiety effects of estrogens [124]. Taken together with age-related increase in body fat, women undergoing the menopause are at increased risk for insulin resistance, hypertension, and dyslipidemia – increasing CVD risk [125]. In some cases, menopausal hormone therapy (MHT) may increase the risk of CVD among menopausal women. If menopausal hormone therapy is to be used in menopausal women, it should be at the lowest effective dose, administered early (within 5 years) of menopause, and should not be prescribed for the purpose of preventing CVD [106].
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10.
Obesity, physical inactivity, and cigarette smoking may increase the risk of CVD more so in women than in men, indicating the need for aggressive management of these CVD risk factors among both women and men [106].
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