Table 9. Overall results on cardiovascular risk factors in the older population. Diagnosis, prevention and treatment.

Sedentariness
BMI: body mass index; COPD: chronic obstructive pulmonary disease; CV: cardiovascular; CVR: cardiovascular risk; DM: diabetes mellitu; DBP: diastolic blood pressure; GLP-1 receptor antagonists: glucagon-like peptide 1 receptor antagonist; HDL-C: high-density lipoprotein colesterol; LDL-C: low-density lipoprotein colesterol; MS: metabolic syndrome; NPH insulin: Neutral Protamine Hagedorn; SBP: systolic blood pressure; SGLT-2: sodium-glucose type 2 cotransporter.
Persons older than 60 years spend 60%-80% of their time in sedentary activities; sedentariness is even greater in persons with cardiovascular disease.
Some secondary activities (eg, reading, using the computer, arts and crafts) are associated with a lower risk of dementia and may enhance social interaction.
Prolonged sedentary time (more common in men) is more harmful than shorter episodes (more common in women).
Sedentariness can negatively impact cardiovascular health despite moderate physical activity. The more sedentary a person, the higher the BMI, blood glucose level and functional limitations after adjustment for physical activity and vice versa.
The relationship between sedentariness and cardiovascular disease is linear (each additional hour of sedentariness is associated with a 22%-27% risk of having cardiovascular risk factors), while more physical activity decreases the probability of cardiovascular risk.
Moderate-intense physical activity (measured with accelerometers) positively impacts cardiovascular risk factors in older people. The benefit of mild physical activity is more controversial varies among studies.
Cardiovascular mortality is 33% lower in non-sedentary versus sedentary individuals older than 60 years and increases by 6.4% for each additional hour per day of sedentary behavior.
In older adults with frailty (a high risk of gait disability according to measurements of functional limitations in the lower extremities, ability to walk 400 meters in ≤15 minutes, take < 20 minutes of moderate-intense physical activity/week), there is a demonstrated linear relationship between sedentariness and cardiovascular risk.
Mortality decreases in formerly sedentary older people, but remains higher than in never sedentary individuals. Equally, becoming newly sedentary increases mortality although the risk is still lower than in consistently sedentary persons.
There are contradictory results on whether programs to increase physical activity in older people also reduce sedentariness and consequently these two behaviors should be approached separately.
There are no strategies that approach sedentariness specifically in older adults.
Clinical practice guidelines should stress both increasing physical activity and reducing sedentariness among older adults.
The recommendations of the World Health Organization on physical activity in persons aged ≥ 65 years consist of a minimum of 150 minutes per week of moderate aerobic activity or 75 minutes of vigorous aerobic activity, or an equivalent combination of moderate and vigorous activity.
Persons not following physical activity recommendations should attempt to increase the duration, frequency and, finally, intensity of exercise as a goal until they reach recommended levels.
Prescription of physical exercise should be progressive, with an individualized plan, and have the same precision as any other medical treatment and should set clear goals. The exercise program should include aerobic exercise, strength training, flexibility and balance, as well as recommendations on health education.
Exercise programs for patients with sarcopenia or frailty should include the specificity, frequency and duration required to achieve improvement.
In older patients with cardiovascular risk factors, cardiovascular conditioning is essential as it attenuates the adverse effect of sedentariness, even in patients not adhering to exercise recommendations.
Perhaps the simplest way to increase aerobic physical activity in robust older adults is to set a goal of exceeding 10,000 steps per day.
Smoking habit
Smoking is a major risk factor for cardiovascular disease and an independent risk factor for stroke and acute myocardial infarction, as well as cardiovascular mortality, independently of age.
The risk is 2-fold higher in smokers than in never-smokers and increases and occurs earlier in heavy smokers.
The risk of all cardiovascular events decreases by 46% in ex-smokers 5-10 years after quitting.
Given the reduction in cardiovascular risk after smoking cessation, it should be recommended even in very old adults.
In peripheral arterial disease, there is evidence that the risk is higher in older smokers than in younger smokers; moreover, the smoking-related risk of abdominal aneurysm remains high irrespective of age.
Smoking is associated with a higher risk of Alzheimer disease and worse cognitive function. However, cognitive decline can be reversed 5 years after smoking cessation and maximum recovery is achieved 30 years after quitting.
Quality of life is impaired by as much as 55% in older smokers, depending on the number of cigarettes smoked and the number of years since starting. Eleven years after quitting, quality of life can be enhanced in older people, reaching the same levels as in never-smokers.
Non-cardiac mortality and lung cancer increases in both smokers and ex-smokers throughout life, reaching a peak at 60-70 years.
In older adults, the number of pack/years also influences the risk of mortality. The longer the time since quitting, the greater the reduction in excess mortality.
Reducing smoking leads to a 10% reduction in preventable admissions and hospital costs associated with smoking-related chronic diseases-common in older people-such as COPD (5 years after quitting), angina, complications of diabetes, and congestive heart failure (between 5 and 14 years after quitting).
Quitting smoking for 2 years reduces the risk of coronary disease and, after 2-4 years, the risk of stroke; maximum reduction is achieved 10-14 years after cessation.
Older people who quit smoking at the age of 65 years gain up to 2 years or life in men and up to 3.7 years in women. In contrast, smokers bring forward the risk of cardiovascular mortality by more than 5 years.
The benefits of smoking cessation are maintained even in persons older than 70 years, indicating that it is never too late to quit.
Recommendations for smoking cessation in older adults include setting a quit date, with a prior preparation period, the use of nicotine replacement therapy, and follow-up to ensure treatment adherence and reduce the risk of relapse.
Older smokers hospitalized for an acute myocardial infarction should more frequently be counseled to quit, as only 40% are currently advised to do so.
Personalized smoking cessation interventions should be considered in older adults rather than routine clinical practice or the use of clinical practice guidelines to improve the results of serious quit attempts and prolong periods of abstinence.
Obesity and metabolic syndrome
Patients with MS have twice the risk of cardiovascular disease than those without MS.
In the Spanish population, the risk of cardiovascular disease in patients with MS is more than 22% higher than in the general adult population; cardiovascular disease predominates in men until the age of 65 years and increases in women after this age.
A strong association has been demonstrated between cardiovascular disease and high blood pressure, cardiovascular events and mortality, type 2 diabetes and MS. To detect these risk factors, the waist-to-height ratio is considered a more effective anthropometric marker than BMI or waist circumference
Results on moderate red wine consumption indicate a relationship with a lower prevalence of MS in an older Mediterranean population with high cardiovascular risk compared with an older Spanish population not consuming red wine.
The results found on higher consumption of low-fat dairy products indicate an association with a lower risk of metabolic syndrome in persons at high risk of cardiovascular disease in a Mediterranean population. In contrast, higher cheese intake was related to a higher risk of MS.
In older patients with a high risk of cardiovascular disease, a Mediterranean diet supplemented with extra virgin olive oil or nuts is not associated with the development of MS. However, these Mediterranean diets are appropriate to cause reversion of metabolic syndrome.
Exercise capacity is inversely related to arterial stiffness and age in persons with MS.
Decreasing arterial stiffness at any age through physical exercise, measured through pulse wave analysis, provides clearer evidence on the effect of physical exercise in reducing cardiovascular risk in patients with MS.
No studies were found on the particular features of the management of obesity and MS in older patients with frailty and functional decline.
No studies were found on the particular features of drug therapy in the treatment of obesity and MS specifically in older patients.
Hypertension
Antihypertensive therapy is effective in the population older than 65 years, demonstrated by a significant reduction in all-cause and cardiovascular mortality, as well as by a decrease in cardiovascular events as a composite outcome or individually (fatal and non-fatal stroke or acute myocardial infarction).
The aim of antihypertensive therapy, in terms of blood pressure targets, is not specifically defined, with a SBP cut-off value of 140 mmHg. Greater reductions in all-cause and cardiovascular mortality have been observed with SBP targets of < 140 mmHg and DBP < 90 mmHg.
Intensive antihypertensive therapy (target SBP value < 120 mmHg) versus standard therapy (target SBP value < 140 mmHg) is more effective in significantly reducing severe composite cardiovascular events (cerebrovascular events such as stroke and coronary events such as acute myocardial infarction) as well as in decreasing all-cause mortality.
Patients without chronic kidney disease at treatment initiation may have a higher risk of developing renal insufficiency (reduced glomerular filtration rate) with intensive therapy.
Se ha de tener en cuenta que cifras tensionales < 140 mmgHg, podrían relacionarse con una mayor tasa de efectos adversos graves. SBP values < 140 mmgHg may be related to a higher rate of severe adverse effects.
Intensive therapy in persons older than 80 years (maintaining SBP values < 120 mmHg) has been shown to produce a significantly greater reduction in all-cause mortality and major cardiovascular events (composite variable) than standard therapy (SBP < 140 mmHg); clinicians should be alert to a possible clinically significant reduction in kidney function (> 30% decrease in glomerular filtration rate) and a higher rate of acute renal insufficiency with intensive therapy.
Treatments aiming at SBP values < 140 mmHg have not shown a significant reduction in mortality in older patients with frailty in studies where frailty is defined as baseline vulnerability (gait speed, grip strength, Fried model, Groeningen frailty index, osteoporotic fracture index).
The risk of cardiovascular events has been demonstrated to be higher in patients older than 75 years with frailty than in those without frailty, independently of the intensity of antihypertensive treatment.
Intensive therapy that achieves sustained SBP values < 120 mmHg in older patients decreases the number of major cardiovascular events and all-cause mortality in absolute terms compared with standard therapy (sustained SBP values < 120 mmHg).
Antihypertensive treatments with diuretics in general (both potassium-sparing and thiazide diuretics) have favorable results versus placebo or other treatments in reducing cardiovascular risk, both in terms of cardiovascular and all-cause mortality. The results are more consistent in terms of their ability to reduce serious cardiovascular events overall and particularly in decreasing cerebrovascular morbidity and mortality (stroke). These antihypertensive treatments with diuretics show contradictory results in terms of the rate of adverse events but the rate is not higher than with other antihypertensive therapies.
Antihypertensive therapy with beta-adrenergic blockers has not been demonstrated to significantly reduce cardiovascular risk versus placebo or other treatments; this treatment has only been shown to significantly decrease cerebrovascular morbidity and mortality versus placebo, but has a higher rate of adverse events than other antihypertensive therapies.
Antihypertensive treatment with calcium channel blockers versus placebo has shown good results in reducing cardiovascular risk, cardiovascular and all-cause mortality, and cardiovascular morbidity and mortality overall and especially in decreasing cerebrovascular events, with a lower rate of adverse events versus other antihypertensive therapies.
Antihypertensive drug therapy with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are less well studied in the older population; only one meta-analysis has demonstrated a reduction in cardiovascular morbidity and mortality measured as a composite outcome but not different events separately.
In the population older than 55 years, simple exercises such as handgrip exercise training for more than 4 weeks produce a clinically significant reduction in SBP and DBP, although the benefit on cardiovascular risk has not been assessed.
Type 2 diabetes mellitus
The retrieved studies assessing intensive vs conventional glucose control in patients ≥ 65 years do not demonstrate reductions in mortality, major cardiovascular events (fatal and non-fatal), or micro- and macrovascular events, but do report a higher yearly rate of severe hypoglycemic episodes. In other studies, strict glucose control in patients ≥ 65 years has shown a reduction in the composite outcome (major macrovascular events and microvascular events), only in terms of a lower incidence of kidney disease.
Studies conducted in patients aged ≥ 80 years with type 2 diabetes have shown that very low (< 6%) or very high (> 8.5%) glycosylated hemoglobin levels were associated with higher mortality compared with intermediate levels (7.0%-7.4% or 8%-8.4%).
Studies have demonstrated a “U”-shaped association between blood glucose levels and frailty in older people with type 2 diabetes: the risk of frailty increases with extremely high, low or elevated blood glucose levels.
Treatments based on strict blood glucose control in older patients with type 2 diabetes have an increased risk of falls, functional deterioration and some geriatric syndromes.
Low glycosylated hemoglobin levels (7%-7.9%) have been associated with worse functional status than higher levels (8%-8.9%) in patients with type 2 diabetes and a mean age of 80 years.
There are no results from clinical trials evaluating the effect of intensive glucose control on cardiovascular events in older patients with frailty and type 2 diabetes.
In older patients, glycemic control targets should be adapted to functional and cognitive status, comorbidities and life expectancy.
In older patients with type 2 diabetes and good functional and cognitive status, virtually no comorbidity and good life expectancy, it is recommended to maintain targets similar to those of young adults with diabetes (HbA1c 7%-7.5%).
In patients with functional disability, frailty, high comorbidity burden, or dementia, treatment for glycemic control should avoid symptomatic hyperglycemia and hypoglycemia. The aim of treatment is to maintain HbA1c targets of 7.5%-8.5%; targets are around 7.5%-8% in patients with mild or initial-phase disability or around 8%-8.5% if disability is moderate or severe.
In patients receiving palliative care, it is recommended to avoid symptomatic hyperglycemia and hypoglycemic episodes, not perform HbA1c monitoring and maintain glycemia < 200 mg/dL.
In patients with type 2 diabetes ≥ 65 years, metformin is recommended as the first-line oral glucose-lowering agent due to its ability to reduce mortality and other cardiovascular events and because it does not cause hypoglycemia or weight gain; it can also reduce age-related comorbidities. Metformin is contraindicated in patients with a glomerular filtration rate < 30 mL/min per 1.73 m2 due to its tendency to accumulate in blood and the increased risk of lactic acidosis.
Studies with patients with type 2 diabetes discharged with a principal diagnosis of acute myocardial infarction or heart failure demonstrate that treatments with thiazolidinediones (pioglitazone) and metformin reduced all-cause mortality. These results contradict those of other studies reporting a higher risk of admission for heart failure and acute myocardial infarction (with rosiglitazone) or all-cause mortality. Thiazolidinediones increase weight, produce fluid retention and increase the risk of heart failure, loss of bone mineral density in older women with diabetes and fracture risk.
Drug therapy with sulfonylureas in patients with type 2 diabetes aged ≥ 65 years has not been demonstrated to reduce mortality but has been shown to increase the risk of hypoglycemia; there are no studies demonstrating a reduction in macro- or microvascular complications.
Glibenclamide use is not recommended in patients with glomerular filtration rate < 30 mL/min per 1.73 m2 or in those with severe liver failure or an elevated risk of hypoglycemia (a history of severe hypoglycemia, cognitive decline, major depression, advanced age with pluripathology and disability, and low BMI).
Meglitinides have been demonstrated to have a lower risk of hypoglycemia than sulfonylureas. There are no studies demonstrating their effect or benefit on cardiovascular events in the older population with diabetes. Repaglinide is excreted mainly through the biliary route and can be an alternative in patients with glomerular filtration rate < 30 ml/min per 1.73 m2.
Alpha-glucosidase inhibitors (acarbose) reduce postprandial glycemia without increasing the risk of hypoglycemia in older patients with type 2 diabetes; clinicians should bear in mind their adverse gastrointestinal effects (flatulence and diarrhea) and scarce efficacy.
Use of dipeptidylpeptidase-4 (DPP-4) inhibitors in older patients with type 2 diabetes has proven effectiveness in reducing glycosylated hemoglobin and glycemia and demonstrated safety even in adults of advanced age in terms of the incidence of cardiovascular events, mortality, and hospitalization for heart failure and has also been shown to be well tolerated (very low risk of hypoglycemia and neutral effect on weight). DPP-4 inhibitors can be administered in patients with renal insufficiency by adjusting the dose, except lingliptin due to its biliary excretion.
In patients with type 2 diabetes aged ≥ 70 years, use of lixisenatide, a glucagon-like peptide-1 antagonist, reduces glycosylated hemoglobin and postprandial glycemia versus placebo. It is also associated with greater weight loss and more frequent development of gastrointestinal symptoms such as nausea and vomiting. In two pooled analyses of patients aged ≥ 65 years in clinical trials with lixisenatide and liraglutide, no differences were found in safety or efficacy compared with younger patients.
There are no studies on GLP-1 receptor antagonists demonstrating their effect on cardiovascular events in older adults with type 2 diabetes, although liraglutide and semaglutide have decreased cardiovascular events in studies with younger patients with type 2 diabetes. These drugs have been associated with a risk of pancreatitis, although this finding has not been confirmed in all studies.
Studies of the effect of treatment with sodium-glucose type 2 cotransporter (SGLT-2) inhibitors have demonstrated that they act independently of insulin, interfering with glucose reabsorption and favoring glucosuria.
Empagliflozin has been demonstrated to reduce all-cause and cardiovascular mortality; empagliflozin, canagliflozin and dapagliflozin have been shown to reduce hospitalization for heart failure.
Data show no differences in safety and efficacy between the older and younger population; however, these drugs should be administered cautiously in the older population due to the lack of specific data for this age group. Older patients should also be well selected due to their tendency to hypertension and sensitivity to water loss, as well as their risk of fractures (canaglafloxin), toe and metatarsal amputations and possible rare cases of euglycemic ketoacidosis (entire drug group).
Basal insulin analogs (glargine, determir and degludec) have not been shown to improve glycemic control but have been associated with a lower frequency of hypoglycemic episodes (nocturnal). These treatments can be considered as the treatments of choice versus NPH insulin in patients with a tendency to hypoglycemia.
In older patients with diabetes, maintenance of combined therapy with oral antidiabetic agents is recommended to reduce insulin doses and avoid the use of complex insulin regimens.
In older patients, insulin therapy is associated with a higher risk of hypoglycemia, falls and fractures; therefore, decision-making on this therapy should be personalized in this age group with priority given to safety.
Biphasic, or premixed, forms of insulin are associated with better glycemia control (in patients poorly controlled with basal insulin); these forms are also associated with weight gain and a higher risk of hypoglycemia.
Simplifying and de-escalating antidiabetic treatment is recommended in older patients after comprehensive geriatric assessment. The use of more complete regimens (e.g., basal-bolus) should be reserved for patients requiring them and who maintain good quality of life, life expectancy and self-care ability.
A multimodal intervention consisting of physical exercise and nutritional education has been shown to be effective in improving functional status in older patients with type 2 diabetes mellitus and frailty.
Dyslipidemia
Primary prevention measures for dyslipidemia should be the same in older adults as in younger adults, including smoking cessation and avoiding sedentariness and overweight.
Diet is especially important in the older population, with avoidance of restrictive diets and malnutrition risk, particularly in persons with cognitive decline and nursing home residents.
Older patients benefit from a comprehensive approach with attention paid to comorbidity and geriatric syndromes.
Drug therapy used for secondary prevention should be the same in older patients as in the younger population.
Lipid-lowering therapy in the older population, with LDL-C reduction, prevents both individual and composite cardiovascular events (cardiovascular death, myocardial infarction, stroke, and coronary revascularization), especially in secondary prevention, with similar benefits as those in the younger population.
Initiating statin therapy should be considered in primary prevention in older patients at high or very high cardiovascular risk.
Initiating low-dose statin therapy is recommended in patients with significant renal insufficiency or a high probability of drug interactions, depending on their tolerance and target LDL-C levels, to avoid more serious secondary effects (such as myalgia or myopathy) and rare adverse effects (such as rhabdomyolysis).
Alcohol consumption
In the general population, recommended intake should not exceed 25 grams of alcohol per day, because, after this cut-off, the potential benefit of alcohol decreases. Given that older adults are more sensitive to the effects of alcohol, it has been postulated that neither sex should exceed 10 g alcohol per day.
The recommendation of 10 grams of alcohol per day seems to be too restrictive, based on current scientific evidence; on the other hand, older adults should never be advised to start or increase alcohol consumption to gain a cardioprotective effect.
Current consensus on healthy alcohol consumption in adults holds that there is a U-shaped protective effect with light-moderate intake and a harmful effect with intake of large quantities.
Despite the possible protective effect of light-moderate alcohol consumption in older adults, there are potential interactions between alcohol and some drugs, including antidiabetic agents, anticoagulants and antithrombotics.
The possible cardioprotective effect of alcohol intake seems to be influenced by sex, age, consumption pattern, genetics, and improved lipid profile (increased HDL-C and reduced LDL-C), better glycemic control (reduced blood insulin level on increasing insulin sensitivity), decreased platelet aggregability and markers of systemic inflammation (C-reactive protein, interleukin 1α and 6 and tumor necrosis factor), which seems to translate into reduced atherosclerosis.
Alcohol intake, even in moderate quantities (< 30 g alcohol per day), seems to increase blood pressure, although this does not increase overall cardiovascular risk or risk of heart failure.
Moderate intake (< 20 g per day) decreases the risk of heart failure in adults, probably through its protective effect on known risk factors for heart failure such as diabetes mellitus, hypertension, and ischemic heart disease.
The effect of maintaining light-moderate alcohol intake in older persons with heart failure is unclear. The data on its long-term effects on mortality are contradictory.
Alcohol abuse has no protective cardiovascular effect and increases the risk of heart failure and hypertension.
Response to rehabilitation is better among adults > 65 years than among the younger population; important factors seem to be a social and family environment favoring abstaining from alcohol and maintaining prolonged treatments.
It is essential to approach the specific factors associated with relapses in older adults, such as isolation and health problems, as well as the belief that it is too late to change.
Among older people in rehabilitation, resuming social and family relationships is considered essential to prevent recurrences.
Older adults should undergo alcohol detox as inpatients due to the greater complications and length of the process, partly influenced by comorbidity.
Benzodiazepines should be used with extreme caution, due to the higher risk of adverse effects. Evidence on other drug therapy is limited.
Long-term follow-up and support are essential to maintain abstinence.