Knowledge Gaps in Cardiovascular Care of the Older Adult Population

Abstract

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.

Arrhythmias in Patients ≥80 Years of Age

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Primary prevention with statins for older adults

“…Current evidence from trial data does not support a link between statins and cognitive dysfunction 7. However, concerns remain about the vulnerability of this age group to adverse effects from polypharmacy and the general lack of evidence to guide the prevention of CVD 8. A recent review of primary prevention studies of randomised controlled trials found no evidence of a reduction in CVD mortality in those older than 75, and it concluded that follow-up was too limited to exclude important adverse events from lipid lowering drugs 9.…”

Einstein, the Blind Men, and the Elephant: Making Sense of Heart Failure With Preserved Ejection Fraction

“…Insights gained from this work should inform what may be the most important question, the true elephant in the room: why do people develop HFpEF in the first place? These inherently multidisciplinary efforts require “embracing [the] complexity” (57) of HFpEF, and incorporate many of the principles, assessment techniques, and translational research aims of geriatric cardiology (58,59). …”