Dr. Jose Silva-Cardoso,
As the population grows older, the subject of Cardiovascular Therapy in the Very Elderly becomes more and more relevant. Professor Ferenc Follath (Zurich, Switzerland) mentioned that this population frequently has several co-existing cardiovascular diseases and other co-morbidities, and is thus a more fragile group. Age-related physiologic changes may affect drug absorption, bioavailability and drug distribution, half-life, metabolism and excretion, as well as drug pharmacodynamics. These patients are at a higher risk of developing adverse events and have a poorer prognosis. Professor Follath focused on heart failure (HF), referring to the fact that, in EuroHF Survey-I, 26% of the patients were 80 years or older. Compared to younger patients, they had a higher prevalence of preserved systolic function and atrial fibrillation, renal insufficiency, anaemia, infection and dementia. They were frequently under complex drug regimens including not only HF-drugs, but also antibiotics, bronchodilators, NSAIDS and neurological drugs. Decreased hepatic metabolic capacity frequently occurs in the elderly. Of particular concern is also the frequent decline in renal function, which may not be detected by simply measuring serum creatinine. Both abnormalities should favour the use of caution when treating this population, as suggested by the TIME-CHF study, where an aggressive BNP-guided therapy was unable to reduce mortality or morbidity in those above 75, and produced an increased incidence of adverse events. Hypotension and renal failure are frequent consequences of aggressiveness in treatment. He proposed that, in this extreme of life, prolongation of life itself should not be considered as important as the improvement of quality of life. To attain the latter objective, he suggested the avoidance of aggressive therapeutic titration and the adjustment of final dose to the patient response and not to guidelines indication (which, in fact, were based on evidence derived from studies done in a younger population). Careful blood pressure and renal function monitoring are also important considerations. Professor Nigel Becket (London, Great Britain) went on to refer to the very high prevalence of isolated systolic Hypertension (HTN) in the very old. Although HTN is an important risk factor for CV events, namely stroke, and seems associated with a higher rate of dementia, doubts existed as to the validity of treating the very elderly. An earlier meta-analysis seemed to show that, in this population, a lower blood pressure was associated with worse prognosis. Another meta-analysis showed that, in this population, the treatment of HTN reduced stroke but increased total mortality. These doubts were dissipated by the HYVET study, which showed that in patients aged 80 years and older, with blood pressure (BP) ≥ 160/110 mmHg, indapamide ± perindopril as compared to placebo was able to reduce total mortality, stroke and the incidence of heart failure, without an excess of serious adverse events. Target blood pressure was 150/80 mmHg. Doubts subsist as to how much below 150 mmHg should BP be lowered. Professor Pierre Amarenco (Paris, France) mentioned that dyslipidemia is a risk factor for ischemic heart disease in the elderly and that there is evidence of prognostic benefit derived from the use of statins in this population. There is however a paucity of data regarding the population of patients aged 80 and older. He mentioned that there is a weak relationship between LDL values and fatal stroke. Several studies showed that the use of statins in dyslipidemic patients was able to reduce the incidence of nonfatal stroke. As to secondary prevention, statins proved to be beneficial after an ischemic stroke, but deleterious after a hemorrhagic stroke. Professor Dan Atar (Oslo, Norway) referred the importance of anti-thrombotic regimens in improving prognosis after Acute Coronary Syndromes. An increased haemorrhagic risk is the price to be paid and should not be neglected since in real life, it may offset the benefits. In fact, the incidence of bleeding complications is higher in registries than reported in clinical trials, because the population is older in the first case. Age per se is one of the main risk factors for bleeding complications. This is why in the very elderly, a population more prone to bleeding complications, he suggests individualization of anti-thrombotic regimens, favouring a more conservative approach with low dosages.
Cardiovascular drug therapy in the very elderly
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