Practical Issues in the Care of Frail Older Cardiac Patients

Introduction

Despite a decline in recent decades in overall cardiovascular mortality in developed countries, the overall burden of cardiovascular disease remains substantial. The incidence of coronary artery disease (CAD), acquired valvular heart disease (VHD), and heart failure (HF) increases with age, resulting in significant growth in the prevalence of these conditions in the context of population aging. The lifetime risk for symptomatic CAD after the age of 40 years is 49% in men and 32% in women, and the average age of patients suffering a first myocardial infarction is 64.9 years in men and 72.3 years in women. Of those who die from CAD, over 80% are aged 80 years and older. The prevalence of acquired VHD also rises with age, from less than 2% below the age of 65 years to 13% over the age of 75 years. From a population perspective, mitral regurgitation (MR) is the most common form of VHD, followed by aortic stenosis (AS). However, among persons referred to hospital with VHD, AS is more common than MR, with a prevalence of 43% and 32%, respectively, in one large European study. Finally, the prevalence of HF also rises with age, and octogenarians face a 20% lifetime risk of developing HF.

Although the burden of heart disease is greatest among older patients, therapeutic recommendations are usually extrapolated from clinical trials conducted on relatively younger, generally healthier, and highly selected patients. Historically, a significant majority of potential candidates for these trials has been excluded because of multiple medical and age-associated comorbidities, a trend that persists today. Furthermore, clinical trials generally measure “hard outcomes,” such as rates of death or of other cardiovascular events, outcomes that may not be as important to some older patients as quality of life, preserving cognition, or maintaining functional independence in the community. The publication of the Hypertension in the Very Elderly Trial (HYVET) study illustrated some progress made in this regard, as well as the significant gaps that remain. In this multicenter randomized controlled trial of 3845 patients aged 80 years and older, treatment of hypertension with indapamide, with or without perindopril for 2 years, was well-tolerated and reduced the risk of stroke, death, and HF; there were no differences in the number of trial participants who experienced cognitive decline. In contrast to most prior cardiovascular trials, HYVET specifically targeted older patients, with the average age of participants being almost 84 years, thus filling an important gap in hypertension management literature. However, compared to the general population, HYVET participants had fewer comorbid conditions, were not demented, and outcomes such as functional decline, caregiver burden, or institutionalization have not been reported.

Clinicians are thus left with the difficult task of determining how best to apply the results of clinical trials to real-life older patients. The purpose of this chapter is to provide a framework to assist clinicians in the process of determining the most appropriate courses of action for frail older cardiac patients.