CardioBuzz: Prevention for Octogenarians

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An article by a British physician specializing in geriatric medicine stated that the oldest patients -- those 80 and older -- are being too aggressively treated with statins and antihypertensives for stroke prevention.

I thought it would be interesting to contact some U.S. cardiologists to get their take on this issue and frankly I was amazed by just how much docs on this side of the pond had to say about this. Here are some of the responses I received, which have been "ever so lightly" edited for style and length.

Daniel Lackland, DrPH, Medical University of South Carolina

[Referring to this statement in the British commentary: "The epidemiology suggests that, by this age, hypertension is not an attributable risk factor for stroke ..."] -- I do not feel that is a valid evidence-based statement. Elevated blood pressure is a stroke and cardiovascular disease risk factor at all ages, including the very old. In the elderly, there is little evidence of the benefit of blood pressure reduction.

Ken Uchino, MD, Cleveland Clinic's Cerebrovascular Center

The attributable risk of stroke due to hypertension may decrease in the elderly, partly because other factors such as atrial fibrillation become more dominant. Not just in stroke but in many conditions, it has been noted that the traditional risk factors in a disease have a much smaller contribution at older age (e.g., hypertension's contribution to dementia). Pooling data from multiple studies, it has been shown across blood pressure ranges that a higher risk of stroke is observed with higher systolic and diastolic blood pressures into age 80s. A lack of an observed association between disease (stroke) with a factor (hypertension) does not necessarily translate that intervening of the factor would not reduce disease. This was clearly shown in the case of cholesterol, where no consistent association with stroke risk has been shown in multiple studies. Yet, clinical trials using statins have shown that stroke is indeed reduced if the degree of cholesterol reduction is large and the study size is large enough. We cannot assume that because the contribution of hypertension is smaller as one gets older, that treatment would not reduce stroke.

If one is old, the risk of events is higher, but the time horizon is shorter. Prioritizing may be important. If one takes the author's view, all preventive treatments may be unfruitful. Most elderly who present to doctors want to have symptoms treated. Treatment to prevent events (MI, stroke, bone fracture) could be relegated similarly to cancer (no screening at old age). I think it comes back to the fact that true informed decision making is difficult. We should still prioritize what is important in elderly patients with multiple problems or limited time horizon.

William O'Neill, MD, Henry Ford Hospital

I wholeheartedly agree with the author that we overprescribe medications in elderly, asymptomatic elders. I never start patients in their 80s on statins for primary prevention. If they have not had a cardiac event by that age, it is unlikely that they will during their life. Antihypertensives can cause severe orthostatic hypotension and I am very conservative with these agents. Finally, the polypharmacy that occurs with elders can be described as unsafe practice. I often see patients coming in with 15 to 20 different medications they are supposed to take. I honestly don't know how they keep the medicines straight. I try to limit meds to three or four at most and ideally at a once-a-day dose.

Adam Skolnick, MD, NYU Langone Medical Center

One should not generalize about over- or undertreating patients over age 80 with antihypertensives or statins. Chronological age is not the same as functional age. It depends on whether the medication is being used for primary or secondary prevention of cardiovascular events and on the prognosis of the individual patient. Although for an older individual without known cardiovascular disease and without significant risk factors, these medications may not be indicated as primary prevention, for those patients with known cardiovascular disease they may prevent a disabling stroke or myocardial infarction. In fact, the absolute risk reduction is higher for older patients who tend to have a higher absolute risk of cardiovascular events. When assessing prognosis, web-based resources like eprognosis.org are quite helpful. If a patient has a prognosis greater than a year and has known cardiovascular disease, they should not be denied these therapies that have been proven to prevent cardiovascular events, which may reduce quality of life and independence.

Marschall Runge, MD, PhD, University of North Carolina School of Medicine

The risks of polypharmacy in the elderly are real. No question there. However, the question of risk reduction in stroke is clearly something that evokes strong reactions from individuals. This is a good example of the importance of physicians discussing these difficult issues with their patients. A major stroke is very feared in the patients I see – much more than a sudden death from a cardiac arrhythmia or even cancer. Plus, the cost of care for stroke patients is enormous when one considers assisted living, physical and occupational therapy, and other costs. It is also important to note that the risk of atrial fibrillation increases dramatically with age and that atrial fibrillation is a major risk for stroke. Treatment of hypertension is important in lessening the risk of atrial fibrillation. In addition, low-dose, coated aspirin can be important in elderly patients at risk of stroke.

Statins have been transformational in reducing the risk of myocardial infarction. In this manner, they also reduce stroke. The issue of statin side effects evokes strong feelings. The data on how frequently statin side effects (particularly myalgias) occur are far less than conclusive, although there are a number of double-blind, crossover studies now being conducted that will, as an additional outcome, address this question. That said, many millions of individuals across the world take statins with no side effects at all. I do not recommend avoiding statins until we better understand this side effect profile. After all, the key to reducing healthcare costs is prevention, not withholding medications.

Rami Kahwash, MD, Ohio State University Wexner Medical Center

This [overprescription of statins and antihypertensives in patients 80 and older] may be true, especially in otherwise healthy individuals with a low cardiovascular risk profile (although those are rare in this specific age group) and in elderly patients with severe noncardiovascular comorbidities in whom the overall protective effect of statins and antihypertensives is uncertain. The decision to use them has to be individualized based on each patient's risk profile and their overall projected benefits. Statin and hypertensive drugs should be recommended to all patients who meet their indications per published guidelines, regardless of age limits. However, in certain populations, a physician-to-patient discussion of possible adverse effects and benefits is necessary to reach a mutual decision before withholding such therapies.

John Erwin III, MD, Scott & White Heart and Vascular Institute

I do not necessarily agree that statins and antihypertensives are overprescribed in patients older than 80. I do agree that it is important to take into account the person's overall health picture, expectations, and overall frailty index in the decision-making process with the patient. I feel that the perspective was somewhat overly simplified in an area that is certainly not simple. We know from the SHEP trial that not only were the short-term benefits favorable for the active arm of blood pressure management, but the 22-year follow-up also showed a persistence in meaningful reduction in cardiovascular death rates as well as an increase in life expectancy. While life expectancy should not be our only goal, a combination of longevity and quality of life (which is certainly better in the absence of ongoing sequelae of cardiovascular disease) is an important goal that most patients desire. The author also failed to point out the increasingly important role that atrial fibrillation plays in stroke in the elderly (as many as one in three strokes in octogenarians have an association with atrial fibrillation). The prevalence of atrial fibrillation is certainly increased in poorly controlled hypertensive people. The author relies heavily upon registry data and observational studies, which are important but sometimes do not allow us the luxury of making such broad strokes with our conclusions.

Aryan Aiyer, MD, University of Pittsburgh Medical Center Heart and Vascular Institute

We are beginning to see that many of the benefits in treating blood pressure and high cholesterol that are found in younger cohorts are not necessarily seen with the same robustness in the older cohorts. This probably has to do with the fact that age itself is such a huge risk factor for stroke and should receive greater weight than other risk factors (e.g., hypertension, hypercholesterolemia) when we are assessing an individual's risk. Unfortunately, we cannot modify age itself so doctors naturally have been trained to treat those risk factors that we can modify. The author provides no proof to say that statins and antihypertensives are overprescribed in the elderly. What percentage of patients over the age of 80 are taking these drugs? And of these patients, how many are those who have had prior heart attacks and strokes, subgroups where the multiple clinical trial data suggest benefit in the use of these drugs? It appears the author makes this claim based on current practice that he suspects pushes doctors to treat the elderly the same way we treat younger people.

James Brorson, MD, University of Chicago Comprehensive Stroke Center

The author raises an important cautionary note against overtreatment of elderly persons with antihypertensives and statin medications, but publicity surrounding this opinion piece carries risk of misinterpretation by those who don't fall into the category of patients he is describing. His comments pertain to primary prevention in elderly patients -- that is, persons over 80 years who have never had a stroke or heart attack. For patients with known history of atherosclerotic cardiovascular disease or stroke, treatment with cholesterol-lowering statin medications and treatment of high blood pressure remain the most effective treatments that we have for reducing stroke and mortality. As recognized in recent revisions of national guidelines for blood pressure management and cholesterol-lowering treatments, recommendations need to be based on the particulars of the individual patient's characteristics, including age and vascular disease history.

B. Hadley Wilson, MD, Carolinas HealthCare System's Sanger Heart & Vascular Institute

I agree that these may be overprescribed in elderly patients over age 80 and should not be generalized based on the lack of any large scale studies in this age group and potential side effects with statins and especially fall risks with antihypertensives in the elderly. Their use should be individualized according to the patient's severity of hypertension and dyslipidemia and particularly in regard to whether that patient has had a prior serious cardiovascular event.

John Higgins, MD, MBA, University of Texas Health Science Center at Houston (UTHealth)

I believe in the U.S. that statins and antihypertensives are used appropriately in all age groups, and while there are guidelines that aid in management, ultimately it is an individual decision between the physician and the patient, after weighing the risks and benefits of treatment as well as factoring in the patient's quality of life, other medical conditions, risks for stroke and heart attack, and life expectancy. If a patient has already suffered a myocardial infarction, stroke, or has peripheral vascular disease (secondary prevention), we know that statin use may help prevent further events even in the elderly patient, and so I generally use them in my functional and "physiologically young" elderly for prevention of further events. There is less evidence for benefit in those older than 80 years being started for primary prevention, so I tend to only consider this if I believe they are at higher risk for these events or if they have had some warning signs that may portend a higher risk, such as a suspected transient ischemic attack. Also, if they are still quite active, exercising, and doing well, it is hard to convince them to take another medication that can potentially result in some side effects, such as myalgias.

Many of us in practice have frail elderly patients that can get symptomatic with dizziness, weakness, or falls if we are too aggressive with lowing their blood pressure, so I think it is reasonable to ease back a little with respect to target blood pressure goals in those who are older than 80.

CardioBuzz is a blog by Todd Neale for readers with an interest in cardiology.

From the American Heart Association: