Age-associated increased central arterial stiffness, increased peripheral resistance, and impaired vascular reactivity contributed to hypertension being the most prevalent risk factor for CVD in older adults [6]. By age 75, approximately 80 % of women and 70 % of men in the USA are classified as hypertensive, yet they have the lowest rates of optimal control [7, 8]. With vascular aging, the systolic blood pressure increases progressively, whereas the diastolic blood pressure peaks at approximately age 50 and then plateaus before declining after 60 years of age in both men and women. As a result, isolated systolic hypertension (ISH , defined as systolic blood pressure over 140 mmHg and diastolic blood pressure below 90 mmHg) is the dominant form of hypertension in older adults. In turn, ISH is strongly associated with an increased risk for stroke, end-stage renal disease, myocardial infarction (MI), heart failure, and CV and all-cause mortality. While the treatment of hypertension at any age (including the very elderly), reduces CV and cerebrovascular events (Table 21.2), optimal treatment thresholds and target blood pressures have not been clearly defined [9, 10].

In the Hypertension in the Very Elderly Trial (HYVET) , 3845 patients 80 years of age or older (mean 83.6 years, 60.5 % women) with systolic blood pressure ≥160 mmHg were randomized to the diuretic indapamide 1.5 mg or matching placebo [10]. Perindopril or placebo was added as needed to achieve a target blood pressure <150/80 mmHg. The primary outcome was fatal or nonfatal stroke. After a mean follow-up of 1.8 years, active treatment was associated with a 30 % reduction in the primary outcome, and reductions in secondary outcomes of incident heart failure and all-cause mortality. The results of HYVET led to a recommendation by several hypertension guideline committees to aim for a goal of <150 mmHg when treating systolic hypertension in patients ≥80 years of age.

More recently, the Systolic Blood Pressure Intervention Trial (SPRINT) randomized 9361 patients ≥50 years of age (28.2 % ≥75 years of age) at increased cardiovascular risk (as defined by subclinical or clinical CVD, chronic kidney disease, 10-year risk of CVD ≥15 % based on the Framingham Risk Score, and/or age ≥75 years) and with baseline systolic blood pressure 130–180 mmHg to intensive treatment (target blood pressure <120 mmHg) or standard treatment (target blood pressure <140 mmHg) [11]. Patients with diabetes mellitus, symptomatic heart failure in the preceding 6 months, recent acute coronary syndrome (ACS) , prior stroke, orthostatic systolic blood pressure <110 mmHg, unintentional weight loss (a component of frailty), or residence in a nursing home or assisted living facility were excluded. Women and patients with multimorbidity were also under-represented. The primary outcome was a composite of myocardial infarction (MI), other ACS, stroke, heart failure, or cardiovascular death. The study was stopped prematurely at a median follow-up of 3.26 years due to a significant benefit of intensive treatment on the primary outcome (2.19 % per year with standard treatment vs. 1.65 % per year with intensive treatment, hazard ratio 0.75, 95 % CI 0.69–0.89, p < 0.001). Outcomes were similar in patients ≥75 years of age compared to those <75 years but the absolute benefit was numerically greater in the older subgroup. All-cause mortality, CV mortality, and incident heart failure were significantly reduced with intensive treatment, but there was no effect on MI, ACS, or stroke. The number needed to treat for 1 year to prevent one primary outcome event was 185. The mean number of blood pressure medications was 1.8 in the standard treatment group and 2.8 in the intensive treatment group. Serious adverse events, including acute kidney injury, electrolyte abnormalities, hypotension, and syncope (but not injurious falls) were all significantly more frequent in the intensive therapy group. Annual rates of serious adverse events attributed to anti-hypertensive treatment were 1.44 % in the intensive therapy group and 0.77 % in the standard therapy group (number needed to harm 149). The incidence of adverse events was similar among patients older or younger than age 75. The effects of intensive treatment on quality of life and cognitive function have not yet been reported.

The implications of SPRINT for treatment of older adults with hypertension are uncertain, as the modest absolute benefit with respect to major CV events and death must be balanced against the potential for adverse events, increased burden of medications, and unknown impact on quality of life, functional status, and cognition. In addition, a substantial proportion of older adults would not have met the SPRINT inclusion/exclusion criteria, and the applicability of the findings to these individuals is unknown. Based on the results of HYVET and current guidelines, it is reasonable to treat individuals ≥75 years of age who are suitable candidates for anti-hypertensive drug therapy to a target systolic blood pressure of <140 mmHg (age 75–79 years) or <150 mmHg (age ≥80 years). More aggressive treatment should be individualized based on the clinical profile and patient preferences.

Management of hypertension in older adults is often complicated by orthostatic or post-prandial hypotension [12], which may be associated with light-headedness and increased risk for falls and syncope. In addition, “white coat” hypertension is common in older adults (i.e., office blood pressure higher than home blood pressure), and older individuals with stiff arteries may exhibit pseudohypertension (blood pressure measured by sphygmomanometer higher than central aortic pressure) [13, 14]. For these reasons, it is important to measure blood pressure in the sitting and standing positions and, when feasible, to obtain blood pressure readings in the home environment [12]. In some cases, 24-hour ambulatory blood pressure monitoring may be helpful in determining the presence and severity of hypertension, as well as the variability in blood pressure readings [15]. In patients with significant orthostatic hypotension (decline in systolic blood pressure ≥20 mmHg on standing), titration of anti-hypertensive therapy should be very gradual and should include periodic assessments of orthostatic blood pressure changes and evaluation for symptoms attributable to orthostasis.

Dyslipidemia remains an important risk factor for CVD in older adults up to age 85; after age 85, the association of lipid levels with CVD is less clear [16–18]. In addition, the strength of association between cholesterol levels and CVD declines with age, such that total cholesterol and LDL cholesterol become less predictive of CV events at older age. Factors affecting the relationship between cholesterol and CVD risk at increased age include survival bias among individuals with low CVD risk despite increased cholesterol levels, and the impact of co-existing diseases (e.g., malignancy, chronic inflammatory disorders) and malnutrition (a common condition in older adults). Statins are highly efficacious for the treatment of dyslipidemia, and numerous trials have documented the benefits of statins on CVD outcomes [19–22]. However, few patients over age 80 have been enrolled in these trials, and patients with complex comorbidity have been excluded. In addition, statin side effects, such as myalgias, may be more common in older adults, and there is weak evidence that statins may be associated with cognitive impairment in some individuals. Recognizing the paucity of evidence on statins in older patients, current guidelines recommend that treatment decisions consider anticipated benefits and adverse effects (including their time horizon), life expectancy, comorbidities, and individual treatment priorities [23]. In addition, the guidelines advise caution in using high intensity statin therapy in individuals over 75 years of age.

Diabetes mellitus (DM) is a powerful and independent predictor of the development and progression of CVD in older adults, imparting an increase in relative risk of CAD of 1.4 in men and 2.1 in women 65 and older with a significant sex interaction (i.e., stronger association in women) [24]. Although the relative risk in individuals over the age of 65 is lower than in younger individuals with DM, the high prevalence of DM in older adults results in greater excess risk [25].

Management of CV risk in patients with DM should focus on treating co-existing CVD risk factors, including hypertension and dyslipidemia, which are present in 71 and 65 % of older diabetics, respectively [21]. Additionally, utilization of an angiotensin-converting enzyme inhibitor (ACE-I) in older adults with diabetes is effective for reducing CV mortality [26]. Regular physical activity and maintaining a healthy body weight should be encouraged. Additional recommendations for managing DM in older adults are provided in Chap. 23.

Smoking accounts for 30 % of the attributable risk of all strokes and 36 % of first acute coronary events [27]. In older adults the prevalence of smoking decreases but it still remains a significant risk factor. Although the relative risk for MI or death as a result of smoking in an individual over the age of 70 is twice that of an individual age 55–60, older patients are less likely to receive smoking cessation counselling or interventions [28].

Individuals who smoke should be advised of the risks associated with smoking and given guidance on cessation strategies. Elderly individuals may be resistant to changing life-long habits, but the negative effects of continued smoking irrespective of age demand continued efforts to promote smoking cessation.

Multimorbidity , defined as the presence of 2 or more chronic conditions, increases exponentially with age and is present in over 70 % of individuals 75 years or older [29]. By the age of 65, more than 60 % of individuals have 2 or more chronic conditions, >25 % have 4 or more chronic conditions, and nearly 10 % have 6 or more conditions; by age 85, >50 % of individuals have 4 or more chronic conditions and 25 % have 6 or more conditions. The accumulation of chronic conditions culminates in a vastly heterogeneous population of older adults for whom balancing the management of multiple medical problems becomes paramount.

Among Medicare beneficiaries with CVD, the burden of multimorbidity is substantial; for example, over 50 % of individuals with a diagnosis of heart failure or stroke have 5 or more co-existing chronic medical conditions [29]. In older adults with CVD, the most common concomitant non-CVD conditions are arthritis, anemia, and diabetes mellitus, with prevalence rates ranging from 40 to 50 %. Other common conditions include chronic kidney disease, cognitive impairment, chronic obstructive lung disease, and depression, each of which much be considered when developing individual treatment strategies for the management of CVD [30].

Older adults with multimorbidity are frequently seen by numerous general and specialist providers which can result in competing management strategies and numerous prescriptions for medications. Polypharmacy , often defined as concomitant use of five or more medications, is associated with markedly increased risk for drug–drug interactions, drug–disease interactions, and therapeutic competition (the recommended treatment for one condition may adversely affect and/or compete with another co-existing condition) [31]. Approximately 50 % of older adults are taking at least one medication with no active indication, and many of these drugs are initiated during hospitalization, such as stress ulcer prophylaxis and antipsychotics for delirium [32]. Careful medication reconciliation including prescribed medicines, over the counter pharmaceuticals, and herbal therapies should be performed at each provider interaction. Adverse consequences of polypharmacy including poor adherence, adverse drug events, hospitalization, and mortality are related not only to the number of medications but also to the regimen complexity, so attention should be given to limiting the number of medications as well as simplifying the dosing schedule [32–34].

Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently taken by older adults to relieve burdensome pain or for treatment of arthritis. However, NSAIDs, including the cyclo-oxygenase 2 (COX-2) inhibitors , increase the risk of atherothrombotic vascular events and incident heart failure [35]. In addition, NSAIDs have adverse interactions with many CV medications, including diuretics, other anti-hypertensive agents, and antithrombotic drugs. NSAIDs have also been associated with worsening renal function and increased risk for gastrointestinal bleeding. For these reasons, the FDA and the American Heart Association suggest minimizing the use of NSAIDs when feasible, and using the lowest possible doses for the shortest period of time [36]. Polypharmacy and medication management are discussed in greater detail in Chap. 5.

Approximately 13 % of community dwelling adults over the age of 65 have a diagnosis of dementia. However, the total burden of disease is likely to be much higher due to under-recognition of dementia by patients, families, and health care providers, particularly in the early stages [37, 38]. In people over the age of 80, the prevalence of dementia increases to 40 %, and in advanced heart failure patients, 30–60 % have comorbid dementia [39, 40]. Older individuals with CVD also have a high prevalence of mild cognitive impairment (the prodromal phase of dementia) as compared to individuals without CVD, and patients with cognitive impairment and CVD have worse outcomes than those with CVD alone. Older adults with heart failure have a twofold increased risk of impaired cognition, including deficits in attention, executive function, and episodic memory, and these impairments tend to be more pronounced during episodes of decompensation [41]. Executive dysfunction, in particular, can reduce the ability to adhere to recommended therapies and participate in disease management programs [42]. In part for these reasons, the presence of cognitive impairment increases cost, management complexity, and mortality rates in older adults with CVD. Diagnosis and management of dementia are discussed in Chap. 4.

Frailty is a geriatric syndrome that represents an accelerated path of biological decline across multiple interrelated organ systems and a loss of homeostatic reserve in response to stressors [43]. Although different criteria for frailty have been proposed, the frailty phenotype originally described in the Cardiovascular Health Study comprises unintentional weight loss, exhaustion, weakness, slowness, and low physical activity (pre-frail: 1–2 criteria; frail: ≥3 criteria) [43]. More recently, cognitive impairment has emerged as an additional component of frailty [44]. The estimated prevalence of frailty in community cohorts is 7 % but increases to 20 % in individuals over age 80. In older patients hospitalized with CVD, especially heart failure, it is estimated that frailty rates approach 50 % [45]. Frailty is associated with an increased risk of adverse outcomes including falls, functional decline, disability, institutionalization, and death [43, 46, 47]. A bidirectional relationship exists between frailty and CVD such that frailty is an independent predictor of the development and progression of a wide range of CV disorders [48]. Conversely, the presence of CVD increases the risk of frailty, and older adults with concomitant frailty and CVD have significantly worse outcomes than those with CVD alone (hazard ratios ranges from 2 to 4 depending on the specific disease). Chapter 1 provides a comprehensive discussion of the recognition and management of frailty.

Although disease-focused evaluation of symptoms may facilitate assessment of the primary CV diagnosis, it does not allow for a more comprehensive evaluation of the multitude of factors that may impact optimal management. Implementing a more patient-centered approach to prioritizing goals of care within the context of co-existing multimorbidity, geriatric syndromes, cognitive impairment, and social and psychological factors can result in a management strategy better aligned with patient preferences. Table 21.3 provides an overview of commonly used tools for assessment of geriatric patients. The reader is also referred to Chap. 8 for practical guidance on office based geriatric assessment.

While chest pain or discomfort is the most common presenting symptom in patients of all ages with coronary artery disease (CAD ), dyspnea is frequently the presenting symptom in older adults and women, particularly in the presence of multimorbidity. Atypical or non-specific symptoms are also common in older adults with CAD and may include weakness, confusion, decline in functional status, reduced physical activity, nausea, and loss of appetite. For these reasons, a high clinical suspicion for CAD in older adults should be maintained (especially the very elderly). Older adults may also be less likely to recognize or report symptoms of CAD due to reduced physical activity or cognitive impairment. Further, older adults may minimize symptoms owing to fear of possible interventions, hospitalization, and loss of independence.

Ischemic heart disease is the leading cause of mortality in both men and women in the USA, with nearly 85 % of deaths occurring in individuals 65 years and older and over 50 % in those 75 and older [49, 50]. The high prevalence of ischemic heart disease in older adults contributes to the increased number of deaths, but greater in-hospital and 6-month mortality rates are also a significant factor.

A critical step in optimum management of older adults with acute myocardial infarction (AMI) is prompt diagnosis and re-vascularization, if appropriate, but such treatment is contingent upon recognition of symptoms and the presence of diagnostic electrocardiographic (ECG) changes . In the Global Registry of Acute Coronary Events (GRACE), almost 50 % of participants >85 years with an ACS presented with dyspnea rather than chest pain [51]. In the Framingham cohort, silent or unrecognized infarcts accounted for almost 60 % of all MIs in individuals over age 85 [52]. Current practice guidelines recommend that an ECG should be obtained and reviewed within 10 min of presentation in individuals with symptoms consistent with ACS. In older adults, particularly women, the time to first ECG is considerably longer than in younger patients and it is more likely to be non-diagnostic [52]. The higher prevalence of non-specific symptoms, pre-existing ECG abnormalities, and non-ST segment elevation MI (NSTEMI) in elderly patients can further delay treatment initiation.

Reperfusion therapy in the form of fibrinolysis or more commonly primary percutaneous coronary intervention (PCI) in ST-elevation MI (STEMI) is associated with reduced in-hospital mortality, subsequent heart failure, and long-term morbidity and mortality [53, 54]. Despite a greater incremental benefit obtained by elderly patients, they are less likely to receive reperfusion therapy [55]. In the Myocardial Infarction National Audit Project (MINAP) , only 55 % of patients ≥85 presenting with STEMI received reperfusion therapy as compared to 84 % of patients age 65 or younger. Primary PCI is the treatment of choice if performed within 90 min of arrival to the hospital and within 12 h of onset of symptoms. [56] Increased actual and perceived risks in older adults undergoing PCI likely contribute to lower utilization rates.

The management of chronic CAD with or without antecedent MI focuses on optimum risk factor modification and symptom control. As a result of vascular aging and accumulation of risk factors, CAD in older adults tends to affect multiple arteries and to be more diffuse and more severe than in younger adults. Diagnostic stress testing is indicated in older adults to investigate suspected CAD but baseline ECG abnormalities warrant concomitant imaging (echo, magnetic resonance imaging, or nuclear perfusion) to improve accuracy. Physical limitations may restrict the use of exercise stress testing but pharmacological stress testing (e.g., adenosine, regadenoson or dobutamine) provides a suitable alternative. Coronary computed tomographic angiography (CTA) is an alternative to stress imaging in selected cases; a limitation of this technique is the need for intravenous contrast administration and potential risk for acute kidney injury. Coronary angiography is appropriate in selected older patients with markedly abnormal stress test findings and/or limiting symptoms that do not respond adequately to medical therapy.

Management of stable CAD is designed to alleviate symptoms, improve quality of life, and reduce the risk of adverse ischemic events. First line anti-anginal therapy should include a beta-blocker if tolerated. Alternative medications include calcium channel blockers, nitrates and ranolazine. Side effects from beta-blockers and calcium channel blockers are more common in older adults and may include fatigue, weakness, and loss of energy, constipation, dizziness, low blood pressure, lower extremity swelling, and depressive symptoms.

Elective PCI for the management of stable angina symptoms is an alternative treatment strategy and may be beneficial in individuals intolerant of optimal medical therapy or in those who remain symptomatic despite medications. Although PCI is effective in reducing symptoms, data from the COURAGE trial indicate that routine PCI in patients with chronic stable CAD does not reduce mortality or risk of MI compared to optimal medical therapy alone (including aggressive CV risk reduction) [74]. The findings of COURAGE were similar in patients younger or older than 65 years.

In appropriately selected patients, coronary artery-bypass grafting (CABG) reduces symptoms and improves quality of life. In high risk individuals, CABG also confers a mortality benefit [75]. Older patients undergoing CABG are more likely than younger patients to have multimorbidity, cognitive impairment, reduced functional status, and more advanced and diffuse CAD [76]. As a result, perioperative morbidity and mortality are higher, with higher rates of respiratory failure, bleeding, acute kidney injury, atrial fibrillation, heart failure, and delirium. In addition, postoperative cognitive impairment is more common in elderly individuals. For additional information on cardiothoracic surgery, see Chap. 10.

Heart failure is primarily a disorder of older adults in part because CV aging, especially increased vascular and myocardial stiffness, increases vulnerability for developing heart failure [77]. In addition, heart failure is the “final common pathway” for nearly all CV disorders afflicting older adults. Heart failure affects 5.7 million Americans with approximately 870,000 new cases annually in individuals ≥55 years. It is the most common cause of hospital admission in individuals >65 years of age and is responsible for an estimated 1 million hospital discharges as primary diagnosis each year at a cost of approximately $30 billion in 2012 [78]. Heart failure contributes to more than 250,000 deaths annually in the USA, of which >85 % are in individuals over the age of 65. Mortality rates in advanced heart failure approach those of metastatic lung cancer; however, these poor outcomes are infrequently communicated to and comprehended by patients and families. Not only does heart failure account for significant adverse health outcomes, it has a major impact on quality of life, disability, and independence in elderly patients. See Chap. 6 for further discussion of palliative and end-of-life care in advanced heart failure.

Dyspnea on exertion, reduced exercise tolerance, orthopnea, lower extremity and abdominal swelling, and general fatigue are characteristic symptoms in both young and older adults with heart failure. Reduced baseline physical activity in older adults due to disability or sedentary life style can mask exertional symptoms. In contrast, non-specific symptoms including confusion, reductions in physical activity and functional status, nausea and loss of appetite are more common expressions of heart failure in elderly patients.

The goals of heart failure management in older adults should focus on reduction of symptom severity, improving quality of life, maintenance of functional status and independence, avoidance of hospitalization and institutionalization, and extending life in alignment with patient-centered goals. An interprofessional team approach to care is critical and should incorporate cardiovascular, non-cardiovascular, and social factors. Studies have shown that team care reduces readmissions and improves quality of life in older patients with heart failure . However, recent data indicate that up to two-thirds of readmissions are due to causes other than heart failure, which underscores the need to individualize care and to address prevalent comorbidities [79].