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Table 2 Potential benefits, harms and knowledge gaps of different CVD risk management strategies (primary prevention) for older people as mentioned in the CPGs (n = 47)

From: Systematic review of clinical practice guidelines recommendations about primary cardiovascular disease prevention for older adults

 

Potential benefits

Potential harms

Knowledge gaps

CVD risk assessment

Provides an estimate of CVD* risk in older people

Risk models underestimate CVD risk for older people

Risk models not rigorously tested/reliable in older people

Disagreement about the efficacy of risk assessment in older people (75+)

Most CVD risk models focus on short term risk, and are therefore inevitably more likely to classify older people as at high risk and the young as at low risk

Beneficial in older patients with multiple risk factors and good quality of life

Repeated screening of cholesterol is less important as lipid levels are less likely to increase after age 65

Older people could be considered at high CVD risk based on their age while other risk factors are relatively low

Disease labeling healthy older people

CVD risk management overall

CVD risk reduction

Risk of adverse effects is higher in older people

Limited available evidence for older people esp. older people with comorbidities and ‘oldest of old’ (age definitions are variable)

Part of lifetime approach to CVD prevention

Resources are likely to be concentrated on older people, who may not be able to benefit in their remaining life (time needed to treat to benefit)

Similar relative benefit but greater absolute benefit for older people due to higher pre-treatment risk

Lack of generalizability of RCTs† to older people in the community

Similar benefit in old people as in young people (when taking into account higher case fatality rates after a CVD event in older people and temporal discounting of life years gained)

Disagreement about the efficacy of risk management in older people (75+)

Costs associated with inappropriate prescribing in older people

Implication of knowledge gaps is that patient preferences and potential harms must be taken into account more, not just treatment benefits

Improved quality of life

Both BP and cholesterol medication

Morbidity/mortality benefit in older people

Risk of adverse effects is higher in older people, esp. frail and very old; risk is acceptable as long as the patient is carefully monitored

Limited available evidence for older people esp. frail old and older people with comorbidities; age definitions are variable

Choice of drug should not be age dependent and is less important than degree of BP/cholesterol reduction

Lack of generalizability of RCTs to older people in the community

Benefit for different treatment threshold/dosages in older people provided

Benefits provided for specific drugs

Benefits provided for different older age groups, age definitions are variable

Blood pressure medication

No upper age limit to benefit

Risk of diabetes onset with thiazide diuretics

Limited available evidence on the benefits/harms of lowering SBP§ below certain threshold in older people

Pre-existing very high risk might set a ceiling effect to the benefits of treatment; incl. in older patients

Risk of postural hypotension especially with alpha blockers

Older people are under-represented in trials vs. incentive to recruit more elderly to get enough high risk patients and CVD events for adequate power

Morbidity but not mortality benefit in very old patients

Reducing BP‡ has benefits for other conditions beyond CVD (cognitive decline, dementia)

Unknown whether certain medication classes are superior to others in preventing cognitive decline

Cholesterol medication

Stronger evidence for the benefits of cholesterol medication for secondary prevention than primary prevention in older people

Small increase in all-cause mortality in older people

Association between high cholesterol and mortality weaker in older people

Higher risk muscle toxicity in older people

Frailty is an additional risk factor for myopathy

Benefit for older people with risk factors other than age

Increased risk of cancer in older people

Benefit continuing well tolerated medication vs. starting medication

Very small risk of new-onset diabetes in older people but does not outweigh benefit

Lifestyle

Benefit of healthy diet, physical activity, smoking, moderate alcohol intake

Not discussed

Not discussed

Benefits of physical activity in older people include mortality benefit, improved quality of life and CVD risk reduction.

Weight loss and reduction of salt intake lowers blood pressure

Aspirin

Reduced risk of CVD events/myocardial infarctions but older people need to have higher baseline risk for benefits to outweigh harms

Risk of adverse effects increases with age in particular gastrointestinal bleeding and hemorrhagic strokes

Not discussed

  1. *CVD: cardiovascular disease; †RCT: randomized controlled trial; ‡BP: blood pressure; §SBP: systolic blood pressure