Most cardiovascular diseases (CVDs) increase in prevalence and severity with age, and most clinicians provide care for a substantial number of elderly patients with disorders of the heart and vascular system. According to the American Heart Association, nearly 70% of all US adults ≥ 60 years old and more than 85% of those ≥ 80 years old have known CVD (Fig. 65–1).1 Despite earlier treatment of risk factors and progressive improvements in therapies over the past several decades, heart disease remains the leading cause of death in the Medicare population. Furthermore, more than half of all cardiovascular procedures in the United States are performed in patients age 65 years and older, and the total cost for CVD in this population exceeded $115 billion in 2011.1 With the progressive aging of our population,2,3 these figures will continue to rise. For these reasons, an understanding of the effects of aging on the development of CVD and the utility of cardiovascular therapies in the context of other age-related medical concerns (eg, multimorbidity, polypharmacy, frailty) is critical for reducing risk and improving outcomes in older patients.
Prevalence of cardiovascular disease by age and sex, from the National Health and Nutrition Examination Survey (2009-2012). Data from the American Heart Association’s 2016 Statistical Fact Sheet.
OVERVIEW OF CARDIOVASCULAR AGING PROCESSES
Normal aging is associated with diffuse changes in cardiovascular structure and function (Table 65–1).4,5 These processes have important effects on the cardiovascular system with direct clinical implications (Table 65–2). Taken together, these changes contribute to the exponential rise in the incidence and prevalence of CVD in the geriatric population, including the marked increase in incidence of coronary artery disease (CAD), heart failure (HF), atrial fibrillation (AF), and stroke in older adults. In addition, cardiovascular aging promotes the emergence of many age-associated CVD syndromes, including isolated systolic hypertension (the dominant form of hypertension in older adults), HF with preserved ejection fraction (HFpEF), calcific aortic stenosis, and “sick sinus syndrome.” Each of these conditions is discussed in subsequent sections of this chapter.
TABLE 65–1.Effects of Aging on the Cardiovascular System and Other Organ Systems |Favorite Table|Download (.pdf) TABLE 65–1. Effects of Aging on the Cardiovascular System and Other Organ Systems
Gross anatomy of the heart
Increased left ventricular wall thickness and decreased cavity size
Endocardial thickening and sclerosis
Increased left atrial size
Valvular fibrosis and sclerosis
Increased epicardial fat
Increased lipid and amyloid deposition
Increased collagen degeneration and fibrosis
Calcification of fibrous skeleton, valve rings, and coronary arteries
Shrinkage of myocardial fibers with focal hypertrophy
Decreased mitochondria, altered mitochondrial membranes
Decreased nucleus: myofibril size ratio
Biochemical changes of the myocardium
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