CHAPTER 65: CARDIOVASCULAR DISEASE IN THE ELDERLY: PATHOPHYSIOLOGY AND CLINICAL IMPLICATIONS

INTRODUCTION

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 aged 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.

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.