Assessing Cardiovascular Risk in Older Adults Integrating Frailty and Competing Risks

Introduction: In middle-aged adults, time spent being sedentary is associated with cardiovascular (CV) health risks independent of structured physical activity (PA). However, data are sparse regarding the impact of sedentary behavior on CV risk in older adults. The extent to which the absolute duration or intensity of daily PA reduces CV risk in older adults is also unknown. Objectives: Our objective was to examine the cross-sectional association between objectively-measured sedentary behavior and predicted CV risk among older adults in the Lifestyle Interventions and Independence for Elders (LIFE) study. The secondary objective was to evaluate associations between the duration/intensity of daily PA and predicted CV risk. Methods: LIFE is a randomized clinical trial to determine if regular PA prevents mobility disability among mobility-limited older adults. Activity data were collected by hip-worn accelerometer at baseline prior to participation in study interventions. Only participants with at least three days of accelerometry data (≥ 10 hrs wear time) were included. Unadjusted and adjusted linear regression was used to model the relationship between accelerometry measures and predicted 10-year Framingham risk of Hard Coronary Heart Disease (HCHD; i.e. myocardial infarction or coronary death). Adjusted models included demographic confounders (e.g. education, race, income) and health parameters (e.g. depression, cognition, arthritis) not in the risk score. Accelerometry cut-points were (in counts/min): sedentary behavior: < 100; low-intensity activity: 100-499; higher intensity activity: > 500. Results: Participants (n = 1170; 78.7 ± [SD] 5.3 years; 66.1% female) had a median HCHD risk of 10.3% (25 th -75 th %: 5.7-18.6). Over a mean accelerometer wear time of 8.1 ± 3.2 days, participants spent 77.0 ± 8.2% of their time sedentary. They also spent 16.6 ± 5.0% of their time in low-intensity PA and 6.4 ± 4.4% in higher-intensity PA. For all PA performed (> 100 counts/min), participants achieved a median of 393.4 (337.8-473.5) counts/min. In the unadjusted model, time spent sedentary (β = 2.41; 95% CI : 1.94, 2.89), in low-intensity PA (-2.56; -3.03, -2.08), and in higher-intensity PA (-1.60; -2.09, -1.11) were all associated with HCHD risk (all p’s < 0.001). These associations remained significant after adjustment. The mean intensity of daily PA was not significantly associated with HCHD risk in any model (p > 0.05). Conclusions: Daily time spent being sedentary is positively associated with predicted 10-year HCHD risk among mobility-limited older adults. Duration, but not mean intensity, of daily PA is inversely associated with HCHD risk score in this population.

Positive airway pressure (PAP) is the first-line treatment for obstructive sleep apnea (OSA), but evidence on its beneficial effect on major adverse cardiovascular events (MACE) and mortality prevention is limited. To determine whether PAP initiation and utilization are associated with lower mortality and incidence of MACE among older adults with OSA living in the central US. This retrospective clinical cohort study included Medicare beneficiaries with 2 or more distinct OSA claims identified from multistate, statewide, multiyear (2011-2020) Medicare fee-for-service claims data. Individuals were followed up until death or censoring on December 31, 2020. Analyses were performed between December 2021 and December 2023. Evidence of PAP initiation and utilization based on PAP claims after OSA diagnosis. All-cause mortality and MACE, defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights were used to estimate treatment effect sizes controlling for sociodemographic and clinical factors. Among 888 835 beneficiaries with OSA included in the analyses (median [IQR] age, 73 [69-78] years; 390 598 women [43.9%]; 8115 Asian [0.9%], 47 122 Black [5.3%], and 760 324 White [85.5%] participants; median [IQR] follow-up, 3.1 [1.5-5.1] years), those with evidence of PAP initiation (290 015 [32.6%]) had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% CI, 0.52-0.54) and MACE incidence risk (HR, 0.90; 95% CI, 0.89-0.91). Higher quartiles (Q) of annual PAP claims were progressively associated with lower mortality (Q2 HR, 0.84; 95% CI, 0.81-0.87; Q3 HR, 0.76; 95% CI, 0.74-0.79; Q4 HR, 0.74; 95% CI, 0.72-0.77) and MACE incidence risk (Q2 HR, 0.92; 95% CI, 0.89-0.95; Q3 HR, 0.89; 95% CI, 0.86-0.91; Q4 HR, 0.87; 95% CI, 0.85-0.90). In this cohort study of Medicare beneficiaries with OSA, PAP utilization was associated with lower all-cause mortality and MACE incidence. Results might inform trials assessing the importance of OSA therapy toward minimizing cardiovascular risk and mortality in older adults.

Background: The relationship between Positive Airway Pressure (PAP) therapy and its implications for mortality and cardiovascular risk among older adults with sleep apnea has garnered increasing attention in recent years. This literature review synthesizes findings from various studies to illuminate the multifaceted impacts of PAP therapy on health outcomes in this demographic. Literature Review: The literature on Positive Airway Pressure (PAP) therapy reveals a complex relationship between its use, mortality, and cardiovascular risk in older adults with sleep apnea. The studies reviewed provide substantial evidence that while PAP therapy is a cornerstone treatment for obstructive sleep apnea syndrome (OSAS), its efficacy in improving cardiovascular outcomes and reducing mortality is influenced by factors such as patient adherence and the severity of the condition. Conclusion: In conclusion, the literature collectively underscores the significance of PAP therapy in managing obstructive sleep apnea and its associated cardiovascular risks in older adults. While there is evidence supporting its benefits, particularly in reducing mortality and improving cardiovascular health, the overall effectiveness is heavily contingent upon patient adherence to treatment. Future research is essential to clarify the long-term benefits of PAP therapy and to develop strategies that enhance compliance, ultimately aiming to mitigate mortality and cardiovascular risks in this vulnerable population.

Sedentary behavior is an emerging risk factor for cardiovascular disease (CVD) and may be particularly relevant to the cardiovascular health of older adults. This scoping review describes the existing literature examining the prevalence of sedentary time in older adults with CVD and the association of sedentary behavior with cardiovascular risk in older adults. We found that older adults with CVD spend >75 % of their waking day sedentary, and that sedentary time is higher among older adults with CVD than among older adults without CVD. High sedentary behavior is consistently associated with worse cardiac lipid profiles and increased cardiac risk scores in older adults; the associations of sedentary behavior with blood pressure, CVD incidence, and CVD-related mortality among older adults are less clear. Future research with larger sample sizes using validated methods to measure sedentary behavior are needed to clarify the association between sedentary behavior and cardiovascular outcomes in older adults.

Besides age, other discriminators of atherosclerotic cardiovascular disease (ASCVD) risk are needed in older adults. To examine the predictive ability of coronary artery calcium (CAC) score vs age for incident ASCVD and how risk prediction changes by adding CAC score and removing only age from prediction models. We conducted an analysis of pooled US population-based studies, including the Framingham Heart Study, the Multi-Ethnic Study of Atherosclerosis, and the Cardiovascular Health Study. Results were compared with 2 European cohorts, the Rotterdam Study and the Heinz Nixdorf Recall Study. Participants underwent CAC scoring between 1998 and 2006 using cardiac computed tomography. The participants included adults older than 60 years without known ASCVD at baseline. Coronary artery calcium scores. Incident ASCVD events including coronary heart disease (CHD) and stroke. The study included 4778 participants from 3 US cohorts, with a mean age of 70.1 years; 2582 (54.0%) were women, and 2431 (50.9%) were nonwhite. Over 11 years of follow-up (44 152 person-years), 405 CHD and 228 stroke events occurred. Coronary artery calcium score (vs age) had a greater association with incident CHD (C statistic, 0.733 vs 0.690; C statistics difference, 0.043; 95% CI of difference, 0.009-0.075) and modestly improved prediction of incident stroke (C statistic, 0.695 vs 0.670; C statistics difference, 0.025; 95% CI of difference, -0.015 to 0.064). Adding CAC score to models including traditional cardiovascular risk factors, with only age being removed, provided improved discrimination for incident CHD (C statistic, 0.735 vs 0.703; C statistics difference, 0.032; 95% CI of difference, 0.002-0.062) but not for stroke. Coronary artery calcium score was more likely than age to provide higher category-free net reclassification improvement among participants who experienced an ASCVD event (0.390; 95% CI, 0.312-0.467 vs 0.08; 95% CI -0.001 to 0.181) and to result in more accurate reclassification of risk for ASCVD events among these individuals. The findings were similar in the 2 European cohorts (n = 4990). Coronary artery calcium may be an alternative marker besides age to better discriminate between lower and higher CHD risk in older adults. Whether CAC score can assist in guiding the decision to initiate statin treatment for primary prevention in older adults requires further investigation.

This study investigated whether higher intensity of resistance exercise habit not only lead to greater muscle strength but also higher levels of hypertension and arterial stiffness, while these cardiovascular risks would be reduced by bathing habit in older adults. One hundred ninety-six older adults asked questionnaire about resistance exercise and bathing habits, along with the International Physical Activity Questionnaire Long form to evaluate physical activity and aerobic exercise habits. Maximum knee extension strength (MVC), systolic blood pressure (SBP), and brachial-ankle pulse wave velocity (baPWV) were measured in fall. Participants with resistance exercise habits (n = 34 of 196) were included in the further analysis, and an exploratory analysis was conducted on participants with resistance exercise habits but without aerobic exercise habits (n = 19 of 34). According to the exploratory analysis, MVC was moderately associated with exercise intensity regardless of bathing habits. Exercise intensity was significantly correlated with SBP (r = 0.592, p = 0.012). This relationship became stronger after adjusting for bathing habits (r = 0.744, p = 0.006). BaPWV was positively correlated with exercise intensity after adjusting for bathing habits (r = 0.563, p = 0.036). Older adults who habitually perform high-intensity resistance exercise had greater muscle strength but aggravate hypertension and arterial stiffness. Bathing habits partly prevent cardiovascular risk without diminishing the improvements in muscle strength induced by high-intensity resistance exercises. Importantly, BP is increasing in winter and decreasing in summer. Our results set the stage of the future research that investigates how reduce the cardiovascular risk in older adults with high-intensity resistance training habits in each season, especially in winter.

To establish the effect of three types of treatment – multicomponent exercise (MEX); the oral hypoglycaemic drug metformin (MET); combined therapy comprising exercise plus metformin (MEXMET) – on cardiovascular risk in older adults with type 2 diabetes (T2D) and with comorbidities in an early stage of the disease (HbA1c < 7.5%). A sample of 284 participants was evaluated for multifactorial cardiovascular risk at baseline and at 24-month intervention according to anthropometric and hemodynamic components, lipid profile, glycaemia and cardiorespiratory fitness (CRF). Participants underwent one of three conditions: MEX (n = 59), training in three sessions per week; MET (n = 30), using metformin 850 mg twice daily; MEXMET (n = 195), combining exercise and metformin. After the 24-month intervention MEX and MEXMET showed more positive results than MET therapy. MEX decreased body mass (BM; 4%), waist circumference (WC; 4%), body mass index (BMI; 3%), systolic blood pressure (SBP; 11%), diastolic blood pressure (DBP; 11%), triglycerides (21%), and glycaemia (12%), and increased cardiorespiratory fitness (CRF; 18%). Conversely, the MET group showed increased WC (2%), waist-to-hip ratio (WHR) (3%), and SBP (5%). Differences between MEX and MET groups presented large effect sizes for BM, WC, WHR, SBP, DBP and CRF, and moderate effect sizes for BMI and glycaemia. MEX was the most effective therapy in decreasing cardiovascular risk in the early stage of T2D in older adults with multimorbidity and attenuated the adverse effects of pharmacological therapy in MEXMET treatment.

BackgroundThe prevalence of cardiovascular disease is burgeoning in low- and middle-income countries (LMICs). In sub-Saharan Africa, the prevalence of cardiovascular risk factors is increasing, though rates of CVD diagnosis and management remain low. Awareness of the influence of social determinants of health (SDOH) on cardiovascular outcomes is growing, however, most work focuses on high-income countries. Material needs security is a measure of SDOH that may be particularly relevant for LMICs. This study investigated the relationship between material needs security and cardiovascular risk in older adults living in South Africa.MethodsThe analysis included 5059 respondents age ≥ 40 in the Health and Aging in Africa survey, an observational cohort study administered in 2014 in Mpumalanga Province, South Africa. Linear regression models tested the association between material needs and eight cardiovascular risk factors (waist-to-hip ratio, body mass index, blood pressure, glucose, cholesterol, LDL, and triglycerides). Adjusted linear regression models controlled for sociodemographic confounders.ResultsThere were significant adjusted associations found between increased material needs security and four cardiovascular risk factors, including waist-to-hip ratio (β = 0.001; 95% CI [0.00002,0.002]), BMI (β = 0.19; 95%CI=[0.14,0.24]), glucose (β = 0.46; 95%CI=[0.02,0.90]), and triglycerides (β = 0.26; 95%CI=[0.02,0.49]).ConclusionIncreased material needs security was associated with significantly increased cardiovascular risk in older adults in rural South Africa. These findings can inform the approach to treatment and management of cardiovascular disease in South Africa and similar LMICs. Future investigations should evaluate the implementation and efficacy of interventions that recognize the role of material needs security in cardiovascular risk.

Cardiovascular Risk Scales Association with Cerebrospinal Fluid Alzheimer's Disease Biomarkers in Cardiovascular Low Cardiovascular Risk Regions.

Influences of lifestyle habits on cardiovascular disease risk among older adults are not well established. The authors present evidence from the Cardiovascular Health Study that dietary, physical activity, and smoking habits assessed late in life are associated with cardiovascular disease risk among adults aged 65 years or older. Persons consuming fatty fish twice per week had a 47% lower risk of coronary death compared with those who consumed fatty fish less than once per month, while cereal fiber intake (about two whole-grain bread slices per day) was associated with a 14% lower risk of myocardial infarction or stroke. Modest alcohol intake (1-6 drinks per week) predicted the fewest subclinical cerebrovascular abnormalities. Compared with little activity, moderate and high leisure-time activity predicted 28% and 44% lower mortality, respectively, while compared with nonexercisers, low, moderate, and high exercise intensity predicted 30%, 37%, and 53% more years of healthy life, respectively. Former and current smokers had 25% and 44% fewer years of healthy life than those who never smoked; lifetime smoking (pack-years) predicted higher mortality. Clinical practice and public health implications, gaps in knowledge, and future research directions are summarized.

Psychosocial correlates of alexithymia were examined in 102 healthy, older adults (ages 53-83; 76% male). Alexithymic ( n = 26) and non-alexithymic ( n = 30) groups, defined by top ( S 70) and bottom ( h 54) quartiles of the distribution of Toronto Alexithymia Scale (26-item) scores, were compared with respect to psychosocial, psychophysiological, and biomedical risk factors for cardiovascular disease. Both categorical ratings and continuous scores of alexithymia were associated with significantly greater levels of trait anxiety, anger-in, neuroticism, hostility, perceived stress, depression, and lower levels of social support. Compared to non-alexithymics, alexithymics displayed significantly greater blood pressure responses to anger provocation and tended to have a greater percent body fat. The groups did not differ in resting cardiovascular parameters, heart rate reactivity, fasting glucose and lipoprotein lipids, body mass index, waist-to-hip ratio, social desirability, or trait anger. These findings suggest several psychosocial and psychophysiological pathways by which alexithymia may confer risk for cardiovascular disease among older adults.

The aortic-femoral arterial stiffness gradient, calculated as the ratio of lower-limb pulse-wave velocity (PWV) to central (aortic) PWV, is a promising tool for assessing cardiovascular disease (CVD) risk, but whether it predicts incident CVD is unknown. We examined the association of the aortic-femoral arterial stiffness gradient measures carotid-femoral stiffness gradient (femoral-ankle PWV divided by carotid-femoral PWV) and the heart-femoral stiffness gradient (femoral-ankle PWV divided by heart-femoral PWV), as well as PWV, with incident CVD (coronary disease, stroke, and heart failure) and all-cause mortality among 3109 participants of the Atherosclerosis Risk in Communities Study cohort (age, 75±5 years; carotid-femoral PWV, 11.5±3.0 m/s), free of CVD. Cox regression was used to estimate hazard ratios (HR) and 95% CIs. Over a median 7.4-year follow-up, there were 322 cases of incident CVD and 410 deaths. In fully adjusted models, only top quartiles of carotid-femoral stiffness gradient (quartile 4: HR, 1.43 [95% CI, 1.03-1.97]; and quartile 3: HR, 1.49 [95% CI, 1.08-2.05]) and heart-femoral stiffness gradient (quartile 4: HR, 1.77 [95% CI, 1.27-2.48]; and quartile 3: HR, 1.41 [95% CI, 1.00-2.00]) were significantly associated with a greater risk of incident CVD. Only high aortic stiffness in combination with low lower-limb stiffness was significantly associated with incident CVD (HR, 1.46 [95% CI, 1.06-2.02]) compared with the referent low aortic stiffness and high lower-limb stiffness. No PWVs were significantly associated with incident CVD. No exposures were associated with all-cause mortality. The aortic-femoral arterial stiffness gradient may enhance CVD risk assessment in older adults in whom the predictive capacity of traditional risk factors and PWV are attenuated.

Introduction:Osteoporosis is a prevalent metabolic bone disorder, particularly affecting the elderly, and is often linked to cardiovascular morbidity. This study investigated the associations among osteoporosis, biochemical markers, bone mineral density (BMD), and cardiovascular disease (CVD).Materials and Methods:A cross-sectional analysis was conducted among 280 individuals diagnosed with osteoporosis and 182 without osteoporosis to assess the relationship between osteoporosis and serum levels of triglycerides, total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and homocysteine (HCY). Correlations between these biochemical indices and BMD were evaluated. CVD prevalence was compared between osteoporosis and non-osteoporosis groups, and receiver operating characteristic curve analysis was used to assess the predictive potential of BMD for CVD risk.Results:Higher triglyceride, TC, and LDL levels were positively associated with osteoporosis, while elevated HDL and HCY levels showed inverse associations. Triglyceride levels correlated negatively with BMD, whereas TC and HDL demonstrated positive correlations. LDL showed a weak negative association, and HCY exhibited a strong inverse correlation with BMD. Individuals with osteoporosis had lower BMD and a higher incidence of CVD compared to those without osteoporosis. Logistic regression confirmed that reduced BMD significantly increased cardiovascular risk.Conclusion:This study highlights significant associations among osteoporosis, lipid profiles, HCY levels, BMD, and CVD. The findings suggest that dyslipidemia and altered HCY metabolism may contribute to both bone loss and cardiovascular pathology. BMD may serve as a potential biomarker for identifying individuals at increased cardiovascular risk. Further longitudinal research is needed to establish causal relationships and assess long-term clinical outcomes.

Identifying a Predictive Biomarker for Kidney Decline and Cardiovascular Risk in Older Adults: Evidence from a Large Cohort Study

Dyslipidemia is one of the most modifiable risk factors in preventing heart disease. Evidence demonstrates that the process of atherosclerosis, a result of dyslipidemia, begins in young adults. Initiating statin therapy has been shown to reduce the risk of cardiovascular events and mortality. Determining the right statin medication and dose for an older adult based on national guidelines can be challenging, as multiple factors must be considered in this decision. When initiating statin therapy, clinicians should determine the appropriate percentage of reduction in low-density lipoprotein cholesterol needed to achieve the target goal. Additionally, when changing from one cholesterol-lowering medication to another, knowledge of equivalent dosing is important. Generally, statin drugs are well tolerated with a good safety profile in older adults but are underused in this patient population. Issues such as existing comorbid conditions, polypharmacy with the potential for drug-drug interactions, impaired drug metabolism, and decreased functional status can contribute to adverse events and increase the frequency of myalgias and less frequently, hepatotoxicity. Clinicians prescribing statin therapy for older adults need to remain current on advances in research regarding potential interactions and contraindications within this drug class.