Drug therapy for arterial hypertension and atrial fibrillation in frail patients : Are there any new insights and recommendations?

Abstract

The frail and elderly are considered to be at particular risk of suffering an adverse drug reaction. Empirical studies confirm the increased rate of adverse drug reactions. Whether frailty perse impairs drug metabolism or the underlying organ ageing processes and multimorbidity cannot be answered with certainty based on current data. Cardiovascular diseases exhibit aconsiderable interdependence with frailty. For example, there is adisproportionate syndromal interdependence between heart failure and frailty, and the typical ageing processes of the sinus node can be interpreted as heartbeat frailty. Multimorbidity in the elderly often includes acluster of chronic cardiovascular diseases, often leading to the use of several cardiovascular medications as required. More recent definitions of polypharmacy assess the appropriateness of drugs rather than their number. The Fit-fOR-The-Aged (FORTA) list, the PRISCUS 2.0 list and the "Cochrane Library Special Collection on deprescribing", for example, offer apractice-oriented assessment aid. In the treatment of arterial hypertension, the target values for older people have also been set ever lower in recent years. In the case of frail elderly people, on the other hand, the guidelines do not specify astrict blood pressure target corridor; tolerability is the crucial factor here. When initiating antihypertensive therapy in frail individuals, one can consider monotherapy-in adeparture from the standard case of dual combination therapy. The OPTIMISE study showed that discontinuation of one blood pressure medication did not lead to better tolerability of the drug therapy. Current studies come to differing conclusions regarding the risk-benefit assessment of new oral anticoagulants compared to vitaminK antagonists in the anticoagulation of frail elderly people with atrial fibrillation. Shared decision-making, which could improve adherence particularly in older people, is recommended.