Targeting Vascular Risk Factors in Older Adults

Abstract

For many years vascular disease prevention strategies have been focused on reducing undertreatment, often using a “one-size-fits-all” approach to increase patient adherence. The paradigm of this approach has been the proposal of a polypill targeting multiple vascular risk factors, a standard treatment aimed at maximizing vascular protection. Conversely, during recent years an increasing emphasis has been placed on the issue of potential overtreatment, frequently resulting from the same treatment approach in all patients despite significant individual differences in comorbidity and life expectancy. In type 2 diabetes mellitus (T2DM), data from randomized clinical tr ials1 have shown uncertain or negative benefit-risk trade-offs associated with aggressive treatment of hypertension and hyperglycemia. These results, added to the well-known exclusion of elderly individuals with multiple morbidities from nearly all clinical trials, have informed recent guidelines, which now recommend more moderate targets for treatment of T2DM and hypertension in older participants, especially those considered frail or affected by important comorbidities.1 These treatment recommendations raise thepossible strategyof treatmentdeintensification forhighbloodpressure and hyperglycemia inpatientswithvaluespreviously identified as optimal and now labeled as low. This issue was addressed by Sussman and colleagues2 in a large retrospective sample of older individuals with T2DM (mean age, 78 years) from the Veterans Health Administration actively treated for T2DM or high blood pressure. They found that treatment deintensification (ie, dosage reduction or drug withdrawal) was performed in one-quarter or less of participants with low blood pressure (systolicbloodpressure<130mmHgordiastolicblood pressure <65 mm Hg) or a low hemoglobin A1c (HbA1c) level (<6.5%) (to convert to a proportion of total hemoglobin,multiply by 0.01). Moreover, whether treatment reduction occurredwasonlyweakly associatedwith apatient’s bloodpressure or HbA1c level and predicted life expectancy, suggesting that physicians are generally reluctant to deintensify treatment even in conditions that make benefits of therapy limited in comparison with potential harms. This interpretation is confirmed by a further study from theDepartmentofVeteransAffairs in thepresent issueofJAMA Internal Medicine. Caverly et al3 surveyed a national sample of health care professionals providing primary care, showing that almost half of themwouldnotworry aboutharmsof tight glycometabolic control obtained with an insulin secretagogue in an older patient at high risk for hypoglycemia. This approach to therapy was largely explained by the concern of making the patient’s HbA1c level fall out of Department of VeteransAffairs performancemeasures,which, as the authors point out, have never targeted values less than 7.0%. Nearly one-quarterof thehealthcareprofessionals interviewedwould even be concerned about malpractice liability risk with deintensification of hypoglycemic medications. In keepingwith these data, Sussman and colleagues2 call for a change in guidelines, qualitymeasures, and clinical performance management that should include recommendations and incentives to avoid overtreatment. This statement is alsoconsistentwitha recentanalysisofoutpatientandemergencydepartmentperformancemeasures in theUnitedStates that shows a lack of measures addressing overuse, especially regarding treatments.4 Yet, somecaveats shouldbe raised.Although studies ofmore aggressive control of risk factors have generally failed to show a reduction of cardiovascular events inT2DM, fewdataexist regarding theprognostic effectofdeintensification, especially in patients with good treatment tolerance. Conversely, more stringent targets are still recommended, although with a low level of evidence, for younger patients with a low risk for adverse events.1 In addition, incentives for treatmentwithdrawalmight carry a risk of avoiding potentially useful preventive strategies, especially in the present time of resource constraints. Less is not alwaysmore, andweshouldnot riskeliminating thebenefitsof therapywhile attempting to lower the risk. A proposed stratification of antihypertensive and antidiabetic treatment strategies according to patient vulnerability is described in the Figure, including issues that should be further clarified andpossible solutions. A first step is represented bytheneedforsimplebutclear indicatorsofvulnerability,which Related articles pages 1942 and 1994 Treatment Deintensification in Older Patients With Diabetes Mellitus Original Investigation Research