Heart Disease In Older Adults Research Articles

Dietary Patterns and Common Diseases in Chinese Elderly: Exploring Associations and Providing Guidance for Personalized Interventions

The current state of geriatric disease prevention and treatment in China has not yet been able to meet the urgent needs brought about by an aging population, and specific dietary patterns can significantly improve or exacerbate the risk of certain diseases. However, the relationship between geriatric diseases and the dietary patterns of the Chinese elderly population has not been fully explored. CLHLS 2018 were analyzed in the present study. Principal component analysis was employed to identify the main dietary patterns of the Chinese elderly, and binary logistic regression models were used to analyze the associations between these dietary patterns and the 16 common diseases. Four main dietary patterns were identified in the Chinese elderly population: Egg-Milk Pattern, Salt-preserved vegetable-Nut Pattern, Vegetable-Fruit Pattern, and Fish-Meat Pattern. Higher scores for the Egg-Milk Pattern were associated with a greater risk of heart disease, stroke or cardiovascular disease, respiratory disease, glaucoma, prostate tumor, and Parkinson's disease in older adults (p<0.05). Higher scores for Salt-preserved vegetable-Nut Pattern correlated with a greater risk of hypertension, heart disease, and uterine tumors and a lower risk of rheumatism or rheumatoid disease in older adults (P<0.05). The higher scores of the Vegetable-Fruit Pattern were associated with a lower risk of heart disease in older adults (p<0.05). Finally, higher scores of the Fish-Meat Pattern correlated with a lower risk of heart disease, stroke, and cardiovascular disease and a greater risk of rheumatic or rheumatoid disease in older adults (p<0.05). The same dietary pattern may have contrasting effects on different diseases. The correlations between dietary patterns and diseases derived from this study may provide a basis for the prevention and individualized management of diseases in the elderly.

CROSS-TISSUE COMPARISON OF AGING BIOLOGY MEASURES AS NOVEL BIOMARKERS FOR HEALTHY AGING

Abstract We compared the role of aging biology biomarkers measured in saliva (N=5,808) and blood (N=9,934) as novel biomarkers for prevention of stroke and heart disease in a sample of older adults (aged 50 and older) from the Health and Retirement Study (HRS). Individuals who consented for blood and saliva draw in the HRS 2016 Venous blood and 2008 Telomere length studies were included. Measures in saliva included telomere length. Measures in blood included DNA methylation and physiology biomarkers. The main outcomes included stroke, heart disease and disease-free aging. Cases and disease-free adults were matched on age and sex using a probit link and propensity scores. No association was observed between saliva-based telomere length with stroke or heart disease. In contrast, blood-based biomarkers of aging biology showed strong associations with stroke and heart disease. Biologically older individuals had 3- and 2.5-times higher odds of stroke based on DNA methylation Grim Age (aOR=3.00, 1.87, 4.82, P< 0.001) and Physiology-based Phenotypic Age (aOR=2.50, 1.57, 3.98, P<0.001). Individuals who were biologically older had 3.6- and 2.3-times higher odds of heart disease according to physiology-based Phenotypic Age (aOR=3.64, 95% CI 2.68, 4.94, p < 0.001) and DNA methylation Grim Age (aOR=2.36, 95% CI 1.73, 3.23, P<0.001). Findings of the present study suggest that saliva-based telomere length and blood-based DNA methylation and physiology biomarkers likely capture different aspects of individual aging and vary in their precision and sensitivity as novel biomarkers for prevention of stroke and heart disease in older adults.

Measures of Aging Biology in Saliva and Blood as Novel Biomarkers for Stroke and Heart Disease in Older Adults.

The role of aging biology as a novel risk factor and biomarker for vascular outcomes in different accessible body tissues such as saliva and blood remain unclear. We aimed to (1) assess the role of aging biology as a risk factor of stroke and heart disease among individuals of same chronologic age and sex and (2) compare aging biology biomarkers measured in different accessible body tissues as novel biomarkers for stroke and heart disease in older adults. This study included individuals who consented for blood and saliva draw in the Venous Blood Substudy and Telomere Length Study of the Health and Retirement Study (HRS). The HRS is a population-based, nationally representative longitudinal survey of individuals aged 50 years and older in the United States. Saliva-based measures included telomere length. Blood-based measures included DNA methylation and physiology biomarkers. Propensity scores-matched analyses and Cox regression models were conducted. This study included individuals aged 50 years and older, who consented for blood (N = 9,934) and saliva (N = 5,808) draw in the HRS. Blood-based biomarkers of aging biology showed strong associations with incident stroke as follows: compared with the lowest tertile of blood-based biomarkers of aging, biologically older individuals had significantly higher risk of stroke based on DNA methylation Grim Age clock (adjusted hazard ratio [aHR] = 2.64, 95% CI 1.90-3.66, p < 0.001) and Physiology-based Phenotypic Age clock (aHR = 1.75, 95% CI 1.27-2.42, p < 0.001). In secondary analysis, biologically older individuals had increased risk of heart disease as follows: DNA methylation Grim Age clock (aHR = 1.77, 95% CI 1.49-2.11, p < 0.001) and Physiology-based Phenotypic Age clock (aHR = 1.61, 95% CI 1.36-1.90, p < 0.001). Compared with saliva-based telomere length, blood-based aging physiology and some DNA methylation biomarkers are strongly associated with vascular disorders including stroke and are more precise and sensitive biomarkers of aging. Saliva-based telomere length and blood-based DNA methylation and physiology biomarkers likely represent different aspects of biological aging and accordingly vary in their precision as novel biomarkers for optimal vascular health.

Multiancestry Genome-Wide Association Study of Aortic Stenosis Identifies Multiple Novel Loci in the Million Veteran Program.

Calcific aortic stenosis (CAS) is the most common valvular heart disease in older adults and has no effective preventive therapies. Genome-wide association studies (GWAS) can identify genes influencing disease and may help prioritize therapeutic targets for CAS. We performed a GWAS and gene association study of 14 451 patients with CAS and 398 544 controls in the Million Veteran Program. Replication was performed in the Million Veteran Program, Penn Medicine Biobank, Mass General Brigham Biobank, BioVU, and BioMe, totaling 12 889 cases and 348 094 controls. Causal genes were prioritized from genome-wide significant variants using polygenic priority score gene localization, expression quantitative trait locus colocalization, and nearest gene methods. CAS genetic architecture was compared with that of atherosclerotic cardiovascular disease. Causal inference for cardiometabolic biomarkers in CAS was performed using Mendelian randomization and genome-wide significant loci were characterized further through phenome-wide association study. We identified 23 genome-wide significant lead variants in our GWAS representing 17 unique genomic regions. Of the 23 lead variants, 14 were significant in replication, representing 11 unique genomic regions. Five replicated genomic regions were previously known risk loci for CAS (PALMD, TEX41, IL6, LPA, FADS) and 6 were novel (CEP85L, FTO, SLMAP, CELSR2, MECOM, CDAN1). Two novel lead variants were associated in non-White individuals (P<0.05): rs12740374 (CELSR2) in Black and Hispanic individuals and rs1522387 (SLMAP) in Black individuals. Of the 14 replicated lead variants, only 2 (rs10455872 [LPA], rs12740374 [CELSR2]) were also significant in atherosclerotic cardiovascular disease GWAS. In Mendelian randomization, lipoprotein(a) and low-density lipoprotein cholesterol were both associated with CAS, but the association between low-density lipoprotein cholesterol and CAS was attenuated when adjusting for lipoprotein(a). Phenome-wide association study highlighted varying degrees of pleiotropy, including between CAS and obesity at the FTO locus. However, the FTO locus remained associated with CAS after adjusting for body mass index and maintained a significant independent effect on CAS in mediation analysis. We performed a multiancestry GWAS in CAS and identified 6 novel genomic regions in the disease. Secondary analyses highlighted the roles of lipid metabolism, inflammation, cellular senescence, and adiposity in the pathobiology of CAS and clarified the shared and differential genetic architectures of CAS with atherosclerotic cardiovascular diseases.

Association between tobacco smoking and heart disease in older adults: a cross-sectional study based on the Chinese Longitudinal Healthy Longevity Survey.

The association between the risk of heart disease and tobacco smoking has been studied in previous work, but there are arguments among various population. We aimed to investigate the association between heart disease incidence and smoking status among older adults. A cross-sectional analysis was conducted with 10,891 older adults in the 2 most recent waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), 2011-2014 and 2014-2018. The data included individual weighting variables to ensure they were nationally representative. The parameters consisted of age, sex, body mass index (BMI), smoking status, and disease history was collected. Smoking measures included current/former/never status, pack-years and the time to first cigarette. Heart disease included coronary artery disease, arrhythmias, heart failure, valve diseases and other heart conditions. Respondents with missed values were excluded. Multivariable logistic regression analyses were performed. Among the 10,006 respondents included in the analyses, 4,501 (44.9%) were men. The median age was 88 years old [interquartile range (IQR), 78-96]. A total of 6,713 respondents (67.1%) were nonsmokers, 1,695 respondents (16.9%) were former smokers, and 1,598 respondents (16.0%) were current smokers. The incidence of heart disease was significantly higher in smokers compared with nonsmokers (14.5% vs. 12.8%, P=0.018). Female smokers and those over 80 years old had higher morbidity than male smokers. After adjusting for sex, age, BMI, hypertension, diabetes, area of residency, alcohol status, and exercise status, smokers still had an increased risk of heart disease [odds ratio (OR) 1.29, 95% confidential interval (CI): 1.10-1.50, P=0.001]. The incidence of heart disease also increased with higher intensity of smoking for each additional pack-year (OR 1.01, 95% CI: 1.00-1.02, P=0.011). For elderly adults, current or former smoking was largely associated with heart disease incidence, especially in females and those over 80 years old. These variables could be considered for inclusion in future heart disease risk prediction models.

Acute Myocardial Infarction in a 13-Year-Old Boy after Bone Marrow Transplantation

BackgroundAdvances in bone marrow transplantation (BMT) present a unique opportunity for treating leukemia in children. It has also increased the risk of long-term complications in the lungs, genitourinary tract, and nervous system. Coronary artery disease is the most common type of heart disease in older adults, but is not generally acknowledged as a complication of BMT, especially in young patients. Case ReportWe report the occurrence of acute myocardial infarction in a 13-year-old boy, approximately 5 years after he received a half-matched related bone marrow transplant from his father for T-cell lymphoblastic leukemia. Acute myocarditis was suspected early in the clinical course on the basis of his age and clinical presentations, such as atypical chest pain and dyspnea. Follow-up coronary angiography revealed a total occlusion of the right coronary artery, as well as diffused lesions of the left main, anterior descending, and circumflex branch. Fortunately, he was discharged from the hospital in satisfactory general condition after complex treatment.Why Should An Emergency Physician Be Aware of This? In this case, its rarity and poor clinical recognition were the main reasons for delayed diagnosis, which led to a delay to coronary angiography. Given the high mortality in cardiovascular complications among BMT recipients, the correct diagnostic assessment in such cases becomes particularly relevant.

0326 Influence of Sleep and Cardiovascular Health on Cognitive Outcomes in Older Adults

Abstract Introduction High and low sleep duration have been associated with reduced executive function (EF) and episodic memory (EM). However, causal pathways have not been identified. Cardiovascular health may contribute to the relationship between sleep and cognitive aging. Sleep disturbance has been associated with increased hypertension and heart disease in older adults, and cerebrovascular insufficiency has been consistently linked with cognitive decline. Therefore, the mediating and moderating effects of cardiovascular disease risk (CVD) on the relationship between sleep duration and longitudinal change in EF and EM were examined. Methods Statistical analyses were preregistered (osf.io/6yw7g). Average total sleep time (TST) over 2-6 nights was estimated using single-channel EEG at baseline (N=332). CVD was estimated using the abbreviated Framingham Heart Score approximately one year post-baseline. Outcome variables were linear change in EF and EM composite scores [BL1] per year up to 7 years after baseline. EF subtests measured semantic fluency, working memory, and task switching. EM subtests measured verbal associative memory, narrative episodic memory, and list learning. Covariates included age, gender, Alzheimer disease (AD) biomarkers (ratio of phosphorylated tau181 to amyloid-ß42), global cognition, and apnea-hypopnea index. Results Greater TST was linearly associated with reduced CVD (ß=-.157, p=.006). Quadratic effects of TST on EF and EM were observed (EF: ß=-.105, p=.002; EM: ß=-.203, p=.007). Lowest TST was related to greater reduction in EF; highest TST was related to greater reduction in EF and EM. Mediating effects of CVD for EF and EM were observed (ps&amp;lt;.05) but were non-significant when age and AD biomarkers were included (p=.10, p=.08, respectively). A non-significant trend indicated CVD moderated effects of TST on EF (ß=.10, p=.055), controlling for age and AD biomarkers. Less sleep combined with higher CVD tended to be associated with greater decline in EF. CVD did not moderate effects of TST on EM (ß=.07, p=.254). Conclusion Consistent with prior literature, CVD and TST were independently associated with cognitive decline. Although findings suggest that CVD may influence effects of TST on cognitive decline, more evidence is needed. Future analyses will examine alternative sleep measures (e.g., sleep efficiency, slow wave spectral density). Support (If Any) NIH: T32-AG000030, P01-AG03991, P01-AG026276, P30-AG066444.

Editors' Note: First-Ever Ischemic Stroke and Increased Risk of Incident Heart Disease in Older Adults

Using a propensity-matched cohort of >20,000 patients with acute ischemic stroke and >70,000 matched nonstroke individuals, Dr. Sposato et al. observed a 4-fold higher odds of major cardiac adverse events among patients with recent acute stroke. Importantly, patients were matched based on vascular risk factors, socioeconomic status, hospitalization frequency, and previous medications. The higher incidence of poststroke heart disease may have been related to the index cerebrovascular event, as the authors state. Alternatively, some patients may have experienced a stroke-induced myocardial stunning from excess sympathetic tone, which is supported by existing animal models and observational studies. Dr. Sioka et al. highlighted their own observations (using myocardial perfusion imaging) that subclinical coronary artery disease after stroke may be more common than expected. As noted by Dr. Sposato et al., the cohort reported by Sioka may have been selected for patients at risk of more coronary artery disease, given the stroke mechanisms and vascular profile of the included patients. Whatever the mechanism of myocardial injury, clinicians ought to monitor closely for concomitant cardiac disease among patients with recent cerebral infarction. Using a propensity-matched cohort of >20,000 patients with acute ischemic stroke and >70,000 matched nonstroke individuals, Dr. Sposato et al. observed a 4-fold higher odds of major cardiac adverse events among patients with recent acute stroke. Importantly, patients were matched based on vascular risk factors, socioeconomic status, hospitalization frequency, and previous medications. The higher incidence of poststroke heart disease may have been related to the index cerebrovascular event, as the authors state. Alternatively, some patients may have experienced a stroke-induced myocardial stunning from excess sympathetic tone, which is supported by existing animal models and observational studies. Dr. Sioka et al. highlighted their own observations (using myocardial perfusion imaging) that subclinical coronary artery disease after stroke may be more common than expected. As noted by Dr. Sposato et al., the cohort reported by Sioka may have been selected for patients at risk of more coronary artery disease, given the stroke mechanisms and vascular profile of the included patients. Whatever the mechanism of myocardial injury, clinicians ought to monitor closely for concomitant cardiac disease among patients with recent cerebral infarction.

Reader Response: First-Ever Ischemic Stroke and Increased Risk of Incident Heart Disease in Older Adults.

In their large population-based study, Sposato et al.1 reported that ischemic stroke was independently associated with a higher risk of a subsequent major adverse cardiovascular event, such as myocardial infarction, congestive heart failure, coronary artery disease, or cardiovascular death. As the authors concluded, it was unclear whether these events were stroke-related or because of preexisting subclincal cardiovascular conditions. Interestingly, using myocardial perfusion imaging (MPI) with 99mTechnetium-tetrofosmin-single-photon emission computed tomography (SPECT), we have recently reported that 62% of 52 patients exhibited myocardial ischemia within a month after an ischemic stroke.2 These patients had no known history or symptoms of coronary artery disease or any other heart disease. Although the etiology of the cardiac abnormalities in the stroke patients remains unclear, it is wise to assess them after the stroke using the noninvasive method of MPI SPECT. MPI SPECT represents a sensitive and accurate method to detect even minimal myocardial dysfunction and proceed with coronary angiography only if the MPI demonstrates abnormalities.2,3

Author Response: First-Ever Ischemic Stroke and Increased Risk of Incident Heart Disease in Older Adults.

We thank Dr. Sioka et al. for their positive comments about our article1 showing a high risk of major adverse cardiovascular events after acute ischemic stroke. They also summarized the results of their study on myocardial perfusion tests among patients with a recent (<30 days) ischemic stroke.2 Dr. Sioka et al. found changes suggestive of myocardial ischemia in 62% of the cases.2 Notably, this was a wittingly selected population of patients with atherosclerotic strokes and a high prevalence of smokers (63%) and hyperlipidemia (58%). Thus, the high prevalence of asymptomatic coronary artery disease (CAD) in this study is somehow expected. Indeed, consistent with their interpretation, asymptomatic CAD is the most likely explanation for the impaired myocardial perfusion tests. However, in less selected populations, cardiovascular complications may not be due to asymptomatic CAD, since the reported prevalence of severe coronary artery atherosclerosis in patients with acute ischemic stroke and no history of CAD undergoing systematic coronary angiography is only 16%.3 Interestingly, the meaning of impaired myocardial perfusion scanning in stroke patients is not well understood. Takotsubo myocardiopathy can occur after stroke and is associated with transiently impaired myocardial perfusion tests in the absence of atherosclerotic CAD.4

A Systematic Review of Cardiogenic Shock in the Setting of Severe Aortic Stenosis: Prevalence, Management, and Outcomes

Objective: The objective of this study was to summarize the prevalence and the available management strategies for cardiogenic shock in the setting of severe aortic stenosis and their outcome. Introduction: Aortic stenosis (AS) is the most common valvular heart disease in older adults. Cardiogenic shock (CS) is a medical emergency, and while management for these two conditions has evolved over the years, little is known about the prevalence, management, and mortality of AS in combination with CS. Methods: We performed a systematic review to identify studies that included patients with severe AS presenting with CS using EMBASE, MEDLINE, and Scopus. Primary outcomes included in-hospital, 30-day, and 1-year mortality. Additional outcomes included procedure-related complications. We registered the study protocol at PROSPERO (CRD42018112245). Results: We included a total of 10 studies representing 338 patients. In-hospital mortality ranged from 43% to 77% in patients treated with Balloon Aortic Valvuloplasty (BAV), 0% in patients who underwent surgical valve replacement (SAVR), and 11% and Transcatheter aortic valve replacement (TAVR). In patients undergoing BAV, 30-day mortality varied between 50% and 55%, and between 19% and 33% in those treated with TAVR. There was limited evidence on the use of Mechanical Circulatory Support (MCS). Conclusion: AS presenting with CS is a rare but fatal condition, and no consensus exists regarding management strategy. Time to intervention on the valve is critical. Valve replacement through either SAVR or TAVR had better outcomes compared to BAV alone. There is limited evidence on MCS as a management strategy in patients with AS complicated by CS.

First-ever ischemic stroke and increased risk of incident heart disease in older adults.

Poststroke cardiac complications are common. It is unknown whether the reason is shared risk factors and preexisting heart disease or stroke-associated myocardial and coronary injury. We tested the hypothesis that first-ever ischemic stroke is associated with increased risk of incident cardiovascular complications in patients without known preexisting cardiac comorbid conditions. This population-based cohort study included residents in Ontario between 2002 and 2012 who were ≥66 years of age without known cardiovascular disease. We compared the incident risk of major adverse cardiovascular events (MACE), defined as myocardial infarction, unstable angina, congestive heart failure, coronary artery disease, coronary artery revascularization, or cardiovascular death, at 1 year in patients with first-ever ischemic stroke vs propensity-matched individuals without stroke (4:1 matching using 31 variables). To estimate cause-specific hazard ratios (HRs), we used Cox regression models adjusted for variables with weighted standardized differences >0.10 or known to influence the risk of MACE. We included 21,931 patients with first-ever ischemic stroke and 71,696 propensity-matched individuals, well balanced on all variables used for propensity matching. First-ever ischemic stroke was associated with increased unadjusted incident MACE risk (HR 4.5, 95% confidence interval [CI] 4.3-4.8). MACE adjusted risk was highest in the first 30 days (HR 25.0, 95% CI 20.5-30.5) and declined both at 31 to 90 days (HR 4.8, 95% CI 4.1-5.7) and at 91 to 365 days (HR 2.2, 95% CI 2.0-2.4). In this large population-based study, ischemic stroke was independently associated with increased risk of incident MACE. Whether this association is explained by stroke-associated cardiac injury, preexisting subclinical cardiovascular comorbid conditions, or both remains unknown.

HearCARE: Hearing and Communication Assistance for Resident Engagement.

Impaired hearing is related to poor health outcomes, including compromised cognitive function, in aging individuals. Hearing loss is the third most common chronic health condition after arthritis and heart disease in older adults and the fourth most detrimental condition related to quality of life in older adults. Only 18% of aging adults who have impactful hearing loss actually use custom-fit amplification. Therefore, the majority of aging individuals entering senior living facilities will have untreated hearing loss. Older adults move to senior communities to maintain or increase their social engagement, to receive care from qualified staff, and to ultimately enhance their quality of life. We know that the majority of individuals over 65 years of age have significant hearing loss, which leaves them with complex listening needs due to low incidence of hearing aid use, group communication situations that are common for social activities, interactive dining environments, and the need for telephone use to connect with loved ones. Busy staff and family members may not be aware of the impact of decreased hearing on quality of life, as well as caregiver burden. HearCARE (Hearing and Communication Assistance for Resident Engagement) is an initiative to provide communication assistance on a day-to-day basis in senior living facilities in a cost-effective manner. This innovative model for delivering audiology services and communication assistance in senior living communities employing communication facilitators who are trained and supervised by an audiologist will be described. Data related to the communication facilitator training, daily activities, interactions with the audiologist, use of devices, and impact on residents, staff, and families will be described.

Glycerophosphocholine Metabolites and Cardiovascular Disease Risk Factors in Adolescents

Background:Glycerophosphocholine (GPC) metabolites modulate atherosclerosis and thus risk for cardiovascular disease (CVD). Preclinical CVD may start during adolescence. Here, we used targeted serum lipidomics to identify a new panel of GPCs, and tested whether any of these GPCs are associated, in adolescence, with classical risk factors of CVD, namely excess visceral fat (VF), elevated blood pressure, insulin resistance, and atherogenic dyslipidemia.Methods:We studied a population-based sample of 990 adolescents (12–18 years, 48% male), as part of the Saguenay Youth Study. Using liquid chromatography-electrospray ionization-mass spectrometry, we identified 69 serum GPCs within the 450 to 680m/zrange. We measured VF with MRI.Results:We identified several novel GPCs that were associated with multiple CVD risk factors. Most significantly, PC16:0/2:0 was negatively associated with VF (P=1.4×10–19), blood pressure (P=7.7×10–5), and fasting triacylglycerols (P=9.0×10–5), and PC14:1/0:0 was positively associated with VF (P=3.0×10–7), fasting insulin (P=5.4×10–32), and triacylglycerols (P=1.4×10–29). The Sobel test of mediation revealed that both GPCs mediated their respective relations between VF (as a potential primary exposure) and CVD risk factors (as outcomes,Pvalues&lt;1.3×10–3). Furthermore, a GPC shown recently to predict incident coronary heart disease in older adults, PC18:2/0:0, was associated with several CVD risk factors in adolescents; these associations were less strong than those with the newly identified GPCs.Conclusions:We identified novel GPCs strongly associated with multiple CVD risk factors in adolescents. These GPCs may be sensitive indicators of obesity-related risk for CVD outcomes in adults, and may improve biological understanding of CVD risk.

Self-Management of Heart Disease in Older Adults

The American Heart Association estimates that 81% of people who die of coronary heart disease are 65 years old or older. The leading risk health behaviors include physical inactivity, poor diet, smoking, and binge drinking. Using the 2011–2012 California Health Interview Survey (CHIS), this study looked at how self-management, which includes a plan developed by a medical professional and the confidence to manage one’s disease, may decrease negative risk behaviors in older adults. The presence of a plan and increased self-efficacy decreased engagement in negative dietary behaviors and low physical activity. Implications for strategies that address heart disease and self-management are discussed.

Association Between 6-Minute Walk Test and All-Cause Mortality, Coronary Heart Disease–Specific Mortality, and Incident Coronary Heart Disease

To examine the association between 6-min walk test (6 MWT) performance and all-cause mortality, coronary heart disease mortality, and incident coronary heart disease in older adults. We conducted a time-to-event analysis of 1,665 Cardiovascular Health Study participants without prevalent cardiovascular disease with a 6 MWT. During a mean follow-up of 8 years, there were 305 incident coronary heart disease events, and 504 deaths of which 100 were coronary heart disease-related deaths. The 6 MWT performance in the shortest two distance quintiles was associated with increased risk of all-cause mortality (290-338 m: hazard ratio [HR] = 1.7; 95% confidence interval [CI] = [1.2, 2.5]; <290 m: HR = 2.1; 95% CI = [1.4, 3.0]). The adjusted risk of coronary heart disease mortality incident events among those with a 6 MWT < 290 m was not significant. Performance on the 6 MWT is independently associated with all-cause mortality and is of prognostic utility in community-dwelling older adults.

What do the recent American Heart Association/American College of Cardiology Foundation Clinical Practice Guidelines tell us about the evolving management of coronary heart disease in older adults?

Biological aging predisposes older adults to increased cardiovascular disease (CHD) and greater disease complexity. Given the high age-related prevalence of CHD and age-related compounding factors, the recently updated American Heart Association/American College of Cardiology Foundation CHD-related guidelines increased their focus on older patients. These guidelines are predominately evidence-based (using data from quality randomized clinical trials) and are organized to delineate medications and procedures that best treat particular cardiovascular diseases. While such rationale and thought work well in young and middle aged adults, they become problematic in patients who are very old. Data pertaining to adults aged ≥ 80 are virtually absent from most randomized clinical trials, and even in the instances when very old patients were included, eligibility criteria typically excluded candidates with co-morbidities and complexities of customary CHD patients. While medications and interventions yielding benefit in clinical trials should theoretically produce the greatest benefits for patients with high intrinsic risk, age-related cardiovascular complexities also increase iatrogenic risks. Navigating between the potential for high benefit and high risk in “evidence-based” cardiovascular management remains a key Geriatric Cardiology challenge. In this review we consider the expanded Geriatric Cardiology content of current guidelines, acknowledging both the progress that has been made, as well as the work that still needs to be accomplished to truly address the patient-centered priorities of older CHD patients.

Valvular Heart Disease in Older Adults: Evolving Technology to Meet the Needs of Aging Patients

Valvular heart disease is associated with aging and the incidence is increasing as the population ages. Aortic stenosis and mitral regurgitation represent the majority of valvular disease in older adults. Severe valvular disease is associated with the development of heart failure, arrhythmia and death. Unfortunately, medical therapy is ineffective for the treatment of severe symptomatic valvular disease. As a result of advances in surgical techniques and catheter-based technologies, older adults who were once deemed ‘too old/sick’ are now being offered definitive treatment. However, the presence of comorbidities and frailty in the elderly make patient selection difficult and prediction of overall response to therapy less reliable compared with younger patients. In the elderly, goals of therapy may differ, with an emphasis placed on quality of life, functionality, maintaining independence and palliation of severe symptoms rather than increased longevity. We review the epidemiology and treatment approaches for valvular heart disease in older adults.

Fatigue, General Health, and Ischemic Heart Disease in Older Adults

Fatigue has been shown to predict ischemic heart disease (IHD) and mortality in nonsmoking middle-aged men free of cardiovascular disease. The aim of this study was to investigate the predictive value of fatigue for IHD and general health in nondisabled individuals free of cardiovascular disease and older than 70 years. The study population was drawn from The Longitudinal Study of Aging Danish Twins. In total, 1,696 participants were followed up for 2-10 years by questionnaires and 10-16 years through registries. Kaplan Meier, Cox Proportional Hazard and logistic regression were used to analyze data. Fatigue was measured with the mobility-tiredness scale, and multivariable-adjusted models included age, sex, socioeconomic position, life style factors, and depression symptomatology. Good general health was defined as no hospitalization due to IHD, no self-reported IHD-related diagnoses, no use of heart medication, sustained good mobility, and participation at follow-up. IHD was defined as first hospitalization due to IHD (ICD10: I20-I25) or death due to IHD as primary cause. Participants without fatigue had higher chances of a sustained good general health at 2 (odds ratio [OR] = 1.45 confidence interval [CI] 95%: 1.08-1.93) and 4 years of follow-up (OR = 1.55 CI 95%: 1.11-2.16), compared with participants with fatigue. Further, participants with fatigue had a significantly higher hazard of IHD during the 10-16 years of follow-up (hazard ratio [HR] = 1.47 CI 95%: 1.08-2.00) compared with participants without fatigue. We concluded that fatigue in nondisabled older adults free of cardiovascular disease is an early predictor for development of subsequent poor general health and IHD.

Framingham Risk Score and Alternatives for Prediction of Coronary Heart Disease in Older Adults

BackgroundGuidelines for the prevention of coronary heart disease (CHD) recommend use of Framingham-based risk scores that were developed in white middle-aged populations. It remains unclear whether and how CHD risk prediction might be improved among older adults. We aimed to compare the prognostic performance of the Framingham risk score (FRS), directly and after recalibration, with refit functions derived from the present cohort, as well as to assess the utility of adding other routinely available risk parameters to FRS.MethodsAmong 2193 black and white older adults (mean age, 73.5 years) without pre-existing cardiovascular disease from the Health ABC cohort, we examined adjudicated CHD events, defined as incident myocardial infarction, CHD death, and hospitalization for angina or coronary revascularization.ResultsDuring 8-year follow-up, 351 participants experienced CHD events. The FRS poorly discriminated between persons who experienced CHD events vs. not (C-index: 0.577 in women; 0.583 in men) and underestimated absolute risk prediction by 51% in women and 8% in men. Recalibration of the FRS improved absolute risk prediction, particulary for women. For both genders, refitting these functions substantially improved absolute risk prediction, with similar discrimination to the FRS. Results did not differ between whites and blacks. The addition of lifestyle variables, waist circumference and creatinine did not improve risk prediction beyond risk factors of the FRS.ConclusionsThe FRS underestimates CHD risk in older adults, particularly in women, although traditional risk factors remain the best predictors of CHD. Re-estimated risk functions using these factors improve accurate estimation of absolute risk.