Coronary Heart Disease Risk Factors in the Elderly

Hypertension, dyslipidemia, impaired glucose tolerance, and obesity remain the major modifiable risk factors for most of the coronary disease afflicting the elderly. The relative risk associated with these established risk factors diminishes with advancing age, but this is offset by a greater absolute and attributable risk. Diabetes is increasing alarmingly in prevalence and operates more powerfully in women, eliminating their coronary disease resistance (relative to men). Interest in this entity now focuses on the insulin resistance syndrome promoted by abdominal obesity that has become so common in the elderly. The isolated systolic hypertension and large pulse pressure that predominate in the elderly is now recognized as a coronary disease hazard. Dyslipidemia, characterized by a high total to high-density lipoprotein cholesterol ratio, is the most predictive lipid profile for coronary disease in the elderly. High triglycerides, accompanied by low high-density lipoprotein cholesterol usually signifies insulin resistance and more atherogenic, small, dense low-density lipoprotein. Left ventricular hypertrophy is an ominous harbinger of coronary disease. Fibrinogen and the leukocyte count are correlated coronary disease risk factors that may indicate unstable lesions. Novel risk factors, such as hemostatic factors, homocysteine, lipoprotein(a), C-reactive protein, and hyperinsulinemia, are worthy of attention, but the efficacy of correcting them in the elderly has not yet been demonstrated. Nor has the efficacy of hormone replacement therapy in women. All the coronary risk factors tend to cluster, and the hazard posed by each is greatly influenced by the burden of coexisting risk factors. High-risk elderly candidates for coronary disease can be efficiently targeted for treatment by global risk assessment, using only the major established risk factors. The distinction between primary and secondary prevention in the elderly is less clear than in the middle-aged because they often have advanced presymptomatic vascular pathology that imposes a coronary event rate comparable to that of the middle-aged who have already sustained a clinical event. Declines in coronary mortality rates in the United States have included the elderly, justifying optimism about the efficacy of preventive measures. Most of the elderly have sufficient remaining life expectancy to warrant vigorous preventive management. Trials of risk factor modification in the elderly indicate that decades of exposure to modifiable risk factors can be countered by measures implemented late in life.