Elderly patients with ischaemic heart disease need our attention!

The world population is aging rapidly.1 Cardiovascular diseases are the leading cause of death and major disability in adults aged 75 years and older.2 Despite positive developments in prevention and treatment, this increase in aging already does and will further affect the burden of ischaemic heart disease (IHD) on the healthcare system.1,3,4 Elderly patients with IHD are more likely to have a higher prevalence of cardiovascular risk factors, especially hypertension, diabetes mellitus and dyslipidaemia4 that need our attention. In this group, concomitant diseases such as arthritis, osteoporosis and age-related sarcopenia, as well as low exercise and functional capacity levels, are more frequently diagnosed than in younger populations. These conditions are the main causes of limitations and disability in daily living. A higher prevalence of depression and anxiety, social isolation and lack of social support further affects the health status and quality of life of older individuals with IHD.4,5 Elderly patients have been markedly underrepresented in major cardiovascular trials,2 as well as in secondary cardiovascular prevention and rehabilitation programmes,4,6 resulting in gaps of knowledge with respect to evidence-based care of elderly adults with IHD. Studies on antihypertensive therapy in the elderly demonstrate benefits in preventing strokes and heart failure, as well as major cardiovascular disease.6 The question of whether higher (<150–160/95–105 mmHg) or lower (<140/90 mmHg) blood pressure targets in elderly patients are more beneficial could not be clearly answered in a recently published Cochrane review.7 The results of a randomised clinical trial by Marcos-Forniol et al.,8 demonstrate that a secondary prevention programme is effective for elderly patients with IHD. After the 12-month intervention, 34.3% more patients in the intervention group had achieved optimum risk factor control. Adherence to guideline-adapted medication and a Mediterranean diet as well as physical performance improved significantly in the intervention group compared to the control group. In contrast, the intervention did not improve quality of life. During the first three years after termination of the intervention, no effect on mortality and/or hospitalisation was observed. The observed improvements in risk factor control and physical performance are especially notable, as they were achievable with a relatively low additional therapeutic effort. A multidisciplinary team provided the intervention. The latter included recommendations to improve lifestyle, maintenance of physical function and modified drug treatment, if required at baseline. Additional appointments with a physician were carried out at the third, sixth and ninth month after baseline. These results demonstrate that giving our elderly patients more attention and time for individualised recommendations is worth the effort, and can improve their health status, physical function and maintenance of independence. Additional studies are needed to delineate optimal strategies for secondary prevention for older adults, including person-centred treatment goals for blood pressure, lipids and diabetes mellitus. The recently published PreFord-Study9 evaluated the long-term effects of a 15-week risk-adjusted multimodal lifestyle intervention in high-risk subjects. The results reveal that a more intensive intervention effort leads to results that are more pronounced and achieve not only risk factor modification but also a significant reduction in cardiovascular morbidity. Although elderly patients currently account for the majority of cardiac hospital admissions and procedures, they are still underrepresented in cardiac rehabilitation (CR) programmes.4,5 CR programmes for elderly patients are safe and effective.4,5 Beside better risk factor control, the results show benefits in exercise, functional capacity and behavioural characteristics, as well as overall quality of life.4,5 Suaya et al.10 evaluated the effects of CR on survival in a large cohort of older patients with coronary disease. The results demonstrate 21% reduced 5-year mortality in CR users compared to CR non-users.10 The most powerful predictor for enrolment in CR in the elderly is the primary physician’s recommendation. On the other hand, lack of referral is probably the major contributor to the underrepresentation of the elderly in CR.4 Thus, strategies to improve referral must focus on convincing the physician of the benefits of secondary prevention and CR for the elderly. In summary, this elegant study by Marcos-Forniol et al.8 demonstrates that even an effort in counselling elderly patients of moderate intensity results in significant benefits. However, we have clear evidence that more intensified treatment, i.e. in structured rehabilitation programmes, whether home based or centre based, results in additional benefits for this patient population. Our elderly patients deserve the extra effort. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.