Why Do Official Guidelines for the Prevention of Cardiovascular Disease Stop Short at the Age of 80?

Heinz Redwood
June 16, 2000 (Reviewed: December 11, 2002)

Diseases of the blood circulation include ischaemic heart disease (leading to heart attacks) and cerebrovascular disease (leading to stroke). The most prominent, measurable risk factor pointing towards these outcomes is hypertension (high blood pressure).

Worldwide, ischaemic and cerebrovascular diseases were the two leading causes of death in 1990 and have been are forecast still to remain be the 'Top-2' in 2020. In their comprehensive study of "The Global Burden of Disease"¹, Murray & Lopez (1996) estimated that the two diseases will be responsible for about 37% of all deaths [34% for men and 40% for women] in the Developed Regions and 25% in the Developing Countries in 2020. In that year, about 5.7 million persons are forecast to die from the two diseases in the Developed Regions and 14.5 million in the Developing Countries.

Cardiovascular 'disability' and the elderly

The two diseases are also expected to be the two leading causes of 'life with disability' in 2020. Since about two-thirds of the disability burden of cardiovascular disease is borne by persons over the age of 60 (59% of men's disability,75% of women's), this will badly affect the quality of life of the elderly unless preventive measures are taken effectively, extensively and in good time.

Mortality statistics for cardiovascular diseases, not surprisingly, put an even more dramatic emphasis on the elderly. For example, In France in 1996, only 25.5% of deaths from cardiovascular disease occurred in persons under the age of 75. Yet the focus of French health policy is to achieve major reductions in cardiovascular mortality of the under-75s: a target for 20% fewer deaths that are regarded as 'premature' [i.e. among the under-75s] was set in 1994 for the year 2000 (Haut Comité de la Santé; Publique², 1998). While the avoidance of premature deaths is an understandable objective, there is no objective reason for applying a lower preventive priority to the aged majority of sufferers with cardiovascular diseases. Modern methods of prevention can be applied and made effective without age discrimination. Indeed, the 'very old' should have the same right of access to preventive medicine as anyone else.

Moreover, there is increasing recognition of the fact that prevention and treatment of the elderly will need to differ from measures that are appropriate for younger age groups, but this is only beginning to be reflected in the translation of risk factors into practical preventive Guidelines.

Risk Factors

Hypertension is a baffling condition in several respects: for primary or 'essential' hypertension, "in about 95% of cases, no cause can be established", and "mild to moderate essential hypertension is usually associated with normal health and well-being for many years" ("Current Medical Diagnosis and Treatment"³; ,1999).

This being so, risk factors leading to hypertension and eventually cardiovascular diseases have been studied in depth and represent a vitally important element in defining preventive guidelines. Apart from the 'unmanageable' aspects of age, gender, genetics, and poverty, the following are widely accepted as prime manageable risk factors for cardiovascular diseases:

* smoking
* obesity
* high levels of alcohol consumption
* unsuitable nutrition
* lack of physical exercise
* elevated total and low density lipoprotein [LDL] cholesterol

[For the background to Risk Factors, see two papers by R. W. Griffith] ⁴

'Manageable' and 'unmanageable' risks

Evidently, the 'manageable' risk factors are associated with lifestyles, and several of them can be inter-linked: for example, unsuitable nutrition with obesity and/or high cholesterol levels, and obesity with lack of physical exercise. Guidelines generally stress the need for lifestyle changes as a first step in controlling the 'manageable' risk factors before resorting to medical interventions and treatment with prescription drugs.

The 'unmanageable' risk factors, too, will often benefit from changes in lifestyle - for example, in old age, but may require early medical treatment in order to prevent the more serious consequences of established hypertension or the worsening of cardiovascular disease. This can be vitally important for elderly patients who have other illnesses that are themselves risk factors for cardiovascular problems, such as diabetes and kidney failure.

Guidelines for the elderly

Although cardiovascular morbidity and mortality are prominently, even predominantly, problems associated with old age, national and international guidelines for the management of hypertension have only recently begun to include guidance that is specifically directed at the elderly or 'very old' segment of the hypertensive population. Whether past neglect was a symptom of 'ageism' or merely an assumption that hypertension and cardiovascular disease were conditions of old age anyway and therefore did not need an age focus, is unclear. What matters is that the special needs and problems of the elderly are now being included in guidelines.

The 1999 Guidelines of WHO [World Health Organisation] - International Society of Hypertension have a section devoted to the "very elderly" and draw attention to the fact that there is as yet very little evidence about the health impact of antihypertensive treatment on patients above the age of 80. Up to that age, benefits and safety do not differ significantly between younger and older patients, "although the absolute effects are typically greater in older individuals because of their higher risk of cardiovascular events" (Guidelines Subcommittee⁵, 1999). The Subcommittee considers the value of antihypertensive treatment of the over-80s as 'uncertain' pending the results of new clinical trials of (or including) the very old.

The absence of such evidence in today's sophisticated health care systems is both incomprehensible and inexcusable. Considering the fact that the over-85s are now the fastest growing segment of the population in the Industrialised World, the sooner evidence is produced, the better.

In the USA, the Sixth Report of the Joint National Committee on...High Blood Pressure (1997) ⁶ adopts a much more practical approach to 'Hypertension in older persons' (i.e. over the age of 60). It draws attention to the fact that systolic blood pressure will predict cardiovascular disease events in the elderly more reliably than the measurement of diastolic pressure, and that the latest evidence suggests that pulse pressure may be an even better marker.

The Report also advises doctors to take special care with measuring the blood pressure of older patients so as to avoid misdiagnosis of pseudohypertension which arises from stiffening of blood vessels, or so-called 'white-coat' hypertension. The latter is a nervous reaction to having your blood pressure tested in the white-coat atmosphere of the doctor's office; it affects the elderly more than younger patients and gives misleadingly high readings of blood pressure.

The Report cites positive evidence of the absolute benefits of antihypertensive treatment of the over-60s. It provides practical guidance by stressing that starting doses of drug treatment should be at about half the dose that would normally be used in younger patients and by pointing out that, for the elderly, some drugs are considerably safer or more effective than others.

The 1999 British Hypertension Society guidelines, too, deal with "elderly hypertensive patients" specifically. In a synopsis of their contents, there is welcome acknowledgment of the fact that, in an ageing society, "it is...important to discuss the elderly as a patient group". The guidelines also advocate antihypertensive treatment of the very old without age discrimination, pointing to its benefits in reducing the risk of heart failure and its possible advantages in helping to preserve cognitive function and reducing the risk of dementia.

"Once started, treatment should be continued after the age of 80. When the initial diagnosis of hypertension is made in a patient older than 80 years, treatment decisions should probably be based on biological rather than chronological age, although there is little evidence to guide treatment policy in this age group" (Williams⁷, 2000).

Once again, firm evidence would help to affirm the case in favour of judgments based on biological age.

In Europe, the Recommendations of the Second Joint Task Force...on Coronary Prevention have also stated clearly that

"Patients who develop symptoms of coronary heart disease for the first time, at any age, should be able to address all aspects of cardiac prevention and rehabilitation according to their individual needs" (Task Fore Report⁸, 1998).

Worth noting: "at any age" and "according to...individual needs" which will differ not only individually but also between the old or 'very old' and younger patients. The report also refers to the absence of firm evidence about the benefits of some risk factor interventions for the 'very elderly' and concludes that "judgment is again required on what action, if any, to take."

Guidelines and their application in clinical practice in Switzerland

A Swiss simulation study (based on 1997 risk factor data) has evaluated the degree to which the latest recommendations by WHO/International Society of Hypertension are being applied in practice. It found that, in terms of drug treatment of hypertension and dyslipidaemia (high cholesterol), actual treatment was well below guideline levels, and the discrepancy between 'recommended' and 'actual' was most striking for the highest recorded age group (65-74):

Recommended and actual drug treatmant
(Swiss model. % of persons treated, 1997)

Age	55-64	65-74
Hypertension - men
Guidelines	40	63
Actual	17	29
Hypertension - women
Guidelines	30	49
Actual	21	32
Dyslipidaemia - men
Guidelines	43	30
Actual	6	7
Dyslipidaemia - women
Guidelines	30	50
Actual	4	5

(Source: Wietlisbach, Rickenbach and Paccaud⁹, March 2000) The table shows that, even for hypertension where drug treatment has been available since the 1950s, only about two-thirds of men and women judged eligible by the international guidelines actually received medication. For high cholesterol, only a tiny minority was treated with drugs in 1997: less than a quarter of men aged 65-74 and just one-tenth of women in that age group.

The report, whilst acknowledging the large under-utilisation gap, also expresses the view that the reality of medical practice is usually more complex than allowed for in guidelines. The 'ideal' practice conditions on which guidelines are based are not replicated in real life: screening is not universal, doctors do not observe recommendations to the letter, and compliance by patients is less than perfect.

Moreover, the authors consider that the international guidelines, based mainly on conditions in the USA, are not necessarily relevant to conditions elsewhere and may therefore be encouraging
excessive use of intensive treatments, especially in countries - including Switzerland - where 'The French Paradox' applies: high cholesterol and low cardiovascular mortality!

With regard to the elderly, the authors of the Swiss Report also criticise the implied intensity of giving medication for both hypertension and high cholesterol to those patients whose hypertension and cholesterol levels are moderate rather than elevated.

In spite of these imperfections and the need to adapt international guidelines to national requirements, the report considers that clinical practice in Switzerland falls far short of what is required in the way of preventive medication, and recommends a blend between "adopting and adapting" the existing guidelines. This would seem to be a wise approach to the treatment of elderly patients.

Footnotes
1. The Global Burden of Disease ed. Murray, A. D. Lopez, Harvard School of Public Health, WHO, World Bank, 1996
2. Haut Comité de la Santé Publique, "La santé en France 1994-1998", La Documentation Française
3. Current Medical Diagnosis and Treatment ed. Lawrence, M. Tierney,  et al., Appleton and Lange, Stamford, Connecticut, 1999
4. "Risk Factors (1) and (2)", R.W. Griffith, http://www.healthandage.org/PHome/gm=20!gc=36!l=2!gid2=608 and http://www.healthandage.org/PHome/gm=20!gc=36!l=2!gid2=612
5. Guidelines Sub-Committee, "1999 WHO-International Society of Hypertension Guidelines for the Management of Hypertension", J of Hypertension, 1999, 17, p151:153
6. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, Arch. Intern. Med., 1997, 157, p2413
7. The 1999 British Hypertension Society guidelines: A synopsis B. Williams, Modern Hypertension Management, 2000, pp. S3--S12
8. Prevention of coronary heart disease in clinical practice - Recommendations of the Second Joint Task Force of European and other Societies on coronary prevention  Task Force Report, European Heart J., 1998, pp. 1424--1503
9. Traitement de l'hypertension, de la dyslipidémie et de l'obésité en Suisse: faut-il adopter ou adapter de nouvelles recommendations internationales? V. Wietlisbach, M. Rickenbach, F. Paccaud, Médecine et Hygiène, 2000, pp. 586--593

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