CVD Prevention in Older Adults: Crucial and Also Controversial

At the recent American College of Physicians Internal Medicine Meeting 2025 in New Orleans, Ariela Orkaby, MD, MPH, assistant professor of medicine at Harvard Medical School, provided a compact overview on the prevention and management of atherosclerotic cardiovascular disease (ASCVD) in older adults. As our population ages, cardiovascular prevention strategies in this demographic become increasingly crucial, yet remain controversial.

Ariela Orkaby, MD, MPH

Courtesy Brigham & Women's Hospital

Burden of Disease

The global burden of ischemic heart disease disproportionately affects older adults, with the cohort aged older than 75 the most rapidly grown segment of the US population. As Orkaby noted, this population, estimated at approximately 16% in 2011, is expected to reach 22% by 2040.

Current risk calculators are not the best tools for estimating CVD risk when applied to older adults, Orkaby said, given a number of significant limitations. Both the traditional ASCVD Risk Estimator and the newer PREVENT calculator are heavily weighted by age but have upper age limits of 79 years, leaving clinicians without validated tools for many elderly patients. And yet, the average 80-year-old today will likely live another decade, she said, adding that life expectancy estimates only tell part of the story.

Frailty is a Critical CV Risk Factor

"Traditional cardiovascular risk factors in older adults have limited predictive data," Orkaby emphasized, leading in to a discussion of evidence demonstrating the significant relationship between frailty and CV outcomes. Data from the National Health and Aging Trends Study (NHATS) demonstrated that frail older adults face substantially higher risks of adverse cardiovascular outcomes, with mortality rates of 58.6% compared to 14.3% in non-frail individuals.

Similarly striking data from a VA study of more than 3 million veterans showed a dose-response relationship between frailty category and CV mortality:

• Pre-frailty: HR 1.6 (95% CI 1.4-1.9)
• Mild frailty: HR 2.7 (95% CI 2.1-3.3)
• Moderate frailty: HR 4.3 (95% CI 3.3-5.6)
• Severe frailty: HR 7.9 (95% CI 6.2-10.3)

The study researchers found that frailty is independently associated with CV death, myocardial infarction, stroke, and revascularization procedures, even after controlling for pre-existing CVD.

Is Frailty Modifiable?

Interestingly, Orkaby next highlighted data from 3 large international cohorts (CHARLS, ELSA, and HRS) suggesting that frailty may be modifiable through lifestyle interventions:

• Smoking increased frailty risk (HR 1.59-1.84 across studies)
• Exercise decreased frailty risk (HR 0.65-0.71)
• Diet quality decreased frailty risk (HR 0.49-0.70)

"A practical approach to frailty screening in clinic can be as simple as a 4-meter gait speed assessment," Orkaby suggested. "Needing more than 5 seconds to walk 4 meters, ie, less than 0.8 meters per second, indicates frailty."

Statins Remain Controversial

Agreement on the use of statins in older adults depends on the state of an individual’s overall CV health. Secondary prevention with statins in older adults with established ASCVD remains supported by guidelines, with high-intensity or maximal statin therapy recommended even for those over age 75 (Grundy et al., Circulation 2018).

However, primary prevention with statin medications in this population remains controversial, Orkaby explained. The Cholesterol Treatment Trialists' meta-analysis found insufficient data to support statins for primary prevention in adults over 75 (HR 0.92, 95% CI 0.73-1.16).

On the other hand, observational data from 326,981 US veterans aged 75 years and older collected by Orkaby and colleagues showed significant benefits with statin use, including reduced all-cause mortality (HR 0.75, 95% CI 0.74-0.76) and CV death (HR 0.80, 95% CI 0.78-0.81).

An important consideration when prescribing statins in older adults is quality of life. Orkaby described 1 study that examined statin discontinuation at end-of-life and revealed benefits that included improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs, with no difference in mortality. A different study, however, found that stain discontinuation was associated with a 33% increased risk of hospital admission for a CV event in a primary prevention cohort of adults aged 75 and older.

2018 AHA/ACC Guidelines for Primary Prevention in Older Adults

Current clinical guidelines from the American Heart Association and the American College of Cardiology reflect this uncertainty with relatively cautious recommendations, according to Orkaby:

• In adults aged 75 years or older with LDL-C levels of 70-189 mg/dL, initiating moderate-intensity statin may be reasonable (Class IIb, Level B-R)
• In adults aged 75 years or older, it may be reasonable to stop statin therapy when functional decline, multimorbidity, frailty, or reduced life expectancy limits potential benefits (Class IIb, Level B-R)
• In adults aged 76-80 years with LDL-C levels of 70-189 mg/dL, measuring coronary artery calcium (CAC) to reclassify those with a CAC score of zero to avoid statin therapy may be reasonable (Class IIb, Level B-R)

The Future: PREVENTABLE Trial

Looking ahead, Orkaby highlighted the ongoing PREVENTABLE trial, which is enrolling 20,000 adults aged 75 years and older and randomly assigning them to receive atorvastatin 40 mg or placebo. This study will assess dementia-free survival, disability-free survival, and secondarily cardiovascular disease-free survival; frailty-free survival will be assessed in an ancillary study. Results from this trial may provide more evidence for a specific recommendation for primary CVD prevention in this age group.

Special Considerations for Older Adults with CAD

Dr. Orkaby concluded by noting that older adults with diagnosed CAD require special consideration because they:

• May present without classic symptoms
• Face higher risks of under-treatment
• Have increased complication rates (delirium, drug-drug interactions, bleeding, AKI)
• Experience longer hospital stays and non-home discharges
• Derive significant benefit from cardiac rehabilitation

The key takeaway: prevention and management of CVD in older adults is intimately connected to geriatric syndromes and requires a nuanced approach that considers function, frailty, and goals of care alongside traditional CV risk factors.

Orkaby AR. Clinical triad: Atherosclerotic cardiovascular disease: prevention and management in specific populations. ASCVD prevention in older adults. Presented at: American College of Physicians Internal Medicine Meeting 2025; April 3-5, 2025. New Orleans, LA.