Cardiovascular Pharmacotherapy in the Elderly

Volkan AYDINa , N. İpek KIRMIZI SÖNMEZb , Ali Serdar FAKc

aİstanbul Medipol University International Faculty of Medicine, Department of Medical Pharmacology, İstanbul, Türkiye
bBahçeşehir University Faculty of Pharmacy, Department of Pharmacology, İstanbul, Türkiye
cMarmara University Hypertension and Atherosclerosis Research Center, İstanbul, Türkiye

ABSTRACT
Aging has a crucial role in the decline of cardiovascular functions, resulting in a high burden of cardiovascular disease in the elderly. Therefore, older patients represent a substantial part of the clinical trials investigating efficacy/safety of cardiovascular drugs, where sub-analyses by age groups usually yield comparable outcomes. This makes cardiac communities to follow overall same therapeutic strategies independent of the age. Nevertheless, elderly population is a highly heterogenous group with an incremental prevalence of multimorbidity and polypharmacy as the age increases. This contributes to underrepresentation of very old patients in clinical drug trials whose findings need to be cautiously extrapolated to this population in clinical practice. Pharmacological management of such patients should be tailored to their physiological status, frailty, pre-existing conditions, concomitant medications, and specific aspects of the drug in the elderly. In this article, we reviewed key considerations of the frequently used cardiovascular medications when prescribed for the elderly.
Keywords: Cardiovascular agents; antihypertensive agents; anticoagulants; platelet aggregation inhibitors; geriatrics

Referanslar

  1. Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH Guidelines for the management of arterial hypertension, the Task Force for the management of arterial hypertension of the European Society of Hypertension endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens.
  2. Benetos A, Bulpitt CJ, Petrovic M, Ungar A, Agabiti Rosei E, Cherubini A, et al. An expert opinion from the European Society of Hypertension-European Union Geriatric Medicine Society Working Group on the management of hypertension in very old, frail subjects. Hypertension. 2016;67(5):820-5. [Crossref]  [PubMed]
  3. Guasti L, Ambrosetti M, Ferrari M, Marino F, Ferrini M, Sudano I, et al. Management of hypertension in the elderly and frail patient. Drugs Aging. 2022;39(10):763-72. [Crossref]  [PubMed]  [PMC]
  4. Benetos A, Petrovic M, Strandberg T. Hypertension management in older and frail older patients. Circ Res. 2019;124:1045-60. [Crossref]  [PubMed]
  5. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-104. [Crossref]
  6. Aronow WS. Managing hypertension in the elderly: what's new? Am J Prev Cardiol. 2020;1:100001. [Crossref]  [PubMed]  [PMC]
  7. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/ NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-324. [Crossref]
  8. Nguyen QT, Anderson SR, Sanders L, Nguyen LD. Managing hypertension in the elderly: a common chronic disease with increasing age. Am Health Drug Benefits. 2012;5(3):146-53.
  9. Shimamoto K, Ando K, Fujita T, Hasebe N, Higaki J, Horiuchi M, et al. The Japanese Society of Hypertension guidelines for the management of hypertension (JSH 2014). Hypertens Res. 2014;37(4):253-390. [Crossref]  [PubMed]
  10. Banik N, Yang SB, Kang TB, Lim JH, Park J. Heparin and its derivatives: challenges and advances in therapeutic biomolecules. Int J Mol Sci. 2021;22(19):10524. [Crossref]  [PubMed]  [PMC]
  11. Dorobantu M, Bogdan S. Unfractionated heparin or low-molecular-weight heparin in the elderly. Int J Cardiol. 2016;222:1084-90. [Crossref]  [PubMed]
  12. Yang HQ, Liu MC, Yin WJ, Zhou LY, Zuo XC. Safety and efficacy of low molecular weight heparin for thromboprophylaxis in the elderly: a network meta-analysis of randomized clinical trials. Front Pharmacol. 2021;12:783104. [Crossref]  [PubMed]  [PMC]
  13. Proietti M, Laroche C, Opolski G, Maggioni AP, Boriani G, Lip GYH; AF Gen Pilot Investigators. 'Real-world' atrial fibrillation management in Europe: observations from the 2-year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase. Europace. 2017; 19(5):722-33. [Crossref]  [PubMed]
  14. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498. [Crossref]  [PubMed]
  15. Cheung CC, Nattel S, Macle L, Andrade JG. Management of atrial fibrillation in 2021: an updated comparison of the current CCS/CHRS, ESC, and AHA/ACC/HRS guidelines. Can J Cardiol. 2021;37(10):1607-18. [Crossref]  [PubMed]
  16. Zeng S, Zheng Y, Jiang J, Ma J, Zhu W, Cai X. Effectiveness and Safety of DOACs vs. Warfarin in Patients With Atrial Fibrillation and Frailty: A Systematic Review and Meta-Analysis. Front Cardiovasc Med. 2022;9:907197. [Crossref]  [PubMed]  [PMC]
  17. Carnicelli AP, Hong H, Connolly SJ, Eikelboom J, Giugliano RP, Morrow DA, et al. Direct oral anticoagulants versus warfarin in patients with atrial fibrillation: patient-level network meta-analyses of randomized clinical trials with interaction testing by age and sex. Circulation. 2022;145(4):242-55. [Crossref]  [PubMed]  [PMC]
  18. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42(34):3227-37. [Crossref]  [PubMed]
  19. US Preventive Services Task Force; Davidson KW, Barry MJ, Mangione CM, Cabana M, Chelmow D, et al. Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;327(16):1577-84. [Crossref]  [PubMed]
  20. Berger JS. Aspirin for primary prevention-time to rethink our approach. JAMA Netw Open. 2022;5(4):e2210144. [Crossref]  [PubMed]  [PMC]
  21. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-826. [Crossref]  [PubMed]
  22. Martinez BK, White CM. Pharmacologic considerations in the management of acute coronary syndrome in elderly patients. Expert Opin Pharmacother. 2019;20(15):1787-90. [Crossref]  [PubMed]
  23. Cesena F. Pharmacoinvasive strategy in ST-elevation myocardial infarction: particularities in the elderly. Arq Bras Cardiol. 2023;120(1):e20220885.
  24. Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014;311(23):2414-21. [Crossref]  [PubMed]
  25. Armstrong PW, Zheng Y, Westerhout CM, Rosell-Ortiz F, Sinnaeve P, Lambert Y, et al. Reduced dose tenecteplase and outcomes in elderly ST-segment elevation myocardial infarction patients: Insights from the STrategic Reperfusion Early After Myocardial infarction trial. Am Heart J. 2015;169(6):890-8.e1. [Crossref]  [PubMed]
  26. Bluhmki E, Danays T, Biegert G, Hacke W, Lees KR. Alteplase for acute ischemic stroke in patients aged >80 years: pooled analyses of individual patient data. Stroke. 2020;51(8):2322-31. [Crossref]  [PubMed]  [PMC]
  27. Trigo P, Fischer GW. Managing atrial fibrillation in the elderly: critical appraisal of dronedarone. Clin Interv Aging. 2012;7:1-13. [Crossref]  [PubMed]  [PMC]
  28. 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-81. [Crossref]  [PubMed]
  29. Ferrari F, Santander IRMF, Stein R. Digoxin in atrial fibrillation: an old topic revisited. Curr Cardiol Rev. 2020;16(2):141-6. [Crossref]  [PubMed]  [PMC]
  30. Zhou J, Cao J, Jin X, Zhou J, Chen Z, Xu D, et al. Digoxin is associated with worse outcomes in patients with heart failure with reduced ejection fraction. ESC Heart Fail. 2020;7(1):138-46. [Crossref]  [PubMed]  [PMC]
  31. Ahmed A, Gambassi G, Weaver MT, Young JB, Wehrmacher WH, Rich MW. Effects of discontinuation of digoxin versus continuation at low serum digoxin concentrations in chronic heart failure. Am J Cardiol. 2007;100(2):280-4. [Crossref]  [PubMed]  [PMC]