Overview

Ensure you are familiar with the principles outlined in Managing cardiovascular disease in frail older people.

CHD and older people

The burden of coronary heart disease increases with age. Reducing cardiovascular risk through lifestyle measures can be recommended regardless of age or frailty but should be considered in line with patient preferences and life expectancy.

Compared to younger adults, the heterogeneity between frail and fit older people with regards to physical and functional status, results in a wider variation in CVS risk and life expectancy:

• a study in the Netherlands has called for a shift from the strict 10-year CVS risk to a patient centred approach that is based on lifetime benefit
• current tools overestimate the risk of CVD in frail older people and they propose a new tool (UPrevent) that is specifically tailored to older people

British Heart Foundation produce excellent patient friendly resources which are often available in a choice of languages to assist your consultations.

Primary or secondary prevention

It is important to determine whether you are considering primary prevention or secondary prevention (i.e. patients with established cardiovascular disease such as coronary heart disease, stroke or TIA or peripheral arterial disease), when thinking about prescribing medication to reduce cardiovascular risk.

In assessing benefits, the pre-treatment risk (e.g. primary or secondary prevention), and the burden of treatable risk factors and competing risks of mortality from other causes should also be taken into account.

Using antiplatelets

Consider stopping aspirin for primary prevention

If aspirin is currently prescribed for older people and/or frail patents for primary prevention of atherosclerotic cardiovascular disease, this should be reviewed in discussion with the patient.

Alternative antiplatelets

For patients intolerant to aspirin and where an alternative antiplatelet has been prescribed, review and discuss with the patient and consider its continued suitability.

Further information

A  summary of clinical trials and an algorithm for the place of aspirin was published in Circulation in 2019.

Stable Angina

Stable angina should be managed medically with the aim to reduce symptoms:

• this may involve the use of beta-blockers, calcium channel blockers, nitrates or other anti-anginals
• patients should be supplied with GTN tablets/spray and they or their carer be confident in their use
• blood pressure and heart rate should also be managed with the aim of reducing symptoms

Medication should be reviewed because they may no longer be required as mobility decreases in frailty.

Acute Coronary Syndromes

Many older people with acute coronary syndrome will undergo coronary intervention (angioplasty and stents) and this can be a lifesaving treatment:

• this will require a period of dual antiplatelets (DAPT)
• a clear plan on duration should be advised by secondary care
• gastro-protection with a proton pump inhibitor is recommended with DAPT in this high risk cohort
• avoid omeprazole/esomeprazole if the DAPT regimen includes clopidogrel due to the potential drug interaction

Medical management (prescription of medication rather than an interventional procedure) may be more appropriate with increasing frailty. This would be decided with the patient by the attending medical team.

Lipid Modification

Lipid modifying medicines should generally not be initiated in patients with a life expectancy less than 2 years. Before initiating lipid lowering therapy, discuss the following with the patient:

• estimated lifetime risk of CVS
• risks of ADEs
• patient preferences

Deprescribing

Consider deprescribing lipid modifying medication:

• the patient may have taken their medication for a long enough period to accrue benefits
• consider on a case-by case basis

Adverse effects of statins

The most widely quoted adverse effects of statins are muscular aches and pains and although this can result in serious muscle toxicity and rhabdomyolysis, this is in fact extremely rare:

• the adverse effects are dose related so a reduction in dose or switching to an alternative statin can often overcome these effects
• frail older people with multimorbidity are more likely to be at risk from muscle ADEs (8-11% in real life compared to 1-5% in clinical studies), polypharmacy and drug interactions with statins
• the decision to discontinue a statin for primary prevention in older people and/or fraility should be made taking into account the patient preferences

Further information

The following resources are available:

• NICE has a useful resource for treatment effects for multimorbidity
• A guide to deprescribing statins has been produced by the Australian Deprescribing Network
• Statins for primary prevention in older people provides an overview of the suitability of statins in this population

When to refer

Consider referral to specialist care if symptoms persist or for further advice.

Case study

Adverse effects

Patient

An 84-year old man living with moderate to severe frailty, multiple morbidities and polypharmacy (21 medicines).

Medication history

He was prescribed seven different cardiovascular medicines including simvastatin tablets 20mg.

Issues identified

He suffered with shortness of breath and severe intermittent claudication which limited mobility and activities of daily living.

During the medication review it was discovered that he was experiencing myalgia and nightmares (adverse effects of simvastatin) both of which were causing significant distress.

Outcome

Through shared decision-making discussions with patient and the STOPPFrail criteria, it was agreed to stop the simvastatin as he prioritised his mobility and sleep over the potential long-term benefits.