Drugs Aging 2005; 22 (10): 859-876

ORIGINAL RESEARCH ARTICLE 1170-229X/05/0010-0859/$34.95/0

 2005 Adis Data Information BV. All rights reserved.

Prevention of Cardiovascular Events

in Elderly People
Wafik Farah Andrawes, Caroline Bussy and Joël Belmin
Service de Gériatrie, Hôpital Charles Foix et Université Paris 6, Ivry-sur-Seine, France

Abstract Background and objective: Cardiovascular disease has been identified as the
leading cause of morbidity and mortality in developed countries. Given the
increase in life expectancy and the development of cardiovascular preventive
measures, it has become increasingly important to detect and prevent cardiovascu-
lar diseases in the elderly. We reviewed the scientific literature concerning
cardiovascular prevention to assess the importance of cardiovascular preventive
measures in old (≥65 years of age) individuals.
Methods: We undertook a systematic search for references relating to prevention
of cardiovascular disease in the elderly, mainly ischaemic stroke, coronary artery
disease and heart failure, on the MEDLINE database 1962–2005. For cardiovas-
cular prevention by drugs or surgery, emphasis was placed on randomised
controlled trials, review articles and meta-analyses. For cardiovascular prevention
by lifestyle modification, major cohort studies were also considered.
Results: Stroke, coronary heart disease and heart failure were found to be the
main targets for cardiovascular prevention in published studies. Antihypertensive
treatment has proven its efficacy in primary prevention of fatal or nonfatal stroke
in hypertensive and high-risk patients >60 years of age, particularly through
treatment of systolic hypertension. Systolic blood pressure reduction is equally
important in the secondary prevention of stroke. Similarly, in nonvalvular atrial
fibrillation, an adjusted dose of warfarin with a target International Normalized
Ratio (INR) of between 2 to 3 prevents ischaemic stroke in elderly patients with an
acceptable haemorrhagic risk but is still under prescribed. Antiplatelet agents are
indicated in elderly patients with nonembolic strokes. Few large-scale studies
have investigated the effect of HMG-CoA reductase inhibitors (statins) on stroke
prevention in old individuals. To date, the largest trials suggest a beneficial effect
for stroke prevention with use of statins in high-risk elderly subjects ≤82 years of
age. Carotid endarterectomy is indicated in carotid artery stenosis >70% and
outcomes are even better in elderly than in younger patients. However, medical
treatment is still the first-line treatment in asymptomatic elderly patients with
<70% stenosis. In ischaemic heart disease, different trials in elderly individuals
have shown that use of statins, antithrombotic agents, β-adrenoceptor antagonists
and ACE inhibitors plays an important role either in primary or in secondary
cardiovascular prevention. Hormone replacement therapy has been used to treat
climacteric symptoms and postmenopausal osteoporosis and was thought to
confer a cardiovascular protection. However, controlled trials in elderly individu-
als changed this false belief when it was found that there was no benefit and even a
860 Andrawes et al.

harmful cardiovascular effect during the first year of treatment. Smoking cessa-
tion, regular physical activity and healthy diet are, as in younger individuals,
appropriate and effective measures for preventing cardiovascular events in the
elderly. Finally, antihypertensive treatment and influenza vaccination are useful
for heart failure prevention in elderly individuals.
Conclusions: Cardiovascular prevention should be more widely implemented in
the elderly, including individuals aged ≥75 years, and this might contribute to
improved healthy status and quality of life in this growing population.

Cardiovascular diseases are related essentially to
atherosclerosis, which starts to develop early in life
and has a slowly progressive course.[1] Over many
years, a number of studies have shown that dys-
lipidaemia is the major determinant of the pathogen-
esis of atherosclerosis by promoting atherogenesis
and accelerating plaque development.[2,3] These
findings suggest that prevention of atherosclerosis
should primarily be aimed at young or middle-aged
individuals.
However, the problem of atherosclerosis is de-
pendent not only on dyslipidaemia. In particular,
several processes strongly associated with advanc-
ing age promote the development of complications
of atherosclerosis and help determine clinical
events. Many epidemiological studies have clearly
shown that other risk factors common in the elderly,
such as hypertension, obesity, diabetes mellitus/glu-
cose intolerance and sedentary lifestyle, influence
atherosclerosis and its complications.[4-6] In particu-
lar, hypertension plays a major role by favouring
plaque rupture with resultant thrombosis and
clinical complications. Inflammation, which is also
a common condition in the elderly, plays a key role
in the development of atherosclerosis[7] and immu-
nocompetent cells are involved in many steps of the
atherosclerotic process. The first visible lesions of
atherosclerosis consist of macrophage-derived foam
cells that contain lipid droplets, and monocytes/
macrophages may play a major role in the later
stages of atherosclerosis.[8-10] Thrombotic condi-
tions are also common in elderly patients and are
directly involved in the onset of clinical complica-
tions. In many cases, the pathogenesis of cardiovas-
cular diseases in elderly subjects is directly related
to thrombosis as a complication of systemic em-
bolisation (for example in cases of atrial fibrillation)
or indirectly when the thrombus complicates athero-
sclerotic changes of vessels. Thus, many targets can
be identified for preventing the complications of
atherosclerosis in the elderly.
With cardiovascular disease having been identi-
fied as the leading cause of morbidity and mortality
in developed countries over recent decades, preven-
tion of cardiovascular disease has emerged as a
major goal of public health. Historically, prevention
of cardiovascular disease commenced with antihy-
pertensive therapy and detection and treatment of
hypercholesterolaemia, focusing mainly on middle-
aged adults. As life expectancy increased and epide-
miological studies progressed, it became more and
more obvious that the burden of cardiovascular dis-
ease in the elderly is considerable. However, little
attention was paid to preventive medicine in elderly
people until recent years, probably because of a false
belief that prevention is too late to be effective in
elderly individuals. In fact, evidence from scientific
studies, namely randomised, controlled trials, shows
not only that cardiovascular prevention is effective
in the elderly, but that it also results in a greater
number of avoided events than in younger individu-
als (figure 1). Moreover, cardiovascular prevention
in the elderly should take into consideration not only
hypertension and dyslipidaemia but also other risk
factors, such as atrial fibrillation, carotid artery ste-
nosis and smoking.
We reviewed the scientific literature relating to
prevention of cardiovascular diseases – primarily
ischaemic stroke, coronary artery disease and heart
failure – in the elderly, with special emphasis on
randomised, controlled studies. We used a systemat-
ic search for references from the MEDLINE

 2005 Adis Data Information BV. All rights reserved. Drugs Aging 2005; 22 (10)
Prevention of Cardiovascular Events in Elderly People 861

a 100 100 Control causes of death.[11] It is also a major cause of disabil-

100 Intervention
ity in at least 15 million patients annually.[12]
80 About 80% of strokes are a result of an ischaemic
Relative risk (%)

60 60
60 event, of which 50% of cases are related to ather-
othrombotic diseases of intra- or extracerebral arter-
40
ies, about 20% are related to embolism of cardiac
20 origin and 25% are a result of occlusion of one of the
0 small deep perforating cerebral arteries.[13] Hyper-
tension, heart disease and thoracic aorta and carotid
b
atherosclerosis are the main aetiologies of ischaemic
(events per 1000 patient-years)

60 stroke in the elderly.

50
50
Antihypertensive Treatment in Elderly
Absolute risk

40
30
20
10 * Antihypertensive Drugs for Primary Prevention of
10 6
0 A number of randomised studies have demon-
Middle-aged Old
Fig. 1. Comparison of results expressed as relative risk reduction
(a) and absolute risk reduction (b) for an intervention producing a
40% reduction in relative risk of cardiovascular events in middle-
aged and old individuals. When results are expressed as number of
events avoided, the efficacy of cardiovascular prevention in the
elderly is obvious. This pattern is often observed in intervention
trials of cardiovascular prevention, as incidence rates of cardiovas-
cular events often increase with age. * indicates four events avoid-
ed; ** indicates 20 events avoided.
database (1962–2005) using the key words: ‘elder-
ly’, ‘cardiovascular diseases’, ‘prevention’, ‘stroke’,
‘coronary heart disease’ and ‘heart failure’. For car-
diovascular prevention by drugs or surgery, we fo-
cused our analysis on randomised controlled trials,
review articles and meta-analyses. For cardiovascu-
lar prevention by lifestyle modification, we also
considered major cohort studies. We also identified
and obtained references from selected review arti-
cles and major textbooks. Our primary objective
was to determine whether cardiovascular prevention
is effective in elderly subjects.
Prevention of Ischaemic Stroke in
Old Persons
Stroke is responsible for the death of about 5
million individuals per year, which makes cer-
ebrovascular disease one of the most important
**
30 Patients for Stroke Prevention
Stroke in Elderly Hypertensive Patients
strated the efficacy of antihypertensive treatment in
the primary prevention of fatal or nonfatal stroke in
hypertensive patients >60 years of age.[14-16] Several
meta-analyses of these trials have concluded that
antihypertensive treatment is effective in reducing
the risk of fatal and nonfatal stroke in elderly hyper-
tensive patients. Table I shows the results of the
major randomised trials of stroke prevention in eld-
erly hypertensives.
Clearly, the importance of stroke-risk reduction
is related to the extent of blood pressure lowering. In
a meta-analysis of 13 trials conducted on 37 000
patients, it was found that for every 5mm Hg reduc-
tion in diastolic blood pressure there was 9.5%
decrease in cardiovascular morbidity and mortality
outcomes.[30,31] Other investigators focused on sys-
tolic hypertension in patients >60 years of age, some
of whom were up to 80 years of age in some studies.
The results of these studies were analysed in a meta-
analysis conducted by Staessen et al.[32] These inves-
tigators found that, compared with diastolic hyper-
tension, systolic hypertension has a stronger correla-
tion with all-cause mortality (relative risk [RR]
1.14; 95% CI 1.07, 1.21; p = 0.0001) and stroke (RR
1.12; 95% CI 1.02, 1.21; p = 0.02) in untreated
patients. The net reductions with treatment in systol-
ic and diastolic blood pressures expressed as per-
centages of values at baseline were 5.96% (95% CI

 2005 Adis Data Information BV. All rights reserved. Drugs Aging 2005; 22 (10)
862 Andrawes et al.

Table I. Stroke reduction in randomized, placebo-controlled trials of antihypertensive drugs

Trial Treatment Placebo Follow-up Mean age RR (95% CI)
n N n N (years) (years)
β-Adrenoceptor antagonists and/or diuretics vs placebo or no treatment
DUTCH TIA[17] 52 732 62 741 2.6 65 0.85 (0.6, 1.21)
Coope and Warrender[18] 20 419 39 465 4.4 69 0.57 (0.34, 0.96)
MRC OLDER[19] 101 2183 134 2213 5.8 70 0.76 (0.59, 0.98)
TEST[20] 3 372 69 348 2.6 70 1.00 (0.75, 1.35)
EWPHE[21] 32 416 48 424 4.7 72 0.68 (0.44, 1.04)
SHEP[22] 105 2365 162 2371 4.5 72 0.65 (0.51, 0.83)
STOP-Hypertension[23] 30 812 55 815 2.1 76 0.55 (0.35, 0.85)
HYVET[24] 6 386 18 394 1.1 84 0.31 (0.12, 0.79)

ACE inhibitors vs placebo or no treatment

PART-2[25] 7 308 4 309 4 61 1.76 (0.52, 5.94)
SCAT[26] 2 229 9 231 5 61 0.22 (0.05, 1.03)
PROGRESS[27] 307 3051 420 3054 4 64 0.73 (0.64, 0.84)
HOPE[28] 156 4654 226 4652 5 66 0.69 (0.57, 0.84)
HYVET[24] 12 397 18 394 1.1 84 0.63 (0.30, 1.31)

Calcium channel antagonist vs placebo

SYST-EUR II[29] 52 2398 77 2297 2 70 0.58 (0.41, 0.84)
DUTCH TIA = Dutch Transient Ischaemic Attack Trial Study Group; EWPHE = European Working Party on High Blood Pressure in the
Elderly Trial; HOPE = Heart Outcomes Prevention Evaluation; HYVET = Hypertension in the Very Elderly Trial Working Group; MRC
OLDER = Medical Research Council Working Party study in older adults; n = number of events; N = number of participants; PART-2 =
Prevention of Atherosclerosis with Ramipril-2; PROGRESS = Perindopril Protection Against Recurrent Stroke Study; RR = relative risk;
SCAT = Simvastatin/enalapril Coronary Atherosclerosis Trial; SHEP = Systolic Hypertension in the Elderly Program; STOP-Hypertension
= Swedish Trial in Old Patients with Hypertension; SYST-EUR = Systolic Hypertension in Europe II; TEST = TEnormin after Stroke and
Transient ischaemic attack.

5.36, 6.28) and 4.91% (95% CI 4.44, 5.38), respec-
tively. Whatever the antihypertensive used, active
treatment of systolic hypertension was associated
with reductions in total mortality of 17% (95% CI 5,
28; p = 0.008), cardiovascular mortality by 25%
(95% CI 8, 39; p = 0.005), all cardiovascular com-
plications by 32% (95% CI 13, 41; p < 0.001) and
stroke by 37% (95% CI 24, 48; p < 0.001). With
respect to absolute benefits, the number of patients-
to-treat for 5 years to prevent one stroke was 32 in
patients ≥70 years of age versus 99 patients in those
60–69 years of age. In young hypertensive patients
(mean age 52 years), the corresponding number of
persons that needed to be treated for 5 years to
prevent one stroke was about 177.[19,32]
Finally, the role of pulse pressure as a risk factor
for total mortality was indirectly evaluated in this
meta-analysis.[32] The investigators concluded that
although systolic blood pressure was positively cor-
related with higher total mortality (p = 0.0001), the
lower the diastolic pressure at any given level of
systolic pressure the higher the death rate (p = 0.05).
Thus, these investigators highlighted the importance
of pulse pressure and its relationship to total mortali-
ty.
The role of antihypertensive agents in stroke-risk
reduction has also been examined[33] in a recent
review article. Although there was no strong evi-
dence that stroke-risk reduction was importantly
related to the type of antihypertensive drug used,
this meta-analysis found a marginally greater risk
reduction with diuretics and/or β-adrenoceptor an-
tagonists than with ACE inhibitors (RR 0.91; 95%
CI 0.83, 0.99), and with calcium channel antagonists
compared with ACE inhibitors (RR 0.89; 95% CI
0.80, 0.99).
Since most randomised controlled trials have
been conducted in elderly subjects <80 years of age,
there has remained a concern about the efficacy of
antihypertensive drugs in very old hypertensive pa-

 2005 Adis Data Information BV. All rights reserved. Drugs Aging 2005; 22 (10)
Prevention of Cardiovascular Events in Elderly People
tients. A meta-analysis of the effect of reduction of
blood pressure in hypertensive patients ≥80 years of
age was conducted by Gueyffier et al.[34] In five
trials that included 1670 patients of that age, 57
patients developed stroke in the treated group com-
pared with 77 in the control group (RR 0.66; 95% CI
0.48, 0.92; p = 0.014), suggesting that there is no
age threshold above which hypertension should not
be treated. Furthermore, preliminary results from
the ongoing Hypertension in the Very Elderly Trial
Working Group study[24] showed a positive effect of
antihypertensive treatment on fatal and nonfatal
stroke prevention in hypertensive patients >80 years
of age (hazard ratio [HR] 0.47; 95% CI 0.24, 0.91)
with no significant changes in total mortality. These
results confirm the conclusions of the meta-analysis
by Gueyffier et al.[34]
Antihypertensive Drugs for Primary Prevention of
Stroke in Other High-Risk Elderly Subjects
One part of the HOPE (Heart Outcomes Preven-
tion Evaluation) trial[35] investigated the effect of an
antihypertensive drug, namely the ACE inhibitor
ramipril 10 mg/day, on stroke incidence in 9297
patients ≥55 years of age with vascular disease or
diabetes plus an additional risk factor, with a mean
follow-up of 4.5 years. The patients were 66 years of
age on average and about half of them were hyper-
tensive. Stroke occurred in 156/4645 patients
(3.4%) in the ramipril group and in 226/4652 pa-
tients (4.9%) in the control group (RR 0.68; 95% CI
0.56, 0.84). Interestingly, stroke-risk reduction was
not dependent on blood pressure level. Moreover,
cognitive alteration was also significantly reduced
in the ramipril group. It should be noted that in this
study, about half of the patients were ≥65 years of
age and the risk reduction for the composite cardio-
vascular outcome related to ramipril was not only
lower in the elderly subjects, but tended to be greater
than in subjects ≤65 years of age.[28]
Antihypertensive Drugs for Secondary Prevention
of Stroke in Patients with Previous Stroke or
Transient Ischaemic Attack
The PROGRESS (Perindopril Protection Against
Recurrent Stroke Study) collaborative group investi-
gated the effect of blood pressure-lowering with the
 2005 Adis Data Information BV. All rights reserved.
863
ACE inhibitor perindopril for secondary prevention
of stroke among 6105 hypertensive and nonhyper-
tensive patients.[27] A new stroke occurred in 307
patients in the active treatment group compared with
420 patients in the placebo group (RR 28%; 95% CI
17, 38), confirming the importance of blood pres-
sure reduction in the secondary prevention of stroke.
Interestingly, stroke-risk reduction was similar in
hypertensive and normotensive patients.
Anticoagulants for Stroke Prevention in
Elderly Patients with Atrial Fibrillation
Atrial fibrillation is the most prevalent arrhyth-
mia seen by physicians.[36] It is well established that
nonvalvular atrial fibrillation is associated with a
5-fold increased risk in stroke compared with sinus
rhythm.[37] Lip and Lowe[38] stated that the annual
relative risk of stroke is 8–12% in patients who have
atrial fibrillation associated with structural heart dis-
ease, earlier embolic events and thyrotoxicosis, and
in those ≥75 years of age with a history of diabetes
or hypertension. These investigators also found that
patients ≥75 years of age with lone atrial fibrillation
(atrial fibrillation in the absence of clear aetiology
and/or complications) have an annual risk of stroke
of 4–8%.[38]
Preventive treatment of stroke among patients
with atrial fibrillation is based on anticoagulation.
Adjusted-dose warfarin has been shown to be effec-
tive in reducing risks of stroke and thromboembolic
disease in people with nonrheumatic atrial fibrilla-
tion.[39] Meta-analysis according to the intention-to-
treat principle showed that adjusted-dose oral an-
ticoagulation is highly efficacious for the prevention
of all strokes with a risk reduction of 61% (95% CI
47, 71) versus placebo.[40] This reduction was simi-
lar for both primary and secondary prevention. An-
other meta-analysis of four studies of primary pre-
vention in patients >75 years found a comparable
benefit to that demonstrated in younger age
groups.[41] The target of anticoagulation therapy in-
volves obtaining a balance between avoiding is-
chaemic stroke and avoiding haemorrhagic compli-
cations. It is important to provide the lowest ade-
quate intensity of anticoagulation to minimise the
Drugs Aging 2005; 22 (10)
864
risk of bleeding, particularly in elderly patients.
Maximum protection against ischaemic stroke in
atrial fibrillation is probably achieved with an Inter-
national Normalized Ratio (INR) of 2–3.[42,43] An
INR of 1.6–2.5 appears to be associated with incom-
plete efficacy compared with higher intensity an-
ticoagulation.
Aspirin (acetylsalicylic acid) offers only modest
protection against stroke in patients with atrial fibril-
lation. The effect is less consistent than that
achieved with oral anticoagulants.[40]
Older age had been identified as a risk factor for
haemorrhagic complications of anticoagulant ther-
apy in previous studies.[44,45] To clarify this relation-
ship, Palareti et al.[46] conducted a study comparing
subjects >75 years of age with younger patients
(mean age 61 years) taking oral anticoagulants.
These investigators found that the oldest group had a
nonsignificant increase in incidence of major
haemorrhage (2.1% vs 1.1% patient-years; p =
0.19). Conversely, the increase in fatal complica-
tions was statistically significant in the older age
group (1.1% vs 0.2% patient-years in younger indi-
viduals; RR 6.4; p = 0.047). A study by Fihn et al.[47]
reported a 4-fold increase in fatal haemorrhage
among patients >80 years of age compared with
those <50 years of age (3.38 vs 0.75 per 100 patient-
years). Thus, age >75 or 80 years should be consid-
ered a risk factor for warfarin-induced fatal haemor-
rhage, but probably not a risk factor for nonfatal
bleeding. Because of the major impact of stroke on
disability and quality of life in the elderly, the bene-
fit/risk ratio for warfarin seems to favour treatment
of very old individuals when advanced age is the
only risk factor for bleeding. As with younger pa-
tients, other risk factors for warfarin-induced bleed-
ing, such as severe renal and/or hepatic failure,
alcoholism, recent haemorrhage, use of aspirin or
NSAIDs, uncontrolled hypertension, poor compli-
ance with treatment and recreational activities ex-
posing the head to trauma, should be identified.
Thus, the risk of warfarin-induced bleeding should
be assessed taking into account all risk factors and
not just age. Moreover, the risk should be evaluated
against that of stroke and consequent disability.
 2005 Adis Data Information BV. All rights reserved.
Andrawes et al.
Finally, as far as possible, it is also important to
explain these points to the patient and to ask for the
patient’s preference.
Despite the higher risk of stroke in patients >75
years of age with atrial fibrillation and a favourable
benefit-risk ratio, warfarin is still underused. In the
study conducted by Brass et al.,[48] it was found that
among 304 patients with atrial fibrillation and with-
out contraindication for anticoagulation, only 117
(38%) were receiving warfarin. Among elderly peo-
ple with atrial fibrillation, warfarin underuse was
more pronounced in the oldest old. White et al.[49]
observed that among patients with no contraindica-
tions, warfarin was given to 2/13 (15%) of patients
>90 years of age, 15/62 (24%) of those 80–89 years
of age and 46/97 (47%) of those 69–79 years of age.
In a more recent study conducted among benefi-
ciaries of a large healthcare system in northern Cali-
fornia, the rate of prescription of warfarin for
nonvalvular atrial fibrillation patients with no con-
traindication to anticoagulation ranged between
57.0% and 61.1% among patients aged 55–64 years,
65–74 years and 75–84 years, and was 35.6% in
those >85 years of age.[50] Vasishta et al.[51] also
found that prescription of anticoagulants to elderly
patients by physicians is still underused in daily
practice. In a questionnaire exploring physicians’
opinions and attitudes about prescription of antico-
agulants, 46 of 68 respondents (68%) considered
that warfarin-related bleeds were more likely in
patients ≥75 years of age, but 38 (56%) still thought
that the benefits of warfarin outweighed the risks.
Among the 68 clinicians who responded, 84% pre-
scribed warfarin in the presence of high-risk factors
for stroke, 70% for patients with moderate risk
factors and only 45% for patients with lone atrial
fibrillation. Nearly all respondents (94%) agreed
that the risk of bleeding was lowest with an INR of
2–3. The factors influencing prescription of antico-
agulants consisted mainly of the risk of falls and
previous stroke and, to a lesser extent, dementia,
limited life expectancy, age >80 years and drug
interactions. However, the risk of severe haemor-
rhagic complication in older persons with a history
of fall has probably been exaggerated. Man-Son-
Drugs Aging 2005; 22 (10)
Prevention of Cardiovascular Events in Elderly People
Hing et al.[52] found that in persons taking warfarin,
fall-related subdural haematomas were infrequent
and the benefits of warfarin in the prevention of
stroke in elderly patients with nonvalvular atrial
fibrillation greatly exceeded the risk of subdural
haematoma.
Recently, a new line of treatment, the oral direct
thrombin inhibitor ximelagatran, was found to be
effective in preventing thromboembolism in patients
with atrial fibrillation. To compare its efficacy with
warfarin, a randomised, double-blind, multicentre
trial was conducted among 3922 patients (mean age
71.6 years) with nonvalvular atrial fibrillation and
additional stroke risk factors.[53] Adjusted-dose war-
farin (target INR 2–3) or fixed-dose oral ximelaga-
tran 36mg twice daily were administered to patients.
The primary endpoint was all strokes (ischaemic or
haemorrhagic) and systemic embolic events. The
primary event rate with ximelagatran was 1.6% per
year compared with 1.2% per year with warfarin
(absolute difference, 0.45% per year; 95% CI –0.13,
1.03 per year; p < 0.001 for the predefined noninfer-
iority hypothesis). When all-cause mortality was
included in addition to stroke and systemic embolic
events, the rate difference was 0.10% per year (95%
CI –0.97, 1.2 per year; p = 0.86). There was no
difference between treatment groups in rates of ma-
jor bleeding, but total bleeding (major and minor)
was lower with ximelagatran (37% vs 47% per year;
95% CI for the difference, –14, –6.0 per year;
p < 0.001). Serum ALT levels rose to greater than
three times the upper limit of normal in 6.0% of
patients treated with ximelagatran, usually within 6
months, and typically declined whether or not treat-
ment continued; however, one case of documented
fatal liver disease and one other suggestive case
occurred. Since treatment by oral thrombin inhibi-
tors has similar efficacy to anti-vitamin K drugs and
is easier to manage (because of use of fixed doses
and simpler biological surveillance), these drugs are
of great interest for old patients with atrial fibrilla-
tion,[53] and their use in this age group should be
evaluated in appropriate trials that include elderly
patients.
 2005 Adis Data Information BV. All rights reserved.
865
Role of Lipid-Lowering Drugs in Stroke
Prevention in Elderly
Direct evidence relating to the relationship be-
tween hypercholesterolaemia and stroke remains
unclear.
The Asia Pacific Cohort Studies Collaboration
showed that a high total cholesterol level was asso-
ciated with a significantly increased risk of fatal and
nonfatal ischaemic stroke of the order of 25% (95%
CI 13, 40) compared with subjects with normal
cholesterol level.[54] However, risk of thromboem-
bolic stroke was not significantly related to hyperc-
holesterolaemia after adjustment for other risk fac-
tors in men in the Honolulu Heart Program and the
Framingham study.[55]
The Scandinavian Simvastatin Survival Study
Group study of patients with a mean age of 58.1
years and coronary heart disease showed a signifi-
cant reduction in the incidence of stroke in patients
receiving simvastatin (RR reduction 30%;
p = 0.024).[56] In the Cholesterol and Recurrent
Events study,[57] stroke risk was reduced by 32% in
pravastatin-treated subjects (p = 0.03), whereas in
the West of Scotland Coronary Prevention Study,[58]
the reduction in stroke risk was nonsignificant
(11%; p = 0.57).[58] However, the number of old
subjects (>70 years of age) in these trials was small.
Only two large-scale, randomised trials have in-
vestigated the effects of HMG CoA reductase inhib-
itors (statins) in large samples of elderly subjects.
The PROSPER (Prospective Study of Pravastatin in
the Elderly at Risk)[59] trial conducted on 5804 sub-
jects 70–80 years of age with a history of risk factors
for cardiovascular disease found that pravastatin did
not reduce the incidence of stroke compared with
placebo (RR 1.03; 95% CI 0.81, 1.31). However,
there was a trend towards a reduction in transient
ischaemic attack (TIA) risk (RR 0.75; 95% CI 0.55,
1.00; p < 0.051). In the Heart Protection Study,
which included 20 536 individuals 40–80 years of
age (of whom 5806 subjects were ≥70 years of age)
with coronary heart disease, occlusive arterial dis-
ease and/or diabetes, treatment with simvastatin was
associated with a significant reduction in the rate of
fatal and nonfatal stroke (RR 0.75; 95% CI 0.66,
Drugs Aging 2005; 22 (10)
866
0.85; p < 0.0001).[60] Interestingly, in this trial the
risk reduction in vascular disease was similar in
subjects ≥70 years of age compared with younger
subjects.
Overall, even if their conclusions are not in com-
plete agreement, the results of these studies suggest
that statins might provide a beneficial effect in terms
of stroke prevention in high-risk elderly subjects. It
should be noted that if only a few subjects were ≥80
years of age at entry in these trials, many more were
≥80 years of age at the end of follow-up.
Finally, adverse events were reported in similar
frequencies in patients receiving and not receiving
statins with no clear evidence of increasing rate of
cancers in the statin-treated group.[59,60]
Management of Carotid Stenosis
Clinical studies have shown that ischaemic stroke
is influenced by large vessel atherosclerosis, partic-
ularly internal carotid artery stenosis, and increases
with the degree of stenosis.[61,62] Among sympto-
matic patients with 70–99% carotid stenosis >75
years of age, the risk of ipsilateral ischaemic stroke
was higher than in younger patients following medi-
cal treatment. Similarly, the risk of stroke was
greater among older patients with a 50–69% stenosis
under medical treatment than in the younger age
group.
Surgical treatment consisting of carotid endarter-
ectomy has yielded better results in patients ≥75
years of age with 50–99% internal carotid artery
stenosis than in younger patients.[63] Among surgi-
cally-treated patients in the North American Symp-
tomatic Carotid Endarterectomy Trial, the absolute
risk reduction for ipsilateral ischaemic stroke in
patients with 70–99% stenosis was 28.9% (95% CI
12.9, 44.9) in those ≥75 years of age, 15.1% (95%
CI 7.2, 23) in those 65–74 years of age and 9.7%
(95% CI 1.5, 17.9) in those <65 years of age. Among
patients with 50–69% stenosis, the absolute risk
reduction was significant only in those ≥75 years of
age. The absolute risk reduction was 17.3% (95% CI
6.6, 28) versus 5.3% (95% CI 0.1, 10.7) in those
65–74 years of age and –1.2% (95% CI 7.1 4.7) in
those <65 years of age.
 2005 Adis Data Information BV. All rights reserved.
Andrawes et al.
Medical treatment in the form of platelet antiag-
gregation agents and risk factor modification are
most appropriate for symptomatic patients with
<50% stenosis.[64] The Asymptomatic Carotid Ath-
erosclerosis Study Group trial showed that combin-
ing surgical and medical therapy may be beneficial
in asymptomatic patients with 60% stenosis but the
trial investigators concluded that medical treatment
remains the main treatment even when stenosis
reaches 70%.[65]
Antiplatelet Agents for Stroke Prevention in
the Elderly
Antiplatelet agents have been shown to be capa-
ble of reducing risk of stroke in patients with prior
noncardioembolic TIA and stroke compared with
placebo.[66,67] Aspirin, dipyridamole, ticlopidine and
clopidogrel all reduce the risk of stroke when used
for secondary prevention.[68-70] Furthermore, the An-
tiplatelet Trialists’ Collaboration meta-analysis re-
viewed 287 randomised placebo-controlled trials
that included subjects at high risk for cardiovascular
events and concluded that antiplatelet agents re-
duced the risk of stroke by 25%, whether or not
patients had prior stroke or TIA.[71] Unfortunately,
the effects of antiplatelet agents were not reported
by age group. In the 1994 meta-analysis by the
Antiplatelet Trialists’ Collaboration, the reduction
in risk of cardiovascular events with antiplatelet
agents was similar in high-risk subjects ≥65 years of
age to that seen in younger high-risk subjects.[72] In
subjects with hypertension and no prior cardiovas-
cular disease, aspirin was not found to be more
effective than placebo for the primary prevention of
stroke.[73,74]
In a randomised, double-blind trial conducted in
middle-aged (mean age 63 years) patients with prior
history of stroke or TIA, no difference in stroke was
seen in patients receiving aspirin (325 mg/day) com-
pared with those taking warfarin (target INR
1.4–2.8). However, minor bleeding was significant-
ly more frequent in the warfarin group than in the
aspirin group (RR 1.51; 95% CI 1.22, 1.87).[75]
Similar conclusions were reported in a recent Coch-
rane review[76] that evaluated studies comparing me-
Drugs Aging 2005; 22 (10)
Prevention of Cardiovascular Events in Elderly People
dium-intensity anticoagulation with warfarin (target
INR 2.1–3.6) and antiplatelet agents for secondary
prevention of stroke. In these trials, the effects by
age group were not detailed, but because haemor-
rhagic complications of warfarin therapy are known
to increase with age, aspirin appears to be more
appropriate than warfarin for secondary prevention
of nonembolic stroke in the elderly.
Moreover, as indicated in the previous section,
antiplatelet agents were found to be effective in
preventing stroke in asymptomatic patients with
carotid stenosis <70% and might represent the main
treatment for elderly patients with carotid stenosis
>70% who are either ineligible for or refuse surgery.
Prevention of Coronary Heart Disease in
Elderly Patients
Because of increased life expectancy, coronary
heart disease is an increasing cause of morbidity and
mortality in elderly individuals. Trials in elderly
individuals have shown that treatment of hyperten-
sion and use of antithrombotic agents, β-adre-
noceptor antagonists, ACE inhibitors and statins
plays important roles in the primary and secondary
prevention of ischaemic heart disease.
Treatment of Dyslipidaemia
The causal role of elevated serum cholesterol in
the pathogenesis of atherosclerosis and its clinical
complications is well established. Moreover, reduc-
ing serum cholesterol with statins has been shown to
significantly reduce mortality and morbidity from
cardiovascular disease in randomised, controlled
primary and secondary prevention trials.[56,77,78] Tri-
als conducted on elderly subjects have focused only
on secondary prevention. The PROSPER study that
included 5804 vascular patients between 70 and 82
years of age showed that statin therapy significantly
reduced risk of death by coronary heart disease.[59]
In this study, pravastatin lowered low-density lipo-
protein (LDL) cholesterol by 34% and also reduced
the incidence of the primary endpoint (composite of
coronary death, nonfatal myocardial infarction and
fatal or nonfatal stroke) to 408 events in 2891 treated
persons between 70 and 82 years of age compared
 2005 Adis Data Information BV. All rights reserved.
867
with 473 events in 2913 persons who received pla-
cebo (RR 0.85; 95% CI 0.74, 0.97; p = 0.014). The
combined endpoint of coronary heart disease death
and nonfatal myocardial infarction risk was also
reduced (RR 0.81; 95% CI 0.69, 0.94; p = 0.006).
Similarly, in the Heart Protection Study, which
included 20 536 individuals 40–80 years of age,
simvastatin was found to produce a highly signifi-
cant proportional reduction in the incidence of first
nonfatal myocardial infarction or coronary death in
treated patients (27% reduction; 95% CI 21, 33;
p < 0.0001). As mentioned previously, the risk re-
duction in vascular disease in this trial was similar in
subjects ≥70 years of age compared with younger
patients.[60]
Statins appear to act by exerting a plaque-
stabilising effect, not only by lowering LDL choles-
terol but also by reducing the level of isoprenoids,
molecules that play an important role in the metabo-
lism of proteins responsible for cell growth.[79,80]
Statins also have an anti-inflammatory effect and
reduce platelet reactivity,[81,82] roles that are addi-
tional to their antiatherosclerotic effect.
Antithrombotic Therapy for Prevention of
Ischaemic Heart Disease in the Elderly
Platelet activation and thrombin generation are
the key mechanisms in the pathogenesis of acute
coronary syndromes, and antithrombotic therapy is
therefore a cornerstone in their prevention.[83]
Inhibition of platelet aggregation by aspirin has
been found to be effective for preventing myocardial
infarction and cardiovascular death, especially in
postinfarction patients and in those with coronary
heart disease.[71] Moreover, aspirin has also been
found to be effective in the secondary prevention of
vascular events in subjects with vascular disease
and/or hypertension.[72,73]
In the Antiplatelet Trialists Collaboration meta-
analysis,[72] there was a 27% reduction in cardiovas-
cular complications (myocardial infarction, stroke
and vascular deaths) in aspirin-treated versus non-
treated patients and the secondary prevention risk
reduction was similar in middle- as well as old-aged
individuals.
Drugs Aging 2005; 22 (10)
868
Similarly, long-term oral anticoagulation with
warfarin alone or in association with aspirin was
found to reduce cardiovascular events in postinfarc-
tion patients <75 years of age compared with treat-
ment with aspirin alone (203 events/1216 [16.7%]
warfarin-treated patients versus 181 events/1208
[14.2%] aspirin- and warfarin-treated patients and
241 events/1206 [20%] aspirin-treated patients).
However, use of warfarin is very restricted because
of numerous food-drug interactions and the high risk
of bleeding when combined with aspirin.[84]
Ximelagatran has been shown to be effective in
preventing death, nonfatal myocardial infarction and
severe recurrent ischaemia in post-infarction pa-
tients with a mean age of 69 years.[85] To our knowl-
edge, age subgroup analyses of this study have not
been published.
Role of β-Adrenoceptor Antagonists and
ACE Inhibitors for Prevention of Coronary
Heart Disease in the Elderly
The risk of death in elderly subjects surviving
myocardial infarction is considerably diminished by
administration of β-adrenoceptor antagonists. In pa-
tients 65–75 years of age included in a randomised,
multicentre study with a mean follow-up of 17
months after infarction,[86] there were 52 deaths
among the 348 patients administered timolol versus
83 in the 384 patients who received placebo
(p < 0.05). Moreover, there were 38 reinfarctions in
the treated group versus 69 in the nontreated group
(p < 0.01). Age subgroup analysis in this study
showed that the effect of β-adrenoceptor antagonists
was similar in patients <65 years of age and those
≥65 years of age. Other randomised studies also
concluded that there are favourable effects with use
of β-adrenoceptor antagonists in elderly subjects
surviving myocardial infarction.[87,88] Despite these
results, several studies have reported underutilisa-
tion of this therapeutic class as secondary prevention
in this group of patients.[89,90]
Similarly, ACE inhibitors have been found to
prevent coronary events in high-risk individuals.
The HOPE study[28] was conducted in 9297 subjects
with a mean age of 66 ± 7 years and a history of
 2005 Adis Data Information BV. All rights reserved.
Andrawes et al.
coronary artery disease, stroke, peripheral vascular
disease, diabetes, hypercholesterolaemia, cigarette
smoking, hypertension or documented microalbu-
minuria. This trial showed that ramipril significantly
reduced the incidence of myocardial infarction (RR
0.8; 95% CI 0.7, 0.9; p < 0.001) compared with
placebo in these high-risk patients. Interestingly,
subgroup analysis revealed a similar or even greater
risk reduction in subjects >65 years of age compared
with younger patients included in this study. More-
over, ACE inhibitors have been proven to be effec-
tive in postinfarction patients for reducing the risk of
cardiovascular death and events, including re-infarc-
tion.[28] Similarly, use of enalapril reduced mortality
and morbidity among 4228 patients with a mean age
of 59.1 years, asymptomatic left ventricular dys-
function and a history of ischaemic heart disease,
hypertension, diabetes and cigarette smoking in-
cluded in the Studies of Left Ventricular Dysfunc-
tion trials.[91] There was a marked reduction in the
risk of myocardial infarction (RR 23%; 95% CI 11,
34; p < 0.001) and unstable angina (RR 20%; 95%
CI 9, 29; p < 0.001). Cardiac deaths also decreased
(p < 0.03). Other ACE inhibitors have shown simi-
lar effects.[92]
Shilpak et al.[87] have confirmed the beneficial
effect of β-adrenoceptor antagonists and ACE inhib-
itors on survival in elderly post-infarction patients.
These investigators found a lower adjusted 1-year
mortality for patients treated with ACE inhibitors
(HR 0.80; 95% CI 0.73, 0.87) or β-adrenoceptor
antagonists (HR 0.76; 95% CI 0.64, 0.90) than for
patients who received no medication. The combina-
tion of these two drugs offered a greater benefit over
the use of either medication alone (HR 0.68; 95% CI
0.59, 0.80).
Hormonal Therapy in Elderly Women and
Prevention of Coronary Heart Disease
Hormone replacement therapy has been used es-
sentially to treat climacteric symptoms, such as vas-
omotor symptoms and vulvovaginal atrophy, and to
prevent osteoporosis related to menopause.
Numerous observational studies have found a
lower incidence rate of coronary heart disease
Drugs Aging 2005; 22 (10)
Prevention of Cardiovascular Events in Elderly People
among women using hormonal therapy compared
with nonusers. One of the largest cohort studies, the
Nurses’ Health study, found that hormone replace-
ment therapy reduced cardiovascular events.[93]
Among 48 470 menopausal women between 30 and
63 years of age followed for 10 years, major corona-
ry events were significantly lower in hormone re-
placement therapy users (RR 0.56; 95% CI 0.40,
0.80; p < 0.0001) than in nonusers. However, after
taking into account women’s socioeconomic status
in multivariate analysis, it was concluded that the
benefits of hormone replacement therapy on corona-
ry heart disease were not significant. In fact,
randomised studies conducted in women with coro-
nary heart disease (HERS [Heart and Estrogen/Pro-
gestin Replacement Therapy] I and II) and in
healthy women not only demonstrated the lack of
benefits of hormone replacement therapy on corona-
ry heart disease but also found an unexpected in-
crease in the incidence of ischaemic events, espe-
cially during the first year of treatment.[94,95] Howev-
er, it should be noted that in these trials, hormonal
therapy consisted of conjugated estrogen and
methylprogesterone acetate. Thus, the conclusions
of these studies cannot be extrapolated to use of
other types of hormone replacement therapy, partic-
ularly transdermal estrogen and microdose proges-
terone, which have rather different cardiovascular
and metabolic effects than those of hormone re-
placement therapy regimens used in these tri-
als.[96,97] Nevertheless, hormone replacement ther-
apy is currently no longer considered appropriate for
cardiovascular prevention in elderly women.
Prevention of Heart Failure in the Elderly
Several studies support the concept that heart
failure is a preventable disease in the elderly. Meta-
analysis of trials of hypertensive elderly subjects
found a significant risk reduction with active treat-
ment compared with placebo (RR 0.60; 95% CI
0.49, 0.74).[98] A meta-analysis analysing outcomes
of hypertensive patients ≥80 years of age in con-
trolled trials confirmed that antihypertensive treat-
ment significantly diminished the risk of heart fail-
ure (RR 0.58; 95% CI 0.37, 0.83).[34] Placebo-con-
 2005 Adis Data Information BV. All rights reserved.
869
trolled trials show that antihypertensive strategies
that include diuretics, β-adrenoceptor antagonists or
ACE inhibitors as first-line strategies significantly
reduce the incidence of heart failure.[18,22,27,99] In the
small number of studies that have compared differ-
ent antihypertensive strategies in the prevention of
heart failure, diuretics were more effective than α-
adrenoceptor antagonists, calcium channel antago-
nists and even ACE inhibitors.[98,100]
Heart failure is a preventable disease also in
normotensive elderly subjects. Interestingly, the
HOPE trial[101] showed that the ACE inhibitor
ramipril is capable of reducing the incidence of heart
failure in patients at high risk for cardiovascular
events (figure 2), and this effect was found to be
independent of hypertension or left ventricular dys-
function.
Influenza vaccination also seems to be an effec-
tive way of preventing hospitalisation for heart fail-
ure and other cardiac reasons in the elderly. This
was supported by the cohort study of Nichol et
al.,[102] who investigated the association between
influenza vaccination during the 1998–1999 and
1999–2000 seasons and the risk of hospitalisation
for heart disease in elderly subjects. They found that
there was a significant reduction in hospitalisation
for congestive heart failure during both influenza
seasons (odds ratio [OR] 0.81 and 0.73, respective-
ly; p < 0.001). It should be noted that this effect was
also demonstrated in subjects with no major medical
conditions at baseline.
Lifestyle Modification for the Prevention
of Cardiovascular Disease in the Elderly
Smoking, physical activity and diet are the main
lifestyle habits related to cardiovascular health in
elderly.
Benefits of Smoking Cessation in the Elderly
Several studies ascertained the noxious effects of
smoking in the elderly. For example, LaCroix et
al.[103] prospectively examined the relationship be-
tween cigarette-smoking habits and mortality from
all causes, cardiovascular causes, and cancer among
7178 persons ≥65 years of age without a history of
Drugs Aging 2005; 22 (10)
870 Andrawes et al.

a Placebo
100
Ramipril
Contrary to false beliefs, smoking-cessation
counselling can be effective in elderly subjects. Dale
−21.8 −22.5
80 et al.[106] reported a 24.8% 6-month abstinence rate
Relative risk (%)

after counselling 313 patients 65–82 years of age

60
with nicotine dependence. Similarly, in a study of
40
1070 non-institutionalised male and female smokers
65–74 years of age, Orleans et al.[107] implemented a
20 programme of smoking cessation with transdermal
nicotine patch and reported a 29% 6-month absti-
0 nence rate. These encouraging results seem better
b than the abstinence rates reported in middle-aged
160
individuals (up to approximately 18.5%).[108] How-
(events per 1000 patient-years)

140 ever, to date, no large-scale study has assessed the

120 effects of a smoking cessation programme on car-
−31
Absolute risk

100 diovascular mortality in the elderly. In our view,

80 −19
60
40
20
0 Beneficial Cardiovascular Effects of Physical
<65 years ≥65 years
Fig. 2. (a) Relative and (b) absolute risk of heart failure in patients
<65 years of age or ≥65 years of age in the Heart Outcomes
Prevention Evaluation trial.[101] Although the relative risk reductions
were very similar in subjects <65 years of age compared with older
subjects, the number of cardiovascular events avoided was much
greater in the latter group.
myocardial infarction, stroke or cancer. These in-
vestigators found that current smokers had higher
rates of cardiovascular mortality than those who had
never smoked (figure 3) [adjusted for age and com-
munity, RR 2.0 (95% CI 1.4, 2.9) for men and RR
1.6 (95% CI 1.1, 2.3) for women].[103] A study
conducted in 2030 Chinese subjects ≥70 years of
age[104] with a mean follow-up of 36 months found
an elevated risk of all-cause mortality among current
smokers, both in males (RR 1.4; 95% CI 0.9, 1.9)
and females (RR 1.6; 95% CI 1.0, 2.5). Similar
conclusions were obtained in a prospective French
cohort study among 2786 subjects ≥65 years of
age.[105] The risk of mortality was similar in never
smokers and former smokers who had stopped 20
years previously (figure 3), confirming what has
already been found by other investigators.[103] This
point emphasises the importance of smoking cessa-
tion, regardless of age.
smoking cessation should be widely recommended
to elderly smokers, even to those with nicotine de-
pendence.
Activity in the Elderly
Several large-scale epidemiological studies have
reported that elderly individuals partaking in regular
physical activity have better cardiovascular out-
comes than age-matched sedentary individu-
als.[109-112] Studies have also examined outcomes in
elderly subjects who have changed their physical
activity habits. Wannamethee et al.[113] measured the
effects of physical activity on all-cause mortality
and major cardiovascular events during 4-year fol-
low-up in 4311 men without a history of coronary
artery disease and a mean age of 63 years. In the
inactive/occasionally active, light, moderate and
moderately vigorous/vigorous activity groups, the
mortality rates per 1000 person-years were 18.5,
11.4, 7.3 and 9.1, respectively (adjusted RR 1.00;
0.61 [95% CI 0.48, 0.86]; 0.50 [95% CI 0.31, 0.79];
0.65 [95% CI 0.45, 0.94]). Men who were sedentary
and who began at least light activity during follow-
up had significantly lower all-cause mortality than
those who remained sedentary. Physical activity was
associated with lower cardiovascular (RR 0.66 [95%
CI 0.35, 1.23]) and noncardiovascular mortality (RR
0.48 [95% CI 0.27, 0.85]) than inactivity. In another
study, the 811 sedentary women with a mean age of

 2005 Adis Data Information BV. All rights reserved. Drugs Aging 2005; 22 (10)
Prevention of Cardiovascular Events in Elderly People
75.9 years who became active had a significantly
lower mortality rate from cardiovascular causes than
the 2198 women who remained sedentary (HR 0.64;
95% CI 0.42, 0.97).[114] Similarly, Schnohr et al.[115]
found that among 7023 healthy subjects 20–79 years
of age in Denmark, those who increased their lei-
sure-time physical activity from low to moderate
had a significantly lower risk of death than those
reporting low physical activity at both examinations
(RR 0.64; 95% CI 0.49, 0.83 in men; RR 0.75; 95%
CI 0.57, 0.97 in women). Exercise programmes per-
formed in elderly subjects have been shown to be
associated with improvements in functional capaci-
ty, percent body fat, body mass index and serum
lipids, and these changes are comparable to those
seen in younger subjects.[116-118] Even if intervention
trials showing a clear-cut reduction in cardiovascu-
lar events are lacking, moderate and regular physical
activity should be widely recommended to elderly
sedentary individuals.
Effects of Diet on Cardiovascular Health in
the Elderly
Diet has also been recognised as a significant
environmental factor related to cardiovascular
health. Observational studies have shown that in
elderly subjects, consumption of vegetables, fruits,
cereals[119] and unfried fish[120] are associated with
better cardiovascular outcomes than in noncon-
Global mortality rate (per 1000 patient-years)
140
120
100
80
60
40
20
0
Fig. 3. Mortality rates among 7678 individuals ≥65 years of age by
smoking status[103]
 2005 Adis Data Information BV. All rights reserved.
871
sumers.[121] Also, the Mediterranean diet which
combines several of these dietary patterns has been
found to be associated with lower cardiovascular
mortality in the elderly (HR 0.71; 95% CI 0.58,
0.88).[122] Interestingly, the effect of this healthy diet
pattern on cardiovascular outcomes seems indepen-
dent of other healthy lifestyle factors such as physi-
cal activity, nonsmoking habits and moderate alco-
hol consumption and a dose-effect type relationship
was found between the number of healthy lifestyle
patterns and cardiovascular risk reduction (figure 4).
Moderate alcohol consumption has been found to
be protective against coronary atherosclerosis in
middle-aged women.[123] In the Healthy Ageing: a
Longitudinal Study in Europe project, moderate al-
cohol consumption in elderly subjects was associat-
ed with a lower incidence of all-cause and coronary
heart disease mortality compared with noncon-
sumers.[122]
A salt-restricted diet has consistently been found
to diminish blood pressure in the elderly. However,
the blood pressure lowering effect is small and no
impact of salt restriction on the incidence rate of
cardiovascular disease has been demonstrated.[124]
Even if intervention trials investigating the ef-
fects of dietary modification in the elderly are lack-
ing, we think that sufficient data are available to
recommend the Mediterranean-type diet, rich in
vegetable and fruits, to elderly individuals in order
to prevent cardiovascular events. In addition, mod-
erate alcohol consumption should not be forbidden
Nonsmokers
in elderly people without specific alcohol-related
Former smokers
Current smokers
problems.
Perspectives
Cardiovascular prevention is not only important
in middle-aged patients but must be implemented in
the continually expanding population of elderly sub-
jects who are at a more advanced stage of athero-
sclerosis. An increasing number of investigators are
including elderly patients in studies and demonstrat-
65–69 70–74 ≥75 ing the benefits of different preventive strategies,
Age group (years) until now limited to middle-aged individuals, in this
particular group. The beneficial effects of cardiovas-
cular prevention are strikingly apparent when the
Drugs Aging 2005; 22 (10)
872 Andrawes et al.

Healthful lifestyle factor score

4
and ACE inhibitors[129] are underused in elderly
3 patients, especially by those with a history of myo-
2 cardial infarction despite the important need for
1.0 0 to 1 cardiovascular prevention in this setting.
In conclusion, we believe that cardiovascular
0.8 prevention should be more widely implemented in
the elderly, including subjects ≥75 years of age, and
Survival probability

0.6 that this might contribute to improved health status

and quality of life in this growing segment of the
0.4 population.

0.2 Acknowledgements
No sources of funding were used to assist in the prepara-
0.0 tion of this study. The authors have no conflicts of interest
0 1 2 3 4 5 6 7 8 9 10 that are directly relevant to the content of this study.
Time (years)
No. at risk factor score
4 437 433 426 415 406 392 376 360 337 267 192
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Correspondence and offprints: Professor Joël Belmin, Ser-
vice de Gériatrie, Hôpital Charles Foix et Université Paris 6,
7 avenue de la République, 94205 Ivry-sur-Seine, France.
E-mail: j.belmin@cfx.aphp.fr
Drugs Aging 2005; 22 (10)