Epidemiology of CVD in the Elderly

Karen P. Alexander MD

Duke University Medical Center

Duke Clinical Research Institute

Disclosures: (1) Minor Research: Schering Plough, Merck

(2) Consultant: Gilead

Prevalence of CVD by Age and Sex(NHANES 2003-2006)

REF: Heart Disease and Stroke Statistics- 2010 Update; Circulation 2010:121;e46-e215

AGE (yrs)

PO

PU

LA

TIO

N (

%)

CVD = CHD, CHF, Stroke

#1 Heart Disease#2 Cancer#3 Stroke#4 COPD/Lung#5 Alzheimer's

Increase in the Oldest OldU.S. Population Aged 85+ (millions)

REF: U.S. Census Bureau, “We the American Elderly,” 1993.

Consider that in most CHD outcome studies, “long-term” follow up is 3-5 years.

Age 75 →11.7 yrs

Age 85 →6.6 yrs

Age 90 →4.8 yrs

Chronic Health Conditions

40%

Trouble Hearing

Trouble Seeing

20% 13%

Cognitive Impairment

REF: Health and Retirement Survey, CDC National Health Interview Survey, CHS Fried, J Geront Biol Sci 2001REF: Health and Retirement Survey, CDC National Health Interview Survey, CHS Fried, J Geront Biol Sci 2001

Older Adults: Disability

REF: Griffith L, et al. Age and Ageing 2010;39:738-745

Canadian Study of Health and Aging 9,008 Community Dwelling Seniors

Basic (physical) and Instrumental (functional) ADLs

Cause of Disability

#1 Arthritis#2 Foot Problems#3 Heart Disease#4 Vision Problems#5 Cognitive Impairment

Resource Use – CVD Dx Codes

2006

79 million office visits

4 million ED visits

6 million hospitalizations

7 million procedures

503 billion dollars

direct and indirect costs

REF: Lloyd-Jones D, et al. Heart and Stroke Statistics- 2010 Update. Circulation 2010;121;e46-e215

Cardiovascular Health Study

• 5,888 Participants Age ≥65 years (1989-1990)

– Mean Age 72.8 yr– HTN (58%), DM (16%), Smoking (12%)– Prior MI (10%), Stroke (4%), HF (5%)– Mean Total Chol = 211 mg/dL– Medications

• Lipid lowering (6%), Antihypertensive (47%)

• Semiannual contact- 10 years of follow up

REF: Arnold AM, et al, JAGS 2005;53:211-218

Incidence of Heart Disease Caucasian Male: 10 year follow up

Rat

e/1,

000

Per

son

-Yea

rs

Age (Yrs)

REF: Arnold AM, et al, JAGS 2005;53:211-218

CHD = Fatal and Non-fatal MI, Angina, coronary revascularization

Incidence of Stroke Caucasians: 10 year follow up

Rat

e/1,

000

Per

son

-Yea

rs

Age (Yrs)

REF: Arnold AM, et al, JAGS 2005;53:211-218

INTERHEART: RF for First MICase- Control of Acute MI

Young Old*

Smoking 3.33 (2.86 - 3.87) 2.44 (2.10 – 2.84)

HTN 2.24 (1.93 – 2.60) 1.72 (1.52 – 1.95)

Diabetes 2.96 (2.40 – 3.64) 2.05 (1.71 – 2.45)

Abdominal Obesity 1.79 ( 1.52 – 2.09) 1.50 (1.29 – 1.74)

Lipids: ApoB/ApoA1 4.35 ( 3.49 – 5.42) 2.50 (2.05 – 3.05)

Fruits and Vegetables 0.69 (0.58 – 0.81) 0.72 (0.61 – 0.85)

Exercise 0.95 (0.79 – 1.14) 0.79 ( 0.66 – 0.94)

Alcohol 1.00 (0.85 – 1.17) 0.85 (0.73 – 1.00)

Psychosocial Stress 2.87 ( 2.19 – 3.77) 2.43 (1.86 – 3.18)

93.9% 87.9%Population Attributable Risk

REF: Yusuf et al, Lancet 2004;364:937-52 * Old = Men >55 yrs; Women >65 yrs

Healthy People 2010

• Goal: Lower CHD mortality by 20% by 2010

• Risk Factor Population Targets– Mean TC 199 mg/dL– Smoking 12% – HTN 16%– DM 6%– Obesity 15%– Inactivity 20%

REF: http://www.cdc.gov/nchs/hphome.htm

Trends in Risk Factors*The good news

Cholesterol Smoking

REF: Capewell S, Bulletin WHO 2010;88:120-130

HP 2010

HP 2010

* Linear Time Plots based on NHANES 1988-1994 and NHANES 1999-2002

Trends in Risk Factors The bad news

Systolic Blood Pressure BMI

REF: Capewell S, Bulletin WHO 2010;88:120-130

Estimated Reduction in CHD Deaths by Risk Factor Modifications

Three Scenarios

Choles

tero

l

Systo

lic B

P

Smok

ing

Physic

al Acti

vity

BMI

Diabet

es

REF: Capewell S, Bulletin WHO 2010;88:120-130

Re

duc

tion

in D

eath

s fr

om C

HD

Estimated Reduction in CHD Deaths by AgeThree Risk Factor Scenarios

45-54 55-64 65-74 75-84

Re

duc

tion

in D

eath

s fr

om C

HD

Age Group

REF: Capewell S, Bulletin WHO 2010;88:120-130

Prevalence of HBP in Adults (NHANES 2003-2006)

REF: Heart Disease and Stroke Statistics- 2010 Update; Circulation 2010:121;e46-e215

AGE (yrs)

PO

PU

LA

TIO

N (

%)

Hypertension in the ElderlyFramingham Cohort

Prevalence of HTN Control of HTN

MEN MEN WOMENWOMENREF: Lloyd-Jones et al, JAMA 2005;294:466-472

Conclusions• CVD is the leading cause of death

– Incidence increases with age– CVD >men; CHF equal; Stroke >women

• Risk factors contribute to new events– explaining up to 85% of PAR for first MI

• Improvements in Chol and HTN offset by worsening obesity and DM– Long way to go for Healthy People 2010 Goals– BP is poorly controlled relative to guidelines, especially

among older women– HTN may explain up to 25% of new events