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 ) REF: Heart Disease and Stroke Statistics Update; Circulation 2010:121;e46-e215 AGE (yrs) POPULATION (%) CVD = CHD, CHF, Stroke

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

Increase in the Oldest Old U.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 2001

Older Adults: Disability REF: Griffith L, et al. Age and Ageing 2010;39: 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 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 Update. Circulation 2010;121;e46-e215

Cardiovascular Health Study 5,888 Participants Age ≥65 years ( ) –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:

Incidence of Heart Disease Caucasian Male: 10 year follow up Rate/1,000 Person-Years Age (Yrs) REF: Arnold AM, et al, JAGS 2005;53: CHD = Fatal and Non-fatal MI, Angina, coronary revascularization

Incidence of Stroke Caucasians: 10 year follow up Rate/1,000 Person-Years Age (Yrs) REF: Arnold AM, et al, JAGS 2005;53:

INTERHEART: RF for First MI Case- Control of Acute MI YoungOld* Smoking3.33 ( )2.44 (2.10 – 2.84) HTN2.24 (1.93 – 2.60)1.72 (1.52 – 1.95) Diabetes2.96 (2.40 – 3.64)2.05 (1.71 – 2.45) Abdominal Obesity1.79 ( 1.52 – 2.09)1.50 (1.29 – 1.74) Lipids: ApoB/ApoA14.35 ( 3.49 – 5.42)2.50 (2.05 – 3.05) Fruits and Vegetables0.69 (0.58 – 0.81)0.72 (0.61 – 0.85) Exercise0.95 (0.79 – 1.14)0.79 ( 0.66 – 0.94) Alcohol1.00 (0.85 – 1.17)0.85 (0.73 – 1.00) Psychosocial Stress2.87 ( 2.19 – 3.77)2.43 (1.86 – 3.18) 93.9% 87.9% Population Attributable Risk REF: Yusuf et al, Lancet 2004;364: * 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:

Trends in Risk Factors* The good news CholesterolSmoking REF: Capewell S, Bulletin WHO 2010;88: HP 2010 * Linear Time Plots based on NHANES and NHANES

Trends in Risk Factors The bad news Systolic Blood Pressure BMI REF: Capewell S, Bulletin WHO 2010;88:

Estimated Reduction in CHD Deaths by Risk Factor Modifications Three Scenarios Cholesterol Systolic BP Smoking Physical Activity BMI Diabetes REF: Capewell S, Bulletin WHO 2010;88: Reduction in Deaths from CHD

Estimated Reduction in CHD Deaths by Age Three Risk Factor Scenarios Reduction in Deaths from CHD Age Group REF: Capewell S, Bulletin WHO 2010;88:

Prevalence of HBP in Adults (NHANES ) REF: Heart Disease and Stroke Statistics Update; Circulation 2010:121;e46-e215 AGE (yrs) POPULATION (%)

Hypertension in the Elderly Framingham Cohort Prevalence of HTN Control of HTN MEN WOMEN REF: Lloyd-Jones et al, JAMA 2005;294:

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