The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease (CVD) is the leading cause of death and major disability in adults aged 75 and older. Despite the effect of CVD on quality of life, morbidity, and mortality in older adults, individuals aged 75 and older have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older adults with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in nursing homes and assisted living facilities. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older adults typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision-making, and recommend future research to close existing knowledge gaps. To achieve these objectives, a detailed review was conducted of current American College of Cardiology/American Heart Association (ACC/AHA) and American Stroke Association (ASA) guidelines to identify content and recommendations that explicitly targeted older adults. A pervasive lack of evidence to guide clinical decision-making in older adults with CVD was found, as well as a paucity of data on the effect of diagnostic and therapeutic interventions on outcomes that are particularly important to older adults, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older adults representative of those seen in clinical practice and that incorporate relevant outcomes important to older adults in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older adults and enhance person-centered care of older individuals with CVD in the United States and around the world.

There is a dramatic increase in the prevalence of PAD, CAS, and AAA with advanced age. More than 20% and 30% of octogenarians and nonagenarians, respectively, have vascular disease in at least 1 arterial territory.

To the Editor: Hyperglycemia, with or without pre-existing diabetes mellitus, is associated with adverse outcomes in patients with acute coronary syndromes (1). Whereas blood glucose levels (BGLs) Ն200 mg/dl are associated with adverse outcomes after acute myocardial infarction (AMI), the association of moderate elevations or hypoglycemia with cardiovascular mortality in STsegment elevation myocardial infarction (STEMI) patients is not well characterized. We hypothesized that both hypoglycemia and moderate elevations of the BGL during STEMI would be associated with increased rates of adverse outcomes, irrespective of diabetic status.Clinical data in STEMI patients were pooled from the Thrombolysis In Myocardial Infarction (TIMI)-10A/B, Limitation of Myocardial Infarction Following Thrombolysis in Acute Myocardial Infarction (LIMIT-AMI), and Optimal Angioplasty versus Primary Stenting (OPUS)-TIMI-16 studies (n ϭ 4,224). The trial designs have been previously described. Angiographic data (n ϭ 1,260) were available from all trials except OPUS-TIMI-16. We divided all patients into six groups based on the BGL. Previous studies have focused on severe hyperglycemia (BGL Ͼ 199 mg/dl), so previously described (2) definitions of impaired glucose tolerance (BGL 100 to 125 mg/dl, n ϭ 1,229) and diabetes (BGL Ն126 mg/dl) were used. To determine whether risk increased in parallel with increasingly severe hyperglycemia, patients with a BGL Ն126 mg/dl were arbitrarily divided into mild (BGL 126 to 149 mg/dl; n ϭ 792), moderate (BGL 150 to 199 mg/dl; n ϭ 702) and severe (BGL Ͼ199 mg/dl; n ϭ 598) hyperglycemia. Hypoglycemia was defined as a BGL Ͻ81 mg/dl (n ϭ 325). A BGL of 81 to 99 mg/dl represented euglycemia (n ϭ 578). Admission BGLs were drawn except in the OPUS-TIMI-16 study, where BGLs were drawn Ͻ48 h from admission. Individual and combined end points of death or recurrent myocardial infarction were analyzed at 30-day follow-up.Analyses were performed using Stata version 7.0 (Stata Corp., College Station, Texas) or higher. Continuous variable values are reported as the mean Ϯ SD or median with 25% and 75% confidence intervals. Continuous variables were analyzed using the Student t test for two-way comparisons and analysis of variance for Ͼ2-way comparisons. The chi-square test was used to analyze categorical variables. A multivariate logistic regression model for mortality at 30 days was generated using BGLs of 81 to 99 mg/dl as the referent group.Compared with euglycemia, patients with hypoglycemia had lower body weight and were more often diabetic. Compared with euglycemia, patients with hyperglycemia were older, with higher heart rates, prevalence of hypertension, congestive heart failure (CHF), and diabetes, but less tobacco use. Patients with a previous diagnosis of diabetes accounted for 17.5% of all patients, but they accounted for 69.4% of patients with a BGL Ͼ199 mg/dl. A BGL Ն126 mg/dl was present in ϳ50% of patients without a diagnosis of diabetes.Higher BGL was associated with a higher TIMI risk score (TRS) for ...

Abstract-The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results ofCirculation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0000000000000380The American Heart Association, the American College of Cardiology, and the American Geriatrics Society make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Copies: This document is available on the World Wide Web sites of the American Heart Association (professional.heart.org) and the American College of Cardiology (www.acc.org). A copy of the document is available at http://professional.heart.org/statements by using either "Search for Guidelines & Statements" or the "Browse by Topic" area. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.Expert peer ...

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