Schwartz Janice B
Department of Medicine, University of California, San Francisco, San Francisco, CA; Jewish Home of San Francisco, San Francisco, CA; Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA.
Trends Cardiovasc Med. 2015 Apr;25(3):228-39. doi: 10.1016/j.tcm.2014.10.010. Epub 2014 Oct 18.
Recent cardiovascular prevention guidelines place a greater emphasis on randomized placebo-controlled trial data as the basis for recommendations. While such trial data are sparse for people over the age of 75 or 80 years, data demonstrate altered risk-benefit relationships in these older patients. Primary prevention strategy decisions should consider estimated life expectancy and overall function as well as cardiovascular event risks, magnitude and time to benefit or harm, potentially altered adverse effect profiles, and informed patient preferences. Data support treatment of systolic hypertension to reduce stroke, cardiovascular events, and dementia in older patients with at least a 2-year estimated lifespan with modifications in systolic blood pressure goals and a need for greater attention to non-cardiovascular side effects such as falls in the very old. Lowering of elevated cholesterol levels with HMG-CoA reductase inhibitors for primary prevention in people over the age of 75 years requires greater individual considerations, as benefits may not accrue for 3-5 years and there is the potential impact of adverse effects. There is a rationale for lipid-lowering treatment in the more highly functional older patient with cardiovascular (especially stroke) risk higher than side effect risks in the near term and with an estimated lifespan longer than the time to benefit. Aspirin has higher side effect risks and requires a longer time to achieve benefit. Trial data are lacking on exercise interventions, but multi-system benefits have been shown in older patients such that exercise should be part of a preventive regimen. Preventive therapy in the very old means considering not only medical issues of co-morbidities, polypharmacy, and altered risk-benefit relationship of medications but also adjusting goals and approaches across the older agespan in keeping with informed patient preferences.
近期的心血管疾病预防指南更加强调将随机安慰剂对照试验数据作为推荐的依据。虽然针对75岁或80岁以上人群的此类试验数据较少，但数据表明这些老年患者的风险效益关系有所改变。一级预防策略决策应考虑预期寿命、整体功能以及心血管事件风险、获益或危害的程度和时间、潜在改变的不良反应特征以及患者的知情偏好。有数据支持对收缩期高血压进行治疗，以降低老年患者的中风、心血管事件和痴呆风险，这些患者的预期寿命至少为2年，同时需调整收缩压目标，并更加关注非心血管副作用，如高龄患者的跌倒。对于75岁以上人群使用HMG-CoA还原酶抑制剂进行一级预防以降低升高的胆固醇水平，需要更多的个体化考虑，因为获益可能在3至5年后才会显现，且存在不良反应的潜在影响。对于近期心血管（尤其是中风）风险高于副作用风险且预期寿命长于获益时间的功能较好的老年患者，有进行降脂治疗的理论依据。阿司匹林有较高的副作用风险，且需要更长时间才能获益。关于运动干预的试验数据不足，但已表明运动对老年患者有多种系统益处，因此运动应成为预防方案的一部分。对高龄患者进行预防性治疗不仅要考虑合并症、多种药物治疗以及药物风险效益关系改变等医学问题，还要根据患者的知情偏好，在整个老年阶段调整目标和方法。
