The future of cardiovascular care for older adults is a pressing issue, and experts are stepping up to address it. At the American Heart Association's 2025 Scientific Sessions, a panel of experts highlighted the need for innovative solutions to improve the health and well-being of aging individuals. But here's where it gets controversial: the current system is failing to adequately represent and support this vulnerable population.
The Imperative for Change: Reflecting the Realities of Aging
Cardiology care models and clinical trials must evolve to better mirror the diverse needs and challenges faced by older adults. Despite advancements in digital health and medical research, older adults remain underrepresented in cardiovascular studies, leading to unique barriers in hypertension control and an increased risk of polypharmacy and overtreatment.
Barriers to Digital Tools: Overcoming Real-World Challenges
John A. Dodson, MD, MPH, an associate professor at New York University, shed light on the persistent gaps in blood pressure control among older adults. Despite the increasing use of mobile devices for health management, comorbidities, mobility limitations, and medication adherence challenges continue to hinder effective hypertension management. Dodson emphasized that the success of digital health tools relies on understanding and addressing the real-world barriers faced by older adults.
One significant barrier is the 'utility cost' - the feeling that using new technology simply isn't worth the effort. Privacy concerns, resistance to change, and physical limitations such as impaired vision, hearing loss, arthritis, or tremors, can all make device use challenging. Additionally, cognitive decline can affect memory and reasoning, further complicating the implementation of health interventions.
To illustrate this point, Dodson discussed the RESILIENT trial, a phase 2 study testing mobile health-based cardiac rehabilitation (mHealth-CR) among adults aged 65 and older with ischemic heart disease. While the trial did not significantly increase 6-minute walk distance compared to usual care, patient engagement played a crucial role in improving functional capacity. This suggests that motivation, support, and better predictive tools are essential for maximizing the benefits of digital interventions.
Expanding Representation: Enrolling Older Adults in Coronary Disease Trials
Michael Nanna, MD, MHS, an assistant professor and interventional cardiologist at Yale School of Medicine, focused on the persistent underrepresentation of older adults in coronary artery disease research. Although age-based exclusions are less common now, older adults are still indirectly excluded from trials due to comorbidities, frailty, transportation issues, polypharmacy concerns, and lack of physician engagement.
Nanna emphasized the importance of enrolling patients across the biological aging spectrum to achieve generalizable results. This rationale guided the LIVEBETTER study, a PCORI-sponsored trial comparing beta-blockers and calcium channel blockers for angina management in adults aged 65 and older. What sets this trial apart is its design, with the primary endpoint selected through patient and caregiver input, focusing on global quality of life - an outcome often overlooked in trials.
Engaging caregivers is crucial for successfully enrolling older adults in randomized trials, and the LIVEBETTER study incorporates remote follow-ups and community partnerships to reduce barriers. Nanna highlighted that pragmatic trials in older adults are not only feasible but essential, and integrating stakeholder voices, respecting clinician-patient bonds, and adapting to the needs of older patients are key to success.
Deprescribing and Polypharmacy: Navigating Complex Care
Mark Effron, MD, a professor of medicine and cardiologist at Ochsner Health, shifted the discussion towards deprescribing and medication burden. Using a real-world case, Effron demonstrated how a single patient could meet guideline-directed medical therapy criteria for four conditions, resulting in up to eleven medication classes just to treat their heart disease. While medications help manage cardiovascular disease, their cumulative burden can create new health risks, especially for older adults who may experience poor adherence, drug interactions, falls, disability, hospitalizations, and adverse cardiovascular outcomes.
Effron warned of the 'inherent tension' between therapy and polypharmacy, where clinicians must constantly weigh the benefits and potential harms of each drug, particularly when they don't align with the patient's goals. He also highlighted the concept of 'therapeutic competition,' where a treatment for one condition can worsen another. For older adults with comorbidities, these cascading effects require close monitoring and a patient-centered approach to strike a balance between helping the patient and avoiding harm.
Effron discussed the promise of n-of-1 trials, which test medication withdrawal within individual patients to guide personalized decisions. These trials provide personalized pharmacotherapy and therapeutic precision, considering the heterogeneous clinical phenotype, drug metabolism, responsiveness to therapy, and health priorities of each patient.
The future of cardiovascular care for older adults is a complex and challenging journey, but with innovative trials, digital tools, and a patient-centered approach, we can reshape the landscape and improve the health and well-being of this vulnerable population. The question remains: How can we ensure that older adults are adequately represented and supported in cardiovascular research and care? We invite you to share your thoughts and experiences in the comments below.
