Cardiovascular and Cerebrovascular Disease in Older Adults
What to know
Cardiovascular disease is the leading cause of death in older adults. Key concepts: hypertension management in the very old (individualize; avoid orthostasis; SPRINT-type intensive control benefits some but risks falls), heart failure with preserved ejection fraction (common in elders), atrial fibrillation and stroke risk (CHA2DS2-VASc), and acute coronary syndromes with atypical presentations (dyspnea, fatigue, syncope rather than chest pain). Anticoagulation decisions balance stroke reduction against bleeding (HAS-BLED). Carotid disease, transient ischemic attack, and secondary stroke prevention are core. Orthostatic hypotension is a frequent culprit for falls and syncope.
Traps
Questions test that older adults often present atypically: painless MI, silent ischemia, or delirium as the first sign. Don't assume "normal" blood pressure excludes disease; check orthostatics. Overly aggressive BP lowering can cause falls and AKI. Anticoagulation is often underused in the very old despite clear benefit; weigh fall risk but don't withhold reflexively. Distinguish systolic from diastolic heart failure management.
Rule of thumb
"Treat the patient, not the number": goals of BP and anticoagulation should reflect function, fall risk, and life expectancy.
Worked example
An 80-year-old with AF, CHA2DS2-VASc 5, and one prior mechanical fall. Stroke risk outweighs bleeding risk; a direct oral anticoagulant with renal dosing is reasonable, plus fall-risk mitigation-not abandonment of anticoagulation.
Worked example 2
New dyspnea and fatigue in an 84-year-old diabetic: consider atypical ACS; obtain ECG and troponin.