Our recommendations for cardiovascular disease prevention in older adults, considering frailty

Blood pressureFor frail and not-frail patients without limited life expectancy, a goal blood pressure of < 140/90 mm Hg is reasonable with careful attention to risks, including orthostasis, falls, and polypharmacy
Treatment may need to be tailored to standing blood pressure
LipidsFor patients over age 75 without cardiovascular disease or frailty and with a life expectancy of at least 2 years, consider a statin for primary prevention, starting at a low dose
DiabetesAim for the lowest hemoglobin A1c that does not cause hypoglycemia; relax hemoglobin A1c goals with increasing frailty
Use hypoglycemic agents with caution
AspirinFor patients over age 75 without frailty or cardiovascular disease and no major bleeding risk, but at high risk, consider low-dose aspirin for primary prevention of nonfatal myocardial infarction
Carefully consider bleeding risk to ensure that benefit outweighs risk
Exercise and weightFor all older adults, and particularly those with frailty, prescribe:
Balance training, such as tai chi, to decrease the risk of falls
Stretching at least twice a week
Moderate-intensity aerobics such as walking or swimming for 150 minutes per week Resistance training at least twice a week for 20-minute intervals
General encouragement of daily activity
Smoking cessationSmoking cessation remains beneficial at all ages and stages of life
All counseling interventions and nicotine replacement are effective
NutritionA balanced diet, rich in whole grains, fruits, vegetables, nuts, fish, and lean meats is beneficial at all ages and stages of life
Unique challengesInappropriate polypharmacy and complexity of medication regimens increases risk of drug events and falls
Multimorbidity requires the balance of multiple medical conditions to create a comprehensive plan
Explore goals of care and advance directives in creating a patient-centered prevention plan; engage in shared decision-making