It turns out that the Isley Brothers, who sang that 1966 Motown hit “This Old Heart of Mine (Is Weak for You),” were onto something when they linked age to an aching and flagging heart. Heart disease, the nation’s leading cause of death and disability, has been diagnosed in about 6 percent of Americans ages 45 to 64, but in more than 18 percent of those over 65, according to the Centers for Disease Control and Prevention. Old hearts are physiologically different. “The heart gets stiffer as we age,” said Dr. John Dodson, director of the geriatric cardiology program at NYU Langone Health. “It doesn’t fill with blood as easily. The muscles don’t relax as well.”
Age also changes the blood vessels, which can grow rigid and cause hypertension, and the nerve fibers that send electrical impulses to the heart. It affects other organs and systems that play a role in cardiovascular health, too. “After age 75 is when things accelerate,” Dr. Dodson said.
But in recent years, dramatic improvements in treatments for many kinds of cardiovascular conditions have helped reduce both heart attacks and cardiac deaths. “Cardiology has been blessed with a lot of progress and research and drug development,” said Dr. Karen Alexander, who teaches geriatric cardiology at Duke University. “The medications are better than ever, and we know how to use them better.”
But in 2017, among patients with nonischemic heart failure meaning that the heart isn’t pumping effectively but there is no blocked artery, another influential study showed that I.C.D.s did not reduce mortality for patients over 70. The device only prevented sudden cardiac deaths, the authors noted — and those occur more frequently in younger patients. Moreover, “at 85 or 90, sudden death is not necessarily the worst thing that can happen,” Dr. Matlock said, compared to death from “progressive heart failure, which can go quickly or last for years; it’s unpredictable.” The wallop of an I.C.D. shock can also frighten and distress older patients, who often are unaware that the device can be deactivated with a computer.
Cardiologists and researchers still debate how much I.C.D.s benefit older patients. But because cardiac drugs have grown so much more potent since 2005, a major multisite study is underway to determine, among patients at lower risk of sudden death, whether medications alone might now be more effective.
Medications alone already appear to be at least as effective in treating older people who have suffered the kind of heart attacks not caused by a suddenly and completely blocked artery. (Technically these are referred to as NSTEMI, for non-ST-segment elevation myocardial infarction.) Half of these occur in people over 70, said Dr. Vijay Kunadian, a professor of interventional cardiology at Newcastle University in England and the lead author of a recent study in The New England Journal of Medicine.
Older people often are underrepresented in research, “There are a lot of preconceived biases.” So her team recruited an older-than-typical sample (average age 82) in which to compare the benefits of conservative and invasive treatment. Half of the 1,500 patients in the study began a regimen of cardiac medications that included blood thinners, statins, beta blockers and ACE inhibitors. The other half had more invasive treatment, starting with an angiogram (an X-ray of the blood vessels). Then, roughly half of that group received a stent or, in much smaller numbers, underwent bypass surgery. These patients were also prescribed the same kinds of medications as the patients who were treated with drugs alone.
Over four years, the team found no difference in the patients’ risk of cardiovascular death or a nonfatal heart attack. Although surgical risks generally rise with age, complications were low in both groups. Facing such situations, older patients and their families need to ask important questions, Dr. Alexander said: “How is this going to help me, and what are the other options, especially if it’s invasive? Is it necessary? What if I don’t do this?” Dr. Kunadian agreed. “One size does not fit all in this group,” she said. Invasive treatment did not benefit patients, but it didn’t harm them, either.
One intervention known to benefit patients with heart disease is cardiac rehabilitation: a program of regular, supervised exercise that significantly reduces heart attacks, hospitalization and cardiovascular deaths.
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