Primary cardiovascular prevention in older persons: towards adequate risk prediction and effective multi-component interventions

Research on cardiovascular disease prediction and primary prevention in subjects aged 70 and over is both scarce and complicated. Competing risks, fear of ‘medicalisation’ and the need to specifically tailor to the needs of older persons are important considerations. The Cardiovascular Risk Management (CVRM) guideline of the Dutch College of General Practitioners (NHG, 2012) explicitly acknowledges the evidence gaps with regard to older people. Current Dutch risk prediction scores should be developed with data from a recent cohort of older people (>70 years). Since the absolute CV morbidity and mortality risks are already very high, a further challenge is to determine which elderly should be targeted for primary prevention and what effective intervention strategies should be used. Finally, in order to develop successful strategies, patients’ experiences with and preferences for different scenarios for vascular prevention should be studied. Therefore, the overall aim of this study is to build a comprehensive framework for primary cardiovascular prevention in people aged 70 and older. It comprises the full scope of primary prevention, including adequate risk assessment (1), effective interventions to reduce cardiovascular risk (2), and patients’ evaluations and views on cardiovascular prevention. (3) Ad 1. A sex-specific CVD risk prediction model will be developed on a recent cohort of Dutch elderly aged 70 and older. New competing risks techniques will be incorporated in order not to overestimate cardiovascular mortality. For this analysis, data will be used of 3533 participants from the preDIVA study (Prevention of Dementia by Intensive Vascular Care), who were aged 70-78 at baseline. Ad 2. The effectiveness of multi-component interventions targeting cardiovascular risk factors will be studied. Whereas most clinical trials in older people have assessed effectiveness of interventions on single risk factors, in daily practice most older persons face multiple risk factors. The effect of multi-component interventions on change in risk factor profile (i.e. hypertension, hypercholesterolemia, physical exercise, diet, smoking, BMI) and incident CVD and mortality will be assessed. To this end, individual patient data meta-analysis will take place with data from three ongoing RCTs on multi-component cardiovascular prevention in older people in Europe (n=6413). Ad 3. Barriers and facilitators to lifestyle change and determinants of successful cardiovascular prevention in older persons will be analysed in a separate qualitative substudy with interviews among participants of the preDIVA study. In particular, we will focus on the components that participants perceived as most successful during the six years that they received the nurse-led preventive care. Given the increased attention for self-monitoring of cardiovascular risk factors and internet-based approaches to support patient empowerment, in this substudy we also aim to explore how these findings might strengthen the design of innovative developments in cardiovascular prevention. Taken together, this study will explore the who, what and how of cardiovascular prevention in older persons by (1) improving cardiovascular disease and mortality risk prediction for Dutch elderly (‘who’), (2) increasing knowledge on the effectiveness of multi-component interventions on lifestyle change and cardiovascular risk/events (‘what’), and (3) older people’s views on nurse-led vascular prevention and potential new strategies to support lifestyle change (‘how’)(see Figure 1).