Cardiovascular disease presents a great burden for the elderly population, their caregivers and the health system, according to a state–of–the–art review published April 10 in the Journal of the American College of Cardiology.

Francesco Paneni, MD, PhD, et al., examine unresolved clinical problems in the care of elderly patients, summarize the current understanding of the mechanisms implicated in cardiovascular aging, consider the potential of targeting novel pathways, and review the critical aspects of vascular repair.

They explain that among the clinical aspects of cardiovascular disease in elderly patients is systolic hypertension, which, paired with its accompanying fall in diastolic pressure, can hasten the development of myocardial ischemia. Although the medical community currently lacks sufficient understanding of the primary age–related triggers for the patho–physiological processes that contribute to cardiovascular complications in the aging population, the review notes that some interventions have been shown to improve outcomes in patients with isolated systolic hypertension.

According to the authors, heart failure with preserved ejection fraction (HFpEF) is common in elderly patients, especially women. Clinicians often point to the increasing prevalence of HFpEF and its adverse outcomes in the aging patient population; however, there have so far been few evidence–based interventions to halt the development or effects of HFpEF. Vascular aging and amyloidosis, along with frailty and loss of muscle mass and function, also contribute to the increased risk of cardiovascular disease in the aging population.

The review also examines the molecular hallmarks of cardiovascular aging: cellular senescence, genomic instability, chromatin remodeling and mitochondrial oxidative stress. The authors explain that although it has been firmly established that increased oxidative stress and inflammation promote cardiovascular aging, antioxidant supplementation and anti–inflammatory interventions have failed to reduce the risk of cardiovascular events in older patients. However, innovative strategies are emerging that target reactive oxygen species (ROS) and have yielded encouraging preclinical results. Other promising efforts include the development of anti–inflammatory agents that might reduce cardiovascular disease and new molecular targets that are involved in essential pathways regulating ROS production and/or scavenging and pro–inflammatory cytokines.

“These more targeted and selective interventions merit attention, given the disappointments encountered with the application of blunt approaches to limiting oxidative stress in humans,” said Paneni. He adds that lifestyle changes such as caloric restriction or regular endurance exercise may reduce signs of vascular aging.

The authors conclude that “translation of the basic and clinical science reviewed here should prepare us better to confront the burden of cardiovascular disease in our growing older population.”