The future of cardiovascular care for older adults is a critical topic, and experts are stepping up to address the unique challenges faced by this demographic. At the American Heart Association's 2025 Scientific Sessions, the focus was on how we can improve the representation and care of aging adults in cardiology.
The Imperative for Change
Cardiology care models and clinical trials must evolve to reflect the realities of aging. Older adults are often underrepresented in cardiovascular research, and this gap leads to unique barriers in managing their health. For instance, they face challenges in controlling hypertension and are at a higher risk of polypharmacy and overtreatment.
Digital Tools: A Potential Solution, but with Barriers
John A. Dodson, MD, MPH, an associate professor, opened the discussion by highlighting the potential of digital health to bridge the gap in blood pressure control. Despite the increasing use of mobile devices, older adults still struggle with adequate hypertension management due to various factors, including comorbidities and mobility limitations.
Dodson emphasized the importance of understanding the real-world barriers older adults face when adopting new technologies. Many patients express a 'utility cost,' feeling that the effort required to learn new tech is not worth it. Privacy concerns and resistance to change are common and understandable, especially for those who may already be dealing with physical and cognitive limitations.
For instance, impaired vision, hearing loss, arthritis, or tremors can make using devices challenging. Dodson pointed out that implementing health interventions for older adults requires more than just asking them to pick up their phones. It involves understanding their unique needs and providing the right support and motivation.
The RESILIENT trial, a phase 2 study, tested the effectiveness of mobile health-based cardiac rehabilitation (mHealth-CR) in improving functional capacity among older adults with ischemic heart disease. While the trial didn't show significant improvements in walk distance compared to usual care, it did highlight the importance of patient engagement. Those who fully participated in digital rehab tasks showed improvements, suggesting that motivation and support are key.
Dodson believes that selecting patients likely to benefit from digital interventions or providing support to improve engagement could make this approach more effective.
The BETTER-BP study, a pragmatic trial combining behavioral economics and text messaging, achieved an impressive 87% retention rate at 6 months by meeting patients where they are. Bilingual staff, transportation reimbursement, and real-time technical support were key to this success.
Expanding Representation in Coronary Disease Trials
Michael Nanna, MD, MHS, an assistant professor and interventional cardiologist, addressed the underrepresentation of older adults in coronary artery disease research. While age-based exclusions are less common now, older adults are still indirectly excluded due to comorbidities and other factors.
Nanna emphasized the need for generalizable results, which requires enrolling patients across the entire biological aging spectrum. This was the rationale behind the LIVEBETTER study, a PCORI-sponsored trial comparing beta-blockers and calcium channel blockers for angina management in older adults.
What sets this trial apart is its focus on global quality of life, an outcome often overlooked in trials. Engaging caregivers is crucial for successfully enrolling older adults, and the LIVEBETTER study does this by enrolling patient caregivers and assessing their burden longitudinally.
The study also incorporates remote follow-ups and community partnerships to reduce barriers, demonstrating that pragmatic trials in older adults are not only feasible but essential.
Deprescribing and Polypharmacy: A Complex Balance
Mark Effron, MD, a professor and cardiologist, shifted the discussion to deprescribing and medication burden. He highlighted how a single patient could meet guideline-directed medical therapy criteria for multiple conditions, resulting in a complex medication regimen.
While medications help manage cardiovascular disease, their cumulative burden can create new health risks, especially for older adults. Poor adherence, drug interactions, falls, and hospitalizations are all potential consequences. Effron described this as an 'inherent tension' between therapy and polypharmacy, where clinicians must carefully weigh the benefits and potential harms of each drug, especially when they don't align with the patient's goals.
Effron also warned of 'therapeutic competition,' where treating one condition can worsen another. For older adults with comorbidities, these cascading effects require careful monitoring and a patient-centered approach to balance help and harm.
Deprescribing trials, such as the Veterans Affairs study and the OPTIMISE trial, have shown that reducing antihypertensive medications doesn't increase mortality or cardiovascular events. Effron also discussed the promise of n-of-1 trials, which test medication withdrawal within individual patients to guide personalized decisions.
In conclusion, the experts at the AHA 2025 Scientific Sessions highlighted the need for innovative approaches to cardiovascular care for older adults. By addressing digital barriers, expanding representation in trials, and carefully managing medication burden, we can improve the health and quality of life for this demographic.
