Cardiovascular Disease in the Elderly: A Practical Manual
The aging of the worldwide population is having dramatic effects on healthcare delivery, and in no field more than in cardiovascular disease. In the United States, England, and other developed countries, cardiovascular disease remains the leading cause of mortality, with combined prevalence rates of >50% of conditions such as heart failure, arrhythmias, stroke, and peripheral vascular disease in those >75 years of age. In addition, the near-universal risk of developing hypertension during one's life, coupled with the rising rate of other common cardiovascular risk factors, is contributing to the dramatic rise of cardiovascular disease with aging. This is in the background of normative age-related changes in cardiovascular structure and function that result in a phenotype that predisposes older adults to cardiovascular disorders and magnify their sequelae. Accordingly, although mainstream cardiology is becoming de facto geriatric cardiology, in many places, older adults with cardiovascular disease are often not cared for by cardiologists, rather care is being provided primarily by primary care providers, geriatricians, and allied health professions instead of cardiologists. It is with this background in mind that the Oxford Care Manual Cardiovascular Disease in the Elderly: A Practical Manual was written, and it has an important place in the dissemination of high-quality cardiovascular care to a wider and growing audience of healthcare providers of cardiovascular care for older adults.
Cardiovascular Disease in the Elderly is a small, pocket-sized text whose size can be deceiving. In its >300 pages, which are well organized into 14 chapters covering the demography of aging, ischemic heart disease, valve disease, infective endocarditis, heart failure, arrhythmias, syncope and orthostatic hypotension, hypertension, peripheral vascular disease, major clinical trials in older adults, management of older adults undergoing noncardiac surgery, palliative care and end of life, and finally, mental health and cardiovascular disease, there is a lot of material. Each chapter has a specific table of contents, facilitating the location of the needed materials for the busy clinician in training, who is the presumed target of the text. Despite this target audience, rest assured that Gray and Pack have done an outstanding job at presenting a seasoned and senior clinical view that features a healthy bit of skepticism about the growing array of therapeutic interventions available to older adults with cardiovascular disease. Accordingly, one could be confident that providing this Oxford manual to one's trainees will effect a rational and reasonable application of available evidence in optimizing outcomes through what certainly needs to be patient-centered care.
Throughout each chapter there are several useful figures, including the results of cardiac imaging procedures, and tables that summarize the relevant information, including simple diagnostic and therapeutic algorithms. However, the wider application of such testing and their contribution to rising costs suggests that a chapter dedicated to diagnostic testing in older adults would have been a welcome addition. References presented are of high quality, but rely heavily on the National Institute for Clinical Excellence of the National Health Service of the United Kingdom, which has become quite controversial in its goal of “promoting good health and preventing and treating ill health,” and may not been well recognized by readers outside the United Kingdom. Finally, the chapter on major clinical trials is quite useful to highlight the evidence base for recommendations on various aspects of cardiovascular care for older adults. The authors attempted to highlight the limitations of such data as they apply to older adults by noting for each the “impact on the management of elderly patients,” which could have also included more details on whether the population recruited and retained was truly representative of the “geriatric” cohort.
Throughout the manual there are a several blank pages—presumably for the reader to jot notes, which could be helpful in assimilating the information provided by encouraging an interaction between the reader and the data presented. Again, the size of Cardiovascular Disease in the Elderly: A Practical Manual is similar to others in the Oxford Care Manuals, and thus fits in the pocket of one's white coat. Such an approach, although traditional and practical, may soon be outdated with the advent of electronic tools to be used at the bedside to advance the care even of our most vulnerable population. Accordingly, one yearns for an electronic version that could advance the educational process by providing links to relevant streaming video, source documents of relevant citations, and links to important Internet sites.
Overall, Cardiovascular Disease in the Elderly: A Practical Manual does a very nice job, often in the absence of specific data on providing practical, concise recommendations that are not overreaching the available data. It does not delve deeply into the many controversies surrounding the care of older adults with cardiovascular disease, nor does it overemphasize the potential advances that may occur with novel therapies like transcatheter aortic valve replacement, ventricular assist devices, and approaches using system biology to identify novel targets, but it does provide a strong foundation in which trainees can practically and insightfully provide care to our growing population of older adult patients.
- © 2011 American Heart Association, Inc.