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The major modifiable risk factors remain relevant in the elderly. The strength of risk factors associated with CVD diminishes with advancing age, but this lower risk ratio is offset by a higher absolute risk. This makes risk factor control in the elderly at least as cost-effective as in the middleaged. Epidemiologic research has quantified the impact of the standard CVD risk factors in the elderly < 19). Dyslipidemia, hypertension, glucose intolerance, and cigarette smoking all have smaller hazard ratios in advanced age, but this is offset by higher absolute and attributable risks. Diabetes operates more strongly in elderly women than men. further attenuating their waning advantage over men in advanced age. Insulin resistance promoted by abdominal obesity in advanced age is an important feature of the CVD hazard of diabetes in the elderly. Hypertension, particularly the isolated systolic variety, is highly prevalent in the elderly, and is a safely modifiable hazard. Dyslipidemia, particularly the total/HDL cholesterol ratio, remains a major risk factor in the elderly that, in contrast to the total cholesterol, continues to be highly predictive in advanced age. Left ventricular hypertrophy remains an ominous harbinger of CVD in the elderly, indicating an urgent need for attention to its promoters including hypertension, diabetes, obesity, and myocardial ischemia or valve disease. High-normal fibrinogen. C-reactivc protein (CRP). and leukocyte counts in the elderly may indicate the presence of unstable atherosclerotic lesions. As in the middle-aged, all the major risk factors in the elderly tend to cluster so that the hazard of each one is powerfully influenced by the associated burden of the others. Multivariate risk assessment can quantify the joint effect of the burden of risk factors making it possible to more efficiently target elderly candidates for CVD for preventive measures.

Atherosclerotic CVD is usually a diffuse process involving the heart, brain, and peripheral arteries. The presence of one clinical manifestation substantially increases the likelihood of having or developing others . The major risk factors tend to affect all arterial territories and clinical atherosclerosis affecting the heart may also directly predispose to strokes and heart failure. Measures taken to prevent coronary disease should have an additional benefit in preventing atherosclerotic peripheral artery and stroke events as well as heart failure. Coronary artery disease places a patient at considerable risk not only for a myocardial infarction. angina, sudden death, or heart failure, but also for transient ischemic attacks, strokes, and intermittent claudication because of concomitant atherosclerotic disease in the other vascular territories . The incidence of other cardiovascular disease accompanying coronary disease is substantial . The Framingham Study found that in men and women, respectively, an initial myocardial infarction is accompanied by intermittent claudication 9% and 10% of the time, by strokes orTIAs 5% and 8% of the time, and by heart failure 3% and 10% of the time. Persons in the Framingham Study with intermittent claudication had a twoto threefold increased risk of developing coronary disease. Over 10 yr. 45% developed coronary heart disease. After an initial myocardial infarction, strokes and heart failure occurred at three to six times the rate of the general population. The 10-yr probability of a stroke or TIA was 16% in men and 24% in women, a rate three to four times that of the general population. Heart failure occurred in about 30% of patients who had experienced an MI, which represents a fourto sixfold increase in risk. After sustaining an atherothrombotic stroke, 25% to 45% developed coronary disease, a twofold increase in risk. After an Ml coexistence of intermittent claudication increased age-adjusted coronary mortality 1.7-fold in men and 1.5-fold in women, and of recurrent MI increased twofold in men and 1.6-fold in women.