Improving Patient-Centered Cardiovascular Care for Older Adults

There is a growing imperative for cardiology care models and clinical trials to better reflect the realities of aging.

At the American Heart Association (AHA) 2025 Scientific Sessions, speakers emphasized that older adults remain underrepresented in cardiovascular research, face unique barriers to hypertension control, and are at increased risk of polypharmacy and overtreatment.

Barriers to Digital Tools in Hypertension Management

John A. Dodson, MD, MPH, associate professor of medicine at New York University, opened the session by outlining how digital health could help address persistent gaps in blood pressure control.¹ Despite increasing use of mobile devices for managing health, Dodson said rates of adequate hypertension management among older adults are still low due to comorbidities, mobility limitations, and challenges with medication adherence.

The success of digital health tools depends on the real-world barriers older adults face, Dodson emphasized. Many patients experience what he called a utility cost, or the feeling that using new technology simply isn’t worth the effort. “Technology can be frustrating,” he said, adding that privacy concerns and resistance to change are common and understandable.

Physical limitations, such as impaired vision, hearing loss, arthritis, or tremor, can also make device use challenging, as can cognitive decline that affects memory or reasoning. “When we're thinking about implementing an intervention that's designed to change health behavior, it's usually more complicated than simply asking a patient to pick up their phone,” Dodson said, turning to 2 of his team’s National Institutes of Health–funded trials to show the lessons learned on engaging older adults.

The phase 2 RESILIENT trial (NCT03978130) tested whether mobile health–based cardiac rehabilitation (mHealth-CR) could improve functional capacity among adults 65 years and older with ischemic heart disease.² This randomized trial enrolled 400 participants across 5 academic centers and found that mHealth-CR did not significantly increase 6-minute walk distance compared with usual care, with a difference of just 15.6 meters, below the 25-meter threshold for clinical significance. However, patient engagement strongly influenced outcomes. Among those who fully participated in weekly digital rehab tasks, improvements in functional capacity were seen, suggesting that motivation, support, and better predictive tools may be key drivers of benefit.

“If we could either select for patients who were likely to improve before they start these digital interventions, or nudge them to improve along the way, I think this could be an effective approach,” Dodson said.¹

The BETTER-BP study (NCT04114669), a pragmatic randomized trial combining behavioral economics with text messaging for blood pressure adherence, enrolled 20% of participants 65 years or older and achieved an 87% retention rate at 6 months. Dodson credited the high engagement to meeting patients where they are with bilingual staff, reimbursement for transportation, and real-time technical support, rather than leaving patients to their own devices. A full readout of the outcomes data is scheduled for Sunday, November 9.

Expanding Representation in Coronary Disease Trials

Michael Nanna, MD, MHS, assistant professor of internal medicine and interventional cardiologist at Yale School of Medicine, focused on the persistent underrepresentation of older adults in coronary artery disease research.³ Although specific age-based exclusions are less common than in decades past, older adults remain indirectly excluded from trials due to comorbidities, increased frailty, transportation issues, polypharmacy concerns, or lack of physician engagement.

“If you want generalizable results,” Nanna said, “you must enroll patients across the biological aging spectrum.”

This was the rationale behind the LIVEBETTER study (NCT05786417), a PCORI-sponsored trial comparing beta-blockers and calcium channel blockers for angina management in 640 adults 65 years and older.⁴ What sets the trial apart, he said, is its design. The primary end point was selected through patient and caregiver input and an outcome that many patients feel is left out of trials: global quality of life.

“Engagement with caregivers is especially crucial when it comes to successfully enrolling older adults in randomized trials, and that's part of the reason why we decided to enroll patient caregivers themselves in LIVEBETTER in addition to their patient partners and to assess caregiver burden longitudinally,” Nanna explained.³

The study also incorporates remote follow-ups and community partnerships to reduce barriers. “Pragmatic trials in older adults are not just feasible, but they’re essential,” he said. “Integrating stakeholder voices, respecting clinician-patient bonds, rolling across the biological age spectrum, and adapting to the needs of our older patients are really nonnegotiable for success.

Deprescribing and Polypharmacy in Complex Care

Mark Effron, MD, professor of medicine and cardiologist at Ochsner Health, shifted the discussion toward deprescribing and medication burden.⁵ Using a real-world case, he showed how a single patient could meet guideline-directed medical therapy criteria for 4 conditions, resulting in up to 11 medication classes just to treat their heart disease.

Although medications help manage cardiovascular disease, their cumulative burden can create new health risks, especially for older adults who can experience poor adherence, drug-drug interactions, falls, disability, hospitalizations, and even adverse cardiovascular outcomes. This creates what Effron called an “inherent tension” between therapy and polypharmacy, where clinicians must constantly weigh whether the benefits of each drug outweigh its potential harms, particularly when they don’t align with the patient’s goals.

Effron also warned of “therapeutic competition,” where a treatment for one condition can worsen another. For example, beta-agonists for chronic obstructive pulmonary disease may exacerbate atrial fibrillation, or nonsteroidal anti-inflammatory medications for arthritis can heighten bleeding risk. For older adults with comorbidities, he said these cascading effects require close monitoring and a patient-centered balance between helping the patient and avoiding harm.

“We just aren't treating our patients appropriately,” Effron told The American Journal of Managed Care^®. “But we also have to be careful when we overtreat patients that we don't create problems that they wouldn't have had otherwise.”

A pair of deprescribing trials—a Veterans Affairs study in long-term care and the OPTIMISE trial in patients 80 years and older (NCT06935760)—found no increase in mortality or cardiovascular events after reducing antihypertensive medications.^6,7 Effron also discussed the promise of n-of-1 trials, which test medication withdrawal within individual patients to guide personalized decisions.⁵ “It provides personal pharmacotherapy and therapeutic precision in the face of a heterogeneous clinical phenotype, drug metabolism, responsiveness to therapy, and health priorities,” he said.

References

1. Dodson JA. Modernizing hypertension management in older adults: pragmatic trials with digital health. Presented at: AHA 2025 Scientific Sessions; November 7-10, 2025; New Orleans, LA.
2. Dodson JA, Adhikari S, Schoenthaler A, et al. Rehabilitation at home using mobile health for older adults hospitalized for ischemic heart disease: the RESILIENT randomized clinical trial. JAMA Netw Open. 2025;8(1):e2453499. doi:10.1001/jamanetworkopen.2024.53499
3. Nanna M. Opportunities and challenges for the enrollment of older adults in pragmatic trials to address coronary artery disease. Presented at: AHA 2025 Scientific Sessions; November 7-10, 2025; New Orleans, LA.
4. LIVEBETTER: a trial comparing medications in older adults with stable angina and multiple chronic conditions (LIVEBETTER). ClinicalTrials.gov. Updated February 6, 2025. Accessed November 7, 2025. https://clinicaltrials.gov/study/NCT05786417
5. Effron MB. Deprescribing and decision-making: pragmatic trials in cardiovascular care for older adults. Presented at: AHA 2025 Scientific Sessions; November 7-10, 2025; New Orleans, LA.
6. Odden MC, Graham LA, Liu X, et al. Antihypertensive deprescribing and cardiovascular events among long-term care residents. JAMA Netw Open. 2024;7(11):e2446851. doi:10.1001/jamanetworkopen.2024.46851
7. Sheppard JP, Burt J, Lown M, et al. Effect of antihypertensive medication reduction vs usual care on short-term blood pressure control in patients with hypertension aged 80 years and older: the OPTIMISE randomized clinical trial. JAMA. 2020;323(20):2039-2051. doi:10.1001/jama.2020.4871