An American Heart Association scientific statement on secondary prevention of coronary heart disease (CHD) in the elderly pointed out that at necropsy 50% of elderly women and 70–80% of elderly men have obstructive coronary artery disease.¹ Moreover, in the USA, the prevalence of CHD over the age of 75 years is 2.2% for men and 1.3% for women. This sizeable problem has been addressed in other reviews; however, they often consider the elderly as all those over 65 years of age and tend to conclude that the secondary prevention of CHD should be the same as in the young and middle aged. These reviews often ignore the fact that the benefit:risk ratio does change with every decade of life. For example, with aspirin both the absolute benefits and absolute risks are greater at age 60–69 than age 50–59. Moreover, although there is an extensive literature suggesting, for example, that blood pressure and serum cholesterol may be safely lowered up to the age of 75–79 years, with considerable benefit and little increase in risk, the problem remains as to whether the benefits will outweigh the risks at older ages.

These anxieties arise from two main sources: firstly, there is little evidence from randomised controlled trials to guide our decisions in the very elderly (over 80s); and secondly they differ in many ways from younger subjects. Table 1⇓ lists some differences in major and minor categories. The list is far from complete. Pharmacological treatment or lifestyle changes may be inappropriate in the demented patient, weight loss is more often a problem than a therapeutic goal, and dietary change may be resisted as may the standard exercise regimens. If the patient has so many problems you do not know which to address first, the prescription of a drug for secondary prevention …