Abnormal lipoprotein metabolism is an important and modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD), which has been shown in numerous studies to lead to adverse cardiovascular outcomes. As cardiovascular disease (CVD) remains the major cause of morbidity and mortality globally, management of dyslipidemia is a key component of primary and secondary risk-reduction strategies. Because ASCVD risk increases with age, as the population ages, many more people-particularly the elderly-will meet guideline criteria for drug treatment. Statins (HMG-CoA reductase inhibitors) have an unequivocal benefit in reducing ASCVD risk across age groups for secondary prevention. However, the benefit of these drugs for primary prevention in those > 75 years of age remains controversial. We strongly believe that statins should be offered for primary prevention to all older individuals after a shared decision-making process that takes polypharmacy, frailty, and potential adverse effects into consideration. When considering statin therapy in the very old, competing risks of death, and therefore the likelihood that patients will live long enough to benefit from drug therapy, should inform this process. Combination therapies with ezetimibe or proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors should be considered to facilitate the use of tolerable doses of statins. Future investigations of dyslipidemia therapies must appropriately include this at-risk population to identify optimal drugs and drug combinations that have a high benefit:risk ratio for the prevention of ASCVD in the elderly.

Randomized, double-blind, placebo-controlled secondary prevention and primary prevention studies and observational studies have documented that statins reduce cardiovascular events in high-risk patients with hypercholesterolemia. The 2013 American College of Cardiology/American Heart Association guidelines on treatment of hypercholesterolemia support the use of statins in 4 major groups that will be discussed. The Expert Panel of these guidelines could find no data supporting the routine use of nonstatin drugs combined with statins to further reduce cardiovascular events. Since these guidelines were published, a double-blind randomized trial of 18,144 patients with an acute coronary syndrome demonstrated at a 7-year follow-up that the incidence of cardiovascular events was 34.7% in patients randomized to simvastatin plus placebo versus 32.7% in patients randomized to simvastatin plus ezetimibe (hazard ratio = 0.936; P = 0.016). Proprotein convertase subtilisin/kexin type 9 inhibitors further lower serum low-density lipoprotein cholesterol by 50%-70% in patients treated with statins and 4 phase 3 trials including more than 70,000 patients are investigating whether these monoclonal antibodies to proprotein convertase subtilisin/kexin type 9 will lower cardiovascular events.

Numerous randomized, double-blind, placebo-controlled studies and observational studies have shown that statins reduce mortality and major cardiovascular events in older high-risk persons with hypercholesterolemia. The Heart Protection Study showed that statins reduced mortality and major cardiovascular events in high-risk persons regardless of the initial level of serum lipids, age, or gender. The updated National Cholesterol Education Program III guidelines state that in very high-risk persons, a serum low-density lipoprotein (LDL) cholesterol level of < 70 mg/dl (1.8 mmol/l) is a reasonable clinical strategy for moderately high-risk persons (2 or more risk factors and a 10-year risk for coronary artery disease of 10% to 20%), and the serum LDL cholesterol should be reduced to < 100 mg/dl (2.6 mmol/l). When LDL cholesterol-lowering drug therapy is used to treat high-risk persons or moderately high-risk persons, the serum LDL cholesterol should be reduced by at least 30% to 40%. The serum LDL cholesterol should be decreased to less than 160 mg/dl in persons at low risk for cardiovascular disease. Addition of other lipid-lowering drugs to statin therapy has not been demonstrated to further reduce cardiovascular events and mortality.

The American Diabetes Association (ADA) 2013 guidelines state that a reasonable hemoglobin A1c goal for many nonpregnant adults with diabetes is less than 7.0% a hemoglobin A1c level of less than 6.5% may be considered in adults with short duration of diabetes, long life expectancy, and no significant cardiovascular disease if this can be achieved without significant hypoglycemia or other adverse effects of treatment. A hemoglobin A1c level less than 8.0% may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced macrovascular and microvascular complications, extensive comorbidities, and long-standing diabetes in whom the hemoglobin A1c goal is difficult to attain despite multiple glucose-lowering drugs including insulin. The ADA 2013 guidelines recommend that the systolic blood pressure in most diabetics with hypertension should be reduced to less than 140 mmHg. These guidelines also recommend use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in the treatment of hypertension in diabetics unless they are pregnant. Diabetics at high risk for cardiovascular events should have their serum low-density lipoprotein (LDL) cholesterol lowered to less than 70 mg/dL with statins. Lower-risk diabetics should have their serum LDL cholesterol reduced to less than 100 mg/dL. Combination therapy of a statin with either a fibrate or niacin has not been shown to provide additional cardiovascular benefit above statin therapy alone and is not recommended. Hypertriglyceridemia should be treated with dietary and lifestyle changes. Severe hypertriglyceridemia should be treated with drug therapy to reduce the risk of acute pancreatitis.

Persons with peripheral arterial disease (PAD) are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped and hypertension, dyslipidemia, diabetes mellitus, and hypothyroidism treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. The serum low-density lipoprotein cholesterol should be reduced to < 70 mg/dl. Antiplatelet drugs such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to persons with PAD. β-Blockers should be given if coronary artery disease is present. Cilostazol improves exercise time until intermittent claudication. Exercise rehabilitation programs should be used. Revascularization should be performed if indicated.

Multiple randomized, double-blind, placebo-controlled studies and observational studies have demonstrated that statins decrease mortality and major cardiovascular events in high-risk persons with hypercholesterolemia. The Heart Protection Study showed that statins decreased mortality and major cardiovascular events in high-risk persons regardless of the initial level of serum lipids, age, or gender. The updated National Cholesterol Education Program III guidelines state that in very high-risk patients, a serum low-density lipoprotein (LDL) cholesterol level of <70 mg/dL is a reasonable clinical strategy, regardless of age. When a high-risk person has hypertriglyceridemia or low serum high-density lipoprotein cholesterol, consideration can be given to combining a fibrate or nicotinic acid with an LDL cholesterol-lowering drug. For moderately high-risk persons, the serum LDL cholesterol should be lowered to <100 mg/dL. When LDL cholesterol-lowering drug therapy is used to treat high-risk persons or moderately high-risk persons, the serum LDL cholesterol should be reduced at least 30% to 40%. High-risk older persons should be treated with lipid-lowering drug therapy according to National Cholesterol Education Program III updated guidelines to decrease cardiovascular morbidity and mortality. The LDL cholesterol should be decreased to <160 mg/dL in persons at low risk for cardiovascular disease.

Because diabetes mellitus was not being adequately treated according to guidelines in an academic general medicine clinic, 2 of the authors (W.S.A. and A.H.G.) instituted an educational program to see if we could improve the appropriate management of diabetes mellitus in the academic general medicine clinic. Following this educational program, we investigated the appropriate management of 196 unselected patients with diabetes mellitus, mean age 61 years, who were followed up for at least 1 year in an academic general medicine clinic. The blood pressure was reduced to <130/80 mm Hg in 161 of 196 diabetics (82%). The hemoglobin A1c was reduced to <7.0% in 134 of 196 diabetics (68%). Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers were used to treat 50 of 51 diabetics (98%) with coronary artery disease (CAD), ischemic stroke, or peripheral arterial disease; 33 of 35 diabetics (94%) with a glomerular filtration rate <60 mL/min/1.73 m; 54 of 57 diabetics (94%) with microalbuminuria, and 21 of 22 diabetics (96%) with electrocardiographic left ventricular hypertrophy. Aspirin was used to treat 50 of 51 diabetics (98%) with CAD, ischemic stroke, or peripheral arterial disease. beta-Blockers were used to treat 36 of 39 diabetics (92%) with CAD. Statins were used to treat 168 of 196 diabetics (86%). Smoking cessation counseling was documented in 39 of 53 smokers (74%). Of 196 diabetics, 196 (100%) had a neurological examination, 129 (66%) were referred to an ophthalmologist for an eye examination, and 125 (64%) were referred to a podiatrist for foot care. These data show that an educational program on the appropriate management of diabetes mellitus improved the management of diabetes mellitus in an academic general medicine clinic.

Peripheral arterial disease (PAD) is chronic arterial occlusive disease of the lower extremities caused by atherosclerosis whose prevalence increases with age. Only one-half of women with PAD are symptomatic. Symptomatic and asymptomatic women with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Modifiable risk factors that predispose women to PAD include active cigarette smoking, passive smoking, diabetes mellitus, hypertension, dyslipidemia, increased plasma homocysteine levels and hypothyroidism. With regard to management, women who smoke should be encouraged to quit and referred to a smoking cessation program. Hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism require treatment. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in women with PAD and hypercholesterolemia. Anti-platelet drugs such as aspirin or especially clopidogrel, angiotensin-converting enzyme inhibitors and statins should be given to all women with PAD. Beta blockers are recommended if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided as it is ineffective. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery in women are (1) incapacitating claudication interfering with work or lifestyle; and (2) limb salvage in women with limb-threatening ischemia as manifested by rest pain, non-healing ulcers, and/or infection or gangrene. Future research includes investigation of mechanisms underlying why women have a higher risk of graft failure and major amputation.

Hypertension is a common comorbidity in persons with diabetes mellitus, and its prevalence increases with advancing age. Both diabetes mellitus and hypertension are independent risk factors for development in older persons of coronary artery disease, ischemic stroke, peripheral arterial disease, and of congestive heart failure. This article reviews studies addressing the implications of hypertension and the older diabetic.

Randomized, double-blind, placebo-controlled studies and observational studies have demonstrated that statins reduce mortality and major cardiovascular events in high-risk persons with hypercholesterolemia. The aim of this study was to review the evidence for treating high-risk older persons with lipid-lowering drugs. A MEDLINE search of the English-language literature published from January 1, 1989, to June 2006 was conducted to review all studies in which lipid-lowering drug therapy was administered to high-risk older persons. The Heart Protection Study showed that statins reduced mortality and major cardiovascular events in high-risk persons, regardless of the initial level of serum lipids, age, or gender. The updated National Cholesterol Education Program (NCEP) III guidelines state that in very-high-risk patients, a serum low-density lipoprotein (LDL) cholesterol level of <70 mg/dL is a reasonable clinical strategy, regardless of age. When a high-risk person has hypertriglyceridemia or low serum high-density lipoprotein cholesterol, consideration can be given to combining a fibrate or nicotinic acid with an LDL cholesterol-lowering drug. For moderately-high-risk persons, the serum LDL cholesterol should be reduced to <100 mg/dL. When LDL cholesterol-lowering drug therapy is used for high-risk persons or moderately-high-risk persons, the serum LDL cholesterol should be reduced at least 30% to 40%. High-risk older persons should be treated with lipid-lowering drugs according to the NCEP III updated guidelines to reduce cardiovascular morbidity and mortality.

To determine the prevalence of use of antiplatelet drugs, beta-blockers, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in older persons with coronary artery disease (CAD) in an academic nursing home.

We investigated in all older persons with documented CAD who were not terminally ill in an academic nursing home the prevalence of use of antiplatelet drugs, beta-blockers, statins, and ACE inhibitors or ARBs. The physicians taking care of these persons were taught by one of the authors to treat persons with CAD with these drugs to reduce cardiovascular morbidity and mortality.

An academic nursing home.

Of 202 persons, 54 (27%) had documented CAD. The 54 persons with CAD included 27 women and 27 men, mean age 76 +/- 8 years.

Prevalence of use of antiplatelet drugs, beta-blockers, statins, and ACE inhibitors or ARBs.

In 54 persons with CAD, aspirin or clopidogrel was used in 53 persons (98%), beta-blockers in 52 persons (96%), statins in 47 persons (87%), and ACE inhibitors or ARBs in 46 persons (85%). The serum low-density lipoprotein cholesterol was less than 100 mg/dL in 51 persons (94%).

As recommended by evidence-based guidelines, the prevalence of use of aspirin or clopidogrel was 98%, of beta-blockers was 96%, of statins was 87%, and of ACE inhibitors or ARBs was 85% in an academic nursing home.

To determine the prevalence of a hemoglobin A(1c) less than 7.0%, of a blood pressure less than 130/80 mm Hg, and of a serum low-density lipoprotein (LDL) cholesterol less than 100 mg/dL in older persons with diabetes mellitus who were not terminally ill in an academic nursing home.

We investigated in all older diabetic individuals who were not terminally ill in an academic nursing home the prevalence of a hemoglobin A(1c) less than 7.0%, of a blood pressure less than 130/80 mm Hg, and of a serum LDL cholesterol less than 100 mg/dL.

An academic nursing home.

Of 202 persons, 62 (31%) had diabetes mellitus. The 62 diabetic individuals included 33 women and 29 men, mean age 73 +/- 9 years.

Prevalence of hemoglobin A(1c) less than 7.0%, of blood pressure less than 130/80 mm Hg, and of serum LDL cholesterol less than 100 mg/dL.

The hemoglobin A(1c) was less than 7.0% in 55 (89%) of 62 diabetic individuals. The blood pressure was less than 130/80 mm Hg in 52 (84%) of 62 diabetic individuals. The serum LDL cholesterol was less than 100 mg/dL in 55 (89%) of 62 diabetic individuals.

As recommended by the American Diabetes Association, the hemoglobin A(1c) was less than 7.0% in 55 (89%) of 62 diabetic individuals, the blood pressure was less than 130/80 mm Hg in 52 (84%) of 62 diabetic individuals, and the serum LDL cholesterol was less than 100 mg/dL in 55 (89%) of 62 diabetic individuals in an academic nursing home.

To determine the prevalence of adequate control of serum low-density lipoprotein (LDL) cholesterol in older persons who were not terminally ill in an academic nursing home.

An increased LDL cholesterol was 100 mg/dL or higher in very high-risk persons with coronary artery disease (CAD), ischemic stroke, peripheral arterial disease, diabetes mellitus, or 2+ risk factors and a 10-year risk for CAD greater than 20%; 130 mg/dL or higher in moderately high-risk persons with 2+ risk factors and a 10-year risk for CAD of 10% to 20%; and 160 mg/dL or higher in low risk persons with 0 to 1 risk factor.

An academic nursing home.

Two hundred and two persons (104 women and 98 men), mean age 73 years (range 50 to 98 years) residing in an academic nursing home.

Prevalence of use of lipid-lowering drugs and of serum LDL cholesterol less than 100 mg/dL and less than 70 mg/dL in very high-risk persons and less than 130 mg/dL and less than 100 mg/dL in moderately high-risk persons.

Measurements of serum LDL cholesterol were obtained in 135 of 135 very high-risk persons (100%), in 57 of 61 moderately high-risk persons (93%), and in none of 6 low-risk persons (0%). Statins were used in 115 of 135 very high-risk persons (85%) and in 24 of 57 moderately high-risk persons (42%). Ezetimide was used to treat 3 of 135 very high-risk persons (2%). The last serum LDL cholesterol reported was less than 100 mg/dL in 119 of 135 very high-risk persons (93%), less than 70 mg/dL in 108 of 135 very high-risk persons (80%), less than 130 mg/dL in 40 of 57 moderately high-risk persons (70%), and less than 100 mg/dL in 35 of 57 moderately high-risk persons (61%).

Serum LDL cholesterol was measured in 192 of 202 older persons (95%) in an academic nursing home. Serum LDL cholesterol was adequately controlled in 93% of very high-risk persons and in 70% of moderately high-risk persons. Serum LDL cholesterol was optimally controlled in 80% of very high-risk persons and in 61% of moderately high-risk persons.

Pharmacokinetic considerations in the elderly include absorption, bioavailablility, drug distribution, half-life, drug metabolism, and drug excretion. There are numerous physiologic changes with aging that affect pharmacodynamics with alterations in end-organ responsiveness. This article discusses use of cardiovascular drugs in the elderly including digoxin, diuretics, beta-adrenergic blockers, angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, nitrates, calcium channel blockers, alpha-adrenergic blockers, antiarrhythmic drugs, lipid-lowering drugs, and anticoagulants. This article also discusses the adverse effects of cardiovascular drugs in the elderly, medications best to avoid in the elderly, and the prudent use of medications in the elderly.

Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism treated in elderly patients with peripheral arterial disease (PAD) of the lower extremities. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in patients with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to all elderly patients with PAD without contraindications to these drugs. Beta blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery are (1) incapacitating claudication in patients interfering with work or lifestyle; (2) limb salvage in patients with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene; and (3) vasculogenic impotence.

Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism treated in patients with peripheral arterial disease (PAD) of the lower extremities. Statins decrease the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to all persons with PAD. Beta blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery are (1) incapacitating claudication in persons interfering with work or lifestyle, (2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene, and (3) vasculogenic impotence.

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF such as nonsteroidal antiinflammatory drugs should be stopped. Patients with HF and a low left ventricular ejection fraction (systolic heart failure) or normal ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL.

Numerous randomized, double-blind, placebo-controlled studies and observational studies have demonstrated that statins decrease mortality and major cardiovascular events in older high-risk persons with hypercholesterolemia. The Heart Protection Study found that statins decreased mortality and major cardiovascular events in high-risk persons regardless of the initial level of serum lipids, age, or gender. The updated National Cholesterol Education Program (NCEP) III guidelines state that in very high-risk patients, a serum low-density lipoprotein (LDL) cholesterol level of < 70 mg/dl is a reasonable clinical strategy, regardless of age. When a high-risk person has hypertriglyceridemia or low serum high-density lipoprotein cholesterol, consideration can be given to combining a fibrate or nicotinic acid with an LDL cholesterol-lowering drug. For moderately high-risk persons (2 or more risk factors and a 10-year risk for coronary heart disease of 10% to 20%), the serum LDL cholesterol should be decreased to < 100 mg/dl. When LDL cholesterol-lowering drug therapy is used to treat high-risk persons or moderately high-risk persons, the serum LDL cholesterol should be decreased at least 30% to 40%.

Numerous randomised, double-blind, placebo-controlled studies and observational studies have shown that HMG-CoA reductase inhibitors (statins) reduce mortality and major cardiovascular events in elderly high-risk persons with hypercholesterolaemia. The Heart Protection Study showed that statins reduced mortality and major cardiovascular events in elderly high-risk patients regardless of the initial level of serum lipids, age or sex. The updated National Cholesterol Education Program III guidelines state that in very high-risk individuals, a target serum low-density lipoprotein cholesterol (LDL-C) level of <70 mg/dL (1.8 mmol/L) is a reasonable clinical strategy. When a high-risk patient has hypertriglyceridaemia or low high-density lipoprotein-cholesterol, consideration can be given to combining a fibric acid derivative or nicotinic acid with an LDL-C-lowering drug. For moderately high-risk patients (two or more risk factors and a 10-year risk for coronary artery disease of 10-20%), the serum LDL-C should be reduced to <100 mg/dL (2.6 mmol/L). When LDL-C-lowering drug therapy is used to treat high-risk patients or moderately high-risk patients, the serum LDL-C should be reduced by at least 30-40%.

Peripheral arterial disease (PAD) may be asymptomatic, may be associated with intermittent claudication or may be associated with critical limb ischaemia. Coronary artery disease (CAD) and other atherosclerotic vascular disorders may coexist with PAD. Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality and mortality from CAD. Smoking should be stopped and hypertension, diabetes mellitus, dyslipidaemia and hypothyroidism treated. HMG-CoA reductase inhibitors (statins) reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolaemia. Antiplatelet drugs such as aspirin or clopidogrel (especially the latter), ACE inhibitors and statins should be given to all persons with PAD. beta-Adrenoceptor antagonists should be given if CAD is present. The phosphodiesterase type 3 inhibitor cilostazol improves exercise time until intermittent claudication. Chelation therapy should be avoided. Correct implementation of medical therapy significantly reduces the excess mortality associated with PAD. In addition, medical therapy may result in significant improvements in walking ability that may obviate the need for lower extremity angioplasty with stenting and bypass surgery.

Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Patients with HF and an abnormal left ventricular ejection fraction (systolic HF) or normal left ventricular ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/ml. Cardiac synchronized pacing should be considered in patients with severe systolic HF despite optimal medical therapy, with sinus rhythm, and with ventricular dyssynchrony.

Peripheral arterial disease (PAD) may be asymptomatic, may be associated with intermittent claudication, or may be associated with critical limb ischemia. Coronary artery disease (CAD) and other atherosclerotic vascular disorders may coexist with PAD. Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from CAD. Modifiable risk factors such as cessation of cigarette smoking and control of dyslipidemia, hypertension, and diabetes should be treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, and angiotensin-converting enzyme inhibitors should be given to all persons with PAD. beta-Blockers should be given if CAD is present. Exercise rehabilitation programs and cilostazol improve exercise time until intermittent claudication. Indications for lower-extremity angioplasty, preferably with stenting, or bypass surgery are 1) incapacitating claudication in persons interfering with work or lifestyle; 2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene; and 3) vasculogenic impotence. However, amputation should be performed if tissue loss has progressed beyond the point of salvage, if surgery is too risky, if life expectancy is very low, or if functional limitations diminish the benefit of limb salvage.

Elderly persons after myocardial infarction should have their modifiable coronary artery risk factors intensively treated. Hypertension should be treated with beta blockers and angiotensin-converting enzyme inhibitors. The blood pressure should be reduced to <140/85 mmHg and to > or = 130/80 mmHg in persons with diabetes or renal insufficiency. The serum low-density lipoprotein cholesterol should be reduced to <100 mg/dl with statins if necessary. Aspirin or clopidogrel, beta blockers, and angiotensin-converting enzyme inhibitors should be given indefinitely unless contraindications exist to the use of these drugs. Long-acting nitrates are effective antianginal and antiischemic drugs. There are no Class I indications for the use of calcium channel blockers after myocardial infarction. Postinfarction patients should not receive Class I antiarrhythmic drugs, sotalol, or amiodarone. An automatic implantable cardioverter-defibrillator should be implanted in postinfarction patients at very high risk for sudden cardiac death. Hormonal therapy should not be used in postmenopausal women after myocardial infarction. The two indications for coronary revascularization are prolongation of life and relief of unacceptable symptoms despite optimal medical management.