The lifetime’s risk to develop coronary artery disease is quite high. At the age of seventy the risk for a first cardiovascular event is 34.9 % in men and 24.2 % in women. The average age for a myocardial infarction is 64.5 years in men and 70.3 years in women.

The majority of older patients does not show any clinical symptoms for a clinically relevant CAD. Nevertheless, in many of these patients subclinical CAD can be detected. For example, the Cardiovascular Health Study (CHS) provided evidence of significant carotid artery stenosis >50 % in adults above 65 years and without any known cardiovascular risk factors in 4.3 % of men (age group between 65 and 74 years) increasing to 10.9 % in men over 85 years as well as in 3.4 % and 11.8 % in women, respectively. Left ventricular hypertrophy as another cardiovascular risk factor was detected in 2.1–6.3 % in men and 1.9–5.2 % in women (in the above mentioned age groups) [3].

When combing several cardiovascular characteristics (ECG abnormalities, ABI <0.9, increased Intima-Media-Thickness, echocardiographic abnormalities, angina pectoris or claudication), a retrospective analysis of the Cardiovascular Health Study could discover a prevalence for subclinical cardiovascular diseases of up to 61 %. In correspondence with these findings, Wong et al. took the MESA Trial and found a prevalence for subclinical atherosclerosis (measured as an increased Intima-Media-Thickness, low ABI, or presence of coronary or abdominal aortic calcifications) in 55 % of men at the age between 45 and 54 years ‘old’ streichen and a prevalence of 100 % in men at the age between 75 and 84 years (in women, prevalence was 32 % as well as 98 % in the above mentioned age groups). In most cases, calcifications of the abdominal aorta gave a hint for the underlying subclinical atherosclerosis. Aortal calcifications appear in equal numbers in men and women, whereas coronary calcifications appear more often in men [4]. The detection of abdominal aortal calcification was a strong predictor for other markers of subclinical atherosclerosis (increased carotid Intima-Media-Thickness, low ABI, coronary calcification).

The risk for cardiovascular disease rises dramatically with increasing age. In general more than half of all men and one third of all women at the age of 70 years have a 10 % risk to experience a cardiovascular event within the next 10 years. Data of the Framingham Heart Study shows, that the risk for coronary artery disease can step up as much as 5-fold depending on the number of atherogenic risk factors. Generally speaking, the well-known atherogenic risk factors in young people keep their atherogenity in older patients, although gender differences have to be considered. For example, an increased systolic blood pressure is strongly associated with CAD in young and old people of both ages, whereas an increased diastolic blood pressure is of only marginal significance in older women.

From a global perspective, hypertension is responsible for the death of more than 7 million people per year, thus being the most important of all risk factors. Hypertension among US-citizens is the most frequent cardiovascular risk factor: it appears in 2/3 of all men above 65 years and in about 80 % of women above 75 years. Younger people (<40 years) more often have an isolated diastolic hypertension (i.e. systolic pressure below 140 mmHg, diastolic above 90 mmHg). At the age of 50 years, systolic hypertension becomes more prominent (either as an isolated systolic hypertension or as a combined systolic/diastolic hypertension). In life’s sixth decade, isolated systolic arterial hypertension becomes the dominant subtype. At the age between 60–69 years, about 80 % of all people with hypertension demonstrate an isolated systolic arterial hypertension due to an increased stiffness of the great arteries. Additional risk factors such as diabetes mellitus or chronic renal insufficiency, which can also lead to arterial stiffness, can accelerate the rigidity of great arteries thus causing isolated systolic hypertension even in younger ages.

Meanwhile several studies (e.g. the Framingham Heart Study) stress the superiority of an increased pulse pressure and reduced diastolic blood pressure compared to an isolated systolic hypertension with regard to cardiovascular risk stratification in the elderly. After the age of 50 years, systolic blood pressure rises disproportionate to the diastolic blood pressure. After the age of 60 years, diastolic blood pressure drops further resulting in an increase of pulse pressure. Among the ages between 50 and 70 years, there is a positive correlation of the systolic blood pressure and a negative correlation of the diastolic blood pressure with the risk for CAD. This observation underscores the superiority of the pulse pressure in contrast to the systolic hypertension for the prediction of CAD risk.

Age is another important parameter on the hemodynamic system and therefore strongly influences the risk for CAD. This means, that with increasing age there is a gradual transition from diastolic to systolic hypertension and then to pulse pressure as predictors for CAD risk. In addition it could be shown, that the combination of systolic and diastolic blood pressure was superior to the single use of systolic blood pressure in the risk assessment for CAD. In general, the systolic blood pressure is a better predictor for CAD than diastolic blood pressure in people above 50 years. Nevertheless, the risk for CAD can be strongly influenced by a very high systolic or very low diastolic blood pressure. The National Health and Nutrition Examination Survey (NHANES), for example, has demonstrated, that a diastolic blood pressure below 70 mmHg, which appears in about 30 % of untreated people with isolated systolic hypertension, increases the risk for CAD. Factors associated with low diastolic blood pressure were advanced age, female gender as well as diabetes mellitus, but not state of treatment. A recently published sub analysis of the Framingham Heart Study confirmed these results in 791 individuals with a mean age of 75 years: here, persons with isolated systolic hypertension (and prior CVD events) have increased risk for recurrent CVD events in the presence of diastolic blood pressure <70 mmHg versus DBP 70–89 mmHg, whether treated or untreated, supporting wide pulse pressure as an important risk modifier for the adverse effect of low diastolic blood pressure [5].

Initial sub analysis of the Framingham Heart Study suggested that no positive correlation exists between serum cholesterol levels and CAD risk in older men. Meanwhile, some studies could prove, that serum cholesterol levels strongly predict new as well as recurrent cardiovascular events in older men and women. For example, Aronow et al. proved in a study with a 40–48 months follow-up with groups of 644 older men and 1488 older women a 12 % increase in the risk for cardiovascular events with each 10 mg/dL rise of total cholesterol [6]. In a meta analysis by Manolio et al., based on 22 US and international cohort studies, serum cholesterol levels showed a rather weak predictive power in older men and women. In these studies, the frailty and comorbidity of patients strongly influenced the results, so after adjusting for these factors, total cholesterol regained predictive power for future cardiovascular events [7].

With regard to HDL cholesterol, Castelli et al showed an inverse correlation between low HDL cholesterol and new coronary events [8]. A similar association was shown in the above mentioned study by Aronow et al., in which a 70 % increased risk for cardiovascular events in men and a 95 % increased risk in women was seen with every descent of 10 mg/dL of HLD cholesterol. Additional results of this study showed, that hypertriglyceridemia is only a weak risk factor in women, but not in men. Whereas total cholesterol did not consistently prove to be a predictor for CAD events, the determination of HDL cholesterol or the relation between total cholesterol/HDL cholesterol consistently proved to be an important predictor for CAD risk.

What about the potential benefits of pharmacological interventions in elderly patients with hypercholesterolemia? Several studies could show that the effectiveness of such lipid lowering interventions is comparable to those in younger patients. For example, in the well-known 4S Study (Scandinavian Simvastatin Survival Study), a placebo-controlled study in high risk patients (the majority of which had proven CAD), the treatment with a statin (simvastatin) lead to a 43 % reduction of CAD mortality in subjects above 65 years as compared to subjects below 65 years. Moreover, the CARE-Study (Cholesterol and Recurrent Events Study) proved, that a statin therapy was even more effective in patients above 65 years in reducing cardiovascular events (32 % risk reduction) in comparison to the risk reduction in patients below 65 years (19 % risk reduction).

Altogether, there are only a few studies about lipid interventions specifically in older patients. One of these studies is the PROSPER-study performed in men and women between the age of 70–82 years and a history or risk factors for vascular diseases. These patients were treated with the statin ‘Pravastatin’ (40 mg/day; n = 2.891) or placebo (n = 2.913). After an average follow-up of 3.2 years the primary end point was analysed (i.e. a combined end point of coronary death, non-fatal myocardial infarction and fatal or non-fatal stroke). Pravastatin reduced LDL-cholesterol by 34 % and thereby significantly reduced the incidence of the primary endpoint (hazard ration 0.85, 95 % CI, 0.74–0.97, p = 0.014). It also reduced coronary death and the risk for non-fatal myocardial infarctions (0.81, 0.69–0. 94, p = 0.006). Surprisingly, new cancer disease appeared significantly more often in patients treated with pravastatin as compared to the placebo group (1.25, 1.04–1.51, p = 0.02). In the meantime, several metaanalyses of studies using pravastatin or other statins could convincingly eliminate any increased incidence of risk for cancer under chronic statin therapy. At last, the Cholesterol Treatment Trialist’ Collaboration with more than 170,000 patients in 26 studies has to be mentioned. This trial showed a 22 % general benefit of a lipid lowering therapy for the reduction in CAD events. No significant differences were seen in the age group below 65 years, 65–74 years, and older than 75 years. In addition, this study shows a rather weak effect of a lipid lowering therapy in very old patients (i.e. only a 16 % risk reduction).