The higher the baseline cardiovascular risk and the more aggressive the CVRM, the greater the therapy benefit that could be expected. However, therapy benefit is also positively related to the possible duration of CVRM, which is often much shorter in older patients. In addition, competing risk is also a bias to be taken into account, especially in the elderly. Furthermore, the risk of side effects could be higher in older patients so, again, we have to take frailty, life expectancy, expected therapy benefit and therapy harm into account.

Van Trier and her team nicely estimated from the PHARMO Database Network (which links primary and secondary healthcare settings), using the SMART-REACH model, that in 1817 patients aged 71–80 years and hospitalised for ischaemic heart disease (36% women; median age at event of 74 years), the additional effect of a low-density lipoprotein cholesterol (LDL-c) target of < 1.4 mmol/l instead of < 1.8 mmol/l and a blood pressure target of < 130 mm Hg instead of < 140 mm Hg was still a median gain of 0.6 event-free life years [6]. As expected, the greatest effect (up to 1.7 event-free years) could be achieved in patients not even reaching the less strict targets. Do not forget that not only the statistical calculation is an estimation, but also the SMART-REACH model uses estimated data from several large randomised trials. What is worrying is the considerable number of patients with missing risk factor documentation (1186 of the 3003) in the study by Van Trier et al., suggesting that CVRM in older patients is no longer taken very seriously.

As already shown in the SPRINT trial, targeting a blood pressure to < 120 mm Hg versus < 140 mm Hg resulted in a hazard ratio of 0.75 in 9361 very high-risk CV patients, 28% of whom were older than 75 years (mean age 79 years) without more clinically relevant side effects [7].

For LDL‑c lowering, it has been extensively proven (pharmacologically as well as with Mendelian randomisation) that there is a log-linear association per unit change [1].

Thus more strict CVRM in older patients still has benefits, especially when a cardiovascular event has already occurred (except in patients with end-stage heart failure or on dialysis), but we always have to take frailty, life expectancy, expected therapy benefit and therapy harm into account.