• One in four older adults reports experiencing a fall each year. These falls often cause significant adverse outcomes such as injuries, hospitalizations, and death.
• Even when injury does not occur, falls may elicit a fear of falling that is associated with a tendency for functional decline and a decrease in quality of life.
• Falls may be attributed to cardiovascular disease (CVD) causes or co-occurring non-CVD causes, or they may be related to medication side effects. Examples of CVD and non-CVD causes include the following:
  • Hypotension (from medication)
  • Autonomic dysfunction
  • Reduced cardiac output
  • Syncope
  • Visual impairment
  • Gait and balance problems
  • Cognitive impairment
• Falls are most often a result of multiple contributing factors.
• More than 60% of adults hospitalized with CVD have a moderate to high risk for falls.
• Other contributing factors to falls include non-CVD medication effects, fluid intake, and environmental factors.

• Medications associated with falls include the following:
  • Antidiabetic agents
  • Digoxin
  • Diuretics
  • Benzodiazepines
  • Antidepressants
  • Antipsychotics
  • Antiepileptics
  • Opioids
  • Type 1A antiarrhythmics
  • Angiotensin-converting enzyme (ACE) inhibitors

• Other risk factors include the following:
  • Orthostatic hypotension
  • Syncope
  • Frailty and sarcopenia
  • Sensory impairment and musculoskeletal problems
  • Cognitive impairment

• Clinical assessment and physical assessment should be performed and include the following:
  • Include the patient, family, and caregivers when asking about recent falls.
  • Conduct a comprehensive review of medications and alcohol use.
  • Observe the patient's gait and balance.
  • Perform a brief physical frailty assessment.
  • Assess weakness and gait speed.
• Consider the following cardiovascular targets to reduce fall risk:
  • Orthostatic hypotension (OH)
    • Perform OH vital signs at least once, monitor standing and supine blood pressures in patients with confirmed OH and ask the patient about any signs or symptoms of hypotension after a meal.
    • Manage salt and fluid intake, discontinue medications that worsen OH, have the patient sit upright for 30 minutes after meals, and avoid prolonged bedrest when hospitalized.
  • Neurally mediated syncope
    • Inquire about loss of consciousness (LOC) symptoms and identify potential causes, such as vasovagal or carotid sinus syndrome.
    • Perform medication reconciliation and address the primary cause.
  • Cardiac syncope due to arrhythmias
    • Inquire about LOC symptoms, perform an electrocardiogram (ECG) and conduct ambulatory cardiac monitoring to identify causes such as tachycardia, bradycardia, or conduction diseases.
    • Perform medication reconciliation and address the primary cause.
  • Nonarrhythmic cardiac syncope
    • Perform an ECG and cardiac imaging to assess for and identify aortic stenosis, ischemia, cardiomyopathy, or other causes.
    • Perform medication reconciliation and address the primary cause.
  • Frailty and sarcopenia
    • Perform frailty assessments, such as 5-time chair stand and gait speed assessments.
    • Encourage cardiac rehabilitation or exercise, address comorbidities, and institute guideline-based therapies to optimize cardiovascular disease status.
  • Sensory impairment
    • ​Evaluate proprioception and standing balance, refer the patient for a formal eye examination, and evaluate the home for potential hazards.
    • Address any home hazards, ensure optimal lighting, encourage adequate footwear, and collaborate with physical and occupational therapy for evaluation, management, and assistive devices.
  • Musculoskeletal problems
    • Observe the patient's gait and identify any comorbidities, such as arthritis, that contribute to an impaired gait.
    • Collaborate with physical and occupational therapy for gait and balance evaluation, exercise program, and assistive devices.
  • Cognitive impairment
    • ​Perform a cognitive assessment to identify executive function or visuospatial deficits.
    • Review medications, remove home hazards, and collaborate with physical and occupational therapy to optimize safety.
  • Environment
    • ​Perform a home assessment.
    • Inquire about proper footwear.
• Work collaboratively with the patient, their family, and support network to develop strategies to address falls and the risk for falls.
• To assist patients in finding a balance between fall risk and maintaining quality of life, encourage safe practices without severely restricting activities.

• When treating older patients on anticoagulants, minor and major bleeding is a concern.
• Despite the risk of bleeding, oral anticoagulant therapy should not be withheld in patients at risk for falling.
• Use of a non-vitamin K oral anticoagulant is preferred.
• For patients on atrial fibrillation therapy, consider stroke risk, bleeding risk, and patient preference.

Denfeld Q. E., et al. (2022). Preventing and managing falls in adults with cardiovascular disease: A scientific statement from the American Heart Association. Circulation: Cardiovascular Quality and Outcomes, 15(6), Article
e000108. https://doi.org/10.1161/HCQ.0000000000000108