One panelist missed the deadline for completing the ratings of round one, and one panelist had to leave early in round two. The rating sheets of the other panelists were 100% complete.

Outcomes of the appropriate judgements about starting and stopping CPM did not differ a lot between the two rounds. It appeared that after the panel discussion, the uncertainty was slightly decreased resulting in a slightly increased amount of ‘inappropriate’ judgements. The amount of scenarios which were assessed as ‘appropriate’ was almost the same in both rounds.

Detailed figures with outcomes of ratings

We summarized the main results into three figures (Figs. 3, 4 and 5). In these figures the outcomes of the combined appropriateness judgment for starting and stopping medication are displayed, using the colours as described in Fig. 2. See Additional file 4 for all appropriateness scores. In general, these figures show the impact of cardiovascular variables, age, life expectancy, complexity of health problems, and hindering side effects on the appropriateness of prescribing CPM. As visualised in Fig. 3, the appropriateness of prescribing PAI was mostly influenced by the history of ASCVD, and almost not depending on age and complexity of health problems. For antihypertensive and cholesterol lowering medication, the figure shows that, besides the effect of SBP-level on prescription of antihypertensive treatment, increasing complexity of health problems, and to a lesser extent increasing age, negatively influence the appropriateness of prescribing CPM. Figure 4 shows that hindering side effects of CPM were almost never accepted in patients without a history of ASCVD, leading to the judgement that CPM is inappropriate for this group. In patients with a history of ASCVD, the appropriateness of prescribing CPM depends on the seriousness of the side effects in case of PAI, and is negatively influenced by increasing age and increasing complexity of health problems in case of antihypertensive and cholesterol lowering medication. For patients with a low life expectancy, prescription of CPM was judged not being appropriate anymore (Fig. 5).

Fig. 3
figure 3

Appropriateness of cardiovascular preventive medication in patients ≥75 years. *Number of health domains (somatic, functional, mental, social) with problems limiting daily functioning, range 0–4. Note: a) diastolic blood pressure was set to ≥70 mmHg; b) the appropriateness judgments displayed in this figure and Fig. 5 are combinations of the appropriateness judgments for starting and stopping cardiovascular preventive medication. Abbreviations: D=Disagreement: at least four panelists rated in the 1–3 range and at least four panelists rated in the 7–9 range; I = Inconsistent outcome: clinically impossible combination of appropriateness judgment of starting and stopping; LDL-C=Low-density lipoprotein cholesterol; SBP = systolic blood pressure

Fig. 4
figure 4

Appropriateness of cardiovascular preventive medication in patients of ≥75 years, in presence of side effects. Number of health domains (somatic, functional, mental, social) with problems limiting daily functioning, range 0–4. Note: diastolic blood pressure was set to ≥70 mmHg. Abbreviations: LDL-C= Low-density lipoprotein cholesterol; SBP = systolic blood pressure

Fig. 5
figure 5

Appropriateness of cardiovascular preventive medication in patients of ≥75 years, when life expectancy < 1 year. Number of health domains (somatic, functional, mental, social) with problems limiting daily functioning, range 0–4. Note: a) diastolic blood pressure was set to ≥70 mmHg; b) the appropriateness judgments displayed in this figure and Fig. 3 are combinations of the appropriateness judgments for starting and stopping cardiovascular preventive medication. Abbreviations: LDL-C= Low-density lipoprotein cholesterol; SBP = systolic blood pressure

Main patterns and arguments

Individual context

During the clarifying session it was discussed that in clinical practice the decision on starting or stopping CPM is based on two elements: the scientific evidence (population level) and the individual clinical context of a patient (individual level). The panelists agreed to focus the discussions and ratings on the level of scientific evidence as much as possible. However, they emphasized that in practice, the individual context of the patient is leading. Therefore, the panelists noted that the individual context of a patient may alter the appropriateness of starting or stopping, in a way that the final clinical decision may be different than the panels’ judgement.

Complexity of health problems

There was a general trend that, with increasing complexity of health problems, the combined appropriateness judgments for CPM tended to shift from appropriate to start and inappropriate to stop, through uncertain to start and uncertain to stop, towards inappropriate to start and appropriate to stop (Fig. 3). Although less pronounced, a similar trend was seen for increasing age. However, complexity of health problems had little influence on the appropriateness judgements of PAI in absence of hindering side effects.

The panelists reasoned that with increasing age, and accumulating health problems, older adults increasingly deviate from the average trial participant. Therefore, they especially questioned the generalizability of trials results for older adults with complex health problems. Regarding antihypertensives it was mentioned, that in general, for older adults the risk to develop side effects is higher, and this risk is often related to treatment intensity. Also, side effects are more likely to be more severe in older adults, especially when they are less healthy. This resulted in a trend to consider strict blood pressure regulation less appropriate with increase of complexity of health problems and age (Figs. 3, 4 and 5). In the discussions about cholesterol medication and PAI similar arguments were mentioned.

Another argument was that time to benefit can conflict with remaining life expectancy. The panelists reasoned that complex health problems are related with shortened life expectancy, and they considered the time-to-benefit of cholesterol lowering medication relatively long. As results the panelists judged that for older adults with complex health problems, it was inappropriate to start, and uncertain or appropriate to stop cholesterol lowering medication (Fig. 3). In contrast, in clinical scenarios with ASCVD, the time to benefit of PAI was considered relatively short. For these scenarios the panelists judged that, regardless of complexity of health problems, starting PAI was appropriate, and stopping PAI was inappropriate (Fig. 3).

History of ASCVD

The panelists argued that in old age, and in presence of complex health problems, a previous ASCVD event remains a strong risk factor for future ASCVD events. They expected most benefit for those with a history of ASCVD and noted that the number needed to treat is lower after an ASCVD event. This led the panelists to judge that for most clinical scenarios with ASCVD it was appropriate or uncertain to start, and inappropriate to stop CPM (Fig. 3). Regarding antihypertensive treatment, the panelists tended to target at lower SBP value for people with higher ASCVD risk, especially for older adults without complex health problems. When there was no previous ASCVD, the panelists more often judged starting inappropriate, and stopping uncertain or appropriate. This trend was most clear for PAI, and a similar trend was seen for cholesterol lowering medication (see Additional file 3 for the considerations). Last, there was disagreement about the appropriateness of stopping cholesterol lowering medication when LDL-C level ≤ 2.5 mmol/l in relatively young and healthy older adults without ASCVD; some panelists considered low LDL-C on treatment prove of effective treatment and, a reason to continue, while others considered it an extra reason to stop (Additional file 4: Table 3.1).

Side effects, life expectancy and quality of life

Severe or hindering side effects and a life expectancy < 1 year, were both strong reasons to shift the judgement of CPM towards inappropriate to start/ appropriate to stop (Figs. 4 and 5). The most important argument for this trend was that these side effects have a negative impact on quality of life and/or daily functioning. The panelists discussed that in general, quality of life becomes more in focus when health deteriorates and the end of life approaches. Consequently, it was generally considered appropriate to stop CPM in order to improve the quality of life or daily functioning in presence of complex health problems, and/or short life expectancy, especially when the ASCVD-risk was relatively low, or when the risk of death by non-ASCVD was high. However, it was noted that when the risk of ASCVD is high and a person is relatively young and healthy, the benefits of treatment may outweigh the burden, and it may appropriate to continue treatment despite the presence of hindering side effects. As a consequence, some clinical scenarios with side effects were judged uncertain (Fig. 4). The panelists were more reluctant towards the appropriateness of stopping PAI in presence of ASCVD, especially when side effects were mild (Fig. 4). See Additional file 3 for more discussion about this topic.

‘Not starting’ and ‘stopping’: two different concepts

The panelists concluded that the decision not to start medication is different from the decision to stop medication. They were generally more reluctant and uncertain about stopping compared to ‘not starting’. It was reasoned that for an 85 year old individual, evidence to newly start CPM is rather weak. However, if this person already has been using CPM since the age of 70, they were reluctant to stop because evidence for starting medication in the past was strong, and he endured it for 15 years already. Besides, high quality evidence about the safety of stopping is scarce, and stopping could be harmful. It was also mentioned that at the start of treatment it is unknown who will develop side effects, while for current users (in most cases) it is. An older representative mentioned that getting the advice to stop one’s medication can be perceived as ‘you have been given up’, and added that taking preventive medication can provide a sense of security. At the same time physicians expressed their reservations to ‘take away’ patients’ medication, and because of anticipated regrets if an ASCVD-event should occur following an advice to stop CPM.

For some clinical scenarios it was judged that it was appropriate not to change (the blue boxes in Fig. 3); on the one hand starting medication could lead to side effects (which can lower quality of life, even when unrecognized), and on the other hand, there was a discussion that stopping medication might disturb an internal balance. This sentiment was also underlined by older representatives of the target population. They added that knowing what you have is sometimes preferred over not knowing what you’ll get.

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