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Cardiovascular Disease in the Older Adult: Where Are We 4 Decades Later?Open Access

State-of-the-Art Review

JACC Adv, 3 (2) 100820
Sections

Central Illustration

Abstract

The 1986 Bethesda Conference on Cardiovascular Disease (CVD) in the Elderly, co-chaired by Drs Nanette Wenger, Frank Marcus, and Robert O’Rourke delineated the anticipated social, political, ethical, economic, and technological impact of an aging population on the incidence, prevalence, and management of CVD in the United States and worldwide. In the ensuing 4 decades, older patients have come to comprise an increasingly large proportion of the CVD population, and there has been an explosion of research in all aspects of CVD affecting older adults. Correspondingly, geriatric cardiology is now an established field within cardiovascular medicine. In this communication, we provide a focused update on intersections between CVD and geriatrics from basic science to clinical practice, a review of major advances in diagnosis and treatment of older adults with CVD, and a preview of future research directions in the still-evolving field of geriatric cardiology.

Highlights

Patients of advanced age with CVD often present with complex geriatric syndromes that distinguish them from patients typically enrolled in cardiovascular trials.

Major advances in cardiovascular medicine and geroscience have markedly altered the diagnosis and treatment of CVD in older patients.

Optimal management of older patients with CVD requires integration of geriatric principles into routine clinical care, including aligning treatment with patients’ goals and preferences through shared decision-making.

Introduction

The 18th Bethesda Conference of the American College of Cardiology, “Cardiovascular Disease in the Elderly,” was convened in 1986 in response to an unprecedented growth of the older adult population in the United States and the emerging discipline of geriatric cardiology.1 In 2020, the U.S. population aged 80 and older constituted over 13 million persons, with the number of Americans aged 65 and older estimated to reach 22% of the total population by 2040.

The pervasive theme of the conference was that physiologic age comprising physical function and cognitive ability, and accumulated medical conditions, rather than chronological age alone, should be the major determinants of health care. Medicare benefits were being challenged, as is Medicare accessibility and coverage today.

The Bethesda Conference included many societal recommendations directed to the general public and to society’s elected representatives who formulate and promulgate public policy as it relates to health care and myriad social services. Other recommendations were directed to health professionals who care for older adult patients, whereas others targeted the scientific, research, and educational communities, including the American College of Cardiology (ACC). This current manuscript examines the current status of geriatric cardiology 4 decades after the Bethesda Conference.

General issues

Geriatric syndromes

Since its inception in the 1940s, the geriatric specialty has grown exponentially, resulting in research into the pathophysiology and treatment of geriatric syndromes. Frailty is characterized as a phenotype of vulnerability and/or accumulated deficits. The many definitions of frailty include phenotype and cumulative deficit models, all of which predict outcomes better than chronologic age alone.2 The acceptance of these definitions has advanced the ability to describe the prevalence of and study interventions for frailty. Concomitantly, there has been progress in the evolving field of geroscience, which identifies the shared foundations of aging and disease underlying frailty and geriatric syndromes.3 These shared domains of aging include a constellation of subcellular mechanisms (eg, genomics, epigenetics, mitochondrial function, senescence, and inflammation) commonly referred to as “aging hallmarks” that are fundamental to aging physiology (Figure 1).4 These normal physiologic processes are more likely to be overcome when toxic exposures, stresses, and lifestyle factors erode resilience. In this way, the aging physiology and phenotype of older adults can be more accurately understood and studied. There is great interest in interventions that may slow aging, increase resilience to aging mechanisms, and extend good health (ie, health span). Some examples of such studies currently underway include the Targeting Aging with Metformin trial (addressing metabolic and nutrient sensing dysfunction), the Statins in Reducing Events in the Elderly trial,5 and Pragmatic Evaluation of Events and Benefits of Lipid-Lowering in Older Adults trial (randomizing to atorvastatin or placebo addressing inflammation and vascular cognitive trial.6

Figure 1
Figure 1

Advancing Health With a Geroscience Perspective

Cognitive function includes neurodegenerative disease such as dementia, delirium, depression, anxiety.

Shared-decision making, patient-centered care, quality of life (QOL)

Cardiovascular guidelines historically avoided delving into age-related aspects of care, largely because they were out of scope. Yet recently, health context including life expectancy and goals of care are being acknowledged as relevant considerations. The Geriatric 5 Ms (mind, mobility, medications, multicomplexity, and matters most) provide one useful framework for delivering age-sensitive care, shifting focus from disease-centric to person-centric decision-making.7 This frameshift acknowledges that for some, survival may be less important than function, and cure less important than QOL.

Technology and digital health

The care of all patients, inclusive of older adults, has been transformed by technological advances (ie, smartphones, activity trackers, blood pressure home monitors, etc). Technology can be extremely helpful in geriatric cardiology care, but it has to be geriatric-sensitive in its development to ensure continued use.8 Video visits during the COVID-19 pandemic accelerated technology adoption by older patients and encouraged active participation in their health care. Some barriers to the uptake include internet access, emphasizing the need for improved health equity.9 Medication reminders and mobile cardiac rehabilitation (CR) bring health care directly to the home-bound older adult, overcoming transportation barriers and/or risks to vulnerable older patients associated with trips to health care settings.10 In addition, devices track sedentary behavior and life space, identify subclinical arrhythmias, and monitor home blood pressures, adding assessment and safety checks to the home environment.

Sociopolitical, ethical, and legislative approaches

Our use of language to describe older adults reflects our social views and influences our conversational biases. For example, the term ‘elderly’, historically defined as those ≥65 years of age, implies a degree of infirmity. Yet many 65-year-olds are far from infirm. ‘Older adults’—the preferred term—only implied chronologic age without suggesting associated function.11 The term ‘elderhood’ describes the life phase that has its own challenges, priorities, and privileges. Many older adults experience time with dementia and/or disability for themselves or their loved ones as their lives are progressively longer. As cardiovascular clinicians, we also recognize the shared pathways for vascular disease and cognitive and physical function in our practice. In the clinical setting, these shared pathways may necessitate partnership across the care team to address the multiple conditions. Dedicated federal funds have accelerated research to prevent and/or mitigate dementia, yet caregiving continues to fall on loved ones who are often ill-equipped. Patients experiencing dementia and disability need caregivers at home and in the community. The demographic shift will continue to keep these issues central in our social and political discourse for decades to come.

Cardiac rehabilitation

CR is a multicomponent secondary prevention intervention that guides exercise (aerobic, strength, balance), adherence, risk reduction, lifestyle (diet, activity), and social support. It carries a Class 1 indication after cardiac surgery, myocardial infarction, or percutaneous coronary intervention, and for stable angina or peripheral artery disease, and Class 2a indication for stable systolic heart failure (HF). CR optimizes recovery after a cardiac event, both in respect to the intrinsic cardiovascular disease (CVD) and the debilitating effects of hospitalization. While the benefits of CR have been known for many years, implementation has lagged, especially among eligible older patients.12 A common misconception is that CR may not have as much value for an older adult with complex medical and functional challenges. In contrast, older adults who are most functionally impaired often benefit the most, with vital functional gains as well as fewer falls, rehospitalizations, depression, and nursing home placements.13

COVID-19 accelerated consideration of remote-based models of CR care. Many older adults benefit from care in their homes or community centers, using wearables and other telehealth technologies to stay connected to hospital-based personnel. This remains an area of clinical innovation and research.14 Other research is exploring the utility of CR to mitigate frailty, often emphasizing strength training with dietary enhancements.

Palliative care

In 1986, palliative care was not yet on the radar screen of cardiologists, but over 20 years, it has grown substantially, driven in large part by the aging of the population and increased prioritization of QOL as a primary therapeutic objective. Whereas palliative care grew out of the hospice movement and is associated with care at the end of life, the model has evolved such that palliative care is delivered concurrently with invasive, life-prolonging interventions.15 Patients in palliative care receive vital medical care to cure serious illness but with consideration of avoiding procedures or medications less likely to yield benefits and which may cause poor QOL.16 A more recent component of palliative care has been the assessment of goals of care in determining whether to deactivate implanted cardiac devices, such as defibrillators and ventricular assist devices.

Deprescription

Deprescription extends from precepts of optimal care, as the utility of any medication may change over time. Not only are aggregate medication regimens likely to become excessive over the time as multiple evidence-based medication regimens typically accumulate for patients prone to multimorbidity but also age-related changes in pharmacokinetics and pharmacodynamics compound iatrogenic risks. Although deprescription is commonly associated with palliative care, it should ideally be applied to the full spectrum of older patients and goals of care.17

American College of Cardiology: steps and strategies

The Bethesda Conference outlined the following tasks for the ACC:

1.

Encourage involvement of the public in helping their elected representatives develop health care policies for the older adults.

2.

Develop adequate definitions and descriptors of quality cardiovascular care.1

These charges reflect values of influencing national policy on “quality, access, and cost-effectiveness,” preventing “enfeeblement, disability and dependency, rather than an extension of life, regardless of quality,” and assisting clinicians to “encourage active participation by older patients with CVD in their overall health care and…[to] set realistic goals.”1 These values from decades past continue to shape ACC’s current mission to “transform cardiovascular care for all.” Appropriate use criteria, scientific statements, and guidelines define and promote general quality and cost effectiveness. ACC’s legislative advocacy promotes general access to cardiovascular care. Specific application of quality, access, and cost effectiveness to older individuals, integration of geriatric principles into clinical care, inclusion of geriatric considerations in education and guidelines, and promotion of geriatric cardiology research are roles played by the ACC’s Geriatric Cardiology Section (GCS).

In 2010, leaders in geriatric cardiology launched the ACC Geriatric Cardiology Leadership Council. A year later, the Leadership Council founded the GCS as an official member section of ACC to be the professional home for clinicians and scientists with interests in aging and cardiovascular medicine. The GCS currently encompasses work groups in research, advocacy, palliative care, fellows-in-training/early career professionals, and education/training.

Major GCS educational initiatives included the “Essentials of Cardiovascular Care for Older Adults” curriculum (2007, updated in 2017-2018), funded by the John A. Hartford Foundation, and Palliative Care for the Cardiovascular Clinician (2022). The GCS has collaborated with professional societies and member sections in 3 conferences/workshops sponsored by the National Institute on Aging: “Integration of Geriatrics Principles into the Care of Older Adults with CVD.” These included “Multimorbidity in Older Adults with CVD” (2015), “Pharmacotherapy in Older Adults with CVD” (2017), and “Diagnostic Testing in Older Adults with CVD” (2018). The GCS also participated in the “Cancer and CVD” workshop (2021) and crafted clinician and patient education for the ACC.org and Cardiosmart websites. The latter includes sections on “Older Adults and Heart Disease” and “Palliative Care”.

The GCS supports the professional development plan for 1 applicant each year for the National Institute on Aging’s Grants for Early Medical/Surgical Specialists' Transition to Aging Research program. Each year the GCS showcases the best Geriatric research presented at the ACC national meeting and features aging research in cardiovascular medicine through webinars and contributions to ACC.org.

In 2021, the inclusion of geriatric cardiology as a focus area of JACC: Advances provided an important platform for publishing geriatric content to the cardiovascular community.

Specific cardiovascular conditions

Cardiovascular care providers face a growing prevalence of chronologically older adults with more multimorbidity and polypharmacy.18 Herein, we review the evolution of care for specific CVD conditions commonly encountered in older adults.

Coronary artery disease

Thrombolytics for acute myocardial infarctions were just entering clinical care at the time of the Bethesda Conference, at which dose-adjustments for older adults were emphasized.1 Since then, additional, novel classes of antithrombotic agents have emerged. Specifically, antiplatelet drugs such as P2Y12 inhibitors and direct oral anticoagulants pose a significant risk for bleeding in older patients.19 Many related randomized clinical trials which constitute the basis for the United States Food and Drug Administration approval of these drugs had very low enrollment rates of older adults.20

Coronary artery bypass surgery (CABG), plain old balloon angioplasty developed by Andreas Grüntzig in the late 1970s, and a limited number of medications were the armamentarium to address coronary artery disease (CAD) at the 1986 Bethesda Conference. Since then, monumental advances including bare metal stents, drug-eluting stents, novel antithrombotics, and more sophisticated devices have resulted in percutaneous coronary intervention becoming the first line of therapy for obstructive CAD in the majority of patients. At the same time, CABG techniques have evolved significantly with off-pump and, in some cases, minimally invasive direct coronary artery bypass; CABG morbidity and time for recuperation are currently reduced significantly. The “Heart Team'' approach is the standard of care to reach a patient-centric decision on management for patients with complex CAD.21 This is crucial for older adult patients with complex CAD and concomitant medical comorbidities such as chronic kidney disease, various types of anemia, and/or valvular heart disease such as aortic stenosis (AS) and/or mitral regurgitation (MR).22 For instance, in an observational study comprising 1,004 patients with significant valvular heart disease with mean age of 75, many of whom had concomitant CAD, the heart team approach resulted in early observed mortality of 1.7%, which was significantly lower than expected on the basis of both the Society of Thoracic Surgeons 30-day Predicted Risk of Mortality Score (5.2%) and the European System for Cardiac Operative Risk Evaluation II (9.7%).23

Valvular heart disease

At the Bethesda Conference, the prevalence, clinical, and echocardiographic findings of AS and MR were discussed. Surgical intervention was deemed a viable option for older adults, albeit with a higher risk of surgery and a longer recovery compared to younger individuals.1 Since the introduction of transcatheter aortic valve replacement (TAVR) (the first-in-human TAVR occurred in April 2002), the landscape has changed dramatically for AS. While in initial TAVR trials, the older adults and women were underrepresented,24 TAVR surpassed isolated surgical aortic valve replacement in the United States in 2016 and all forms of surgical aortic valve replacement in 2019. Percutaneous options to treat MR including MitraClip and transcatheter mitral valve replacement have become routine procedures across many countries, especially for older adult patients who may not be ideal candidates for surgical intervention.25 Currently, heart valve/structural team meetings are common in most centers providing these advanced procedures and encompass multidisciplinary discussion of the best options for patients. Such approaches based on heart team and multidisciplinary discussions are designed to achieve patient-tailored management options, resulting in decreased early mortality of such procedures, improving patients chances of surviving to older age,23 but also to avoid procedures for those in a multidisciplinary discussion. Invasive approach(es) are deemed to be futile and only increase the burden on the patient and his/her family. Moreover, faster recovery as well as decreasing the need for hospital admission/readmission and, hence, less time spent in health care facilities are major goals of many of the novel percutaneous approaches to address significant valvular heart disease ± CAD in older adults.

Heart failure

At the 1986 Bethesda Conference, the field of HF was on the cusp of 2 major revolutions with substantial implications for older patients. First, “diastolic HF” was becoming recognized as a clinical entity. Second, it had recently been demonstrated that pharmacotherapy could favorably alter the natural history of HF.

Fast-forward 4 decades. It is now known that HF with preserved ejection fraction (HFpEF) accounts for over 50% of HF in older patients and up to 80% in older women. In addition, whereas diastolic HF was often viewed as a “milder” form of HF with a better prognosis, it is now recognized that symptom severity, hospitalizations, and survival are similar in patients with HFpEF and HF with reduced EF (HFrEF) (Figure 2).26 Further, it has now been established that HFpEF is a multisystem disorder involving the heart, skeletal musculature, kidneys, neurohumoral system, and metabolome.12

Figure 2
Figure 2

Epidemiology of HFpEF21

HFpEF = heart failure with preserved ejection fraction.

Prior to 1986, the mainstay of therapy for HF was digoxin and diuretics. In contrast, the 2022 AHA/ACC/HFSA HF guideline provides Class I recommendations for angiotensin-receptor/neprolysin inhibitors, angiotensin converting enzyme inhibitors (ACEis), angiotensin-receptor blockers, beta-blockers, mineralocorticoid-receptor antagonists, and sodium-glucose cotransporter-2 inhibitors for patients with Stage C HFrEF, as well as for diuretics to relieve congestion and hydralazine-nitrates in selected African-Americans.27 ICDs and cardiac resynchronization therapy are recommended for selected patients with HFrEF, and left ventricular assist devices are an option as destination therapy for some older patients with advanced HF.27,28

Developing effective therapies for HFpEF has been more challenging, but sodium-glucose cotransporter-2 inhibitors have proven beneficial in recent studies and currently carry a Class IIa indication.27 The value of angiotensin-receptor/neprolysin inhibitor and mineralocorticoid-receptor antagonist in patients with HFpEF is less clear, and these agents have a Class IIb recommendation.27 In patients with transthyretin cardiac amyloidosis, a disorder that predominantly affects older adults, the guideline provides a Class I indication for tafamadis.27,29

A major limitation of existing data is that older patients, as well as racial and ethnic minority groups, have been markedly underrepresented in most HF trials. Due to age-related changes in pharmacokinetics and pharmacodynamics, as well as increased risk for drug-disease and drug-drug interactions consequent to multimorbidity and polypharmacy, medications of proven efficacy in younger patients may have an altered benefit-to-risk profile in older patients. Thus, treatment must be individualized by considering each patient’s unique medical circumstances, psychosocial milieu, and health care goals and preferences utilizing a shared decision-making process. Encouragingly, in recent years, there has been more appreciation of the importance of including older adults in clinical trials than before, and hence current and future studies will more effectively address this important need.

Finally, the Bethesda Conference presciently noted the potential role of rehabilitation to improve function in older patients with HF. Accordingly, based on numerous studies, current guidelines provide a Class I recommendation for exercise training or regular physical activity for all patients with HF.27

Arrhythmias

At the time of the Bethesda Conference, nonvalvular atrial fibrillation (AF) was just being recognized as a risk factor for stroke, and the role of anticoagulation for stroke prevention had not been clarified. It is now known that nonvalvular AF is a key risk factor for stroke, that the proportion of strokes attributable to AF increases with age, and that AF accounts for over 30% of ischemic strokes in Americans ≥75 years old.

Seminal advances in diagnosis and treatment of AF in older adults since 1986 include: 1) development of risk scores for predicting stroke (eg, CHA2DS2-VASc) and bleeding (eg, HAS-BLED); 2) numerous randomized trials documenting the efficacy of oral anticoagulation for stroke prevention, including in patients of advanced age30; 3) many trials comparing rate-control vs rhythm control, most of which have failed to demonstrate benefit from a rhythm control strategy; 4) catheter-based and surgical procedures for maintenance of sinus rhythm in selected patients; 5) novel direct-acting oral anticoagulants as alternatives to vitamin K antagonists31; and 6) left atrial appendage occlusion as an alternative to anticoagulation in patients at high bleeding risk.32

Preventive cardiology

Since the Bethesda Conference, dimensions of preventive cardiology have expanded to include concerns more meaningful to older adults with CVD. This includes cognitive and functional endpoints, as well as QOL, exercise tolerance, fatigue, falls, mood, and disability.33 Many apply the precept of 5 Ms to guide choices for personalized preventive management.20

Heterogeneity of older adults is relevant; some preventive strategies may provide more value for some older adults than others. For example, the Systolic Blood Pressure Intervention Trial suggested that stringent reduction of blood pressure (<120 mm Hg) provided significant benefits (cardiovascular events, death, cognition), but with the tradeoff that iatrogenic risks increased (eg, syncope, kidney disease),34 which can mediate an increased risk of noncardiovascular death.35

Guidelines are nuanced in their recommendations, with the 2018 cholesterol guideline recommending both the use in some cases and deprescription of statins in other cases for primary prevention in older adults with the same level of evidence and strength of recommendation.36

Key insights on frailty have surged,37 providing a broad construct of health that can inform prognosis and/or therapeutic efficacy and guide approaches to CVD management. Some frail adults do better with therapeutics (sometimes frailty implies they get the greatest value), but others may benefit less.38

Finally, as the field of geroscience matures, identifying consistent mechanistic cornerstones of aging (Figure 1), pharmacological agents that increase resilience to molecular, metabolic, genetic, and inflammatory aging alterations are actively being studied as a means to prevent age-related CVD as well as age-related frailty and vulnerability to other chronic disease.13

Growing sophistication regarding geroscience has reinforced the rationale for exercise training and healthy lifestyle. In particular, aerobic exercise can increase resilience to aging hallmarks as well as cardiovascular benefits. Resistance training has complementary benefits for moderate sarcopenia and frailty.

Unmet needs: clinical trials and beyond

Randomized clinical trials (RCTs) specifically designed for older adults, with special consideration to include mostly underrepresented population in RCTs such as women, racial and ethnical minorities, are critical to address many of the unmet needs and questions toward improving cardiovascular care in older adults (Table 1). Meanwhile, avoiding harms as much as possible should be cornerstones of any clinical management options, and this becomes even more important when dealing with older adults. Indeed, while the risk of some medications, devices, or procedures may be small or negligible for younger patients, it can be quite significant when making decision on such management options for an older adult. This risk-aversion principle should be carefully considered when designing RCTs targeting older individuals.

Table 1 Areas of Focus in Cardiology Research in Older Adults

Area of FocusTypes of ResearchExamplesExamples of Identified Age-Related Trends
Identifying age-related changesBasic, preclinical
Longitudinal cohort studies of healthy persons
Aging animal studies, animal and human cell and tissue studies throughout lifespan
Baltimore Longitudinal Study on Aging
Genomic/proteomic alterations, changes in immune function, rest and exercise CV function, caloric restriction studies, Heterochronic parabiosis studies, ‘hallmarks of aging’
↓ in GFR, resting and exercise CV function, SBP, DBP and PP, hormone levels, pulmonary function, fat-free mass
Discern CVD risk factorsLongitudinal cohorts (community dwelling, of different racial/ethnic background, etc)
Case-control studies
Cardiovascular Heart Study, Framingham Heart Study, ARIC, MESA, Health ABC, Women’s Health Initiative, etcDevelopment of risk score (CVD and stroke prevention)
Define relative risk of traditional CVD risk factors and those more common in older adults (frailty, physical and cognitive impairment, multi-morbidity (dyads or triads)
Trial designed for complex and/or vulnerable older adultsDedicated RCT
Secondary Analyses within larger RCT
RCT stratified on common age-related variables
Adaptive studies
Pragmatic clinical trials
ALLHAT, HYVET
STAREE, PREVENTABLE

ALLHAT = Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; ARIC = Atherosclerosis Risk In Communities; CV = cardiovascular; CVD = cardiovascular disease; DBP = diastolic blood pressure; GFR = glomerular filtration rat; Health ABC = Health, Aging and Body Composition; HYVET = Hypertension in the Very Elderly Trial; MESA = Multi-Ethnic Study of Atherosclerosis; PP = pulse pressure; PREVENTABLE = Pragmatic Evaluation of events And Benefits of Lipid-lowering in older adults study; RCT = randomized controlled trial; SBP = systolic blood pressure; STAREE = STAtin therapy for Reducing Events in Elderly.

Evidence supporting CVD prevention and treatment strategies in older adults at the time of the Bethesda Conference was primarily extrapolated from a limited number of clinical trials and observational studies in adults mainly under the age of 75 years.1 Despite older adults comprising the majority of patients with these common cardiovascular conditions and often incurring worse CVD outcomes, most older patients were excluded from practice-informing RCTs, either by upper age cut-offs or by exclusion criteria common in older CVD patients (chronic renal disease, functional and/or cognitive limitations, frailty, polypharmacy, multimorbidity, and/or nursing home residents).39 Thus, the generalizability of these RCTs to the most vulnerable, ‘real world’ older CVD patients is uncertain.

Since the Bethesda Conference, geriatric cardiology investigators have made strides in documenting the importance of age-related changes in genetics/molecular pathways, cardiovascular structure, function, and physiology and their contribution to CVD vulnerability, management, and prognosis. Alternative clinical trial designs have developed to accommodate complex older adults and employ outcomes ‘that matter’. These advances provide the framework for future research to better understand intersections between aging and CVD and to improve care and outcomes for the expanding population of older adults with CVD. Table 2 summarizes key areas for future research in geriatric cardiology.

Table 2 Future Geriatric Cardiology Unmet Needs/Topics

Geriatric clinical trial design

Employ trial designs which embrace heterogeneity of older adults (polypharmacy, multimorbidity, cognitive/functional changes).

Problem based, transdisciplinary.

Integrate age-related changes.

Outcomes which are meaningful to patients (physical and cognitive function), patient goal concordance, free from dementia and/or disability, emphasize quality of life/well-being.

Consider hybrid models which integrate physical and virtual environments for trials and intervention.

Include representative patient advocates on all phases of clinical trial planning.

Adapt study design to accommodate physical and/or cognitive limitations.

Clinical research on persons over 80 years old, those with functional and/or cognitive impairment, women, underrepresented minorities, home-bound patients, those with frailty, and nursing home residents.

Geriatric research topics

Explore the etiology, possible causative effect, common underlying aging change of high co-incidence of cognitive impairment and several CVDs (heart failure, atrial fibrillation, chronic CAD, valvular heart disease).

Research to optimize care and preserve function of older adults with known cognitive and/or functional impairment with CVD.

Clarify the role of specific aging ‘hallmarks’ to CVD, especially to geriatric CV syndromes (HFpEF, AF, NSTEMI, ISH) and potential mitigating factors (frailty, sarcopenia, cognitive decline) and possible target of senolytics.

Studies which examine incorporating several existing guideline-directed cares across disciplines which focus on a similar/related problem.

Studies which inform deprescribing priorities, timing, and strategies.

Clarify the importance and role of nutrition and exercise on CVD prevention and management.

While keeping geriatric sensitivity parameters in mind, explore the use of artificial intelligence to inform individual risk factor and prognostic indicators.

AF = atrial fibrillation; CAD = coronary artery disease; CVD = cardiovascular disease; HFpEF = heart failure with preserved ejection fraction.

While, as discussed earlier, appropriate RCTs are the cornerstone, there are other important unmet needs that are required to be addressed to bring the learning from RCTs into clinical practice such as implementation strategies and guidelines, policies, reimbursement models, etc. Such efforts need specific attention from cardiology societies, such as the ACC, as outlined earlier, as well as policymakers and health care governing bodies such as the Center for Medical Services and private insurance entities.

Conclusions

During the past 4 decades, clinical cardiology has progressively evolved toward geriatric cardiology. Older adults now populate our clinics, diagnostic laboratories, hospital clinical and intensive care units, and interventional and surgical suites.

Nowhere in medical practice is shared decision-making more relevant, incorporating patient-preferred clinical outcomes. Practice guidelines address the disease, but the astute clinician incorporates consideration of geriatric syndromes, multi-morbidity, resultant polypharmacy, cost considerations, and other socioeconomic modulators (Central Illustration).

Central Illustration
Central Illustration

Key Areas of Focus of Geriatric Cardiology in 2024

Molecular, metabolic, physiological, and genetic changes with aging (geroscience) are integrated into all aspects of prevention, presentation, diagnosis, and management of cardiovascular disease in older adults. Geriatric syndromes, including polypharmacy, multiple chronic conditions, frailty, and cognitive/physical function, impact shared decision-making. Clinicians and patients can arrive at the best decisions for the care of each individual patient considering the clinical practice guidelines as well as patient-preferred outcomes and values. The concepts of prevention and cardiac rehabilitation are different at older ages. The need for more research tailored to older adults and focused on the 5 Ms (mind, mobility, medications, multicomplexity, and what matters most) is emphasized in the current era, especially for the very old and frail adults and nursing home residents. 5 Ms = mind, mobility, medications, multicomplexity, and matters most.

Mandates to the American College of Cardiology and other professional societies include advocacy for access to and adequacy of Medicare coverage for geriatric patients, limitation of out-of-pocket medical care and medication costs, inclusion of older adults in preventive, translational, diagnostic, and therapeutic studies and clinical trials, and attention to the social determinants of health predominant at older age.

Funding support and author disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Abbreviations and Acronyms

5 Ms

mind, mobility, medications, multi complexity, and matters most

ACEI

angiotensin-converting enzyme inhibitor

AF

atrial fibrillation

AS

aortic stenosis

CABG

coronary artery bypass surgery

CAD

coronary artery disease

CR

cardiac rehabilitation

CVD

cardiovascular disease

GCS

Geriatric Cardiology Section

HF

heart failure

HFpEF

heart failure with preserved ejection fraction

HFrEF

heart failure with reduced ejection fraction

MR

mitral regurgitation

RCT

randomized clinical trial

TAVR

transcatheter aortic valve replacement

References

Footnotes

The participation of these individuals or the materials should not be interpreted as representing the official viewpoint of the U.S. Department of Health and Human Services, the National Institutes of Health, or the National Institute on Aging, except where noted.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.