Since 1900, life expectancy has steadily increased in the U.S., thereby propelling growth of a new population of older adult survivors. Whereas only three million adults were aged 65 years and older in 1900, the geriatric population is anticipated to reach 72.1 million by 2030 and 88.5 million by 2050. Though aging is not synonymous with cardiovascular disease (CVD), physiological aging predisposes to CV pathophysiology. Increasing CVD prevalence is proportional to the growth of the geriatric population. Older adults consistently fill most CV waiting rooms and hospital floors, and these patterns are accelerating. Not surprisingly, there is a growing interest among cardiology providers for data-driven insights to guide management amidst confounding complexities of old age. The relatively new field of geriatric cardiology reflects a shift in the demographics and disease, therefore needing age-specific patient-centered skills and insights. Therapy may still be oriented to prolonging life but should also focus on preserving quality, function, independence, and cost effectiveness.

As pediatric cardiology demands an expertise in medication dosing, pharmacodynamics, pharmacokinetics, cardiac procedures, and other idiosyncrasies tailored towards the pediatric population, older cardiac patients require caregiving strategies that respond to age-related intricacies. Given that mortality and morbidity risks increase with age, a strong argument can be made for aggressive management, since absolute risk reduction is likely to accrue from every procedure and medication. However, risks of iatrogenesis also increase with age. It is daunting to think that a well-intended intervention has a significant chance of making a senior patient’s circumstances much worse.

Therefore, therapy must account for age-associated changes in development (e.g., cognitive changes, sarcopenia, diminished resiliency), metabolism (altered pharmacodynamics and pharmacokinetics), and intrinsic vulnerabilities (falls, delirium, incontinence, pain, fatigue) which fundamentally transmute goals and process of care. Similarly, older adult management must incorporate strategies to contend with predictable multimorbidity, polypharmacy, functional decrements, and sensory (visual and auditory) limitations. Diagnosis, risk stratification, therapy (medications, devices, procedures), process of care (access, monitoring, follow-up, prevention), transitions of care, education, informed consent, and every other aspect of management is pertinent when evaluating a geriatric patient with cardiac disease. 

Another key priority is improved understanding of the mechanisms underlying the soaring CV disease incidence in relation to age. In some respects, disease probably arises from cumulative impact of risk factors over the course of a lifetime. One example of such prolonged progression is heart failure with preserved ejection fraction (HFpEF). HFpEF does not arise in a week, month, or year but over decades of exposure followed by myocardial and vascular remodeling, chronotropic incompetence, and skeletal muscle weakening. We are only beginning to understand how this occurs on the cellular and biochemical level, but it seems that fundamental shifts in gene expression and mitochondrial function occur over time. The Expert Analysis article and Patient Case written by Matthew Maurer, MD, FACC to inaugurate the Geriatric Cardiology Clinical Topic Collection on ACC.org reflect some evolving insights regarding amyloid that typify the age-specificity of mechanisms pertinent to HFpEF and other CVD, as well as the implications that treatments we consider for our 80-year-old cardiac patients may soon be fundamentally different from those we consider for younger adults.

Another dimension of complexity of care in relation to older CVD patients relates to the variability by which age-related physiology and disease progress. Some of this may reflect differences in environment (pollution, family support, culture) and lifestyle (exercise, smoking, alcohol), but there are also substantive differences in gene expression, metabolism, and many other primary factors, few of which have yet to be integrated into management decisions. Not infrequently, several patients of a given chronologic age will have varying levels of frailty, as well as cognitive and functional impairment. Such variability would ideally prompt personalization of the care provided, even for the simplest of CVD processes.

The decision of instituting “evidence-based care” for a fragile elderly patient, who is not represented in the trial data and, thus, for whom therapeutic benefits are often uncertain, and avoiding discrimination based on age alone is a continuous challenge. Management of older CV patients is rife with management conundrums and ironies. Today, age stands out as the leading risk factor for CVD, but age is also the leading risk for not receiving contemporary standards of care (e.g., fewer invasive procedure, fewer secondary preventive medications). The CRUSADE Quality Improvement Initiative showed that nearly 7% of patients with ST–segment-elevation myocardial infarction (STEMI) eligible for reperfusion therapy did not receive it. It remains unclear if this was judicious restraint for patients for whom therapy was deemed futile (for which there remains no clear-cut standard or process) versus the possibility of ageism (presumably inadvertent) by providers who have not been exposed to the skills to best respond to age-related complexity.

While some are skeptical that geriatric care should be considered an independent field, there is much ambiguity with regard to medical management amidst frailty, pain, cost, access, and other dimensions of geriatric complexity. Some seasoned clinicians may claim that these skills accrue as a sense of gestalt developing over time, but for fellows and even practicing providers, it seems imperative that training curricula grow to advance perspectives and skills needed to better evaluate and manage older CV patients successfully.

Geriatric cardiology is fascinating in its breadth of disease process, and the newly evolving understanding of age-related pathophysiology. The cardiovascular complications plaguing the elderly are not limited to HFpEF but extend to the breadth of cardiology, including, heart failure with reduced ejection fraction (HFrEF), coronary heart disease, valvular disease, peripheral vascular disease, pulmonary hypertension, arrhythmias, conduction disease, and syncope. As our understanding grows with regard to the pathophysiology, so too will our understanding for improved treatment and processes of care.

It’s with the above background and the utmost delight that we hope to bring to you on a monthly basis, clinical content that is pertinent to the CV clinician privileged in taking care of our elderly population. Future clinical content featured in the Geriatric Cardiology Clinical Topic Collection of ACC.org will revolve around a myriad of diseases, technology, manpower-specific issues, as well as processes of care that revolve around the CV care of the elderly.

References:

1. Forman DE, Rich MW, Alexander KP, et al. Cardiac care for older adults: tme for a new paradigm. J Am Coll Cardiol 2011;57:1801-10.
2. Gharacholou SM, Alexander KP, Chen AY, et al. Implications and reasons for the lack of use of reperfusion therapy in patients with ST-segment elevation myocardial infarction: findings from the CRUSADE initiative. Am Heart J 2010;159:757-63.

Keywords: Adult, Aged, Alcohols, Arrhythmias, Cardiac, Cognition, Coronary Disease, Cost-Benefit Analysis, Curriculum, Delirium, Follow-Up Studies, Goals, Heart Conduction System, Heart Diseases, Heart Failure, Humans, Hypertension, Pulmonary, Incidence, Informed Consent, Life Expectancy, Life Style, Muscle, Skeletal, Myocardial Infarction, Numbers Needed To Treat, Pain, Pediatrics, Peripheral Vascular Diseases, Polypharmacy, Prevalence, Quality Improvement, Risk Factors, Sarcopenia, Smoking, Standard of Care, Survivors, Syncope

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