Revascularization Decisions in the Elderly Require a Holistic Approach: AHA

Optimizing revascularization strategies and overall care for patients ages 65 and older with cardiovascular disease requires a holistic approach, according to a scientific statement released by the American Heart Association (AHA).

In the paper, published last week in Circulation, the authors lay out the evidence base and suggest real-world approaches to managing cardiovascular disease in elderly individuals.

It’s not news that the US population is aging—and that it’s doing so “very rapidly”—but the details may startle, said writing group chair Abdulla A. Damluji, MD, PhD (Cleveland Clinic Foundation, OH). A decade ago, children and older adults accounted for around 15% and 23%, respectively, of the population. By 2035, the proportions will be equal. By 2060, however, “one in four people in the community [will be] above 65 years of age,” he told TCTMD.

A few existing clinical trials, such as SENIOR-RITA and FIRE, have focused on revascularization in older adults. Yet for the most part, these patients are excluded from trials, “because they are complex: they come in with multiple problems,” said Damluji. Thus, the evidence these studies gather doesn’t apply to the elderly, whose many conditions can include dementia, sensory decline, physical impairments, and frailty, among others.

The Cleveland Clinic, where he practices, is the first hospital in the US to introduce a Cardiovascular Center on Aging for care delivery, a concept that is gaining traction at other centers.

“We are faced in clinical practice,” Damluji noted, “by these questions of: what do we do [with] these patients?” Current revascularization guidelines devote only a few paragraphs to advising on the best approaches in this age bracket, Damluji added.

Moreover, there’s no single answer as to what patients want, so clinicians must ask for their preferences on how to proceed. For someone who’s in their mid-80s, the goal may not be to live longer. Oftentimes these individuals say, “’I want to live better, I want to walk, I don’t want angina, I don’t want heart failure, I want to breathe, I don’t want fatigue,’” Damluji commented. “But they don’t tell you: ‘I want to live to 95.’”

Perspective From Geriatric Medicine

Damluji et al, in the AHA statement, delve into the concepts of chronological versus biological age, atypical presentations, and the value of considering lessons from the geriatric field. They make a case for cardiologists using the “5Ms of Geriatrics” as a framework: Matters Most, Medications, Mind, Mobility, and Multicomplexity.

The document also expounds on why age actually impacts the development of CVD.

“Age-related cardiovascular changes, such as increased arterial stiffness, endothelial dysfunction, and reduced elasticity, increase the risk for hypertension, atherosclerosis, and other risk factors,” the authors explain. “Older adults often experience additional complications, including obesity, diabetes, and metabolic diseases, further increasing their cardiovascular risk.”

In this context, patients can have strong preferences about the goals of care, such as balancing quality of life versus longevity, they note. “This scientific statement outlines key aims: to review age-related cardiovascular changes and geriatric syndromes, provide pragmatic revascularization strategies, and advocate for shared decision-making.”

Damluji highlighted several takeaways for clinical practice.

Firstly, “risk assessment in the older adult population should include assessing geriatric conditions . . . that do not fit in one disease category” but instead present as syndromes, he said. Cardiologists aren’t trained to assess these so they can benefit from collaborating with a geriatrician.

“The second thing is the care for these older patients is quite complex, and knowing cardiovascular aging physiology is important,” he added. The aging process can increase systolic blood pressure, for instance, as well as the risk of thrombosis. These changes, Damluji advised, “have implications for people undergoing revascularization procedures” and should impact the “judgment call” between CABG and PCI.

The answer of course depends on presentation, whether that’s acute coronary syndromes, stable ischemic heart disease, or coronary artery disease combined with aortic valve disease, he added.

Lastly, cardiologists treating the elderly should pay close attention to “transitions of care” with input from a multidisciplinary team, said Damluji. “That includes a geriatrician and geriatric pharmacist alongside the cardiologist and the cardiac surgeon so that we can address these issues for older patients.”

The data to aid decision-making in this setting are still being gathered, the statement stresses.

“Evidence is needed to guide revascularization strategies, timing, and approach in the context of frailty, multimorbidity, and other geriatric syndromes,” Damluji et al write. They call for randomized controlled trials that include a broader spectrum of adults age 75 and up. Novel approaches such as proteomic and genomic profiling might help stratify elderly patients’ risk as well, they suggest.

Guidelines should be updated to emphasize the need for a comprehensive perspective encompassing frailty, cognitive function, and life expectancy, the authors say. “Developing tools for individualized decision-making that incorporate patient preferences, geriatric risks, and holistic care outcomes is essential for optimizing management.”

As of now, said Damluji, debate continues over practicalities like which methods are best for risk stratification, the preferred tool for assessing frailty, and the ideal medical therapy regimen for reducing complications. He predicted the ongoing LIVEBETTER and REHAB-HFpEF studies, though not specific to revascularization, will provide some guidance.