Known–Unknowns in Geriatric Cardiology
Giuseppe Cocco 1,*, Philipp Amiet 2
Cardiology Office, Marktgasse 10a, CH-4310 Rheinfelden / Switzerland
Medical Office, Schiffackerweg 2, CH-4310 Rheinfelden / Switzerland
* Correspondence: Giuseppe Cocco
Academic Editor: Bodh I. Jugdutt
Special Issue: Aging and Heart Failure
Received: February 05, 2020 | Accepted: March 09, 2020 | Published: March 19, 2020
OBM Geriatrics 2020, Volume 4, Issue 1, doi:10.21926/obm.geriatr.2001111
Recommended citation: Cocco G, Amiet P. Known–Unknowns in Geriatric Cardiology. OBM Geriatrics 2020; 4(1): 111; doi:10.21926/obm.geriatr.2001111.
© 2020 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
The present article summarizes the current state of understanding in geriatric cardiology in terms of the main developments in the field. The focus of the present review is on the therapeutics, into the specific characteristics of the elderly patients dealing with the prevention of arterial hypertension, bradycardic arrhythmias, atrial fibrillation, coronary artery syndromes, valve heart diseases, and heart failure. Progress in the field of medicine has rendered possible to treat lethal cardiac diseases in the extremely old patients. Nonetheless, data regarding the very old cardiac patients are limited, and it is dangerous to directly extrapolate the experience with the young patients to the old ones. ● Preventive therapies are important in the old cardiac patients, although these therapies differ from those for young patients. ● Very old patients with arterial hypertension benefit from antihypertensive treatment, although the therapeutic strategy of one-size-fits-all cannot be applied. ● Elderly patients often require a cardiac pacemaker. In the case of patients with sinus node dysfunction, pacing modes capable of preserving atrioventricular synchrony are associated with a reduced incidence of atrial fibrillation. In the case of patients with atrioventricular block, the importance of synchronization is debatable. Implantable cardioverter-defibrillators may be used in very old patients, although a limited number of studies evidencing this in elderly patients are available. ● In very old patients with atrial fibrillation, ablative therapies are seldom used. OAC is useful in such cases, although the HAS-BLED score is inadequate for assessing the real bleeding risk in the old people. ● Patients who are ≥80 years old and exhibit acute coronary syndromes would benefit more from a myocardial revascularization compared to a medical therapy, while in the patients who are ≥90 years old, revascularization and medical therapy are equivalent. ● In the very old patients with severe aortic stenosis, transcatheter valve replacement is safe and efficient, while antithrombotic therapy is problematic. The treatment of mitral regurgitation is different in the very old and the young patients; the mortality is high and there is no consensus on the best therapy. Tricuspid regurgitation is recognized as a serious problem in certain old cardiac patients; however, the best therapeutic approach to this problem has not been discovered so far. ● Information regarding the geriatric patients with heart failure is inadequate due to lack of clinical details in the population-based studies and because clinical trials typically enroll younger patients. Elderly patients with heart failure constitute a heterogeneous group and differ substantially from the younger patients enrolled in the clinical trials. The limited data indicate that a proven therapy for heart failure that reduces mortality and morbidity in the younger patients is also beneficial in elderly patients. However, elderly patients exhibit different responses to the pharmacotherapy in comparison to the younger patients, as the former are susceptible to adverse events, such as orthostatic hypotension, renal dysfunction, electrolyte disturbances, and interactions with the medications prescribed for the treatment of comorbidities. Close monitoring of elderly patients undergoing HeFa treatment is essential to ensure optimal outcomes. The number of old people is large, and progress in the field of medicine has made it possible to treat lethal cardiac diseases in very old patients. Certain individuals are biologically younger in comparison to their anagraphic age; however, geriatric patients are often frail and exhibit much comorbidities. The demand for invasive therapies and novel drugs has led to rapidly increasing expenditures. Practicing cardiologists are encountering increasing number of consultations for very old patients. This creates a requirement for training a greater number of geriatric cardiologists to offer the best of care to the old patients. Owing to the comorbidities, several of which are critical in nature, in the elderly patients, the geriatric cardiologists must be, first of all, master internists at all times. Old patients, with their peculiar pharmacokinetics and multiple illnesses, are also oversensitive to drugs. Several aspects of geriatric cardiology are unknown even now. There is a necessity to understand the effects exerted by the aging process on the human heart. Studies in this direction should command priority in the financial as well as the other forms of support.
Geriatric cardiology; old cardiac patients; geriatric cardiac diseases
G. Bernard Shaw once wrote, “Do not try to live forever, you will not succeed”. Certain people are biologically younger in comparison to their anagraphic age, and there is no globally accepted definition for the geriatric age [1,2,3]. However, conventionally, people ≥65 years of age are referred to as ‘old’, the people with age ranging between 65 and 74 years as referred to as ‘early old’, and those ≥75 years of age are referred to as ‘late elderly’ . Modern medicine has contributed largely to the increase in the life-span of humans. A recent Swiss study  reported that between the years 1995 and 2014, the mortality rate associated with the cardiovascular diseases decreased by 20%; since 1990, the medial life-expectancy increased by 7.5 years for men and by 4.5 years for women; at the end of the year 2018, the median life-span was 83 years and 20% of the Swiss people were ≥65 years old. Statistics predict that in 2065, 30% of the Swiss people shall be ≥65 years old. In the USA, the elderly population is expected to have an increase of 126% by 2050, rendering those older than 65 years of age as the most rapidly growing segment in the population . The scenario is similar in most of the developed countries as well. All these aspects form a domain of geriatrics. However, in the developed countries, cardiac patients are now older and further complex in comparison to the situation a decade ago, and practicing cardiologists are encountering patients with a higher number of comorbidities as well as geriatric conditions, such as cognitive impairment and frailty, which complicate the disease management and influence the outcomes. A recent American Heart Association Scientific Statement  considered four commonly encountered geriatric syndromes, namely, multimorbidity, polypharmacy, cognitive decline and delirium, and frailty, and laid a strong emphasis on integrating these syndromes into the cardiovascular care for older patients. The complex interplay between each geriatric syndrome and acute cardiovascular illness gives rise to novel healthcare issues that are partially independent of the underlying disease, creating novel challenges for the involved doctors, the cardiologists in particular.
Technological advances in the field of cardiac disease management have widened the range of available therapeutic options for patients with the most advanced diseases. The demand for advanced therapeutics is increasing expenditures. Therefore, in most developed countries, the costs of the healthcare systems are already unsustainable, and it is no longer sure that technological advances would be able to align with the shifts in the patients and the payers [8,9,10]. Consequently, therapeutics ought to be used rationally and adapted to the individual necessities and comorbidities [11,12]. It is noteworthy that the priorities and necessities of the senior patients differ from those of the young patients and also from those of their relatives and the medical personnel. The seniors wish to maintain independence, adequate dealing with the daily necessities, and good quality of life. For instance, it is most important for seniors to be living in a familiar space without suffering. In this context, geriatric cardiology has emerged as a discipline that aims to adopt the principles of geriatric medicine into everyday cardiology practice. Accordingly, the responsibilities of a geriatric cardiologist may include traditional evidence-based cardiac management plus a comprehensive geriatric assessment, medication reduction, team-based coordination of care, and explicit incorporation of patient goals into the management of the disease .
The present article provides a review of the recent developments in the field of geriatric cardiology, with focus on the specific characteristics of the elderly in the prevention of cardiovascular events, arterial hypertension (AH), bradycardic arrhythmias, atrial fibrillation (AF), coronary artery syndromes (CAS), valve heart diseases (VHDs), and heart failure (HeFa).
2. Prevention of Cardiovascular Events
Preventive therapy in primary care is guided by the risk thresholds for future cardiovascular events. Common sense and evidence-based medicine recommend a balanced diet suitable to the age and the physical necessities of the seniors. A central role should be assigned to the appropriate treatment of the comorbidities, particularly by avoiding unnecessary drugs, pharmacological interactions, and side-effects.
In recent years, it has been accepted that LDL-C plays a central role in the development of arteriosclerosis and the associated complications; therefore, a high priority has been assigned to the treatment of high LDL-C. The 2019 ESC/EAS Guidelines  recommend a ≥50% reduction in LDL-C from the baseline and a treatment goal of achieving an absolute LDL-C of <55 mg/dL (<1.4 mmol/L) for the very high-risk patients. In regard to the patients at high risk, a ≥50% reduction in LDL-C and a goal of achieving LDL-C <70 mg/dL (<1.8 mmol/L) are recommended. Several risk calculators have been developed for the assessment of the risk thresholds for future cardiovascular events. The most frequently used ones are SCORE, SCORE-HDL, PROCAM, AGLA, FRAM, and PCE . However, all these have been used only in the patients of age up to 75 years, and are not valid for older patients. Therefore, at present, there are no globally accepted guidelines and recommendations for therapy for the treatment of high LDL-C in very old patients.
It has been demonstrated that a significant number of elderly patients with CAD are resistant to aspirin therapy, and that fasting blood glucose levels are closely related to aspirin resistance in the elderly patients with CAD . A total of 22,781 elderly people in retirement communities were inquired regarding aspirin usage, and it was revealed that daily use of aspirin increased the risk of kidney cancer and almost doubled the risk of CAD; in addition, small, non-significant increased risks of stroke were observed in both males and females . A previous study  has reported the effects of low-dose aspirin for primary prevention in 400 healthy ≥70-years-old seniors. In comparison to the placebo, aspirin was observed to induce significantly more adverse gastrointestinal symptoms, clinical gastrointestinal bleeding in 3% of the patients, and a significant decrease in the mean hemoglobin levels. The authors of the study suggested that caution should be exercised when aspirin is used for primary prevention in the case of cardiovascular diseases in the elderly. Another study  reported that low-dose aspirin exerted no effect on the cognitive function in middle-aged to elderly people who were at increased cardiovascular risk. Furthermore, the recent ASPREE study  has also confirmed that the use of low-dose aspirin as a primary prevention strategy in older adults results in a significantly higher risk of major hemorrhage and did not result in a significantly lower risk of cardiovascular disease in comparison to the placebo. Therefore, it is inferred that low-dose aspirin plays no significant role in the primary prevention of cardiovascular diseases in the elderly.
In secondary prevention, aspirin has been demonstrated to be effective in reducing ischemic events, although little is known regarding the bleeding risks in the elderly. Two previous studies [21,22] estimated the bleeding risks in elderly patients associated with the use of aspirin for secondary prevention, and both the studies reported a significant risk for bleeding. Therefore, the use of aspirin for secondary prevention in the elderly is indicated, although with close monitoring of the patients for aspirin-related adverse events, such as gastrointestinal irritability or bleeding risk, owing to the increased vulnerability of this subgroup, particularly in the context of polypharmacy, comorbidities, and frailty.
3. Arterial Hypertension
The prevalence of AH, systolic hypertension, in particular, is continuously rising throughout the world. AH is mainly the clinical expression of arterial stiffening that occurs as a consequence of aging. It is established that in geriatric patients, AH represents a major risk factor for cardiovascular morbidity and mortality, as well as for cognitive decline and loss of autonomy occurring later in life . Older patients with AF are at the greatest risk of catastrophic complications, particularly stroke, as well as for intracranial hemorrhage (ICH) . In Switzerland, 47% of the men and 38% of the women between the age of 65 and 74, and greater than 50% of the ≥75-years-old AF patients are treated for AH . The 2018 ESC Guidelines for AH  recommend that in the patients with age ≥65 years, systolic pressure should be reduced to 130–139 mmHg, and that these values should be reached independent of the comorbidities. Indeed, the real evidence obtained in the community-dwelling older people with few comorbidities and preserved autonomy corroborates the beneficial effects of lowering the blood pressure in older hypertensive subjects even after the age of 80, and the observational studies conducted with frail older individuals treated for AH have reported higher morbidity and mortality rates compared to those with lower blood pressure levels . Despite this, even though AH is, in practice, among the most common reasons for an outpatient medical visit, several hypertensive patients, especially the seniors, have poorly controlled blood pressure levels . Clearly, in the very old subjects, the therapeutic strategy of one-size-fits-all is not applicable, owing to the enormous functional heterogeneity among these individuals. Geriatric medicine, therefore, recommends considering the function/frailty/autonomy status of older people as well as frequent assessments for possible symptomatic hypotonic blood values, orthostatic symptoms, worsening of the renal function, and occurrence of electrolyte disturbances [28,29].
4. Cardiac Pacemakers and Implantable Cardioverter Defibrillators
Cardiac pacemakers and implantable cardioverter defibrillators (ICD) are important therapies with expanding indications for their application. Aging is associated with progressive fibrosis in both the sinus node and the atrioventricular (AV) conduction system (AV node, right and left bundles, and His bundles). Consequently, bradycardia due to sinus node and AV dysfunction is common in the elderly. In the presence of irreversible causes, implantation of a permanent cardiac pacemaker is often required in patients with symptomatic bradycardia. In the case of elderly patients with sinus node dysfunction, pacing modes capable of preserving AV synchrony are associated with a reduced incidence of AF and an improved quality of life. In the patients with AV block, the importance of preserving AV in the elderly remains debatable and is being evaluated presently .
The feasibility of ICD implantation in elderly patients has not been studied sufficiently. Recent data  suggest that older age, by itself, is not associated with a significant increase in the rates of complications arising from these devices. Noseworthy et al.  assessed the feasibility and safety of ICD therapy in the patients with age >80 years. The patients were divided on the basis of age into the following two groups: group 1: 70–79-years-old, and group 2: ≥80-years-old. The two groups were similar in gender distribution, NYHA class, and the indication for implantation. Survival and complication rates were observed to be similar in the two groups. Therefore, age alone may not be sufficient as a suitable criterion for excluding ICD implantation, and the current consensus guidelines for ICD implantation appear to be generalizable for treating the octogenarians who are otherwise medically fit . Notably, a recent DANISH Trial  demonstrated that ICD in non-ischemic HeFa does not result in a reduction in the long-term mortality.
5. Atrial Fibrillation
Aging is associated with progressive fibrosis in the atria. Several pathologies, such as renal insufficiency, AH, VHDs, diabetes mellitus, sleep apnea, obesity, and unhealthy lifestyle habits such as tobacco, alcohol, and reduced physical activity are the predisposing factors for AF, and contribute to the occurrence of its complications [33,34,35]. There is evidence that non-steroid antirheumatic drugs not only worsen the renal function, they also increase the risk for AF [36,37,38]. A strong correlation has been observed between age and the occurrence of AF, and being fueled by the aging of the population, this arrhythmia has become an epidemic. As a matter of fact, at present, the physicians are regularly encountering challenges in the management of AF in old patients. Currently, in the patients of age ≥65 years, the prevalence of AF is approximately 5%, and in 1.4% of these cases, AF remains undetected; 25% of the patients with age ≥40 years shall have AF in their lifetime . Furthermore, the prevalence of AF is expected to double in the next four decades, and the 2016 ESC guidelines for the management of AF  recommend an “opportunistic” screening for the patients aged ≥65 years.
AF is responsible for up to 30% of the cerebrovascular strokes [36,37,38,39,40,41,42], and the treatment relies heavily on the prevention of stroke through the use of oral anticoagulation (OAC). Ischemic (CHA2DS2-VASc) and hemorrhagic (HAS-BLED) scores are used for guiding the OAC. These scores incorporate age as a factor, although unfortunately, there exist several limitations when these scores are applied to very old patients; currently, no scoring systems specifically developed and validated for guiding OAC in the elderly are available . The HAS-BLED score mainly predicts the major bleeds, at least 80% of which are extracranial hemorrhages, particularly gastrointestinal, that carry low (<6%) mortality rates, are rarely the cause of the disability, and are manageable; however, this score does not provide specific assessment of the risk of ICH, which is possibly the greatest concern in the older patients. Therefore, it is not possible to identify the old patients with AF, in whom the risk of ICH plus fatal or disabling extracranial hemorrhage is likely to exceed the risk of fatal and disabling ischemic stroke, through the HAS-BLED scoring system. Therefore, Belmonte et al.  believes that it would be beneficial to develop a novel scoring system dedicated to the older patients with AF, which would encompass all the risk factors specific to this subset of the population.
OAC remains underused in the patients with age ≥80 years, due to the concerns of bleeding complications, comorbidities (renal dysfunction mainly), and poor functional autonomy [41,42,43]. However, age and frailty per se do not form absolute exclusion criteria for OAC in patients with AF who require OAC. A study  conducted with ≥90-year-old patients who were treated with OAC revealed that, compared to the patients without AF, the AF patients exhibited an increased risk of ischemic stroke and similar risks of ICH. Among the AF patients, the use of warfarin, compared with no antithrombotic therapy, was associated with a positive net clinical benefit, a lower risk of stroke, and no difference in the ICH risk. The use of non-vitamin K antagonists (NOACs), compared with no antithrombotic therapy, was associated with a lower risk of ICH, with no difference in the risk for ischemic stroke. Therefore, OAC may be considered a thromboprophylaxis for very old patients, while NOACs would be the more favorable choice. However, there are no one-size-fits-all NOACs, and this also applies to elderly, particularly the vulnerable patients . Furthermore, a significant proportion of geriatric patients cannot be treated with the necessary OAC because of the comorbidities, and in these patients, occlusion of the left atrial appendage may be a valuable choice .
Radiofrequency ablation is emerging as an effective therapy in the treatment of AF . In reality, this therapy is rarely used in the old patients, partially because AF is sustained and mostly because of the comorbidities. Rhythm-control is also rarely indicated in the geriatric patients, who are generally treated using heart rate-control, usually through a β-blocker or diltiazem or verapamil . In drug-resistant, poorly-tolerated AF, AV junction catheter ablation and pacemaker implantation has been used as the final option and has proven to be quite effective .
6. Coronary Artery Syndromes
The 2019 ESC-Guidelines for CAS  recommend the use of a pretest propensity risk of disease (PPRD), which is calculated using the age and sex of the patient, clinical presentation of the myocardial ischemia, and the Canadian Cardiovascular Society (CCS) grading of AP. The PPRD would assist in saving medical resources by allowing an effective selection of appropriate diagnostic procedures (non-invasive versus invasive) and therapeutic treatment (invasive-surgical versus conservative-pharmacological). The non-invasive approach is suitable for the patients with a medial (<85%) PPRD, while the invasive approach would be suitable for those with high (>85%) PPRD or severe AP (CCS grade > III). The PPRD is always higher in the old compared to the young patients as age is an important factor for its computation. A necessary invasive approach for treating potentially lethal and treatable conditions should not be avoided in old patients, although with the consideration of comorbidities and frailty. Notably, old patients with CAS often present with atypical symptoms, e.g., they present more often with dyspnea rather than pain, or with atypical localization of AP. In addition, such patients usually present with either an unstable AP or a non-ST-segment elevation myocardial infarction, and present less frequently with ST-segment elevation myocardial infarction .
In previous years, the interventional risk of coronarography and revascularization has reduced, and the related techniques have been improved. Therefore, it is possible to perform further invasive interventions in the old patients compared to previous times. Recent data  demonstrate that patients with age ≥80 years would benefit more from a myocardial revascularization compared to intensive pharmacological therapy. However, medical therapy and revascularization is not inferior to revascularization in the ≥90-year-old patients. Indeed, modern pharmacological therapy is better compared to previous times, and may reduce symptoms and improve the life-quality and survival, at least in the patients without acute ischemic conditions, rendering it not inferior to revascularization . A conservative approach is followed in the cases for which revascularization is not indicated or is technically impossible, which may also serve as a valid opportunity for the old patients who refuse an intervention. It is understandable why an old patient may refuse an invasive therapy and a polytherapy. However, currently, cardiologists are also encountering old patients who would rather favor an intervention to a polytherapy. Treatment of old cardiac patients must be individualized and presumes adequate information from the patients and their relatives [51,52,53].
7. Valve Heart Diseases
VHDs are associated with high morbidity and high mortality . Since the incidence of VHDs increases with age, the number of patients presenting with VHDs is increasing with the aging of the population. A Euro Heart Survey on VHDs  conducted in 2003 reported that the incidence of VHDs for both mitral and aortic valves was <1% in the old patients with age <64 years and 6% in the ≥75-year-old patients. Notably, 30% of the patients with severe, symptomatic, single VHDs, usually the elderly with relevant comorbidities, did not undergo surgery. A 2015 European VHDs survey  revealed that despite the high prevalence and morbidity associated with VHDs, the awareness and knowledge regarding them in the general population were alarmingly low, with only 3.8% of the population understanding what aortic stenosis (AS) was. Another survey conducted in  reported a small improvement in the general knowledge regarding the VHDs, while the detailed understanding of AS remained low.
In the elderly, the etiology of AS is degenerative in the majority of the cases [52,53,54,55,56,57]. However, large-scale surveys [58,59,60] have reported that 22% of the octogenarians presenting for surgery for isolated AS had bicuspid valve disease. Isolated aortic regurgitation, reported in 2.0%–2.5% of the 70–83-year-old patients [without gender differences], is significantly less common compared to AS [61,62,63].
In developed countries, mitral regurgitation (MR) is the most frequent VHD in the ≥65-year-old patients, while geriatric patients account for approximately 40% of all the patients with MR, among which 4.5% are ≥80 years old . In the Framingham study, the prevalence of moderate MR in 70–83-year-old men was 11.1% . In the elderly, MR occurs mostly due to degenerative and ischemic pathologies [54,62], and is associated with concomitant AS in 22%–48% of the cases.
In the general population, tricuspid regurgitation (TR) has an incidence of 1.2%–1.5% [54,64]. The prevalence of TR increases with age, particularly in females; in the 70–83-year-old patients, the incidence of TR is 5.6% in women and just 1.5% in men . In young patients, TR is usually associated with congenital, infectious, traumatic, and rheumatic pathologies, and rarely culminates in implantation for pacing or leaflet damage due to biopsy [64,65]. On the other hand, in geriatric patients, TR usually develops due to left heart disease . Severe TR is associated with higher mortality and poorer outcomes, regardless of patient age and other comorbidities .
In geriatric patients, VHDs are often associated with CAD [54,66]. Data regarding the elderly subjects are limited, although it is proven that the coexistence of AS and CAD leads to a worse prognosis compared to that for an AS of comparable severity occurring alone [54,66]. Moreover, significant MR is observed in one-fifth of the octogenarians with non-ST elevation myocardial infarction, with poor prognosis [67,68].
The concept of transcatheter aortic valve replacement (TAVR) for the treatment of AS emerged in the early 1990s. In 2002, Cribier  performed TAVR in humans using femoral vein access and a trans-septal approach. The associated techniques and valves are undergoing continual improvement. Since 2005, aortic valves are being implanted using the transfemoral artery, and a trans-apical approach is used only in patients with unsuitable vascular access . The surgical risk is assessed using scores, usually the STS score or the European System for Cardiac Operative Risk Evaluation score . Currently available data present TAVR as safe and efficient, and it is now recommended for the patients at intermediate risk; it is expected that newer data being generated may enable the expansion of the indication for TAVR to low-risk patients as well [70,71,72]. However, the risk scores may be misleading in the ≥80-year-old patients, as peri-operative complications exist beyond the scores, owing to frailty and very old age per se [71,72,73]. Nonetheless, the current data demonstrate that TAVR is beneficial in octogenarians [70,71,72,73,74,75,76,77] as well as in >90-year-old patients [75,76]. Furthermore, a recent study  conducted with asymptomatic patients with very severe AS aged between 20 and 80 years has proven that the incidence of operative mortality or death from a cardiovascular cause was significantly lower in those treated with early surgical aortic valve replacement compared to those who received conservative care.
Recent data report the effect of antithrombotic therapy in TAVR-treated patients. The GALILEO trial  report stated that in patients without an established indication for OAC after successful TAVR, a treatment strategy including rivaroxaban at a daily dose of 10 mg was associated with a higher risk of death or thromboembolic complication as well as a higher risk of bleeding compared to an anti-platelet-based strategy. In a sub-study of the GALILEO trial , it was revealed that in the patients without an indication for long-term OAC after successful TAVR, a rivaroxaban-based antithrombotic strategy was more effective in preventing sub-clinical leaflet motion abnormalities compared to an anti-platelet-based strategy, although the former was also associated with a higher risk of death or thromboembolic complications as well as a higher risk of bleeding. These data demonstrate that a rivaroxaban-based antithrombotic strategy cannot be recommended for the patients who have undergone a successful TAVR.
The etiology of MR plays an important role in the therapy, particularly in old patients. In developed countries, the etiology of MR in geriatric patients is usually secondary [54,61,79,80]; in this clinical setting, the clinical benefit of surgery remains uncertain. The ESC Guidelines  provide no recommendations for the therapy of secondary MR, while the American Guidelines  propose individualized approaches. Currently, mitral valve repair (MVR) is the generally accepted "gold standard" treatment for degenerative MR [81,82,83], while surgical mitral valve replacement (SMVR) is indicated only in cases where the expected clinical improvements exceed the increased operative risk associated with aging and comorbidities [80,81,82,83,84,85]. MVR has a high short-term mortality of 25%–30%, and the limited life-expectancy of old patients, the lower technical complexity of SMVR with shorter cardio-pulmonary bypass times, and a decreased risk of failure with a requirement for reintervention may explain the lower-than-expected rate of MVR . Nonetheless, in octogenarian patients, 15% operative mortality has been reported for SMVR . At present, according to the administrative American databases, MVR was performed in less than 50% of the elderly patient cases [81,82,83,84,85,86,87]. Especially when a concomitant coronary bypass surgery is not planned, most cardiologists are inclined to opt for an optimal pharmacological, and if indicated, cardiac resynchronization therapy . The recent availability of percutaneous devices for the treatment of mitral valve diseases may offer an alternative approach for the management of MR [81,82]. However, the evidence for treatment of MVR with MitraClip is not extensive, and the only transcatheter therapy recommended at present is the one with MitraClip for the high-risk surgical patients; however, it is considered that the treatment is unlikely to improve the quality of life and survival [54,72].
Previously, the approach to TR treatment was rather conservative. However, the understanding of the etiologies and effects of TR have changed, and nowadays, pathology is often being considered for a repair . In elderly patients with long-standing disease, TR frequently raises a challenging treatment dilemma [88,89]. Transcatheter therapies are being tested in feasibility trials, and among these, the Tri-align system has been delivered percutaneously through the right internal jugular vein .
8. Heart Failure
The incidence and prevalence of HeFa increase with age, owing to the physio-pathological changes and the increasing frequency of predisposing comorbidities that occur with aging. Indeed, over 80% of HeFa patients are older than 65 years [90,91,92,93]. Despite that, information regarding geriatric HeFa patients is limited because of lack of clinical trials in population-based studies and because clinical trials typically enroll younger patients. Havranek et al.  studied the charts of Medicare patients hospitalized in the period between 1998 and 1999 with a principal diagnosis of HeFa. After excluding the patients who were <65 years of age, those who were either discharged to other acute-care facilities or discharged with medical advice, or the ones who were receiving long-term hemodialysis, the authors collected data from 34,587 patients. More than half of these patients had CAD and a history of AH, approximately 40% had diabetes, and approximately one-third had chronic obstructive pulmonary disease. Left ventricular ejection fraction was <40% in only 50.4% of the patients in whom it was assessed. Renal insufficiency was more common with advancing age. This study evidenced that elderly HeFa patients are a heterogeneous group and differ substantially from the younger patients enrolled in the clinical trials. The authors of the study suggested that there is an urgent requirement for evidence-based guidance for the treatment in the context of comorbidities, poor renal function, HeFa with preserved left ventricular systolic function (HFpEF), and residence in long-term care facilities. Weir et al.  reported similar data, stating that the prevalence of HeFa increases with age and that the majority of the HeFa patients in the future would be the elderly. Despite these reports, most of the current evidence for the management of this serious condition is provided by the trials that have largely excluded the older patients. As a consequence, older patients who may derive the greatest benefit from the treatments known to reduce morbidity and mortality in HeFa are being treated without any specific recommendations.
Furthermore, the diagnosis and management of HeFa in older adults could be challenging. Therefore, Ahmed  proposed a mnemonic DEFEAT–HeFa approach (Diagnosis, Etiology, Fluid, Ejection frAcion, and Treatment), which would simplify the diagnosis and therapy in HeFa in the geriatric patients.
The PREDICT study  confirmed that much clinical research that is of relevance to elderly patients examines individuals who are younger in comparison to those who have the disease in question, and this is particularly true for HeFa. In the World Health Organization Clinical Trials Registry Platform of HeFa clinical trials, almost all the studies excluded geriatric patients, either by an arbitrary upper age limit or by other exclusion criteria that might indirectly cause limited recruitment of the older individuals. Exclusion criteria were classified into two categories: justified or poorly justified. Among the 251 trials investigating the treatments for HeFa, 64 (25.5%) excluded patients by an arbitrary upper age limit. Such exclusion was significantly more common in the trials conducted in the European Union compared to those conducted in the USA [31/96 (32.3%) versus 17/105 (16.2%)] and in the drug trials sponsored by public institutions compared to the ones organized by private entities [21/59 (35.6%) versus 5/36 (13.9%)]. Overall, 109 trials (43.4%) on HeFa had one or more poorly justified exclusion criteria that could limit the inclusion of older individuals. A similar percentage of clinical trials with poorly justified exclusion criteria was obtained in pharmacological and non-pharmacologic trials. The authors concluded that despite the recommendations of national as well as international regulatory agencies, exclusion of older individuals from the ongoing trials for HeFa continues to be widespread.
In 2009, Cheng and Nayar  reviewed 40 clinical studies on HeFa. The drugs used were angiotensin-converting enzymes inhibitors, angiotensin-II receptor blockers (also referred to as angiotensin II receptor antagonists or AT1 receptor antagonists), β-blockers, diuretics, aldosterone antagonists, digoxin, and [in Afro-Americans] a combination of hydralazine and nitrates. The authors reported that no clinical trials assessing the effects of HeFa treatment exclusively in elderly patients has been conducted. Most clinical trials did not specify the number of included elderly patients or had included 30%–50% elderly patients, usually less than 70 years in age. The insufficient data that are currently available appear to confirm that HeFa therapy, which reduces mortality and morbidity in the non-elderly patients, is also beneficial in elderly patients. However, elderly patients exhibit different responses to HeFa pharmacotherapy compared to the younger patients and are also susceptible to adverse events, such as orthostatic hypotension, renal dysfunction, electrolyte disturbances, and interactions with medications received for the treatment of the comorbidities. Therefore, close monitoring of elderly patients undergoing HeFa treatment is essential to ensure optimal outcomes.
Despite the use of β-blockers for more than 40 years, no study has so far demonstrated that these reduce morbidity and mortality in the elderly, and therefore, β-blockers should not be considered first-line therapy in the treatment of AH in geriatric people . Despite having gained an indisputable status in the therapy of HeFa, β-blockers may exhibit several unknowns when used in elderly patients. Previous epidemiological studies have demonstrated failure in reaching the guideline-recommended β-blocker dose in more than one-half of the old HeFa patients, even in those managed by cardiologists . It is plausible not to withhold treatment with β-blockers when discharging the elderly HeFa patients with left ventricular systolic dysfunction, although a less-tight up-titration than that dictated by the major trials is advisable; moreover, it remains unclear whether to pursue the published target doses or that clinical benefit could be gained with lower doses as well .
Ivabradine has been approved for use as an adjunct in the treatment of selected patients having symptomatic HeFa with reduced ejection fraction (HFrEF), those who are in sinus rhythm, and the ones with resting heart rate of at least 70 beats per minute despite treatment with an evidence-based dose of a β blocker (or the maximal tolerated dose below that), angiotensin-converting enzymes or angiotensin-II receptor blockers, or aldosterone antagonists. Certain authors suggest, although, without evidence, that ivabradine might also be useful in patients with HFpEF [97,98]. Indeed, it has been observed that the safety and efficacy of ivabradine are comparable in young and old patients . However, a recent study confirmed that the evidence for treating elderly HeFa patients is generally extrapolated from the cohorts who are up to 2 decades younger, while the real-life therapy requires extrapolation of findings from the trials conducted in much younger populations; as such, little is known regarding the tolerability and the side-effect profile of evidence-based ivabradine therapy in the elderly patients . Furthermore, most of the geriatric HeFa patients have AF (ivabradine is ineffective in AF), several have a sick-sinus dysfunction (a contraindication for ivabradine), and at least 50% of the geriatric HeFa patients have CAD (role of ivabradine in CAD is not yet elucidated beyond doubts). Therefore, in a real-life cardiology practice, ivabradine is rarely used in geriatric HeFa patients. Prescribing patterns and potential benefits in the elderly are influenced heavily by polypharmacy and the comorbidities. Increasing longevity may become less relevant in the frail elderly, while improving the quality of life is almost always the priority; improving wellbeing, maintaining independence for a longer period, and delaying institutionalization come as bonus. These unknowns have encouraged a recently commenced study  for the assessment of the beneficial and harmful effects of ivabradine in the treatment of CAD and/or HeFa. Unfortunately, data shall again be collected from the currently available publications, in which the data on geriatric patients remains scarce.
Sacubitril/valsartan has been recently approved for the treatment of HFrEF. Since it has been recently introduced in the armamentarium for HeFa treatment, “field-practice” evidence is scarce. A case report  described the effect of sacubitril/valsartan therapy in a hypertensive geriatric patient with HFrEF. Sacubitril/valsartan could reduce dyspnea and blood pressure, and improved the left ventricular pathologic changes as assessed by echocardiography. Another study  reported the effect of sacubitril/valsartan versus olmesartan in 588 hypertensive Asian patients with a mean age of 70.7 years. Sacubitril/valsartan exhibited greater lowering of blood pressure compared to olmesartan, and no relevant side-effects were reported. These data should be considered hypothesis-generating, although they are insufficient for deciding whether the use of sacubitril/valsartan is safe in the geriatric patients with HFrEF.
Lastly, the EMPA-REG OUTCOME trial  demonstrated that empagliflozin, an inhibitor of sodium-glucose cotransporter 2, significantly reduced the risk of cardiovascular deaths, non-fatal myocardial infarction, or non-fatal stroke in subjects with type 2 diabetes mellitus and established CAD, with a greater benefit in those over 65 years of age. In addition, empagliflozin was associated with a reduction in the risk of secondary composite endpoint of HeFa hospitalization or cardiovascular death, with a consistent benefit across the subgroup age as well as in the patients with or without baseline HeFa . Although several factors, including osmotic diuresis, reduction in plasma volume, and sodium retention, may explain the effects of empagliflozin on HeFa and cardiovascular death, the actual underlying mechanism remains uncertain. Empagliflozin has exhibited a good safety profile. However, a higher risk of volume deletion-related adverse events and urinary infections in the elderly patients is expected .
Since the proportion of older people in the population is increasing, practicing cardiologists are encountering an increasing number of consultations from very old patients. Although certain individuals are biologically younger than their anagraphic age, the geriatric patients in general are frail and have several comorbidities. Progress in the field of medicine has rendered it possible to treat lethal cardiac diseases in very old patients. This is certainly good, although the demand for invasive therapies and novel drugs has created a rapid increase in the expenditures.
Geriatric cardiology has become a necessity. Owing to the comorbidities, several of which are critical, in the elderly patients, it is imperative for the geriatric cardiologists to be, first of all, master internists at all times. Old patients, with their peculiar pharmacokinetics and multiple illnesses, are also oversensitive to drugs. The former USA Secretary of Defense, Donald Rumsfeld once wrote, “There are known knowns; the things we know that we know; then there are known unknowns; the things that we know that we do not know; however, there are also the unknown unknowns; the things we do not know that we do not know”. This holds true for geriatric cardiology. It is impossible to directly extrapolate the experience with the young patients to the old people. Given the increasing proportion of the old in the population, there is a necessity to train a large number of geriatric cardiologists to offer the best of care to the old patients. There is also a requirement to understand the effects exerted by the aging process on the human heart, and the studies exploring this should command priorities in the financial as well as other forms of support.
AF: Atrial fibrillation; AP: Angina pectoris; AS: Aortic stenosis; AR: Aortic regurgitation; AV: Atrioventricular; CAD: Coronary artery disease; CCS: Canadian cardiovascular society; HeFa: Heart failure; HfpEF: Heart failure with a preserved ejection fraction; HfrEF: Heart failure with a reduced ejection fraction; ICD: Implantable cardioverter defibrillators; ICH: Intracerebral hemorrhage; NOACs: Non-vitamin K antagonists; MR: Mitral regurgitation; MVR: Mitral valve repair; OAC: Oral anticoagulation; PPRD: Pretest propensity risk of disease; SMVR: Surgical mitral valve replacement; TAVR: Transcatheter aortic valve replacement; TR: Tricuspid regurgitation; VHDs: Valve heart diseases.
G. Cocco collected and analyzed the references, and wrote the paper. Ph. Amiet checked the collection and completness of data, and together with Cocco agreed on the printed data.
The authors have declared that no competing interests exist.
- Denton FT, Spencer BG. How old is old? Revising the definition based on life table criteria. Math Popul Stud. 1997; 7: 147-159. [CrossRef]
- Tyas S, Snowdon DA, Desrosier MF, Riley KP, Markesbery WR. Healthy ageing in the Nun Study: Definition and neuropathologic correlates. Age Ageing. 2007; 36: 650-655. [CrossRef]
- Matter M. Old age is over! Schw. Ärztezeitung. 2020; 101: 44. [CrossRef]
- Orimo H, Ito H, Suzuki T, Araki A, Hosoi T, Sawabe M. Reviewing the definition of “elderly”. Geriatr Gerontol. 2006; 6: 149-158. [CrossRef]
- Murder M, Kurmann R, Kozba R. The old cardiologic patient. – Is a maximal therapy meaningful? CardioVasc. 2019; 18: 26-29.
- Shane M, Bailey SM, Wilkoff BL. Complications of pacemakers and defibrillators in the elderly. Am J Ger Cardiol. 2007; 15: 102-107. [CrossRef]
- Damluji AA, Forman DE, van Diepen S, Alexander KP, Page II RL, Hummel SL, et al. Older adults in the Cardiac Intensive Care Unit: Factoring geriatric syndromes in the management, prognosis, and process of care: A scientific statement from the American Heart Association. Circulation. 2020; 141: e6-e32. [CrossRef]
- Lown B. Introduction to rethink. The lost art of healing. Manual to rethink. 2004: 9-13. In the lost art of healing. Guidance to Rethink. Surhkamp, ISBN 978-3-518-45574-6. 2004. Original language: German.
- Poses RM. Dissatisfaction with medical practice. N Engl J Med. 2004; 350: 1357-1359. [CrossRef]
- Cocco G. Physicians' dissatisfaction. Heart Mind. 2019; 2: 36-39. [CrossRef]
- Lindesay J, Thompson C. Housebound elderly people: Definition, prevalence and characteristics. Int J Geriatr Psychiatry. 1993; 8: 231-237. [CrossRef]
- Dodson JA, Matlock DD, Forman DE. Geriatric cardiology: An emerging discipline. Can J Cardiol. 2016; 32: 1056-1064. [CrossRef]
- Burch GE. Interesting aspects of geriatric cardiology. Am Heart J. 1975; 89: 99-114. [CrossRef]
- Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al. ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk. Eur Heart J. 2020; 41: 111-188. [CrossRef]
- Romanens M, Martin BødtkerMortensen M, Sudano I, Szucs T, Adams A. Extensive carotid atherosclerosis and the diagnostic accuracy of coronary risk calculators. Prev Med Rep. 2017; 6: 182-186. [CrossRef]
- Liu XF, Cao J, Fan L, Liu L, Li J, Hu GL, et al. Prevalence of and risk factors for aspirin resistance in elderly patients with coronary artery disease. J Geriatr Cardiol. 2013; 10: 21-27.
- Paganini-Hill A, Chao A, Ross RK, Henderson BE. Aspirin use and chronic diseases: A cohort study of the elderly. BMJ. 1989; 299: 1247. [CrossRef]
- Silagy CA, McNeil JJ, Donnan GA, Tonkin AM, Worsam B, Champiom K. Adverse effects of low-dose aspirin in a healthy elderly population. Clin Pharnacol Ther. 1993; 54: 84-89. [CrossRef]
- Price JF, Stewart MC, Deary IJ, Murray GD, Sandercock P, Butcher I, et al. Low dose aspirin and cognitive function in middle aged to elderly adults: Randomised controlled trial. BMJ. 2008; 337: a1198. [CrossRef]
- McNeil JJ, Wolfe R, Woods RL, Tonkin AM, Donnan GA, Nelson MR, et al. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med. 2018; 379: 1509-1518. [CrossRef]
- Buresly K, Eisenberg MJ, Zhang X, Pilote L. Bleeding complications associated with combinations of aspirin, thienopyridine derivatives, and warfarin in elderly patients following acute myocardial infarction. Arch Intern Med. 2005; 165: 784-789. [CrossRef]
- Damluj AA, Ramireddy A, Otalvaro L, Forman DE. Secondary cardiovascular prevention in older adults: An evidence based review. J Geriatr Cardiol. 2015; 12: 459-464.
- Benetos A, Petrovic M, Strandberg T. Hypertension management in older and frail older patients. Circ Res. 2019; 124: 1045-1060. [CrossRef]
- Collins R. Elderly vs older, frail vs vulnerable: Towards better understanding of our patients with atrial fibrillation. 2002 PeerVoice 2-.
- Swiss Heart Foundation. Numbers and dates on cardiovascular diseases in Switzerland. Ed. 2016 Schweizerische Herzstiftung. Original language: German.
- Williams B, Mancia G, Spiering W, Agabiti Rosei E, Aziz M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018; 39: 3021-3104. [CrossRef]
- Dan R, Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, et al. Inadequate management of blood pressure in a hypertensive population. New Engl J Med. 1998; 339: 1957-1963. [CrossRef]
- Emrich IE, Bohm M, MaHeFaoud F. The 2018 ESC/ESH Guidelines for the management of arterial hypertension: A German point of view. Eur Heart J. 2019; 40: 1830-1831. [CrossRef]
- MaHeFaoud F, Böhm M, Bongarth CM, Bosch R, Schmieder RE, Schunkert H, et al. Comments on the European Society of Cardiology and European Society of Hypertension for the therapy of arterial hypertension. Der Kardiologe. 2019; 13: 1723. [CrossRef]
- Kusumoto FM, Phillips R, Goldschlager N. Pacing therapy in the elderly. Am J Geriatr Cardiol. 2002; 11: 305-316. [CrossRef]
- Noseworthy PA, Lashevsky I, Dorian P, Greene M, Cvitkovic S. Newman D. Feasibility of implantable cardioverter defibrillator use in elderly patients: A case series of octogenarians. Pacing Clin Electrophysiol. 2004; 27: 373-378. [CrossRef]
- Køber L, Thune JJ, Nielsen JC, Haarbo, Videbæk JL, Korup E, et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med. 2016; 375: 1221-1230. [CrossRef]
- Cocco G, Jerie P. New concepts in the therapy of atrial fibrillation. Cardiol J. 2016; 23: 3-11. [CrossRef]
- Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics--2015 update: A report from the American Heart Association. Circulation. 2015; 131: e29-e322.
- Gillis AM. A sober reality? alcohol, abstinence, and atrial fibrillation. New Engl J Med. 2020; 382: 83-84. [CrossRef]
- Gasparyan AY, Ayvazyan L, Cocco G, Kitas GD. Adverse cardiovascular effects of antirheumatic drugs: Implications for clinical practice and research. Curr Pharm Des. 2012; 18: 1543-1555. [CrossRef]
- Cocco G, Amiet P. Adverse cardiovascular effects of non-steroid antirheumatic drugs: Implications for clinical practice. JCDR. 2018; 1: 19-23.
- Cocco G. Cardiovascular risk in rheumatoid arthritis: An update for general practitioners. J Cardiovasc Res Cradiol. 2018; 1: 1-6.
- Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics-2017 update: A report from the American Heart Association. Circulation. 2017; 135: e146-e603. [CrossRef]
- Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016; 37: 2893-2962. [CrossRef]
- Belmonte M, Ruggiero R, Lombardi F. Oral anticoagulation in the very old patient with atrial fibrillation: Pros and cons. E-J Cardiol Prac. 2019; 17.
- Chao TF, Liu CJ, Lin YJ, Chang SL, Lo LW, Hu YF, et al. Anticoagulation in very elderly patients with atrial fibrillation: A nationwide cohort study. Circulation. 2018; 138: 37-47. [CrossRef]
- Steffel J. Managing stroke risk in older patients with atrial fibrillation: Lesson from the real world. Peer Voce. 2023.
- Sharma SP, Park P, Lakkireddy D. Left atrial appendages occlusion: Current status and prospective. Korean Circ J. 2018; 48: 692-704. [CrossRef]
- First-line treatment of atrial fibrillation: Is radiofrequency ablation ready for prime time?: Non pharmacologic treatment. Medscape. 2020; January 18.
- Rosenthal L, McManus DD. Atrial fibrillation treatment & management. theheart.org Medscape. 2019; November 18.
- Touboul P. Atrioventricular nodal ablation and pacemaker implantation in patients with atrial fibrillation. Am J Cardiol. 1999; 83: 241D-245D. [CrossRef]
- Knuuti J, Wijns WM, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur Heart J. 2020; 41: 407-477. [CrossRef]
- Bhatia LC, Naik RH. Clinical profile of acute myocardial infarction in elderly patients. J Cardiovasc Dis Res. 2013; 472: 107-111. [CrossRef]
- Tegn N, Abdelnoor M, Aaberge L, Endresen K, Smith P, Aakhus S, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): An open-label randomised controlled trial. Lancet. 2016; 387: 1057-1065. [CrossRef]
- Windecker S, Stortecky S, Stefanini GG, da Costa BR, Rutjes AW, Di Nisio M, et al. Revascularisation versus medical treatment in patients with stable coronary artery disease: Network meta-analysis. BMJ. 2014; 348: g3859. [CrossRef]
- Achenbach S, Naber C, Levenson B, Boning A, Schächinger V. Indications for invasive coronary diagnostics and revascularization. Der Kardiologe. 2017; 11: 272-284. [CrossRef]
- Neumann FJ, Byrne RA, Sibbing D, Kastrati N, Frey T, Doenst J, et al. Comments on the 2018 ESC and EACTS Guidelines on myocardial revascularization. Der Kardiologe. 2019; 13: 181-192. [CrossRef]
- Rostagno C. Heart valve disease in elderly. World J Cardiol. 2019; 11: 71-83. [CrossRef]
- Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J. 2003; 24: 1231-1243. [CrossRef]
- Gaede L, Di Bartolomeo R, van der Kley F, Elsässer A, Iung B, Möllmann H. Aortic valve stenosis: What do people know? A heart valve disease awareness survey of over 8,800 people aged 60 or over. EuroIntervention. 2016; 12: 883-889. [CrossRef]
- Gaede L, Aarberge L, Bruinsma BBG, Macarthy P, Musumeci F, Zamorano P, et al. Heart valve disease awareness survey 2017: What did we achieve since 2015? Clin Res Cardiol. 2019; 108: 61-67. [CrossRef]
- Otto CM, Kuusisto J, Reichenbach DD, Gown AM, O'Brien KD. Characterization of the early lesion of 'degenerative' valvular aortic stenosis. Histological and immunohistochemical studies. Circulation. 1994; 90: 844-853. [CrossRef]
- Stewart BF, Siscovick D, Lind BK, Gardin JM, Gottdiener JS, Smith VE, et al. Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study. J Am Coll Cardiol. 1997; 29: 630-634. [CrossRef]
- Dweck MR, Jones C, Joshi NV, Fletcher AM, Richardson H, White A, et al. Assessment of valvular calcification and inflammation by positron emission tomography in patients with aortic stenosis. Circulation. 2012; 125: 76-86. [CrossRef]
- Singh JP, Evans JC, Levy D, Larson MG, Freed LA, Fuller DL, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol. 1999; 83: 897-902. [CrossRef]
- Roberts WC, Janning KG, Ko JM, Filardo G, Matter GJ. Frequency of congenitally bicuspid aortic valves in patients ≥80 years of age undergoing aortic valve replacement for aortic stenosis (with or without aortic regurgitation) and implications for transcatheter aortic valve implantation. Am J Cardiol. 2012; 109: 1632-1636. [CrossRef]
- Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: A population-based study. Lancet. 2006; 368: 1005-1111. [CrossRef]
- Cohen SR, Sell JE, McIntosh CL, Clark RE. Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg. 1987; 94: 488-497. [CrossRef]
- Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O. The growing clinical importance of secondary tricuspid regurgitation. J Am Coll Cardiol. 2012; 598: 703-710. [CrossRef]
- Enriquez-Sarano M, Klodas E, Garratt KN, Bailey KR, Tajik AJ, Holmes DR Jr. Secular trends in coronary atherosclerosis--analysis in patients with valvular regurgitation. N Engl J Med. 1996; 335: 316-322. [CrossRef]
- Kwon DH, Kusunose K, Obuchowski NA, Cavalcante JL, Popovic ZB, Thomas JD, et al. Predictors and prognostic impact of progressive ischemic mitral regurgitation in patients with advanced ischemic cardiomyopathy. A multimodality study. Circ Cardiovasc Imaging. 2016; 9: e004577. [CrossRef]
- Díez‐Villanueva P, Vera A, Ariza‐Solé A, Alegre O, Formiga F, López‐Palop R, et al. Mitral regurgitation and prognosis after non‐ST‐segment elevation myocardial infarction in very old patients. J Am Geriatr Soc. 2019; 67; 1541-1763. [CrossRef]
- Cribier AG. The odyssey of TAVR from concept to clinical reality. Tex Heart Inst J. 2014; 41: 125-130. [CrossRef]
- Figulla HR, Franz M, Lauten A. The history of Transcatheter Aortic Valve Implantation (TAVI) - A personal view over 25 years of development. Cardiovasc Revasc Med. 2019. doi:10.1016/j.carrev.2019.05.024. [CrossRef]
- Reardon MJ, Van Mieghem NM, Popma JJ, Kleiman NS, Søndergaard L, Mumtaz M, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2017; 376: 1321-1331. [CrossRef]
- Sündermann SH, Unbehaun A, Kempfert J, Falk V. Current management of aortic and mitral valve disease. Cardiovasc Med. 2020; 23: W02084. [CrossRef]
- Cheitlin MD, Gerstenblith G, Hazzard WR, Pasternak R, Fried LP, Rich MW, et al. Database Conference January 27-30, 2000, Washington D.C.--Do existing databases answer clinical questions about geriatric cardiovascular disease and stroke? Am J Geriatr Cardiol. 2001; 10: 207-223. [CrossRef]
- Fried LP, Hadley EC, Walston JD, Newman AB, Guralnik JM, Studenski S, et al. From bedside to bench: Research agenda for frailty. Sci Aging Knowledge Environ. 2005; 31: pe24. [CrossRef]
- Yamamoto M, Mouillet G, Meguro K, Gilard M, Laskar M, Eltchaninoff H, et al. Clinical results of transcatheter aortic valve implantation in octogenarians and nonagenarians: Insights from the FRANCE-2 registry. Ann Thorac Surg. 2014; 97: 29-36. [CrossRef]
- Hirji SA, Ramirez-Del Val F, Kolkailah AA, Ejiofor JI, McGurk S, Chowdhury R, et al. Outcomes of surgical and transcatheter aortic valve replacement in the octogenarians-surgery still the gold standard? Ann Cardiothorac Surg. 2017; 6: 453-462. [CrossRef]
- Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, et al. Early surgery or conservative care for asymptomatic aortic stenosis. New Engl J Med. 2020; 382: 111-119. [CrossRef]
- Dangas GD, Tissen JGP, Wöhrle J, Søndergaard L, Gilard M, Möllmann H, et al. A controlled trial of rivaroxaban after transcatheter aortic-valve replacement. New Engl J Med. 2020; 382: 120-129. [CrossRef]
- De Backer O, Dangas GD, Jilaihawi H, Leipsic JA, Terkelsen CJ, Makkar R, et al. Reduced leaflet motion after transcatheter aortic-valve replacement. New Engl J Med. 2020; 382: 120-129. [CrossRef]
- Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: Cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: Cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014; 35: 2383-2431. [CrossRef]
- Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 3rd, Fleisher LA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017; 135: e1159-e1195. [CrossRef]
- Badhwar V, Peterson ED, Jacobs JP, He X, Brennan JM, O'Brien SM, et al. Longitudinal outcome of isolated mitral repair in older patients: Results from 14,604 procedures performed from 1991 to 2007. Ann Thorac Surg. 2012; 94: 1870-1877. [CrossRef]
- Vassileva CM, Mishkel G, McNeely C, Boley T, Markwell S, Scaife S, et al. Long-term survival of patients undergoing mitral valve repair and replacement: A longitudinal analysis of Medicare fee-for-service beneficiaries. Circulation. 2013; 127: 1870-1876. [CrossRef]
- Acker MA, Parides MK, Perrault LP, Moskowitz AJ, Gelijns AC, Voisine P, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014; 370: 23-32. [CrossRef]
- Dayan V, Soca G, Cura L, Mestres CA. Similar survival after mitral valve replacement or repair for ischemic mitral regurgitation: A meta-analysis. Ann Thorac Surg. 2014; 97: 758-765. [CrossRef]
- Mick SL, Keshavamurthy S, Gillinov AM. Mitral valve repair versus replacement. Ann Cardiothorac Surg. 2015; 4: 230-237.
- Silaschi M, Chaubey S, Aldalati O, Khan H, Uzzaman MM, Singh M, et al. Is mitral valve repair superior to mitral valve replacement in elderly patients? Comparison of short‐ and long‐term outcomes in a propensity-matched cohort. J Am Heart Assoc. 2016; 9: 5: e003605. doi:10.1161/JAHA.116.003605. [CrossRef]
- Biancari F, Schifano P, Pighi M, Vasques F, Juvonen T, Vinco G. Pooled estimates of immediate and late outcome of mitral valve surgery in octogenarians: A meta-analysis and meta-regression. J Cardiothorac Vasc Anesth. 2013; 27: 213-219. [CrossRef]
- Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004; 43: 405-409. [CrossRef]
- Havranek EP, Masoudi FA, Westfall KA, Wolfe P, Ordini DL, Krumholz HM. Spectrum of heart failure in older patients: Results from the national heart failure project. Am Heart J. 2002; 143: 412-417. [CrossRef]
- Weir RAP, McMurray JJV, Taylor J, Brady AJB. Heart failure in older patients. Br J Cardiol. 2006; 13: 257-266.
- Ahmed A. DEFEAT – Heart Failure: A guide to management of geriatric heart failure by generalist physicians. Minerva Med. 2009; 100: 39-50.
- Cherubini A, Oristrell J, Pla X, Ruggiero C, Ferretti R, Diestre G, et al. The persistent exclusion of older patients from ongoing clinical trials regarding heart failure. Arch Intern Med. 2011; 171: 550-556. [CrossRef]
- Cheng JW, Nayar M. A review of heart failure management in the elderly population. Am J Geriatr Pharmacother. 2009; 7: 233-249. [CrossRef]
- Grossman E. Why β-blockers are not cardioprotective in elderly patients with hypertension. Curr Cardiol Rep. 2002; 4: 468-473. [CrossRef]
- Lainscak M, Duengen HD, Anker SD. Beta-blockers in elderly patients with heart failure. Ready for prime time? J Am Coll Cardiol. 2009; 54: 2202. [CrossRef]
- Badu-Boateng C, Jennings R, Hammersley D. The therapeutic role of ivabradine in heart failure. Ther Adv Chronic Dis. 2018; 9: 199-207. [CrossRef]
- Pandey A, Kisselman G, MnIntyre W, Lengyel A, Hronyecz H, Dalmia S, et al. A systematic review and meta-analysis of randomized controlled trials evaluating ivabradine in heart failure. Can J Cardiol. 2019; 35: S180. [CrossRef]
- Tavazzi L, Swedberg M, Komajda M, Bohm M, JBorer JS, Lainscak M, et al. Efficacy and safety of ivabradine in chronic heart failure across the age spectrum: Insights from the SHIFT study. Eur J Heart Fail. 2013; 15: 1296-1303. [CrossRef]
- Maagaard M, Nielsen EE, Gluud C, Jakobsen JC. Ivabradine for coronary artery disease and/or heart failure—a protocol for a systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis. Syst Rev. 2019: 8: 39. [CrossRef]
- Zachariah D, Taylor J, Rowell N, Spooner C, Kalra PR. Drug therapy for heart failure in older patients—what do they want? J Geriatr Cardiol. 2015; 12: 165-173.
- Cameli M, Pastore MC, Pagliaro A, Di Tommaso C, Reccia R, Curci V, et al. Sacubitril/Valsartan in an elderly patient with heart failure: A case report. Cardiology. 2017; 138: 3-6. [CrossRef]
- Supasynd O, Wang J, Hafeez K, Zhang Y, Zhang J, Rakugi H. Efficacy and safety of Sacubitril/Valsartan (LCZ696) compared with olmesartan in elderly Asian patients (≥65 Years) with systolic Hypertension. Am J Hypert. 2017; 30: 1163-1169. [CrossRef]
- Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. New Engl J Med. 2015; 373: 2117-2128. [CrossRef]
- Fitchett D, Zinman B, Wanner C, Lachin JM, Hantel S, Salsali A, et al. Heart failure outcomes with empagliflozin in patients with type 2 diabetes at high cardiovascular risk: Results of the EMPA-REG OUTCOME® trial. Eur Heart J. 2016; 37: 1526-1534. [CrossRef]
- Guerra F, Brambatti M, Matassini MV. Current therapeutic options for heart failure in elderly patients. Biomed Res Int. 2017; 2017: 1483873. [CrossRef]