Current and future landscape of cardiogeriatrics

Cardio-geriatrics refers to the study and provision of cardiovascular disease (CVD) care in older adults with specific consideration of chronological age and the process of ageing [1]. While there is no set definition, this typically refers to those aged at least 75 years of age and above. However, in clinical practice, the pathophysiological consequences of ageing are more useful than the absolute number that expresses age. These sequalae pose challenges in the management of CVD in the older adult and include multimorbidity, polypharmacy, cognitive impairment, reduced functional capacity and a loss of social support structures [2]. Current estimates are that by 2050, 1/6th of the world's population will be 85 years and older, which, given that CVD is the leading cause of morbidity and mortality in this age group, is likely to result in an unprecedented burden on our health and social care systems [3]. Therefore, it is expected that this emerging sub-specialty, a partnership forged by geriatricians and cardiologists, will play a key role in guiding the care of CVD in the older adult into the middle of the 22nd century and beyond.

1. What is the current landscape in cardiogeriatrics?

The incidence of CVD increases with age rising to 86% in those >80 years and therefore many of the patients we already see in routine clinical practice fall into this age bracket [4–6]. Most UK centres also do not have ready access to either a geriatrician with expertise in cardiology or vice versa and so provision of specialised care for these patients is often piecemeal. Additionally, how we manage these patients is often an evidence free zone with frailty and old age used as specific exclusion criteria in most CVD trials [7,8].

Therefore, what evidence do we have to guide our current approach. When treating heart failure with reduced ejection fraction, complex device therapies are used less often in this age group. But as has been demonstrated by Safdar et al. (2023) comorbid patients with a mean age 76 derive as much benefit in left ventricular function and symptoms as younger patients [9]. Regarding acute coronary syndrome (ACS) Kaura et al. (2020) demonstrated that the survival advantage of an early invasive approach compared with conservative management in non-ST elevation myocardial infarction (NSTEMI) extends to patients who are aged 80 years or older [10]. However, neither trial was randomised nor was there assessment of frailty or quality of life (QOL). The recent Frail-AF study by Joosten et al. (2023) demonstrated in an elderly (>75 years of age) Dutch population, that switching patients with atrial fibrillation (AF) who are stable on warfarin to a novel oral anti-coagulant (NOAC), increased the risk of harms without additional benefit [11]. Furthermore, they were all patients assessed as being moderately frail (>3/4 on the Groningen Frailty Index).

Finally, the results of the Invasive Treatment Strategy for Older Patients with Myocardial Infarction (SENIOR-RITA: non-St segment ElevatioN myocardial InfarctiOon Randomised Interventional TreAtment) trial were recently published. This trial has randomised individuals over the age of 75 presenting with NSTEMI to an early invasive strategy or conservative arm. Key findings revealed no significant difference in the primary outcome between the two groups. Although it did not improve overall mortality, invasive strategy reduced the need for urgent revascularisation. More-over, the study suggests that the decision to pursue invasive therapy should be individualised to include patients' overall health, co-morbidities, frailty, cognition and treatment goals [12]. To the authors' knowledge, this is the first cardio-geriatric study that includes measurement of such meaningful variables at baseline, and more importantly, measures the impact on these variables following intervention. SENIOR-RITA gives us a glimpse into cardio-geriatric trials of the future.

2. What is the future for this collaborative specialty?

Starting with research priorities, firstly greater representation of this patient group is required within CVD trials, specifically recruiting patients with moderate frailty, resident in care homes, with multimorbidity and/or polypharmacy and even with limited life expectancy. Secondly trials co-designed by patients along with their carers will ensure consideration of meaningful patient reported outcome measures, including QOL, physical and cognitive function and maintenance of independence. Thirdly, evidencing the role of shared decision making (SDM) and patient decision aids in the care of CVD in this patient group, which is yet to see routine usage in clinical practice [13]. Finally, a consensus is needed when approaching cardio-geriatrics by not only defining the numeric age cut off used but also applying geriatric syndromes and frailty scores when utilising terms like “frailty” or “elderly” the meaning of which is often not defined [14].

We are already witnessing the increasing emphasis on geriatrics within the training curriculum. For example, in internal medicine training (IMT) in the UK since 2019, all resident doctors now have a 4-month placement within geriatrics. It is hoped they will then carry this knowledge, skills and experience forward into their chosen higher speciality training (HST) programme, such as cardiology. Formalising this process by developing training fellowships between both cardiology and geriatric HSTs programmes can help this multi-disciplinary approach become embedded within both disciplines. This will result in the expansion of cardio-geriatricians across tertiary, secondary and even primary care, with expertise shared between geriatrics and cardiology [15]. Moreover, we anticipate greater involvement from geriatricians not only during outpatient clinic visits, but also during inpatient care episodes. As a result, we may see improved survival and functional recovery along with a reduction in complications and adverse events during hospitalisation, as has been seen with ortho-geriatrics [16]. We will also see routine representation of cardio-geriatricians at MDT meetings as part of the heart team and cardio-geriatric working groups writing guidelines across the spectrum of CVD in the frail elderly, as has been seen recently the United States with ACS [17]. Finally, establishment of cardio-geriatrics working groups in the UK will go some way to galvanise and formalise this approach, rather like has been seen with cardio-obstetrics and cardio-oncology.

In terms of cardio-oncology, how should the CVD and oncology intersection be managed in this age group. As highlighted by Ioffe et al. (2023), both cancer and CVD have shared risk factors and biological hallmarks, but CVD increases the risk of cancer therapy induced cardiovascular toxicity making the overall care of these already vulnerable patients more complex [18]. Another area in cardio-geriatrics which will need consideration is with congenital heart disease (CHD), which given that “70% of those alive (with congenital heart disease) at 18 years will live to become 70 years of age.” is likely to become a significant and growing issue [19]. As an example how we best manage patients presenting with de-novo CHD in the elderly e.g. secundum atrial septal defect, is uncertain. However, the issue of managing acquired heart disease e.g. coronary artery disease (CAD) in elderly adults with pre-existing CHD will probably represent too niche a population to be able to be evidenced effectively [20]. At present it seems like there are more questions than answers.

In conclusion, cardio-geriatrics is an emerging field focussed on answering one of key questions in the 21st century; how do we best look after the frail and elderly patients presenting with CVD and how is it different to standard care. It is clear that one size doesn't fit all and what a good outcome looks like is very much in the eye of the beholder.

Author contributions

D Warriner conceived the idea in conjunction with all co-authors and wrote the first draft, which was then edited in turn by A Gaur and A Al-Mohammad. All authors approved the final draft.

Financial disclosure

This paper was not funded.

Competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.