Nanette K. Wenger, M.D., Emory University School of Medicine, Atlanta, GA, USA
Approximately 70% of persons older than age 65 in the U.S. have cardiovascular disease, including 85% of those older than age 80. Although adults 75 years and older comprise only about 60% of the U.S. population, they account for > 50% of cardiovascular mortality. Thus the contemporary prototype U.S. cardiology patient is an older adult. Alterations in cardiovascular structure and function with aging substantially impact pathophysiologic mechanisms, predispose to cardiovascular disease, decrease cardiovascular reserve, and increase the risk for adverse outcomes. Cardiovascular disease rarely occurs in isolation at older age, such that management requires consideration of comorbidities as well as geriatric syndromes that include frailty, cognitive impairment, multimorbidity and polypharmacy. Cardiovascular clinical practice guidelines are disease-oriented, with the evidence base deriving from predominantly younger patients. Whereas increased benefit of a favorable intervention may accrue in older adults, given their greater absolute risk of cardiovascular events, this benefit is counterbalanced by the increased risks of adverse effects. Adverse drug events account for about 1/3 of hospital admissions of older adults. There is a transformative effect of aging on cardiovascular disease, including a lesser capacity to tolerate and/or desire medications, devices, or procedures as compared with younger patients. Further, the standard outcome of randomized clinical trials, improved survival, may not reflect the preferences of older adults, whose foremost concerns include improvement or maintenance of function, independence, limitation of symptoms, and decrease in hospitalizations, i.e., improvement in quality of life. Thus geriatric cardiology is the practice of cardiovascular medicine adapted to the needs and complexities of older adults. The emphasis should be on patient-centered outcomes and priorities in contrast to disease-specific outcomes. Patient-centered care is required to embrace this complexity.