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ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with
Giovanni Pulignano1, Michele Massimo Gulizia2, Samuele Baldasseroni3
1Cardiology Department 1, Ospedale San Camillo-Forlanini, Via O. Regnoli, 8 00152 Rome, Italy.
Insights
Transcatheter aortic valve implantation (TAVI) offers treatment for elderly patients with severe aortic stenosis ineligible for surgery. Comprehensive geriatric assessment is crucial for optimizing outcomes and improving quality of life.
Area of Science:
- Cardiology
- Geriatrics
- Public Health
Background:
- Aortic stenosis is a prevalent valvular disease in developed nations, increasing healthcare burdens.
- Many elderly patients with severe aortic stenosis are poor surgical candidates due to age, frailty, and comorbidities.
- Transcatheter aortic valve implantation (TAVI) treats high-risk patients but has variable outcomes regarding mortality and quality of life.
Purpose of the Study:
- To evaluate the influence of frailty on procedural risk in aortic stenosis patients.
- To determine how aortic stenosis and comorbidities affect patient quality of life and survival.
- To assess the impact of geriatric specialist interventions on surgical or TAVI outcomes.
Main Methods:
- Consideration of multi-morbidity, disability, frailty, and cognitive function alongside conventional risk stratification.
- Pre-operative optimization via a multidisciplinary Heart Team approach.
- Systematic application of multidimensional frailty and cognitive assessment tools.
Main Results:
- Frailty significantly impacts procedural risk and post-intervention quality of life.
- Geriatric interventions can potentially mitigate frailty-related complications.
- Multidimensional assessments are key to predicting TAVI and surgical benefits.
Conclusions:
- Comprehensive geriatric assessment is vital for optimizing TAVI and surgical outcomes in elderly aortic stenosis patients.
- Multidisciplinary pre-operative optimization can counteract frailty-related damage.
- Integrating frailty and cognitive assessments into clinical practice improves patient selection and care pathways.
Abstract:
Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.
