Complexities in Geriatric Cardiology: Clinical Dilemmas and Gaps in Evidence

Cardiovascular diseases (CVD) are undoubtedly the leading cause of morbidity and mortality in the elderly. Population aging is a global phenomenon. In developed countries, by the year 2050 one in four people will be aged 65+ years. This ongoing growth of the aging population leads to an increasing burden of CVD. The management of CVD in geriatric patients requires specific considerations. Aging is associated with complex pathophysiology due to decreased organ reserve, which is clinically described as frailty. Additionally, the aging population is extremely heterogenous and frequently characterized by a combination of unique features, including atypical disease presentation, multimorbidity, polypharmacy, altered pharmacokinetics, cognitive impairment, renal impairment, dysautonomia, elevated risk of falls, sarcopenia, and frailty. Furthermore, significant gaps in evidence exist largely due to the limited representation of the very elderly, and especially frail patients, in randomized controlled trials. When combined with issues related to life expectancy, goals of care, bioethics, and patients' preferences, these factors pose intricate challenges for healthcare providers. This literature review summarizes selected clinical scenarios that often introduce dilemmas in the management of elderly patients in cardiology practice, emphasizing the intersection of geriatric medicine and cardiology. These include blood pressure management, management of dyslipidemia, anticoagulation in atrial fibrillation, medical and device treatment of heart failure, antiplatelet and interventional management of acute coronary syndromes, and peri-procedural considerations in severe aortic stenosis. The above will provide guidance for clinical practice, as well as implications for health policies and future research in the field of geriatric cardiology.