Aging in cardio-oncology: Pathophysiology, clinical implications and future directions

Population aging is changing the needs of patients seen in cardio-oncology. Older adults with cancer often have cardiovascular disease, multimorbidity, and reduced physiological reserve, which can complicate treatment and recovery. Patients of the same chronological age may differ considerably in cardiovascular health, functional capacity, and treatment tolerance. Frailty and geriatric assessment can help characterize these differences and inform care. This review examines the biological mechanisms linking aging, cancer, and cardiovascular disease and discusses their implications for cardiovascular risk assessment, cancer treatment decisions, and long-term survivorship. Treatment decisions require consideration of the expected oncological benefit, cardiovascular risk, physiological reserve, life expectancy, and patient preferences. Identifying and addressing reversible vulnerabilities may help patients tolerate effective anticancer therapy while preserving function and quality of life. During survivorship, cardiovascular care should account for previous treatment exposure, changing health status, and adherence to preventive therapies. Closer collaboration between cardio-oncology and geriatric medicine may improve the assessment and management of older patients. Evidence specific to frail and very old adults remains limited. Prospective studies are needed to determine whether geriatric and biological aging measures improve cardiovascular risk prediction, treatment decisions, and patient outcomes.