Closing the Generation Gap

The joint scientific statement by the American Heart Association, American College of Cardiology Foundation, and American Geriatric Society on “Knowledge Gaps in Cardiovascular Care of the Older Adult Population” is a much needed document that addresses important questions relevant to the care of the older adult patients with common cardiovascular diseases.¹ The authors conducted a detailed review of the current American College of Cardiology, American Heart Association, and American Stroke Association’s practice guidelines to identify recommendations of various cardiovascular conditions, including ischemic heart disease, dysrhythmias, valvular heart disease, heart failure, and peripheral and cerebrovascular disease focusing on older patients. The joint statement that resulted from this review summarizes information as they apply to older adults with various heart diseases, identifies critical gaps in knowledge and the evidence to support decision-making, and proposed recommendations for research to close these knowledge gaps, especially in those 75 years and older.

The information provided is timely as the overall demographics of the population shift toward an older age group,^2,3 with a rising prevalence of cardiovascular diseases that contribute to not only increased mortality and disability,⁴ but also to impaired quality of life, loss of independence, and rising health care costs.^3,5 As pointed out,1 the disappointment that despite the known association of advancing age with increased comorbidities, little evidence-based recommendations can be made on how to optimally manage cardiovascular diseases in older adults seen in routine clinical practice and needs to be adequately addressed. The situation is mainly due to the exclusion or scant representation of the elderly, especially those 75 years and older, in randomized clinical trials.^6-8 Even when elderly patients were included, they were relatively healthy with few comorbidities and did not necessarily represent the routine patient seen in the community with higher prevalence of physical or cognitive limitations.⁹ The lack of evidence is particularly palpable in the growing number of older adults residing in nursing homes or assisted care facilities, a population not included in clinical trials.¹⁰ Therefore, the clinical decision-making in the older elderly, and particularly in those with disabilities, is mostly based on extrapolation of information obtained from studies enrolling younger patients with minimum comorbidities or functional limitations; therefore, assessment of safety, efficacy and cost-effectiveness of various diagnostic and therapeutic interventions cannot be made accurately in this population.^11,12 This can only be addressed by conducting large population and community-based studies and clinical trials with the inclusion of a broad spectrum of elderly patients representative of those seen in clinical practice and outcomes, not only limited to survival improvement, but other relevant effects that are important for this population, such as quality of life and functional independence. This is essential, as with the rising costs in health care, the limited resources need to be directed in the most cost-effective way to prevent disease and disability in the elderly with consideration of biological age and frailty rather than chronological age, and with consideration of complexities that arise due to the presence of multiple comorbidities, potential for adverse reaction due to polypharmacy and altered biology that can increase the risk of adverse effects of the growing number of interventions offered to patients with cardiovascular diseases. In this regard, the suggested recommendations have been carefully thought of and address gaps in knowledge from mechanisms to outcomes. Suggestions for the development of new models and patient-friendly tools that incorporate patient preference for decision-making, assessing prognosis, and life expectancy based on comorbidities, frailty, quality of life, functional and cognitive status, and the impact of clinical intervention on the potential decline of these parameters and functional independence,¹³ will further improve cost-effective clinical decision-making.

In summary, the joint statement comprehensively lists knowledge gaps in the cardiovascular care of older adults and provides recommendations to address these serves as a valuable road map for clinicians and investigators to generate the evidence that help promotes strategies to improve quality of care and reduce the burden of cardiovascular diseases in the elderly.