Protein and Exercise to Reverse Frailty in Older Men and Women Undergoing Transcatheter Aortic Valve Replacement: Design of the PERFORM-TAVR Trial

Periprocedural care for frail older patients with aortic stenosis undergoing transcatheter aortic valve replacement

Degenerative aortic stenosis (AS) is an aging-associated disease with alarmingly high mortality that has risen in prevalence in tandem with the global population aging. Treatment options for AS are currently limited to surgical or percutaneous valve intervention, which are associated with significant morbidity. It is increasingly recognized that the care of AS patients is frequently constrained by concomitant frailty, an under-recognized syndrome among older individuals. Many AS patients have concurrent aging-associated diseases, including atherosclerotic diseases, organ impairment, physical frailty, and nutritional deficiencies which limit functional improvement after valve intervention. It has become increasingly crucial for clinicians to address these concurrent issues in frail, older individuals with AS to achieve the best possible outcomes. We aim to review the well-studied relationship between frailty and AS, as well as possible strategies for periprocedural optimization and risk management.

Geriatricians' role in the management of aortic stenosis in frail older patients: a decade later

INTRODUCTION

Increasing evidence supports the implementation of geriatric assessment in the workup of older patients with aortic stenosis (AS). In 2012, an online European survey revealed that geriatricians were rarely involved in the assessment of candidates for transcatheter aortic valve implantation (TAVI). After a "call to action" for early involvement of geriatricians in AS evaluation, the survey was repeated in 2022. Our aim was to investigate whether geriatricians' role changed in the last decade.

METHODS

Online survey conducted between December 16th, 2021, and December 15th, 2022. All members of the European Geriatric Medicine Society were invited to participate. The survey included 26 questions regarding geriatricians' experience with AS and TAVI.

RESULTS

Among 193 respondents (79.8% geriatricians), 73 (38%) reported to be involved in AS evaluation at least once a week. During 2 years prior to the survey, 43 (22.3%) had referred > 50% of their patients with severe AS for TAVI. Age influenced TAVI referral in a considerable proportion of respondents (36.8%). TAVI candidates were mainly referred to specialised cardiac centres with multidisciplinary teams (91.8%), including (47.2%) or not including (44.6%) a geriatrician. A total of 38.9% of respondents reported to be part of a multidisciplinary heart team. Geriatricians were less frequently involved (37%) than cardiologists (89.6%) and surgeons (53.4%) in pre-procedural TAVI management. Cardiologists were more frequently involved (85.5%) than geriatricians (33.7%) and surgeons (26.9%) in post-procedural management.

CONCLUSIONS

Geriatricians' involvement in AS management and multidisciplinary heart teams remains scarce. More efforts should be devoted to implement geriatricians' role in AS decision-making.

The Role of Cardiovascular Rehabilitation in the Elderly Patient

BACKGROUND

Cardiovascular disease is the leading cause of morbidity and mortality in the elderly population. Coronary artery disease, heart failure, and peripheral artery disease constitute the prevailing conditions. Cardiac rehabilitation (CR) represents a cornerstone in the secondary prevention of cardiovascular disease, since it has been associated with significant cardiovascular benefits in the above-mentioned conditions, by significantly reducing cardiovascular outcomes and improving functional independence and quality of life. Besides, CR offers the background for optimizing the control of cardiovascular risk factors and implementing physical exercise, also providing psychological and social support.

SUMMARY

The prevalence of cardiovascular disease increases with age, associating high morbidity and mortality. In addition, comorbidities, frailty, and other geriatric conditions, entities that also entail poor prognosis, are often present in elderly patients. Indeed, frailty is recommended to be systematically addressed in elderly patients with cardiovascular disease, and there is growing evidence regarding the benefits of CR programs in this setting, also associated with lower adverse events during follow-up. However, elderly patients are less often referred to CR after a cardiovascular event when compared to their younger counterparts. In this review, we summarized the benefits of CR programs in the elderly population with established cardiovascular disease, proposing a comprehensive framework that integrates personalized care strategies.

KEY MESSAGES

Cardiovascular disease is the leading cause of morbimortality, especially in the elderly. The management of cardiovascular disease in elderly patients poses unique challenges, since they represent a heterogeneous group and evidence is low. CR can provide significant benefits in older patients, encompassing physical training and specific management of geriatric syndromes.