Cardiac resynchronization therapy in the elderly. How much is it safe and beneficial?

Heart failure is a widespread disease in the western world whose incidence and prevalence are constantly increasing, mainly involving the more advanced age groups. Cardiac resynchronization therapy (CRT) has been shown able to reduce sudden cardiac death and all-cause mortality in patients with heart failure and reduced ejection fraction. Elderly patients are generally under-represented in the clinical trials aimed to evaluate the efficacy of CRT and, chiefly, of implantable cardiac defibrillator (ICD). The simultaneous presence of confounding factors such as co-morbidities, polypharmacy, changes in cognitive status, frailty, are the most important causes for the exclusion of subjects of advanced age from RCTs on the ICD or CRT implant. Current guidelines do not suggest any upper age limit for ICD and CRT but recommend avoiding their use in frail older patients with a life expectancy of less than 1 year. Data from the literature show that CRT has equal dignity in both the elderly and the young, in fostering effective functional and morphological improvements, also suggesting that, in older patients, CRT-D may have little practical value compared to CRT-P given the low incidence of arrhythmic death. Nevertheless, it is necessary to develop RCTs that consider aspects of the elderly patient in relation to CRT such as functional, cognitive and nutritional status.

Prognostic impact of frailty in elderly cardiac surgery patients.

Over the past few decades, the progressive aging of the population combined with the resulting increase in cardiovascular disease and the marked improvement of technologies applied to surgery justify the marked increase of the elderly patients requiring cardiovascular surgery. This claims a highly skilled perioperative management, which should be aimed at treating cardiac disease without increasing risk of hospitalization-related harmful events. Current preoperative assessment for cardiac surgery, such as the European System for Cardiac Operative Risk Evaluation II (EUROSCORE II) and the Society of Thoracic Surgeons (STS) risk score, are limited in their ability to predict perioperative outcomes in older patients.  This is because patients' chronological age should not be considered as the only tool to identify the surgical risk. In recent years, indeed, several studies have highlighted the role of frailty syndrome in determining the prognosis of elderly patients undergoing cardiac surgery. Particularly, some functional aspects, such as gait speed seem to have a high sensitivity and specificity in this regard. Therefore, further research is needed in order not only to identify a unique, fast and easy to use tool aimed to recognize frailty syndrome, but chiefly resulting able to give us information about the effectiveness of focused preoperative interventions. Finally, we need to have scientific data on the role that surgical, percutaneous and transcatheter procedures have on outcome in elderly patients in terms of perioperative mortality, postoperative quality of life and regarding the possible reversibility of frailty. Cardiovascular surgery is to date a "moving target", due to changing face of patients and changing face of technical requirements and perioperative management should reflect such changes.