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COUNCIL PERSPECTIVES

What to Expect From the Evolving Fieldof Geriatric Cardiology

Susan P. Bell, MBBS, MSCI,*y Nicole M. Orr, MD,z John A. Dodson, MD, MPH,x Michael W. Rich, MD,kNanette K. Wenger, MD,{ Kay Blum, NP, PHD,# John Gordon Harold, MD,** Mary E. Tinetti, MD,yyMathew S. Maurer, MD,zz Daniel E. Forman, MDxx

ABSTRACT

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The population of older adults is expanding rapidly, and aging predisposes to cardiovascular disease. The principle of

patient-centered care must respond to the preponderance of cardiac disease that now occurs in combination with the

complexities of old age. Geriatric cardiology melds cardiovascular perspectives with multimorbidity, polypharmacy,

frailty, cognitive decline, and other clinical, social, financial, and psychological dimensions of aging. Although some

assume that a cardiologist may instinctively cultivate some of these skills over the course of a career, we assert that the

volume and complexity of older cardiovascular patients in contemporary practice warrants a more direct approach to

achieve suitable training and a more reliable process of care. We present a rationale and vision for geriatric cardiology as a

melding of primary cardiovascular and geriatrics skills, thereby infusing cardiology practice with expanded proficiencies in

diagnosis, risks, care coordination, communications, end-of-life, and other competences required to best manage older

cardiovascular patients. (J Am Coll Cardiol 2015;66:1286–99) © 2015 by the American College of Cardiology Foundation.

“Education is the best provision for thejourney to old age.”

—Aristotle (1)

G eriatric cardiology is the practice of cardio-vascular (CV) medicine that is adapted tothe needs of older adults. To some degree,

e views expressed in this paper by the American College of Cardiolog

uncil do not necessarily reflect the views of the Journal of the America

m the *Division of Cardiovascular Medicine, Department of Medicine, V

nnessee; yCenter for Quality Aging, Division of Geriatric Medicine, Vande

ssee; zDivision of Cardiology and the Cardiovascular Center, Tufts Medic

ision of Cardiology, Department of Medicine, New York University Sch

rdiology, Washington University School of Medicine, St. Louis, Missouri;

dicine, Atlanta, Georgia; #Geriatric Cardiology Section, American College

titute and David Geffen School of Medicine, University of California,

dicine and Public Health and Epidemiology, Yale School of Medicine,

partment of Medicine, Columbia University Medical Center, New York,

partment of Medicine, University of Pittsburgh Medical Center, and Rese

althcare System, Pittsburgh, Pennsylvania. Dr. Bell is supported by a gr

man Development (2K12HD043483-11) and the Eisenstein’s Women’s Hea

Aging (NIA) grant U13 AG047008. Dr. Tinetti receives funding from th

veloping a patient goals-directed approach to the care of older adults with

A R21 grant (AG045148). Dr. Maurer receives funding from an NIA K24 aw

A grant P30 AG024827 and VA Office of Rehabilitation Research and D

orted that they have no relationships relevant to the contents of this pap

ten to this manuscript’s audio summary by JACC Editor-in-Chief Dr. Vale

nuscript received May 20, 2015; revised manuscript received July 24, 201

all cardiologists know this, recognize this, and invarying capacities, practice this. It has thus far largelybeen a self-taught evolution of skills and style, andusually applied as a means to incorporate thoughtfulconsideration of age, comorbidities, and patients’wishes in relation to current evidence and guidelines,but with the understanding that, in most cases, there

y’s (ACC) Geriatric Cardiology Section Leadership

n College of Cardiology or the ACC.

anderbilt University School of Medicine, Nashville,

rbilt University School of Medicine, Nashville, Ten-

al Center, Boston, Massachusetts; xLeon H. Charney

ool of Medicine, New York, New York; kDivision of

{Division of Cardiology, Emory University School of

of Cardiology, Washington, DC; **Cedars-Sinai Heart

Los Angeles, California; yyDepartments of Internal

New Haven, Connecticut; zzDivision of Cardiology,

New York; and the xxGeriatric Cardiology Section,

arch, Education, and Clinical Center, VA Pittsburgh

ant from the National Institute of Child Health and

rt Fund. Dr. Rich is supported by National Institute

e John A. Hartford Foundation for work related to

multiple chronic conditions; and is supported by an

ard (AG036778). Dr. Forman is supported in part by

evelopment grant F0834-R. All other authors have

er to disclose.

ntin Fuster.

5, accepted July 26, 2015.

AB BR EV I A T I O N S

AND ACRONYM S

ACO = accountable care

organization

CHD = coronary heart disease

CV = cardiovascular

CVD = cardiovascular disease

HF = heart failure

PCI = percutaneous coronary

intervention

SNF = skilled nursing facility

TAVR = transcatheter aortic

valve replacement

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are no data-driven standards by which to guide carefor this vulnerable population. We are compelled,however, to ask, “Is this enough?”

The cardiology community historically embracesadvances in technology, changes in demographics,and national demands for quality reform, all of whichstimulate changes and growth in the field. With thedevelopment and refinement of cardiac trans-plantation and advanced cardiac device therapy, thesubspecialty of Advanced Heart Failure and Trans-plant Cardiology was created to enhance the deliveryof care for patients in this broad domain. With thegrowing procedural therapeutic options for cardiacarrhythmias, the subspecialty of Clinical CardiacElectrophysiology was developed by the CV commu-nity to standardize the skills and competenciesneeded to serve this patient subset. Now, in 2015,there is mounting momentum for yet another periodof growth and expansion.

The rationale for geriatric cardiology is propelledin large part by shifting demographics combinedwith an expanding diagnostic and therapeutic arma-mentarium. The shift, quite likely a result of ad-vancements in medical care and technology forcommunicable and noncommunicable diseases, pri-mary and secondary prevention, and scientific dis-coveries related to disease and improvements insanitation, has led to a situation in which the domi-nating CV patient group has outlived current data-driven recommendations. Average life expectancyhas increased 30 years since 1900 (2); although<3 million U.S. adults were age 65 years and over in1900, they will comprise 19% of the population by2030, including 19 million adults over the age of85 years. The growth of the age 85þ years group isparticularly striking; it is projected to double from itscurrent size by 2036 and triple by 2049 (3).

The magnitude of these demographics is dramatic.For a provider with few older patients it may seemsufficient to rely on a self-taught idiosyncratic geri-atric cardiology approach when needed. But, as thepercentage of older adults, who are inherentlyvulnerable to coronary heart disease (CHD), heartfailure (HF), atrial fibrillation, hypertension, valvularheart disease, pulmonary hypertension, and othercardiovascular disease (CVD) continues to expandacross all dimensions of our specialty, it begs thequestion of whether current practice standards andguidelines are sufficient to accommodate this bur-geoning demographic and whether we are using ourresources appropriately and efficiently to serve thiscomplex population.

Aging itself creates distinctive dimensions to CVDmanagement, as both absolute risk reduction and the

potential for harm from treatment increasewith advancing age. As the percentage ofolder adults grows to represent a larger pro-portion of practice patients, the time spentcontemplating complex management issueswithout data-driven answers will inevitablyincrease and further limit already time-constrained schedules (e.g., which 85-year-old patient with atrial fibrillation should beanticoagulated, when is frailty prohibitive oftranscatheter aortic valve replacement[TAVR], and when does dementia precludepercutaneous coronary intervention [PCI]?).The effect of these management decisions

will have increasingly measureable implications forhospitals and accountable care organizations (ACOs),whose focus on improving quality metrics willexpand in this era of cost containment. From a costperspective, the consequences are significant—despite representing only 13% of the population in2010, older adults accounted for 34% of the nationalhealth expenditure (4). These costs are increasingrapidly as the older population continues to enlarge(5). Compounding these burdens is that older patientshave not only considerable clinical needs, but psy-chological and social needs too. Many anticipate thatthe aging baby boomers will demand greater healthcare resources than the archetypes of older adultswho preceded them as a result of their increasedengagement and assertiveness in a more consumer-driven health care model, adding to complexity andcosts (6). To fulfill that need, we see the mandate tointegrate principles of geriatrics with those of cardi-ology, and to formalize geriatric cardiology as a mani-festation of “patient-centered” care for older adultswho now constitute our dominant patient group.Although the concept is still in evolution and lacks afull armamentarium of precise tools and skillsets todefine the field, the practice of geriatric cardiologyis developing toward a distinctive subspecialty withspecific skills and services to further advance thecare of older patients (Central Illustration).

CASE STUDY:

A GERIATRIC CARDIOLOGY PATIENT

An 81-year-old man presents with shortness ofbreath, difficulty performing his activities of dailyliving, and several episodes of substernal chestheaviness at rest. He is accompanied by his daughter.He was diagnosed with CHD many years ago in thesetting of worsening angina, and was treated with adrug-eluting stent to a proximal left anteriordescending artery stenosis. His medical history is

CENTRAL ILLUSTRATION Future of Geriatric Cardiology: Proposed Care Model and Skillsets Required by Cardiologists Caring forGeriatric Patients

Additional Care Considerations•Care Coordination•Shared Decision-making•End-of-Life Choices•Bundled Payments•Readmission from Non-cardiac Disease•Caregiver Burden•Patient Education

Why Should Cardiologists CareFor Older Patients?•Basic predisposition to cardiac disease in old age leads many patients to rely on their cardiologists for primary management

Skills These Cardiologists Need:•Risk Assessment (cardiac, age, and comorbid perspectives in combination)•Cardiac management tailored to age including medications, procedures, and transitions•Rehabiliation and function integrated as fundamental components of CV care

Distinct Skillsets Necessary For• Outpatient, Acute, and Long-term Care

Goals of Care (Short and Long-term) Can Shift• Mortality but also Function, Independence, Pain, as many patients’ priorities

Multiple Providers•Primary Care•Geriatricians•Cardiologists•Other Specialists•Hospitalists•Surgical Specialties•Physical Therapy•Nurses•Advanced Practice Providers•Pharmacists•Nutritionists

Typical Older Patients•Multimorbidity•Polypharmacy•Frailty• Cognition

Bell, S.P. et al. J Am Coll Cardiol. 2015; 66(11):1286–99.

Framework of contributing and resulting factors involved in the assessment and management of the older adult with cardiovascular (CV) disease highlighting the

complex interplay among health care providers, patient dynamics, goals of care, systems of care, and the necessary key skills to provide optimum patient-centered care.

Y ¼ decreased; [ ¼ increased.

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notable for diet-controlled diabetes mellitus, a 5-cmabdominal aortic aneurysm, Parkinson disease, andmild dementia. Two years ago he was started on flu-drocortisone by his primary care physician forfrequent falls related to orthostatic hypotension,which improved his symptoms. His medicationsinclude aspirin 81 mg daily, carbidopa/levodopa25 mg/100 mg 4 times daily, selegiline 5 mg daily,pravastatin 20 mg, fludrocortisone 0.15 mg daily, anda multivitamin. His review of systems is significantfor recent worsening of his orthostatic symptoms andweight loss. On examination, he is a pleasant, frail-appearing elderly gentleman with body mass index

22.0 kg/m2, blood pressure (BP) 102/68 mm Hgsupine and 79/49 mm Hg standing, and heart rate63 beats/min supine and 80 beats/min standing. Hehas 12-cm jugular venous distension and faint expi-ratory wheezes and bibasilar rales. A frailty assess-ment reveals weak grip strength, reduced physicalactivity, and slow gait speed. He scores 23/30 on theMini Mental State Exam. His primary care physicianattempted a trial of loop diuretic therapy for hisdyspnea in the setting of volume overload, but he wasintolerant due to worsening orthostasis, bothersomenocturia, and 2 recent falls while trying to void in themiddle of the night. His daughter is concerned that he

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seems more confused than several weeks ago, andthinks the new therapies have worsened the situationwithout improving his symptoms. At his baselinebefore presentation he was relatively active, was anavid reader, and enjoyed spending time with hisgrandchildren.

This case highlights the medical complexity andpsychosocial struggles of a typical clinical geriatriccardiology encounter. Although angina and HFsymptoms in a middle-aged adult would typicallyprompt initiation of medical therapy and evaluationfor ischemic heart disease, management for thispatient requires navigating his personal goals andaspirations as well as his daughter’s concerns, inter-preting the relationship between the caregiver andpatient, and assessing decision-making capacities. Inaddition, medical management presents a complextradeoff; treatment of ischemic and HF symptoms iscomplicated by orthostasis, and thus precludes theuse of a typical antianginal regiment (such as beta-blockade, nitrates) or up-titration of loop diuretics.Furthermore, the cardiologist is required to integrateall other contributing and related factors, includingmedications prescribed by other providers thatmay contribute to the current symptoms (Parkinsonmedications), and to determine when to continueevidence-based therapies that may be inappropriatefor this frail older adult with a limited life expectancy.The prognosis of the patient in relation to Parkinsondisease, frailty, and cognitive impairment is para-mount when considering revascularization versusmedical therapy for this otherwise engaged andfunctional older adult. If invasive therapy is consid-ered, procedural complications specific to the geri-atric population (e.g., delirium), as well as highergeneral rates of post-procedural renal failure, infec-tion, and bleeding have to be explained to the patientand caregiver. Furthermore, in the face of multiplecoexisting conditions, decision making must bepredicated on achieving patient-centered outcomessuch as overall function, symptom relief, and survivalrather than typical disease-specific outcomes.

Whereas CV guidelines and standards of care areoriented toward younger adults, most cliniciansdevise individual strategies to optimize care for theirolder patients. Indeed, many cardiologists are adeptat integrating patient-centered priorities with exist-ing medical science. Nonetheless, the principles ofgeriatric medicine combined with management andprocess for older CV patients are not standardized,and core quality metrics for measuring patient-centered outcomes are not sufficiently delineated toteach, implement, or monitor. In a complex system ofmedical care that involves multiple providers,

disparate clinical goals, and often difficult transitionsof care, the lack of a formalized process to address theaging ramifications of CVD results in enormous vari-ability of care, with high risks accruing amidst mul-timorbidity, polypharmacy, cognitive changes, bodycomposition changes, and other aspects of aging.Gaps are especially prominent in trainees who inevi-tably encounter complex older patients, but who lackthe experience and resources for optimizing patient-centered care. As such, the potential for patient andprovider dissatisfaction is increasing.

In the case of our patient, the choice to offer inva-sive versus medical therapy is not clearly informed byclinical trial data. A care plan is developed afternavigating through factors that may modulate theeffect on almost every therapeutic consideration: forexample, the therapy itself (risk-benefit, quality oflife, polypharmacy, multimorbidity), the process(method, type, and intensity), and the patient’s in-trinsic resilience to benefit from any therapy admin-istered (i.e., the ability for a very elderly individualwith cognitive impairment to withstand the hospitalstay, sedation, and anticoagulation associated withPCI, without experiencing a significant adverseevent). Fundamental to decision making are thequestions, “When should the primary focus shift totreating symptoms, rather than preventing diseaseand progression, and at what age should we shiftfocus away from prevention because the benefits areno longer likely to result within the remaining yearsof life?”

Management may be best shaped by an evolvingperspective of CV care that redirects focus fromtreatment of symptoms in relation to a primary CVdisease, to management oriented to multiple chronicillnesses. Geriatric cardiology epitomizes the princi-ple that CVD is only 1 component of a larger, multi-dimensional disease state with concomitant geriatricsyndromes. Selection of assessments and therapies isbest accomplished in the context of the aggregatecircumstances.

THE CONCEPT OF GERIATRIC CARDIOLOGY

RESPONDS TO THE COMPLEXITY AND

DISTINCTIVE NEEDS OF A

GERIATRIC PATIENT

The construct of a new discipline begins with definingits purpose. The broad aim of clinical practice dedi-cated to geriatric cardiology is to better match theprovision of CV care to the cumulative conditions,complexities, and preferences of geriatric patients (7).Although cardiologists, like most physicians, aim toprovide “patient-centered care” (6), the potential

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for therapeutic misalignment is high in a medicalspecialty where procedures and interventions con-stitute a significant component of management.Technological advances for older adults, already anarea of considerable research and economic invest-ment, will only continue to broaden these therapeuticoptions.

Aging has a transformative bearing on CVD suchthat standards applied to younger adults becomerelatively less reliably aligned with the preferencesof geriatric patients (8), as older adults often havereduced capacity to tolerate and even desire medi-cations, devices, and procedures, despite provenbenefits in younger populations, and have anincreasing number of coexisting conditions thataffect health-related quality of life and survival.Even more fundamental, the typical orientation oftherapeutics to a single disease, premising benefitsfocused mainly on morbidity and mortality, is oftenfar afield from the experiences and concerns of olderadult CV patients. Most CV diseases in old age tendto occur within CV syndromes, and the effect ofmultiple diseases transforms illness and manage-ment. CV diseases (e.g., CHD, HF, hypertension, andatrial fibrillation) and non-CV diseases (e.g., chronicobstructive pulmonary disease, arthritis, dementia,and gastrointestinal bleeding) tend to occur con-currently, leading to complexities that entail bio-logical (inflammation, cell signaling, mitochondrialchanges), multimorbid (polypharmacy, contradictingmanagement priorities), and social (patient values,religion, family dynamics, as well as the logisticaland communication barriers related to multipledoctors, nurses, and systems of care) complexities tomanagement. Whereas most clinical recommenda-tions remain premised on standards oriented tomorbidity and mortality, geriatric patients’ concernsmay change to include or even to prioritize qualita-tive and/or functional objectives. Thus, so-called“evidence-based” rationales by which quality ofcare metrics are usually determined, and the forma-tive trials on which the standards are based, havelargely omitted dimensions of multimorbidity, poly-pharmacy, symptomatic status, frailty, avoidance ofdependency and maintenance of independence, in-dividual patient outcome goals, and/or other issuesintegral to many geriatric patients’ realities (9). Ourfocus as cardiologists on “disease-specific outcomes”has to be shifted in the geriatric population to amore intense focus on quality of life by improvingfunctionality and reducing daily symptoms, and anytrials of therapies in this population should bedesigned to ascertain these outcomes. Furthermore,as the burden of chronic conditions increases,

patients report that the escalating number andcomplexity of interventions needed to treat eachcondition becomes as burdensome as the conditionsthemselves (10,11).

Even in the setting of a single CV disease, themanagement of the geriatric patient is encumberedby the lack of clinical trial data. Contemporary clinicalpractice guidelines have mostly relied on ambiguousstatements in relation to aging. For example, the 2013American College of Cardiology/American Heart As-sociation cholesterol guideline (12) states that “addi-tional factors” should be considered when prescribingstatins for primary prevention of atherosclerotic car-diovascular disease in patients age >75 years. Thisreference to “additional factors” implies comor-bidities, medication safety profiles, drug–drug in-teractions, drug–disease interactions, polypharmacyconcerns, patient preferences, and other factors, thatis, a constellation of complex issues beyond the scopeof typical cardiologists and allied providers.

Geriatric cardiology also entails a revised notion ofrisk assessment, that is, away from the traditionalapproach of assessing risk in the context of a singledisease presentation (i.e., HF with cachexia) andtoward a more holistic approach. Cachexia may be asynthesis of advanced HF in combination with frailtyand weight loss, poor caregiver support, diminishedaccess to food, occult malignancy, dental or oral is-sues, altered taste sensitivity and thresholds, anddepression. In contradistinction to current models ofrisk assessment, assessment for the geriatric patientrequires consideration of multimorbidity (13), frailty,sarcopenia, cognitive impairment, and social limita-tions and stressors. Adding to a clinician’s challenge,the cumulative effects of aging are not easily quan-tified. A mounting number of years is a relativelycrude index of the aggregate effects of biological,social, economic, and other dimensions of aging. Therelative presentation and prognosis of an 85-year-oldpatient may be entirely different from another withsubstantially different management implications,with the understanding that there are no standardintegrative metrics to guide personalized therapeuticchoices. Rather, the skill to incorporate physiologicalage with biological age is a vital area of expertisewithin a formalized geriatric cardiology arena.

GERIATRIC CARDIOLOGY AS A

TEACHABLE DISCIPLINE

The need for a framework in which to support andformally instruct the principles of geriatric CV care isalso a critical rationale for the new discipline ofgeriatric cardiology. A formalized geriatric cardiology

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skillset would help providers who must immediatelyhave the ability to facilitate effective care for olderadults, rather than awaiting years of practice experi-ence to develop practical gestalt. Requisite skills forgeriatric cardiology are not intuitive, just as surgicaltechniques are not intuitive to surgeons and requirespecific training. Geriatric principles must be delin-eated and then integrated as a practice standard askey elements of patient-centered care. Likewise,because data are now more readily available throughpatient-to-provider information streams, data-drivenfeedback mechanisms can be developed to rapidlyrefine geriatric assessments, diagnoses, risk stratifi-cation, and management choices in patients withgeriatric complexities. Geriatric cardiology could beorganized to synthesize and incorporate patientfeedback mechanisms as components of adaptable,dynamic approaches to older patients.

Although the interest in and compelling need forgeriatric cardiology is growing, the specialty of geri-atrics has not experienced a similar progression; infact, the number of individuals taking board cer-tification examinations in geriatric medicine hasdeclined. The enthusiasm for geriatric training in theearly years of the practice (14) has never been fullyappreciated, as indicated by the fact that only 56%of 455 national fellowship program positions at145 certified programs were filled in 2014 (15). Thiscompares to 99% enrollment in 824 available CVfellowship positions. There are currently onlyapproximately 7,500 board-certified geriatricians inthe United States, despite estimates suggesting thatover 30,000 are needed. We are cautiously optimisticbut cannot be sure that this pattern will change asshifting demographics create a greater demand for

TABLE 1 Summary of COCATS Training Requirements for Geriatric Ca

Level IBasic training required of all fellows during a standard 3-year fellowship

Level IIAdditional training acquired by a subset of trainees during a standard 3-y

fellowship to perform and interpret specific assessments and renderspecialized care for complex older cardiovascular patients

Level IIIAdditional training and expertise acquired beyond the standard 3-year

fellowship program to include training and experience within the fielgeriatric medicine and palliative care

COCATS ¼ Core Cardiovascular Training Statement; CV ¼ cardiovascular; CVD ¼ cardiov

geriatricians. The development of a geriatric subspe-cialty within the competitive and sought after field ofcardiology has the potential to help fill this criticalclinical gap and to allow provision of specialty care tothe growing senior population if and when specifictraining tools and programs are developed and sup-ported to establish the field. All CV trainees wouldbenefit from a core knowledge base and skillset(akin to the Core Cardiovascular Training Statementlevel 1). Opportunities for advanced training andpractice are also appropriate both for the treatment ofcomplex patients (e.g., our case study) and pro-grammatic advancement (e.g., refining systemizedcare for TAVR patients, akin to Core CardiovascularTraining Statement levels 2 to 3) (Table 1).

Numerous position papers, conferences, andteaching tools (7,16) have cited the importance ofincorporating geriatric principles into the practice ofcardiology, but the emphasis has been primarily on“making the case,” and they have not providedguidance on how to implement the practice (17). Thecritical factor: the overall care of the elderly involvesskills, knowledge, and attitudes that are not acomponent of CV training and have to be developed,refined, and cultivated. There are currently fewwell-demarcated pathways that facilitate dualpathway training in geriatrics and cardiology. Someindividuals have completed separate formal trainingin geriatric and CV medicine, but there has been littleprogrammatic synthesis of the 2 disciplines and/ormechanisms to make this hybrid orientation morepopular and accessible. Vanderbilt University standsout with the first clinical fellowship in CV and geri-atric medicine supported by the American Board ofInternal Medicine, but this has not yet become a

rdiology

� In-depth knowledge of age-related changes in the CV system� Basic knowledge of geriatric assessment skills utilized during

clinical assessment� Basic knowledge and experience of applying patient-centered care to the

management of older adults

ear� Knowledge and understanding of limitations of standard practice guidelines as

related to older adults including diagnostics, pharmacotherapy, andinterventional therapies

� Performance and interpretation of basic geriatric assessment tools utilized forcognition, delirium, and functional status

� Advanced knowledge and understanding of managing CVD in the context ofmultimorbidity including understanding of disease–disease interactions

d of

� Independent comprehensive knowledge of geriatric cardiovascular assessmentand interpretation prior to major interventions (performs range of cognitive,frailty, functional, and social assessments)

� Independent identification and management of geriatric impairments andsyndromes central to overall holistic approach to care

� Comprehensive knowledge and experience discussing and initiatingend-of-life care with some basic experience in palliative driven therapies

ascular disease.

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repeated programmatic initiative. In contrast to otherintegrated training models that have emerged tomeet the needs and interests of the medical com-munity (e.g., Med/Derm [combined medicine anddermatology training] or Peds/ER [combined generalpediatric medicine and emergency care]) and thatfoster a new breed of integrative clinicians, theconcept of a combined geriatrics/cardiology trainingprogram remains exceptional and preliminary.

GERIATRIC CARDIOLOGY IN

CLINICAL PRACTICE

A comprehensive vision for the practice of geriatriccardiology remains nascent. Central to the conceptare unifying goals of improving and advancing care tothe older adult with CVD and tailoring this practice tothe needs of the patient within larger health careinstitutions. From a practical perspective, everycardiologist will benefit from some added training ongeriatric complexities of care to foster elemental skillsand sensitivities of care. In addition, a cardiologistwith more advanced geriatric cardiology skills canconsult with other cardiologists or with internists,emergency room physicians, geriatricians, surgeons,or hospitalists on issues specific to the complexity ofaging as it affects CVD management. Examples ofservices that are currently provided by pioneering“geriatric cardiologists” include: 1) performingcomprehensive geriatric assessments (grip strength,gait speed, cognition, physical function, fall history,orthostatic vital signs); 2) identifying geriatric im-pairments that influence management/outcomes;3) providing risk-stratification for major interventions(e.g., TAVR); 4) addressing polypharmacy, particu-larly as it pertains to the complex regimen for CVsyndromes; and 5) incorporating patient perspectivesand goals (e.g., difficult procedures as well as end-of-life, palliative care) in the management of advancedCV disease.

In some instances, geriatric cardiologists providekey enhancements to established clinical teams, forexample, as members of TAVR teams, atrial fibrilla-tion teams, or HF teams and/or as consultants toother cardiologists for cases with complex geriatricissues. In some institutions, geriatric cardiologistsmay perform as an independent service line ordepartment, providing consultation directly to pri-mary care providers, surgeons, or the emergencydepartment.

ELEMENTS OF GERIATRIC CARDIOLOGY

The specific competencies of geriatric cardiology haveyet to be officially defined and endorsed by the

American Board of Internal Medicine or by a CVsociety, but the formalization of geriatric cardiologyprovides an opportunity to delineate specific pro-ficiencies that fill critical gaps of care. Improved skillsin diagnosis, risk assessment, disease management,and process of care are vital competencies thatrespond to unmet needs in older CV patients. Simi-larly, expertise is needed to more consistently guidecare for older CV patients who are struggling to liveindependently amidst mounting health and physicalconstraints, and to achieve high quality and patient-centered standards of care for older patients in long-term facilities. Geriatric cardiology also entails skillsto facilitate rehabilitation opportunities; enhancecommunications with older patients, patients’ fam-ilies, and other providers; and mitigate caregiverburdens (Table 2).DIAGNOSIS. Diagnostic assessment for older adultswith CVD is inherently complex. Prototypical CVsymptoms of pain, dyspnea, dizziness, exerciseintolerance, and other complaints are less specific inthe context of age-related systemic physiological at-tritions. Consequently, CVD is commonly overlookedin the differential diagnosis and is underestimatedeven if considered. Treatment delays are notorious,and even when implemented, the utility of therapyoften remains uncertain, leading to common sce-narios of unmethodical debate and further delays(18). Paradoxically, in other circumstances CVD canbe overdiagnosed and overtreated among olderadults. The increasing reliance on imaging (e.g.,perfusion imaging or computed tomography scanningfor CHD) or serological (e.g., brain natriuretic peptidefor HF) (19) assessments can lead to CVD diagnosesthat have more to do with age-related vasculatureand physiological changes than disease, but thattrigger treatments with the potential to generategreater risk than benefit amidst multimorbidity, poly-pharmacy, frailty, falls, and other complexities ofcare. Diagnoses of hypertension, obesity, or cachexiaare also indexes that have complex implications inrelation to age. Vascular stiffening may, for example,determine systolic BP, but BP measurements fail toquantify the more clinically relevant parameter ofend-organ perfusion, and thus, BP managementmay inadvertently confound optimal managementdecisions. Likewise, common presenting symptomssuch as dyspnea, for example, are affected by agingvia a multitude of mechanisms and are often morecomplex than volume overload, angina, or paren-chymal lung disease. Compounding this difficulty isthe complexity of assessing volume status amidstvenous insufficiency, decreased skin turgor, and oralmucosa that can be drier due to mouth breathing or

TABLE 2 Key Roles for Geriatric Cardiology

Diagnosis � Assessing symptoms amidst multimorbid conditions and multiple causes� Interpretation of diagnostic testing in context of age� Diagnosing cardiac disease in relation to geriatric syndromes (falls, dizziness, syncope, weakness)

Risk assessment � Comprehensive assessment prior to TAVR, LVAD, heart transplant, and cardiac surgery� Comprehensive cardiac risk assessment prior to noncardiac surgery� Immediate and short-term risk assessment and prognosis in the very elderly

Disease management � Reduction of polypharmacy and adverse drug side effects to align with patient preferences and improvecompliance

� Symptom and disease management in alignment with patient goals of care� Management of disease processes intimately linked to CVD (frailty, cognitive impairment, disability)

Processes of care � Coordination and implementation of specific processes of care to improve transitions (readmission reductionprograms, bundle payments)

� Providing continuity of cardiovascular care across care settings (geriatric clinic without walls)

Physical activity and rehabilitation � Implementation of streamlined pathways to facilitate cardiac rehabilitation� Coordination and access to advice for cardiac rehabilitation staff

Skilled nursing facilities and long-term care � Implementation of care pathways for common cardiac diseases (heart failure)� On site “clinics” and advice for care teams� Prevention of hospital admissions

Communications � Goals of care discussions� End-of-life care discussions

Caregiver burden and support � Coordinating multidisciplinary CVD team to allow streamlined access to support services� Recognition of caregiver burden and crises

CVD ¼ cardiovascular disease; LVAD ¼ left ventricular assist device; TAVR ¼ transcatheter aortic valve replacement.

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medication side effects. Incorporating the patho-physiology of aging and its effect on pulmonary andvascular organ systems in differential diagnosis, aswell as teaching awareness of the peculiarities ofvolume assessment in older adults, are examplesof components of geriatric cardiology expertise andpractice.

Factors such as multimorbidity, frailty, poly-pharmacy, cognitive impairment, functional status,transitional care, and goals of care (Table 3) can alsoaffect presenting symptoms and management de-cisions. For example, in the setting of HF amongolder adults, the burden of multimorbidity isextremely high, with over 50% of individualshaving 5 or more coexisting chronic conditions,including a high prevalence of both frailty andcognitive impairment, which can affect their prog-nosis. This often results in numerous primary andshared causes for a presenting symptom and a moreadvanced stage when disease is finally diagnosed.For example, the diagnosis of a discrete conditionsuch as HF in an older adult with dyspnea iscomplicated by the coexistence of other conditionssuch as chronic pulmonary disease. Indeed, there isgrowing agreement that a broader cardiopulmonarysyndrome may better describe the clinical entityexperienced by many older adults than separatediscrete conditions such as HF and chronic pulmo-nary disease (20). The practice of geriatric cardiol-ogy also entails skills to gauge multimorbidity aswell as complementary skills to assess and integratefrailty (21,22), cognition (23,24), polypharmacy (25),and even patients’ goals of care (26). The potential

for teachable and distinct tool sets are still beingrefined, but even current data suggest the value ofthese domains on risk assessment and management,as well as their ironic underutilization (27).RISK ASSESSMENT. In comparison with younger in-dividuals, risk assessment also entails a broader rangeof factors that affect outcomes. Traditional diseasefactors (e.g., tobacco use, diabetes, and BP) becomecoupled with aging-related risks (e.g., falls, con-fusion, caregiver support, and polypharmacy).Although greater morbidity and mortality risks ofCVD usually imply greater absolute risk loweringbenefits of therapy, there is also the potential forcomplications. Iatrogenesis, hospital-associateddelirium, and lengths of hospital stay are increased.Developing expertise to better assess and integratethese factors into risk assessment begins with firstunderstanding the pathobiology and effect of aging aswell as multimorbidity. This understanding comesfrom a command of the current published data, aswell as deliberation of these factors routinely inclinical practice. Two other issues that complicaterisk assessment is that the outcomes valued by olderadults such as function, symptom relief, and well-being are not measured with current assessmenttools, and the purported absolute risk benefit may notbe realized in the face of competing conditionsthat may determine outcomes more strongly thanindividuals’ CV diseases.

The utility of standardized risk assessments todiscriminate which very old adults will benefit or beharmed by a specific management strategy or inter-vention becomes less reliable (Table 3). Presence of

TABLE 3 Key Geriatric Factors That Fundamentally Affect Routine Cardiovascular Care

Diagnosis Prognosis Disease Management Processes of Care

MultimorbidityPresence of 2 or more

chronic conditions(>70% of older adults)

� Affects and/or complicatesdisease presentation

� Includes chronic diseases(DM, arthritis, COPD) andgeriatric syndromes (falls,incontinence, weight loss)

� Significantly affects short-and long-term diseaseprognosis

� Risk assessment for CVD iscomplex and inaccurate incontext of multimorbidity

� Primary management ofCVD may exacerbatecomorbid conditions

� Chronic coexistingdiseases may precludeguideline-directedtherapies

� Multiple providers,care settings,transitions of care

� Requires integrativeskillset in regard toworking within themultidisciplinary CVDteam and acrossspecialties

FrailtyLoss of physiological reserve

and vulnerability tostressors

� Under-recognized,numerous scales utilized

Diagnostic tools:� Fried frailty criteria: hand

grip strength, gait speed,physical activity, weightloss, exhaustion

� Clinical frailty scale� SPPB

� Associated with increasedrisk of incident CVD anddementia

� Associated with increasedrisk of adverse outcomes(falls, hospitalization,disability, mortality,procedural complications)

� Potentially modifiable soshould be included inmanagement strategies

� Frailty assessment asan integrated processof CVD care

PolypharmacyUse of 4 or more chronic

medications

� Drug–drug/drug–diseaseinteractions or complicationcan be attributed topresenting problem

� Associated with adverseevents, hospitalizations,mortality

� Compliance andundertreatment canresult from financial andlogistical barriers

� Pharmacodynamics/pharmacokinetics anddrug interactions affectdosing

� Drug reconciliationacross transitionsincluding provider andfacility transitions

� Changing formulariesover systems of care

Cognitive impairmentDecline in cognitive abilities

to include memory,language, thinking, andjudgment

� Globally under-recognizedand underdiagnosedImpaired cognition mayaffect or delay presentation

Diagnostic tools:� MMSE� MiniCOG� MoCA

� Commonly associated withCVD and frailty

� Independently associatedwith significantly highershort- and long-termmorbidity and mortalityin CVD

� CVD associated with andpotential risk factor forworsening cognition

� Impaired cognitioninvolves barriers toself-care managementand adherence

� Impaired cognition mayaffect successfultransitions of careand communication

Functional status/disabilityADLs for basic self-care

independenceIADLs for independent living

� Impairment may havedirect link to diagnosis(inability to wash and dressdue to exertion-precipitatedchest pain secondaryto IHD)

Diagnostic tools:� Katz/Bristol ADL scale� Lawton/Barthel IADL index

� Associated with risk ofadverse outcomes,complications,and mortality

� Impaired functionalstatus may affect diseasemanagement such asmedicationadministration ordaily weighing

� Barriers to completinghospital and doctors’visits

� Acute CVD event mayprecipitate worseningin functional status

� CVD management mayoccur over multiplehealth care transitions

Goals of care/advanced careplanning

Patient preferences, shareddecision making, healthcare proxies, living wills,and utilization of end-of-life care practices

� Alignment of goals of carewith diagnostic testing

� Diagnostic certainty vs.symptom managementpreferences

� Quality-of-life diagnosticsin setting of end-of-lifecare

� Inclusive of patient-centered outcomes;independence, functionalstatus.

� Patient-centered shareddecision making

� Therapeutic alignmentwith patient goals

� Complication/difficulties ofidentifying primaryresponsible provider

� Changing ormaintaining goalsof care acrosstransitions

� Loss of documentation

ADL ¼ activities of daily living; COPD ¼ chronic obstructive pulmonary disease; CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; IADL ¼ independent activities of daily living; IHD ¼ ischemic heartdisease; MiniCOG ¼ Mini Cognitive Assessment; MMSE ¼ Mini Mental State Examination; MoCA ¼ Montreal Cognitive Assessment; SPPB ¼ Short Physical Performance Battery.

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cognitive impairment and frailty in a patient with HFwill, for example, significantly increase the risk ofhospital admissions, disability, procedural complica-tions, and mortality (28). At the center of this is theunderstanding that, for a patient who has alreadyreached his or her anticipated life expectancy,the relevance and utility of predicting 10-year mor-tality may have less priority than predicting futurequality of life and the likelihood of maintainingindependence. A geriatric cardiologist can helpclarify immediate-term (days to weeks) goals versus

short-term (within 1 year) goals (i.e., relief of symp-toms, consideration of advanced directives, andperhaps exercise therapy for improved quality of life)versus longer-term goals (midterm [between 1 and5 years] as well as long-term [5 years or longer])(i.e., disease prevention, such as statin therapy orcancer screening).

DISEASE MANAGEMENT AND CARE COORDINATION.

Management of CVD remains fundamentally orientedtoward individual diseases, including application

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of multiple individual disease-specific guidelineswithout integration. A key mandate for geriatric car-diology is to guide CV management as a multimorbiddisease, considering the effect of the aging process ontherapeutic intervention. Even if patients are rela-tively robust, complications and side effects fromcommonly prescribed medications must be antici-pated and circumnavigated in the geriatric popula-tion. Doses suitable for younger adults may lead tounforeseen effects amidst age-related changes inpharmacokinetics, pharmacodynamics (29), volumeof distribution (reduction in plasma protein levels,lean body mass, fat, and total body water with age)bioavailability (11), and renal (30) or hepatic clear-ance, especially in the context of disease. Even whenCVD is unambiguous (e.g., acute non–ST-segmentelevation myocardial infarction), management can beinherently uncertain as age-related differences inpharmacodynamics and pharmacokinetics intensifythe risks of detrimental consequences from basictherapeutic choices. The prevalence of medication-related adverse effects may be affected by increaseddrug–drug interactions; drug–disease interactions(31), including therapeutic competition, in whichtreatment of 1 condition worsens a coexisting condi-tion; and drug–host interactions, such as the age-related changing and slowing of reflexes andadrenergic and parasympathetic systems resulting ina lower likelihood of tolerance (25,32). Absoluterisk benefit may be high in the absence of com-peting conditions when using potent therapies as acritical step to mitigate dire disease-related morbidityand mortality (e.g., revascularization and anti-coagulation), but risks for iatrogenesis (infection,confusion, and bleeding) as well as therapy-relatedburden (e.g., transportation, transitions for supple-mental care, cost, and pain) also rise disproportion-ately. Formal training in pharmacology, methods toensure adherence in the setting of cognitive impair-ment, adherence techniques, and understandingpreferred drugs in relevant dyads and triads of mul-tiple chronic conditions are essential to geriatriccardiology disease management. In addition, theavoidance of therapeutic competition and the mini-mization of treatment burden are skills that must bemastered.

A central premise of geriatric cardiology diseasemanagement is that of team-based care. Treating thegeriatric patient requires input from, and integrationacross, the patients team of physicians, advancedpractice nurses and physicians assistants as well asnurses, pharmacists, midlevel providers, nutrition-ists, speech pathologists, physical and occupationaltherapists, social workers, and palliative care and

hospice consultants. Pharmacists who provide criticalhelp to mitigate drug interactions, advanced practicenurses who not only provide primary cardiovascularcare but also help navigate non-CV medical aspectsof the patient’s presentation, as well as caregiverswho are oriented to the psychosocial componentsof illness are all paramount to the care of the com-plex and multifaceted geriatric cardiology patient.Although they provide complementary expertise,multiple team members can lead to the fragmentationof care and may contribute to treatment burden. Teamcare requires designation of a natural “quarterback,”such as the geriatric cardiologist, responsible forintegrating care across providers and ensuring thatcare is consistent with patients’ outcome goals andcare preferences. Although coordinating care hastraditionally been under the domain of the pri-mary care provider, decisions regarding medications,devices, procedures, and ongoing monitoring mayincreasingly require CV expertise; the geriatric cardi-ologist has the distinctive capacity to enhance in-sights and effective management.

Another substantial component of care for olderadults involves coordinating care across transitions.An older adult recently hospitalized for an acute careevent may, for example, experience multiple transi-tions between services and settings, for example, caretransitions between emergency departments, inpa-tient units, post-acute care settings (skilled nursingfacilities, inpatient rehabilitation, home health), andoutpatient clinic follow-up. Transitions entail com-plex multimorbid management issues, multiple sys-tems of care, and high potential for confusion fromlanguage and documentation along the way. At eachpoint of transition the older adult is vulnerable toadverse events. A fundamental precept of geriatriccardiology is orientation to and emphasis on all stepsof transitional management as essential parts ofaggregate care. Communication (as described in thenext section) is a key skill needed to ensure safe andeffective transitions.

Adherence is especially difficult among olderadults. Reasons include poor coordination of recom-mendations from multiple clinicians and care recom-mendations that are beyond the capability ofcaregivers and patients because of impediments suchas cognitive impairment, visual and hearing limita-tions, physical disabilities, and often, limited financialor social resources. Poor adherence also can evolvewhen recommendations are not commensurate witheach patient’s idiosyncratic goals and preferences(33). Although multiple tools to improve adherence,including medication lists, electronic reminders, pillorganizers and dispensers, and remote monitoring

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devices, have been promoted, suboptimal medicationmanagement remains entrenched. Undoubtedly,steps to ensure that treatment recommendations areconsistent with patients’ goals, preferences, and ca-pabilities and minimize treatment burden across allconditions are at least as important as adherence toolsin improving adherence.

COMMUNICATIONS AND CAREGIVER SUPPORT.

Helping a geriatric patient navigate through the arrayof therapeutic options in contemporary cardiologypractice requires effective communication withpatients and their families. Communications areelemental to delineate patient preferences and toalign management with these choices. The discus-sions entail uncertainty, changes in quality of life,death and dying, palliative and hospice care, as wellas the nuanced risks and benefits of therapeuticchoices. For most clinicians, effective communicationis a skillset that must be learned and honed, espe-cially for patients who are often limited by sensory,cognitive, and language limitations (34,35).

Communication skills also relate to the capacity tocoordinate among clinicians. Many older cardiac pa-tients receive care by many providers concurrently,frequently in numerous care systems, leading todiscrepancies in priorities of care, medications pre-scribed, and overall medical management. Onecrucial communication skill is the ability to elicitspecific, actionable, and reliable outcome goals andpreferences that need to drive decision makingin older adults with multiple and complex healthconditions. Most cardiologists and physicians ingeneral may not wish to acquire this skill or nothave the time to carry out goals elicitation, but theymust ensure that a trained and skilled member of theteam is available to carry out this fundamentalactivity.

Communication skills are also inherently necessaryto navigate predictable family dynamics. As olderpatients lose the ability to adequately care for them-selves, the caretaker becomes more central to theclinical care and decision-making. Mounting stressand fatigue among caregivers are common, alongwith triggers of caregiver frustration (e.g., worseningincontinence, gait instability, and/or cognition). Thegeriatric cardiologist can hone skills of understandingand empathy and can also provide key insightsregarding medications, procedures, and other con-siderations that can mitigate or inadvertently exac-erbate these tensions.

PHYSICAL ACTIVITY AND REHABILITATION. Thereis substantial evidence (36–38) that increased phys-ical activity and exercise-based cardiac rehabilitation

significantly benefits older adults not only throughimproving CV indexes and mortality but also byimproving functional status, psychological disorders,and cognitive function. Despite the remarkable ben-efits reported, cardiac rehabilitation programs con-tinue to be underutilized by older patients with CVD,including low initiation and maintenance rates(39,40). The causes are multifactorial and include lowreferral rates by CV providers, poor communication topatients and families of the significant benefits, andbarriers to maintenance (e.g., transport, cost, psy-chosocial, lack of motivation, physical limitations,fear/anxiety, and concerns about inadequacy). Evenwhen educated on the benefits, both providers andpatients may be concerned about the safety of aphysical activity program amongst a myriad of mul-timorbid conditions. However, it is likely that thisolder inactive population would benefit the greatest(41,42). Geriatric cardiologists are ideally suited tofacilitate cardiac rehabilitation and other programsthat promote physical activity and that help achievehealthful as well as qualitatively beneficial out-comes (e.g., independence, functional gains, andself-efficacy).

POST-ACUTE CARE: SKILLED NURSING FACILITIES

AND LONG-TERM CARE. Cardiologists and specialistsin general have not traditionally had a routine pres-ence in the post-acute care setting because they werelargely not needed after longer lengths of hospitalstay in which to stabilize patients. As legislation andfinancial incentives encourage prompter acute hos-pital discharge (43), older and sicker patients whowere once followed by several consulting specialistsfor the duration of a prolonged hospital stay are beingdischarged rapidly to skilled nursing facilities (SNFs)and long-term care facilities under the care of alreadyburdened generalists without routine communicationwith their specialty providers. Despite inherentproblems, the application of post-acute care is in-creasing, and Medicare increasingly looks to skilledfacilities to improve quality metrics and reduce hos-pital readmissions (44). A total of 14% of Medicarefee-for-service beneficiaries had at least 1 post-acutecare stay in 2010, costing $54.7 billion. Of thosebeneficiaries with 6 or more chronic conditions, 49%had at least 1 post-acute care stay that was associatedwith a 30% higher hospital readmission rate (45).Anticipated legislation is expected to soon link SNFpayments to performance.

The SNF provides a setting to optimize health careresources, as patients discharged to SNFs for ongoingmedical therapy have ready access to physical andoccupational therapy, speech pathology, nutrition

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consultation, and social resources. It provides anopportunity to incorporate the multidimensionalteam in management of complex patients and have apatient-centered approach to care without the acuityand cost of a hospital stay. The potential role of thegeriatric cardiologist to address and manage theneeds of older frail adults with HF, who are at thehighest risk of hospital readmission, through struc-tured care plans could meet an underserved clinicalarea and improve quality metrics.

Options such as direct admission and utilization ofSNF services (nursing care, intravenous therapies,and accurate fluid and weight measurements) forolder patients in the community may be opportu-nities for improved resource utilization and costcontainment.

PALLIATIVE CARE AND END-OF-LIFE DECISIONS. Geri-atric cardiologists and palliative care experts overlapin their orientation to management of CVD in thecontext of advanced pathology and compoundingmultimorbidites. However, whereas geriatric cardi-ologists are oriented to the crossroads of managementby guiding prevention and remediation as well asend-stage management, palliative care experts arerelatively more exclusively oriented to patientsexperiencing predominant decline.

Collectively, both the geriatric cardiologist andpalliative care experts have formidable potential towork in a synergistic fashion; the geriatric cardiolo-gist can distinguish (and facilitate) effective treat-ment amidst dynamic contexts, and the palliativecare experts have the skills to adjust care when reliefand comfort become principal concerns. Such coor-dination of geriatric cardiology and palliative careexperts is well-suited to team-based management.

Geriatric cardiologists can also facilitate andadvance precepts regarding end-of-life decisionmaking, including decisions about resuscitation andeven when to forgo treatment perceived as futile.Guiding advanced directives is also critical, that is,anticipating and facilitating patient-centered man-agement if/when patients lose the capacity to maketheir own decisions. In each instance, the geriatriccardiologist is an important source not only of med-ical insight and expertise, but also of legal profi-ciency and capacities to integrate family dynamics,financial issues, and spiritual concerns. The geriatriccardiologist also serves as an important guide to thesurrogate decision maker, with the key skills to helpthe surrogate navigate a predictable complexityof stress, anxiety, guilt, and moral distress for a pa-tient who can no longer make his or her own de-cisions (46).

FINANCIAL ASPECTS OF

GERIATRIC CARDIOLOGY

The time taken to implement geriatric cardiology pre-cepts may seem to run counter to the pressures in ourcurrent health care environment to increase efficiencyand reduce costs. A geriatric cardiology encounterstarts with listening to the patient’s goals, assessingimpairments (such as cognitive impairment or frailty),reconciling medications, and addressing opportuni-ties for rehabilitation, end-of-life concerns, and othercomplexities that add time to the clinical encounter.Similarly, it entails the predictable time demands oforganizing with nurses, physical therapists, and otherproviders linked to each patient, as well as the timeneeded for extended conversations with patients andfamily members, all of which are currently nonre-imbursable services (47). The assessment of function isintegral to the process, and consulting with caregiversin other specialties is usually required. All of theseaspects make geriatric cardiology financially chal-lenging within a traditional fee-for-service setting.

Nonetheless, the premise of increasing the carevalue that is promulgated by ACOs resonates withthemes and metrics of geriatric cardiology, and themanagement efficiencies achieved by geriatric cardi-ology expertise may ultimately prove to be costsaving by better ascertaining which patients are likelyto benefit from which therapy and thereby mitigatingthe quagmire of prolonged lengths of stay, iatrogen-esis, rehospitalization, and other unintended expen-sive consequences of care.

In addition to ACOs, the Centers for Medicare &Medicaid Services Hospital Readmissions ReductionProgram has incentives to reduce readmissions andprovides another critical rationale for geriatric cardi-ology as a cost-saving element of care (44). Read-missions are heterogeneous and are often unrelated tothe index event (48). Logically, CV expertise that isable to better link geriatric risks to CVmanagementwillbe better equipped to reduce preventable readmis-sions. Additionally, better understanding a patient’sand family’s goals in the final year(s) of life mightobviate the reflexive hospitalization(s) that occurwhen someone in an assisted living or long-term carefacility becomes sick. These strategies are as yet un-tested in trials and represent an opportunity forresearch.

Bundled payments are another area where geri-atric cardiologists can play a role in improving out-comes and, consequently, hospital reimbursement.The Bundled Payments for Care ImprovementInitiative (BPCI) was launched in January 2013 andlinks payments for multiple services in a single acute

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episode, with the goal of reducing incentives forindividual services provided as well as decreasingfragmentation (49). The majority of cardiac diagnosesincluded in the BPCI are procedure-related, includingcardiac valve surgery (including endovascular in-terventions such as TAVR), coronary artery bypassgraft surgery, pacemaker implantation, and PCI. Ageriatric cardiologist provides expertise suited toaccurately assess procedural risk, patient selection,and the consequences of multimorbidity before theprocedure, as well as providing expertise in post-procedure care and transitions that may potentiallyreduce costs.

Similarly, geriatric cardiologists provide skills andperspectives that are complementary to the disease-specific CV management teams. Valvular heart dis-ease, atrial fibrillation, HF, and other diseases arenow often treated by consensus among multipleproviders with synergistic skills. Geriatric cardiologyadds a unique perspective as part of the same servicein orientation to procedures, medications, broadermetrics of outcomes, and limits of traditional carethat all contribute to improved efficiencies andefficacy of therapy.

SUMMARY

On first review of our case study, 1 typical path isfor the cardiologist to manage the patient in align-ment with published guidelines for unstable CHD.Alternatively, others may simply “eyeball” the patient

and conclude that he is too frail for a procedure andthat conservative therapy is the only option. Incontrast, geriatric cardiology starts with the patientand family and delineates goals of care using skillsthat reflect a distinctive thought process and imple-mentation of care. In this case, quality of life and,hence, symptom control was the primary goal, andgiven the absence of any straightforward medicaltherapy, an argument for coronary intervention wasmade. However, the informed patient and familydeclined options for a procedure and chose plans forcomfort care overseen by the geriatric cardiologist.

We continue to see more patients like our casestudy. As we ride the crest of expanding aging de-mographics, new technologies, and new legislation,cardiology providers must refine new processes ofcare that are patient-centered and that foster the bestcare for our new prototypical patients and circum-stances. Our mandate is to optimize care, and ouropportunity is to invigorate practice patterns withtraining in geriatric principles that overlap with car-diology and to instill new standards of diagnostics,risk assessment, and disease management into ourpractice. Geriatric cardiology is evolving as theappropriate approach for this challenge.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.Daniel E. Forman, Section of Geriatric Cardiology,University of Pittsburgh Medical Center, 3471 FifthAvenue, Suite 500, Pittsburgh, Pennsylvania 15213.E-mail: formand@pitt.edu.

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KEY WORDS aging, cardiovascular disease,geriatrics, quality, training