Europe, like the rest of the industrialised world, is facing an unprecedented demographic change: the percentage of the population above the age of 65 will increase from its current level of 17% to over 30% in the year 2050. In the same time interval the proportion of octogenarians will increase even more dramatically from 4% to over 12%.
These changes are not far away from our everyday clinical reality. At the Heart Center Leipzig alone, we have observed a threefold increase in invasive and interventional procedures in octogenarians during the last five years. Disease entities that are highly prevalent among elderly people, such as chronic heart failure and aortic stenosis, are dominating our daily clinical decision-making. However, it may be inappropriate to just extrapolate treatment options that have worked well between the age of 40 to 65 in clinical trials into the treatment realities which we face in elderly patients. The higher prevalence of comorbidities, the limitations of cognitive functions, the lack of optimal social support, and the reduced mobility due to orthopaedic degenerative diseases all contribute to the complexity of therapeutic decisions in elderly patients. This issue of European Cardiology addresses several of the problems that we meet in the treatment of chronic heart failure and aortic stenosis, most notably the analysis of dyssynchrony using 3D echocardiography, the appropriate use of natriuretic peptides in diagnosing and following heart failure patients, and the optimal pre-interventional diagnostic work-up and logistical set-up for transcatheter aortic valve implantation.
Working with elderly patients, however, will not only require new technical tools and approaches but will also challenge our traditional view of therapeutic goals in modern cardiology. Traditionally, hard clinical end-points such as mortality or hospitalisations are used in clinical trials. For octogenarian patients, on the other hand, quality of life and improved exercise capacity may be equally important as compared to prolongation of life. There is a clear need for prospective clinical trials assessing the improvement of exercise capacity and quality of life which can be achieved with today's sophisticated interventional treatments in elderly patients. Additionally, we are in need of closer cooperation with geriatric specialists to optimise the pre-interventional assessment of comorbidities. We are just beginning to realise the importance of frailty scores for the clinical outcomes of interventional therapies. If we as doctors fail to recognise our patients’ special needs and priorities we are in danger of placing more emphasis on technical success than on clinical benefit for our patients.