Coronary artery revascularization in the older adult population

The United States population aged 65 years or older is projected to nearly double by 2060. Since the prevalence of coronary artery disease increases with age, a substantial increase in cases is the direct corollary. This “demographic shift” and concomitant increase in risk factors and longer life expectancy are key drivers of coronary artery disease in older adults. Age-related cardiovascular changes, such as endothelial dysfunction, increased arterial stiffness, and reduced elasticity, increase the risk for hypertension, other cardiovascular risk factors, and atherosclerotic cardiovascular disease. Obesity, diabetes mellitus, and metabolic syndrome are more prevalent with biological aging, further increasing cardiovascular risk in older adults. Each year, more than 720,000 Americans suffer acute myocardial infarction or coronary artery disease-related mortality, with the highest rate in older adults (~20% of adults >65 years). Individuals aged 75 and older account for 30%–40% of all acute coronary syndrome hospitalizations. They often present with complex coronary disease and associated geriatric syndromes like frailty, multimorbidity, and cognitive impairment, which pose a challenge to revascularization strategies. The existing ACC/AHA guidelines for coronary revascularization focus primarily on younger adults, leaving significant gaps for the more complex older adult population. This chapter highlights the need for individualized approaches that consider patient preferences, cognitive function, geriatric syndromes, and life expectancy.