Introduction and Context
The United States is undergoing a dramatic demographic transition: the number and proportion of older adults are rising rapidly, and cardiovascular disease remains the leading cause of morbidity and mortality in this group. The American Heart Association’s 2025 scientific statement “Coronary Artery Revascularization in the Older Adult Population” (Damluji et al., Circulation 2025) responds to major clinical gaps: most revascularization guidelines and trials historically under-represent older adults and rarely address geriatric syndromes (frailty, cognitive impairment, multimorbidity) that materially influence risks, benefits, and patient preferences.
This statement is not a prescriptive guideline that replaces ACC/AHA/ESC revascularization guidance; rather, it is a focused, pragmatic framework designed to help clinicians incorporate geriatric principles into revascularization decisions for older adults. It centers on individualized risk–benefit assessment, integration of geriatric evaluation into the heart-team process, and shared decision-making that reflects life expectancy, functional goals, and patient values.
New Guideline Highlights
– Prioritize individualized care: Revascularization decisions must incorporate physiologic age (frailty, function, cognition), not just chronologic age.
– Routine geriatric screening: Brief, point-of-care assessments for frailty (e.g., gait speed), cognitive function (e.g., MoCA or mini-COG), nutritional status, and social support are recommended when considering revascularization.
– Multidisciplinary heart team expanded: For older adults with complex coronary disease, include geriatricians, cardiac surgeons, interventionalists, nursing/case management, and palliative care as appropriate.
– Shared decision-making and goals of care: Discussion should explicitly address life expectancy, functional recovery, and trade-offs (mortality, stroke, repeat procedures, recovery time, quality of life).
– Treatment strategy principles: Consider less invasive strategies (transradial PCI, percutaneous options) when frailty or limited life expectancy predicts poor recovery; for older adults with complex multivessel or left-main disease and reasonable life expectancy, CABG may still confer long-term survival or symptom benefits and should be discussed.
– Medication and procedural adaptations: Recommendations address antiplatelet selection and duration, bleeding-risk mitigation, contrast exposure reduction, and rehabilitation tailored to older adults.
Key takeaways for clinicians: screen for geriatric syndromes early, involve a broader heart team, individualize the choice of medical therapy vs PCI vs CABG based on functional status and goals, and document patient values in the decision-making process.
Updated Recommendations and Key Changes
Why the statement was issued or updated
– Trial populations and traditional guidelines historically excluded many older adults; the new evidence base (including ISCHEMIA, EXCEL, SYNTAX, COURAGE) and demographic trends necessitate geriatric-focused guidance.
– New data and clinician experience underscore that frailty and cognitive impairment alter procedural risk and recovery trajectories; therefore, formal guidance was needed to standardize geriatric-informed care.
What’s new compared with prior revascularization guidance
– Explicit requirement for geriatric assessment embedded into the pre-revascularization pathway (previous guidelines noted comorbidity but rarely operationalized frailty/cognitive testing).
– Expansion of the heart-team composition to include geriatric expertise and, when relevant, palliative-care input.
– Practical algorithms addressing antiplatelet strategies and bleeding-risk mitigation specifically in older adults.
– Emphasis on patient-centered outcomes (functional independence, cognitive preservation, and quality of life) in addition to traditional endpoints (mortality, MI, stroke).
Evidence driving the changes
– Older adults were underrepresented or excluded in many landmark trials; subgroup analyses and geriatric-focused observational studies show heterogeneity in outcomes by frailty and cognitive function.
– ISCHEMIA (Maron et al., NEJM 2020) and other trials indicate that an invasive strategy does not uniformly improve survival in stable ischemic heart disease—translating trial findings to older, frail patients requires nuanced application.
Topic-by-Topic Recommendations
Pre-procedure assessment
– Core assessments to perform before considering revascularization:
– Frailty screening: gait speed (4-meter walk), timed-up-and-go, or Clinical Frailty Scale; abnormal results should trigger comprehensive geriatric assessment.
– Cognitive screening: MoCA, mini-Cog, or equivalent to identify impairment that may affect consent and recovery.
– Functional status: Activities of daily living (ADLs) and instrumental ADLs (IADLs).
– Comorbidity and polypharmacy review: identify life-limiting illnesses and drug interactions that affect procedural risk or medical therapy.
– Social determinants: caregiver availability, transportation, home support for post-procedure recovery.
Risk stratification and life-expectancy estimation
– Estimate short-term procedural risk (surgical and percutaneous risk calculators remain useful) and overlay geriatric measures to better predict recovery and durable benefit.
– Consider whether expected survival and functional recovery justify the invasiveness of CABG vs PCI vs conservative therapy.
Choice of revascularization strategy
– Acute coronary syndromes (ACS): Standard ACS protocols apply; however, in older adults, procedural details should be adapted—radial access preferred when feasible, bleeding-risk mitigation employed, and geriatric consultation considered for frail patients.
– Stable ischemic heart disease:
– Medical therapy is often preferred when life expectancy is limited or frailty predicts poor recovery.
– For symptomatic relief or when anatomy predicts prognostic benefit, revascularization should be considered with geriatric input.
– For complex multivessel or left-main disease: CABG may offer superior long-term outcomes for suitable older adults with acceptable operative risk and meaningful life expectancy; however, for very frail patients, PCI may offer symptom relief with lower upfront physiologic stress.
Peri-procedural management adaptations
– Vascular access: radial-first approach where anatomy permits to reduce bleeding and facilitate earlier mobilization.
– Contrast and renal protection: minimize contrast, use iso-osmolar agents, and strict hydration strategies for CKD patients.
– Antithrombotic therapy: weigh ischemic benefit vs bleeding risk; tailor DAPT duration and consider newer approaches (e.g., P2Y12 monotherapy in high bleeding risk) with close follow-up.
– Anesthesia and delirium prevention: avoid oversedation, early mobilization, delirium screening and prevention bundles.
Rehabilitation and follow-up
– Early mobilization and tailored cardiac rehabilitation with geriatric-focused components (balance, strength, cognition) improve functional recovery.
– Medication reconciliation and adherence support are critical; involve pharmacists and nurses to reduce polypharmacy and adverse drug events.
– Advance care planning: revisit goals of care and document preferences for future episodes.
Special populations
– Frail older adults: prioritize symptom relief and function; invasive strategies require careful justification and shared decision-making.
– Cognitive impairment/dementia: ensure surrogate decision-makers are engaged; focus on interventions that preserve function and comfort.
– Multimorbidity and limited life expectancy: often favor conservative medical therapy unless revascularization is required for reversible symptoms limiting quality of life.
Recommendation Summary (Practical Checklist)
– Screen every older adult considered for revascularization for frailty and cognitive impairment.
– Use an expanded heart team that includes geriatrics and palliative care when appropriate.
– Base choice of PCI, CABG, or medical therapy on functional status, life expectancy, coronary anatomy, and patient goals.
– Prefer radial access and strategies to reduce bleeding and contrast exposure.
– Provide tailored cardiac rehabilitation and transitional care to preserve independence.
Expert Commentary and Insights
Consensus points
– The writing group emphasizes that age alone should not exclude patients from potentially beneficial interventions; rather, physiologic reserve and goals should guide decisions.
– Geriatric assessments add prognostic and practical value and can often be conducted quickly in cardiology settings.
Controversial areas and ongoing debate
– PCI vs CABG in older adults with complex disease: RCT evidence is limited, and outcomes depend heavily on patient selection. Older adults were often excluded from trials that established the superiority of CABG in selected anatomies, so clinicians must interpret trial findings cautiously.
– DAPT duration and antithrombotic choices: balancing ischemic protection and bleeding risk remains contentious; randomized data in very old/frail populations are sparse.
– How best to operationalize geriatric screening in busy cath labs and clinics: centers will need workflows, training, and resources to implement the statement’s recommendations.
Future research needs
– Trials designed for older adults that include frailty and geriatric outcomes as prespecified measures.
– Studies of tailored antithrombotic regimens and revascularization strategies in frail patients.
– Implementation science to assess how geriatric-informed heart teams change outcomes and resource utilization.
Practical Implications for Clinicians and Health Systems
– For clinicians: add brief frailty and cognitive screens to pre-procedure assessments, engage family and caregivers early, and document functional goals.
– For heart teams: expand membership to include geriatric expertise or establish rapid-access geriatric consultation pathways.
– For systems: invest in transitional care, accessible outpatient rehabilitation adapted to older patients, and quality metrics that capture functional outcomes and quality of life.
Patient vignette (illustrative)
– Mary, an 82-year-old woman with stable angina, hypertension, stage 3 CKD, and mild cognitive impairment, presents with lifestyle-limiting symptoms. Gait-speed testing shows slow gait; the heart team includes a geriatrician. After a frank discussion of goals—Mary prioritizes being able to walk independently—the team recommends a radial-access PCI to relieve angina with a plan for short DAPT and outpatient geriatric-focused cardiac rehab. CABG is discussed but deferred given frailty and her preference to avoid prolonged recovery.
References
– Damluji AA, Nanna MG, Mason P, Lowenstern A, Orkaby AR, Washam JB, Kolkailah AA, Beckie TM, Dangas G, Lawton JS; American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Quality of Care and Outcomes Research. Coronary Artery Revascularization in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation. 2025 Dec 23;152(25):e494-e525. doi: 10.1161/CIR.0000000000001387. Epub 2025 Nov 18. PMID: 41250995.
– Maron DJ, Hochman JS, Reynolds HR, et al.; ISCHEMIA Research Group. Initial Invasive or Conservative Strategy for Stable Ischemic Heart Disease. N Engl J Med. 2020;382(15):1395-1407.
– Stone GW, et al. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. N Engl J Med. 2016;375:2223-2235 (EXCEL).
– Serruys PW, et al. Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease. N Engl J Med. 2009;360:961-972 (SYNTAX).
– Boden WE, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med. 2007;356:1503-1516 (COURAGE).
– Afilalo J, Lauck S, Kim S, et al. Gait Speed and Operative Mortality in Older Adults Undergoing Cardiac Surgery. J Am Coll Cardiol. 2010;56(8):1668-1676.
– Neumann FJ, Sousa-Uva M, Ahlsson A, et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165.
– U.S. Census Bureau. 2017 National Population Projections. (For demographic context.)
Bottom line
The 2025 AHA scientific statement fills a vital gap: it helps clinicians translate coronary revascularization evidence into care plans that meaningfully reflect the needs, risks, and goals of older adults. The core message is straightforward—don’t treat age alone as the deciding factor. Assess physiologic reserve, involve geriatric expertise, and center decisions on the outcomes that matter most to each patient: longer life, preserved independence, and better quality of life.
