Coronary artery disease management in older adults: revascularization and exercise training

Graphical Abstract The figure summarizes the main critical issue in the diagnosis, management and treatment of older patients with coronary artery disease, from symptoms to therapeutic strategies, through assessment of frailty and physical performance. CAA, coronary artery angiography; CAD, coronary artery disease; CCS, chronic coronary syndrome; CMD, coronary microvascular dysfunction; CONUT, controlling nutritional status; COPD, chronic obstructive pulmonary disease; CT, computed tomography; MI, myocardial infarction; MNA-SF, mini-nutritional assessment short form; PNI, prognostic nutritional index; SPPB, short physical performance battery The mean age of patients with coronary artery disease (CAD) is steadily increasing. In older patients, there is a tendency to underutilize invasive approach, coronary revascularization, up-to-date pharmacological therapies, and secondary prevention strategies, including cardiac rehabilitation. Older adults with CAD commonly exhibit atypical symptoms, multi-vessel disease involvement, complex coronary anatomy, and a higher presence of risk factors and comorbidities. Although both invasive procedures and medical treatments are characterized by a higher risk of complications, avoidance may result in a suboptimal outcome. Often, overlooked factors, such as coronary microvascular disease, malnutrition, and poor physical performance, play a key role in determining prognosis, yet they are not routinely assessed or addressed in older patients. Historically, clinicians have relied on sub-analyses or observational findings to make clinical decisions, as older adults were frequently excluded or under-represented in clinical studies. Recently, dedicated evidence through randomized clinical trials has become available for older CAD patients. Nevertheless, the management of older CAD patients still raises several important questions. This review aims to comprehensively summarize and critically evaluate this emerging evidence, focusing on invasive management and coronary revascularization. Furthermore, it seeks to contextualize these interventions within the framework of improved risk stratification tools for older CAD patients, through user-friendly scales along with emphasizing the importance of promoting physical activity and exercise training to enhance the outcomes of invasive and medical treatments. This comprehensive approach may represent the key to improving prognosis in the complex and growing patient population of older CAD patients.