Cardiac resynchronization therapy in the elderly. How much is it safe and beneficial?

Heart failure is a widespread disease in the western world whose incidence and prevalence are constantly increasing, mainly involving the more advanced age groups. Cardiac resynchronization therapy (CRT) has been shown able to reduce sudden cardiac death and all-cause mortality in patients with heart failure and reduced ejection fraction. Elderly patients are generally under-represented in the clinical trials aimed to evaluate the efficacy of CRT and, chiefly, of implantable cardiac defibrillator (ICD). The simultaneous presence of confounding factors such as co-morbidities, polypharmacy, changes in cognitive status, frailty, are the most important causes for the exclusion of subjects of advanced age from RCTs on the ICD or CRT implant. Current guidelines do not suggest any upper age limit for ICD and CRT but recommend avoiding their use in frail older patients with a life expectancy of less than 1 year. Data from the literature show that CRT has equal dignity in both the elderly and the young, in fostering effective functional and morphological improvements, also suggesting that, in older patients, CRT-D may have little practical value compared to CRT-P given the low incidence of arrhythmic death. Nevertheless, it is necessary to develop RCTs that consider aspects of the elderly patient in relation to CRT such as functional, cognitive and nutritional status.