Precision medicine

Elderly heart patients, how Italian-made research predicts high mortality risk in aorta surgery

Avoiding costly and risky cardiovascular interventions when they will bring no real benefit and instead offering more targeted treatment to patients who can benefit from it: this is the aim of two Italian multicentre studies involving cardiologists and geriatricians

by Health Review

27 April 2026

4' min read

Translated by AI

Versione italiana

4' min read

Translated by AI

Versione italiana

Aortic stenosis affects 280 thousand people in Italy, preventing the aortic valve from opening properly and thus obstructing the flow of blood from the heart to the rest of the body. And every year, more than 12 thousand micro-invasive valve replacement operations are performed in our country, but 15% of patients do not survive one year after the operation. Until now, therapeutic decisions to proceed with surgery were guided by two schematic criteria such as age and number of pathologies present; the two Italian studies just published in JACC Cardiovascular Interventions and in the European Journal of Preventive Cardiology show, on the other hand, that full autonomy, good nutrition and physical performance are crucial in measuring patients' risk. In summary, the aim of these studies is to avoid costly and risky cardiovascular interventions when they will not bring real benefit and, on the contrary, to offer more targeted care to the elderly who can benefit from it. The two Italian multicentre studies involved cardiologists and geriatricians from seven large hospitals in Florence, Padua, Ferrara, Bologna, Turin, Rome and Naples.

Parameters to be updated

"Currently, the clinical assessment prior to 'Tavr' (Transcatheter Aortic Valve Replacement) surgery is based on a scoring scale developed decades ago for traditional heart surgery on younger and less frail populations, which calculates the likelihood of death within 30 days of surgery," explains Niccolò Marchionni, Professor Emeritus of Internal Medicine at the University of Florence and study co-author. There is a growing body of evidence suggesting that frailty and global functional impairment play a crucial role in determining clinical outcomes, making their integration into risk assessment indispensable'.

Therefore, the researchers, as reported in JACC Cardiovascular Interventions, subjected 562 patients with an indication for Tavr and a mean age of 83 years to a multidimensional geriatric assessment to quantify frailty, autonomy in basic daily activities, nutritional status, cognitive function, presence of multiple pathologies and disabilities, in order to obtain a complete and clinically relevant picture for assessing the risk of worsening and mortality at one year.

Four criteria

"This tool is able to identify, with a very high accuracy (97%), the 15% of patients who, after surgery, do not survive at least one year or become disabled in the same period,' says Marchionni. 'In particular, the analysis revealed four factors predictive of an unfavourable outcome: nutritional score, number of daily activities preserved, renal function, and systolic pulmonary artery pressure measured by echocardiogram. By combining these four parameters, we derived a numerical score that could be calculated in a few minutes with data already available in the routine pre-intervention evaluation'.

This is not a marginal improvement, but a substantial qualitative leap in the ability to predict who will not benefit from the Tavr. "We can recognise in advance the cases in which the procedure would prove futile: an expensive and invasive intervention with no real benefit for the patient. Avoiding these situations reduces unnecessary risks for the elderly and frees up resources for those who can really benefit,' he emphasises.

New Routes

'At the same time, the work also suggests a new perspective for these high-risk patients. In the future,' adds Marchionni, 'those with unfavourable conditions may be started earlier on 'pre-habilitation' programmes, aimed at correcting the most critical modifiable factors, from malnutrition to muscle weakness, so as to reduce the risk of Tavr being useless'.

Beyond the Tavr

The second study, published in the European Journal of Preventive Cardiology, extends the gaze beyond the Tavr to include elderly people with cardiac amyloidosis and chronic heart failure. 'Thanks to an in-depth geriatric assessment of 956 patients, we identified five different 'vulnerability categories', constructed by combining three aspects: functional disability, risk of malnutrition and physical performance,' notes Carlo Fumagalli, PhD in Pathophysiology of Ageing at the Vanvitelli University of Naples and co-author of both studies. The results showed that patients without any vulnerability (full autonomy, good nutrition, good physical performance) have a two-year survival rate of 92.3%, the most vulnerable ones, on the contrary, survive two years in only about 60% of cases. Furthermore, functional disability was confirmed as the most powerful factor, with an almost fourfold increased risk of death compared to autonomous patients'.

'Today, therapeutic decisions in the elderly with cardiovascular diseases are still too often guided by schematic criteria, such as age or the number of diseases present,' adds Fumagalli. 'Instead, our results show how much more useful it is to understand what that individual patient is like, how autonomous he/she is, how well nourished he/she is, how strong he/she is. This profoundly changes the way we choose treatment'.

Sartorial Care

"The proposed approach overcomes a 'one-size-fits-all' view of the elderly heart patient. Two 80-year-old patients with the same disease,' Marchionni continues, 'may have completely different needs and perspectives. Classifying them in categories of progressive vulnerability helps to better calibrate therapies, controls and even treatment goals, avoiding both overkill and unjustified pessimism'.

'True precision medicine,' Marchionni and Fumagalli conclude, 'is not only made up of sophisticated technologies, but of a more tailored attention to the person, especially when they are elderly and frail. Bringing together the skills of cardiologists and geriatricians, as we have done in this multi-centre collaboration, is the necessary step to offer fairer and more humane care'.