Cardiac Implantable Electronic Devices Management in Older Adults ≥75 Years Old: From Underrepresentation in Clinical Trials to Overrepresentation in Contemporary Clinical Practice.

Cardiac Implantable Electronic Devices (CIEDs), ranging from Permanent Pacemakers (PPMs) for bradycardia, Implantable Cardioverter-Defibrillators (ICDs), to Cardiac Resynchronization Therapy (CRT) with Pacing (CRT-P) or Defibrillation (CRT-D), have been shown to significantly improve morbidity and mortality across a variety of clinical scenarios. The burden of cardiovascular disease and the indications for CIED implantation increase with age. These trends are becoming increasingly apparent with rising life expectancy, necessitating evidencebased therapeutic interventions for older adult patients. However, older adults, particularly those aged ≥75 years, were either markedly underrepresented or excluded from major Randomized Controlled Trials (RCTs) evaluating CIED, in which the mean participant age was predominantly in the 60s. Consequently, there has been a tendency to extrapolate the findings of these trials in subsequent guideline recommendations and consensus statements to older adults despite the lack of clear, adequately tested evidence regarding the benefits and risks of such recommendations in this population. As a result, real-world observational studies, in which older adults are often overrepresented, have largely been relied upon to characterize the efficacy and safety of CIED implantation. Complications associated with CIED implantation and long-term outcomes are generally worse in older adults than in younger patients, particularly among those with premature biological aging, increased frailty, and/or a high burden of comorbidities. Nevertheless, uncertainty remains regarding the balance of benefits and risks associated with certain invasive cardiac device therapies in older adults. This narrative review critically summarizes the current evidence regarding the efficacy and safety of CIEDs in adults aged ≥75 years compared with those aged <75 years.