Core Competencies of the Modern Geriatric Cardiologist: A Framework for Comprehensive Cardiovascular Care in Older Adults

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

In this interesting paper, the authors offer their point of view on the role and importance of geriatric cardiologist in the modern cardiology era. Old patients are increasingly more common and they are characterised by specific needs; therefore appropriate competencies should be developed. 

The paper provides interesting insights coming from the authors' experience, as well as from a narrative review of available evidence. The manuscript is well written, with appropriate statements. 

Given the (almost) single center origin of the manuscript, I would suggest the authors to better state that this "position paper" summarises the idea of a small group of physicians. 

I would also suggest to better develop potential differences among cardiovascular conditions, especially regarding HF. In this context I would suggest to cite more recent papers on the role of frailty in HF, e.g. 10.1002/ejhf.3234 and 10.1002/ehf2.15187, discussing how multi-domain assessment is needed in this context and how frailty impacts on the prognosis of these patients. 

Author Response

Response to Reviewer 1.

We sincerely thank the reviewer for the positive and constructive evaluation of our manuscript and for highlighting the relevance of cardiogeriatric competencies in the context of an ageing cardiovascular population. All revisions have been detailed point by point in the Response to Reviewers document.

1. Clarification of the scope and origin of the position paper

We fully agree with the reviewer’s comment regarding the origin and scope of this manuscript. As suggested, we have clarified that this article represents a position paper reflecting the perspectives of a limited group of physicians with expertise in cardiogeriatrics, largely grounded in a shared clinical experience within integrated cardiogeriatric care pathways.

Accordingly, we have explicitly stated in the Methods (Study Design) and Scope and Limitations sections that:

• this work does not claim to represent an official consensus or guideline,
• it reflects the conceptual synthesis of a small, multidisciplinary group of clinicians,
• and its aim is to propose a pragmatic framework intended to stimulate discussion, education, and future research rather than to provide prescriptive recommendations.

 

2. Development of condition-specific considerations, with a focus on heart failure

We also fully agree that potential differences across cardiovascular conditions deserve clearer emphasis, particularly in heart failure (HF), where geriatric complexity is most pronounced.

In response, we have:

• expanded the sections on heart failure in both the Introduction and Core Clinical Competencies,
• reinforced the discussion on how frailty, multimorbidity, and functional vulnerability specifically modify prognosis, therapeutic tolerance, and decision-making in HF,
• emphasised the necessity of a multi-domain assessment, integrating functional, cognitive, nutritional, and social dimensions alongside conventional cardiac parameters.

As suggested, we have cited and discussed recent, relevant literature addressing frailty in HF, including:

• the impact of frailty on prognosis and hospitalisation,
• the added value of multidimensional assessment beyond disease-centred severity markers,
• and the implications for individualised, proportionate HF management.

These additions strengthen the manuscript’s condition-specific perspective and align the competency framework more closely with contemporary evidence in HF populations.

 

We thank the reviewer for these insightful suggestions, which have helped us improve the clarity, transparency, and clinical relevance of the manuscript.

 

Dr Esser

Reviewer 2 Report

Comments and Suggestions for Authors

1. Content Analysis and Critical Points

The article proposes a solid theoretical framework, but presents some areas that could benefit from further depth to increase its scientific value:

• Lack of Systematic Methodology: The authors state that this is a "narrative review". However, the use of non-systematic search criteria may introduce selection bias. It would be appropriate to include a table summarizing the main studies analyzed to support each competency domain.
• Absence of Framework Validation: The proposed framework remains conceptual and has not yet been prospectively validated⁴. The authors should suggest specific metrics (KPIs) to evaluate the effectiveness of these competencies in real-world clinical practice.
• Integration between Cardiologists and Geriatricians: While the article proposes "dual-profile expertise," it does not delve into the logistical and bureaucratic obstacles (e.g., healthcare reimbursement, legal responsibilities) that might prevent geriatricians from performing advanced cardiological tasks like echocardiography.
• Specificity of Guidelines: The article frequently mentions the limitations of conventional guidelines for older populations⁷⁷⁷⁷. It would be useful to provide a tabular comparison between the "standard" approach and the "cardiogeriatric" approach for specific scenarios, such as heart failure or valvular disease in the very old.

2. Grammatical and Syntactic Aspects

The text is written in high-level academic English, but there is room for improvement in fluidity and precision:

• Use of Verb Tenses: In the "Methods" section, the authors shift from the past tense ("was designed," "was selected") to the present tense ("seeks to offer"). It is preferable to maintain the past tense when describing actions completed during the review process.
• Conceptual Repetitions: The concept that cardiogeriatrics is "insufficiently structured" or "defined" is repeated almost identically in multiple places. An editorial revision could consolidate these observations to make the introduction more incisive.
• Punctuation: In some long sentences, the lack of serial commas or the excessive use of parenthetical clauses makes reading difficult, especially in the descriptions of system-based competencies.

3. Analysis of Abbreviations

The use of abbreviations in the text is extremely limited; while this favors clarity, it also makes the text redundant:

• Failure to Abbreviate Recurring Terms: Terms like "Comprehensive Geriatric Assessment" and "Guideline-Directed Medical Therapy" appear many times. It is a scientific standard to introduce the acronym at the first occurrence (e.g., CGA and GDMT) to streamline the text.
• Consistency: The authors use both ">85 years" and "5 years" in different sections. The use of mathematical symbols should be standardized throughout the document.
• Society Acronyms: Guidelines from the ESC, AHA, and ACC are cited, but the acronyms are not always fully defined at the first mention, assuming prior knowledge that may not be guaranteed for all readers of a multidisciplinary journal.

4. Template

It needs to use the template of MDPI

Author Response

Response to Reviewer 2.

We thank the reviewer for the thorough and constructive evaluation of our manuscript. We are grateful for the insightful comments, which have helped us strengthen the methodological transparency, scientific depth, and clarity of the paper. All revisions have been detailed point by point in the Response to Reviewers document.

Comment 1: Lack of Systematic Methodology

The authors state that this is a "narrative review". However, the use of non-systematic search criteria may introduce selection bias. It would be appropriate to include a table summarizing the main studies analyzed to support each competency domain.

Response:
We thank the reviewer for this important methodological comment. We agree that narrative reviews may be subject to selection bias and have therefore clarified the rationale for adopting a non-systematic approach. As our objective was to develop a competency-based conceptual framework integrating heterogeneous clinical, organisational, and ethical domains, a systematic review methodology was not pursued.

To enhance transparency, we have explicitly acknowledged the potential for selection bias in the Methods (Section 2.2) and justified the appropriateness of a narrative approach for the aims of this position paper. In addition, as suggested, we have added Table 1, which provides a non-exhaustive summary of representative studies and key evidence supporting each cardiogeriatric competency domain.

Changes made:

• Section 2.2 Literature Search and Sources
• Addition of Table 1 summarising key evidence by competency domain

 

Comment 2: Absence of Framework Validation / KPIs

The proposed framework remains conceptual and has not yet been prospectively validated. The authors should suggest specific metrics (KPIs) to evaluate the effectiveness of these competencies in real-world clinical practice.

Response:
We agree with the reviewer that the proposed framework has not yet been prospectively validated. This limitation has been explicitly acknowledged. In response to the suggestion, we have expanded the Future Perspectives (Section 9) to propose concrete and measurable key performance indicators (KPIs) that could be used to assess the real-world impact of cardiogeriatric competencies.

These proposed KPIs include functional decline, unplanned hospitalisation, medication-related adverse events, documentation of shared decision-making, and alignment between delivered care and patient goals, alongside traditional cardiovascular outcomes. We believe this addition clarifies how the framework could be operationalised and evaluated in future clinical and implementation studies.

Changes made:

• Section 9 Future Perspectives (explicit proposal of KPIs)
• Section 10 Conclusions (acknowledgement of lack of prospective validation)

 

Comment 3: Integration between Cardiologists and Geriatricians

While the article proposes "dual-profile expertise," it does not delve into the logistical and bureaucratic obstacles that might prevent geriatricians from performing advanced cardiological tasks.

Response:
We thank the reviewer for highlighting this important practical dimension. We have addressed this point by expanding the discussion in the Future Perspectives (Section 9) to explicitly acknowledge potential barriers to implementation, including regulatory constraints, reimbursement models, and medico-legal responsibilities that vary across healthcare systems.

We intentionally kept this discussion at a conceptual and international level, as these barriers differ substantially between countries, but we believe this addition appropriately recognises the complexity of translating dual-profile cardiogeriatric expertise into practice.

Changes made:

• Section 9 Future Perspectives (discussion of regulatory, reimbursement, and medico-legal barriers)

 

Comment 4: Specificity of Guidelines

It would be useful to provide a tabular comparison between the "standard" approach and the "cardiogeriatric" approach for specific scenarios, such as heart failure or valvular disease in the very old.

Response:
We agree with the reviewer that a more concrete comparison would strengthen the manuscript. Accordingly, we have added Table 2 in Section 4.1 (Cardiovascular Expertise Adapted to Ageing), contrasting standard guideline-based approaches with cardiogeriatric strategies in selected cardiovascular scenarios frequently encountered in very old patients (heart failure ≥85 years, severe aortic stenosis, and atrial fibrillation).

This table aims to illustrate how cardiogeriatric competencies translate into real-world clinical decision-making beyond conventional guideline frameworks.

Changes made:

• Section 4.1 Cardiovascular Expertise Adapted to Ageing
• Addition of Table 2

 

Grammatical and Syntactic Aspects

Comment 5: Use of Verb Tenses

In the "Methods" section, the authors shift from the past tense to the present tense.

Response:
We thank the reviewer for this careful observation. The Methods section has been revised to ensure consistent use of the past tense when describing actions completed during the review process. Present tense has been retained only where appropriate for general statements or future-oriented perspectives.

Changes made:

• Sections 2.1, 2.2, and 2.4 (harmonisation of verb tenses)

 

Comment 6: Conceptual Repetitions

The concept that cardiogeriatrics is "insufficiently structured" is repeated in multiple places.

Response:
We agree with this comment. The Introduction has been edited to consolidate these statements, retaining a single, clear articulation of this concept to improve conciseness and narrative flow.

Changes made:

• Section 1 Introduction (removal of redundant statements)

 

Comment 7: Punctuation and Readability

Some long sentences reduce readability.

Response:
The manuscript has undergone careful editorial revision to improve sentence structure, punctuation, and overall readability, particularly in sections describing system-based and organisational competencies.

 

Analysis of Abbreviations

Comment 8: Use and Consistency of Abbreviations

Recurring terms and society acronyms are not always abbreviated or defined at first mention.

Response:
We have revised the manuscript to ensure that all recurring terms and society names are defined at their first occurrence and consistently abbreviated thereafter, including Comprehensive Geriatric Assessment (CGA), Guideline-Directed Medical Therapy (GDMT), European Society of Cardiology (ESC), American Heart Association (AHA), and American College of Cardiology (ACC). Mathematical notation has also been standardised (e.g., ≥85 years).

Changes made:

• Throughout the manuscript (first occurrences and subsequent usage)

 

Template

Comment 9: MDPI Template

Response:
The manuscript has been formatted according to the MDPI Journal of Clinical Medicine template, including section structure, tables, figures, and captions.

 

Once again, we thank the reviewer for these valuable comments, which have substantially improved the clarity, transparency, and scientific robustness of our manuscript.

 

Dr Esser

Reviewer 3 Report

Comments and Suggestions for Authors

Rémi Esser et al. present a narrative review with the aim to define the core competencies of the geriatric cardiologist in the contemporary era. The manuscript is well-written but introduction and references should be improved. The figure is well presented.
Important changes need to be made:

1. The concept of frailty and its relationship to the field of cardiology should be emphasized;
2. Cite all ESC guidelines in the introduction that highlight the importance of the geriatric cardiologist in various cardiovascular diseases;
3. The role of the geriatric cardiologist is crucial in cardiac rehabilitation. Please discuss this point in the introduction;
4. The section “Cardiovascular Expertise Adapted to Ageing” should be improved by discussing the role of the geriatric cardiologist in individual and diverse cardiovascular diseases such as coronary artery disease, valvular heart disease, peripheral arterial and aortic diseases, and different types of heart failure (above all HFrEF).
5. A specific paragraph must be added on the role of geriatric cardiologist and cardiovascular risk factors such as hypertension, diabetes mellitus, and dyslipidaemias. Regarding diabetes mellitus, it is important to emphasize the key role of the geriatric cardiologist in the diagnosis and management of these patients and their complications, such as diabetic cardiomyopathy. To improve this new paragraph and increase its scientific impact, I suggest adding the following important reference: “Rizza V et al. Diabetic cardiomyopathy: pathophysiology, imaging assessment and therapeutical strategies. Int J Cardiol Cardiovasc Risk Prev. 2024 Sep 28;23:200338. doi: 10.1016/j.ijcrp.2024.200338.”

Author Response

Response to Reviewer 3.

Dear Reviewer,

We sincerely thank you for your careful reading of our manuscript and for your constructive comments. We are grateful for your positive assessment of the overall quality of the manuscript and the figure. We have revised the introduction and expanded key sections to address each of your suggestions in detail, as outlined below.

 

Comment 1: The concept of frailty and its relationship to the field of cardiology should be emphasized.

Response:
We agree with the reviewer that frailty is central to modern cardiovascular care in older adults and should be presented as a transversal concept beyond heart failure. We have strengthened the Introduction to emphasise frailty as a determinant influencing treatment tolerance, procedural risk, functional recovery, and outcomes across multiple cardiovascular conditions.

Changes made:

• Introduction: added a dedicated paragraph emphasising frailty as a cross-cutting concept in cardiology for older adults.

 

Comment 2: Cite all ESC guidelines in the introduction that highlight the importance of the geriatric cardiologist in various cardiovascular diseases.

Response:
We thank the reviewer for this important suggestion. We have revised the Introduction to explicitly reference major European Society of Cardiology (ESC) guidelines that highlight the need for frailty assessment, geriatric syndromes, and individualised decision-making in older patients across cardiovascular diseases. To maintain conciseness while ensuring adequate coverage, we cited core ESC guidelines spanning heart failure, atrial fibrillation, valvular heart disease, and cardiovascular prevention.

Changes made:

• Introduction: added explicit citations to ESC guidelines on heart failure, atrial fibrillation, valvular heart disease, and cardiovascular prevention.

 

Comment 3: The role of the geriatric cardiologist is crucial in cardiac rehabilitation. Please discuss this point in the introduction.

Response:
We agree and have incorporated a specific statement in the Introduction to highlight the geriatric cardiologist’s role in cardiac rehabilitation, particularly in integrating cardiovascular recovery with frailty assessment, comorbidity management, functional reconditioning, and goal-oriented care in very old and vulnerable patients.

Changes made:

• Introduction: added a dedicated sentence addressing cardiogeriatric expertise in cardiac rehabilitation.

 

Comment 4: The section “Cardiovascular Expertise Adapted to Ageing” should be improved by discussing the role of the geriatric cardiologist in individual and diverse cardiovascular diseases such as coronary artery disease, valvular heart disease, peripheral arterial and aortic diseases, and different types of heart failure (above all HFrEF).

Response:
We thank the reviewer for encouraging broader condition-specific discussion. We have expanded Section 4.1 to include concise, clinically grounded considerations for coronary artery disease, valvular heart disease, peripheral arterial disease and aortic diseases, and to better distinguish heart failure phenotypes, with a particular emphasis on HFrEF and the adaptation of guideline-directed therapies to tolerance, multimorbidity, and patient priorities.

Changes made:

• Section 4.1 (Cardiovascular Expertise Adapted to Ageing): added a new paragraph detailing the cardiogeriatric approach across coronary artery disease, valvular heart disease, peripheral arterial and aortic diseases, and heart failure phenotypes (including HFrEF).

 

Comment 5: A specific paragraph must be added on the role of geriatric cardiologist and cardiovascular risk factors such as hypertension, diabetes mellitus, and dyslipidaemias. Regarding diabetes mellitus, it is important to emphasize the key role of the geriatric cardiologist in the diagnosis and management of these patients and their complications, such as diabetic cardiomyopathy. Please add the reference by Rizza et al. (2024).

Response:
We agree and have added a dedicated paragraph addressing cardiovascular risk-factor management as a core domain of cardiogeriatric expertise. This new paragraph focuses on individualising preventive targets and therapeutic intensity in older adults with frailty and multimorbidity, balancing cardiovascular benefit against treatment burden and adverse events. We also expanded the discussion on diabetes mellitus, highlighting the geriatric cardiologist’s role in recognising and managing cardiovascular complications, including diabetic cardiomyopathy. As suggested, we have added the reference by Rizza et al. (2024) to support this section.

Changes made:

• Section 4.1: added a dedicated paragraph on hypertension, diabetes mellitus, and dyslipidaemias in older adults, including diabetic cardiomyopathy.
• References: added Rizza V et al. Int J Cardiol Cardiovasc Risk Prev. 2024;23:200338. doi:10.1016/j.ijcrp.2024.200338.

 

We again thank the reviewer for these valuable comments, which have improved the depth and scientific impact of the manuscript.

Kind regards,

Rémi Esser, MD, PhD
On behalf of all authors

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is improved, but there is a lack of MDPI style

Author Response

Reviewer Comment:
The manuscript is improved, but there is a lack of MDPI style.

Response:
We thank the reviewer for this comment. The manuscript has been carefully revised to further align with MDPI and Journal of Clinical Medicine stylistic requirements. Minor typographical and formatting adjustments have been applied throughout the manuscript, including figures, tables, and end sections. The scientific content remains unchanged.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

The authors responded satisfactorily to my requests and comments.

Author Response

We thank the reviewer for this positive assessment.