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Cardiac rehabilitation (CR) is Class IA indication in patients after an acute cardiovascular (CV) event, with efficacy confirmed even in elderly or frail CV patients CV and geriatric outcomes. However, rate of referral and admission to CR of elderly CV patients remains very low. CV patients admitted in geriatric wards are often complex, multimorbid and frail. Therefore, the present position paper addressees their possible referral to CR, since many have various forms of CV diseases amenable to improve with CR. The multidisciplinary and comprehensive model of CR is applicable to these patients where evaluation and interventions should be tailored to the patient functional and clinical status, aiming to appropriate targets. Cardiologist, Geriatrician and other professionals, should synergistically integrate their competences, thus outlining also the new paradigm of "Cardiogeriatric Rehabilitation and Prevention", possibly leading to an increased awareness of the beneficial effect of CR and to an increased referral to CR from Geriatric departments. Operative recommendations are given, based on appropriateness and priority of indications, clinical risk and frailty level, integrating different expertise to reach more effective programs of care.

At present, the efficacy and safety of anticoagulants, warfarin, or new oral anticoagulants in frail patients remain unknown, as these patients have largely been excluded from both randomized trials and "real-world" studies; as a result, the guidelines do not provide guidance for the management of this population. Frail patients with atrial fibrillation (AF) are significantly less likely to receive oral anticoagulants compared to their nonfrail counterparts; is that an expression of reasonable prudence or malpractice? In this regard, some aspects of physical frailty should be considered: (i) increased vulnerability to stressors, including pharmacological agents with potential severe adverse effects; (ii) frail elderly patients are at high risk of falls and, therefore, of severe traumatic hemorrhages on oral anticoagulation; (iii) frail patients are more likely to have complications during intercurrent affections, potentially responsible for hemorrhages. Prospective "real-world" studies including frail AF patients are necessary. Waiting for more evidence, the doubt whether to prescribe or not an oral anticoagulant to frail AF patients remains legitimate.

Syncope is quite common in older patients, with a 10% prevalence and a 33% 2-year recurrence rate. Syncope-associated morbidity is also common in older patients, ranging from loss of confidence or depressive symptoms due to fear of falling, to fractures and consequent disability and institutionalization. Moreover, advanced age is associated with significant short- and long-term mortality after syncope. Neurally mediated (51%) and orthostatic syncope (12%) are the two most common forms of syncope in the elderly. Indeed, those older than 75 years have orthostatic hypotension in 30.5% of cases, a finding that confirms the clinical relevance of systematically measuring blood pressure in the supine and upright position in this age group. A standardized approach, based on initial evaluation (clinical history, physical examination, 12-lead ECG), followed by neuroautonomic assessment (tilt testing, carotid sinus massage), can obtain a definite diagnosis in more than 90% of older patients with syncope. Given the high rate of carotid sinus syndrome in the elderly, the European Society of Cardiology (ESC) guidelines for the diagnosis and management of syncope suggest carotid sinus massage as part of the initial evaluation. The diagnostic work-up can be completed by advanced tools, such as the implantable loop recorder, useful in making diagnosis when syncope is not so frequent to be detected by standard monitoring methods. The device can also be indicated at an early stage in low-risk patients with recurrent or unexplained syncope. For a comprehensive management of patients with syncope from risk stratification to diagnosis, treatment and follow-up, the ESC guidelines also suggest the implementation of functional and multidisciplinary Syncope Units, which may be successful in reducing inappropriate tests and hospitalization rates.

Syncope is a common symptom accounting for 1.1% of all admissions to the emergency department in Italy. Diagnostic and therapeutic management of patients with syncope may be complex and with a major impact on health expenditure. A standardized approach to syncope may reduce diagnostic tests, hospitalizations and health costs. After the initial "gold standard" evaluation, which includes history, physical examination, orthostatic hypotension test and ECG, several diagnostic pathways can be followed. It has been shown that a correct initial evaluation and a thorough knowledge of syncope can reduce needless testing and increase diagnostic yield, optimizing resource management. In this review we aim to underscore the key points of the management of patients with syncope and the main indications for specific second-level examinations, such as those for neuroautonomic evaluation (tilt table test, carotid sinus massage) and implantable loop recorder. The role of Syncope Units in the management of patients with temporary loss of consciousness is also described.