Faculty Bibliography

OBJECTIVE: Risk stratification models support clinical decision making in acute myocardial infarction (AMI) care. Existing models were developed using data from younger populations, potentially limiting accuracy and relevance in older adults. We describe physician-perceived risk factors, views of existing models, and preferences for future model development in older adults. METHOD: Qualitative study using semi-structured telephone interviews and the constant comparative method. RESULTS: Twenty-two physicians from 14 institutions completed the interviews. Median age was 37, and median years of clinical experience was 11.5. Perceived predictors included cardiovascular, comorbid, functional, and social risk factors. Physicians viewed models as easy to use, yet neither inclusive of risk factors nor predictive of non-mortality outcomes germane to clinical decision making in older adults. Ideal models included multidimensional risk domains and operational requirements. DISCUSSION: Physicians reported limitations of available risk models when applied to older adults with AMI. New models are needed to guide AMI treatment in this population.

BACKGROUND: Epidemiological studies in humans that have evaluated the association between fine particulate matter (PM2.5) and atherosclerosis have yielded mixed results. DESIGN: In order to further investigate this relationship, we conducted a comprehensive search for studies published through May 2014 and performed a meta-analysis of all available observational studies that investigated the association between PM2.5 and three noninvasive measures of clinical and subclinical atherosclerosis: carotid intima media thickness, arterial calcification, and ankle-brachial index. METHODS AND RESULTS: Five reviewers selected studies based on predefined inclusion criteria. Pooled mean change estimates and 95% confidence intervals were calculated using random-effects models. Assessment of between-study heterogeneity was performed where the number of studies was adequate. Our pooled sample included 11,947 subjects for carotid intima media thickness estimates, 10,750 for arterial calcification estimates, and 6497 for ankle-brachial index estimates. Per 10 microg/m(3) increase in PM2.5 exposure, carotid intima media thickness increased by 22.52 microm but this did not reach statistical significance (p = 0.06). We did not find similar associations for arterial calcification (p = 0.44) or ankle-brachial index (p = 0.85). CONCLUSION: Our meta-analysis supports a relationship between PM2.5 and subclinical atherosclerosis measured by carotid intima media thickness. We did not find a similar relationship between PM2.5 and arterial calcification or ankle-brachial index, although the number of studies was small.

OBJECTIVES: To determine the prognostic value of slow gait in predicting outcomes 1 year after acute myocardial infarction (AMI). DESIGN: Observational cohort with longitudinal follow-up. SETTING: Twenty-four U.S. hospitals participating in the Translational Research Investigating Underlying disparities in recovery from acute Myocardial infarction: Patients' Health status Registry. PARTICIPANTS: Older adults (>/=65) with in-home gait assessment 1 month after AMI (N = 338). MEASUREMENTS: Baseline characteristics and 1-year mortality or hospital readmission adjusted using Cox proportional hazards regression in older adults with slow (<0.8 m/s) versus preserved (>/=0.8 m/s) gait speed. RESULTS: Slow gait was present in 181 participants (53.6%). Those with slow gait were older, more likely to be female and nonwhite, and had a higher prevalence of heart failure and diabetes mellitus. They were also more likely to die or be readmitted to the hospital within 1 year than those with preserved gait (35.4% vs 18.5%, log-rank P = .006). This association remained significant after adjusting for age, sex, and race (slow vs preserved gait hazard ratio (HR) = 1.76, 95% confidence interval (CI)=1.08-2.87, P = .02) but was no longer significant after adding clinical factors (HR = 1.23, 95% CI=0.74-2.04, P = .43). CONCLUSION: Slow gait, a marker of frailty, is common 1 month after AMI in older adults and is associated with nearly twice the risk of dying or hospital readmission at 1 year. Understanding its prognostic importance independent of comorbidities and whether routine testing of gait speed can improve care requires further investigation.

The population of older adults is expanding rapidly, and aging predisposes to cardiovascular disease. The principle of patient-centered care must respond to the preponderance of cardiac disease that now occurs in combination with the complexities of old age. Geriatric cardiology melds cardiovascular perspectives with multimorbidity, polypharmacy, frailty, cognitive decline, and other clinical, social, financial, and psychological dimensions of aging. Although some assume that a cardiologist may instinctively cultivate some of these skills over the course of a career, we assert that the volume and complexity of older cardiovascular patients in contemporary practice warrants a more direct approach to achieve suitable training and a more reliable process of care. We present a rationale and vision for geriatric cardiology as a melding of primary cardiovascular and geriatrics skills, thereby infusing cardiology practice with expanded proficiencies in diagnosis, risks, care coordination, communications, end-of-life, and other competences required to best manage older cardiovascular patients.

Background: Fall-related major bleeding is a concern among clinicians who are hesitant to prescribe oral anticoagulation to older adults with atrial fibrillation. Objectives: The aim of this study was to describe the incidence and risk factors of this outcome in large datasets. Methods: We created a retrospective cohort of 33 732 veterans with atrial fibrillation aged >75 years who were new referrals to VA anticoagulation clinics (warfarin therapy) between 1 January 2001 and 31 December 2012. Patients with comorbid conditions requiring warfarin (mechanical heart valve, pulmonary embolus) were excluded. Clinical characteristics, laboratory, and pharmacy data were extracted from the VA electronic medical record. We then linked VA data with Medicare claims data for subsequent hospitalizations. The primary outcome (fall-related major bleeding) was defined as any hospitalization for traumatic intracranial bleeding, hemarthrosis, or fracture-related bleeding. Cox proportional hazards regression was used to determine predictors of interest selected a priori based on prior known associations. Results: Mean patient age was 81.1+/-4.1 years, and comorbidities were common (hypertension 82.2%, coronary artery disease 42.8%, diabetes 33.6%). Over the study period, the incidence rate of fall-related major bleeding was 4.60 per 1000 person-years, and nearly all of these events (99.0%) resulted in traumatic intracranial hemorrhages. In unadjusted models, significant predictors for fall-related major bleeding included dementia (HR 1.84, 95%CI 1.31-2.58), fall within the past year (HR 1.60, 95%CI 1.11-2.29), depression (HR 1.48, 95%CI 1.21-1.80), hypertension (HR 1.24, 95%CI 1.00-1.54), abnormal renal/liver function (HR 1.50, 95%CI 1.06-2.11), prior stroke (HR 1.49, 95%CI 1.13-1.96), and labile international normalized ratio (INR) (HR 1.90, 95%CI 1.12-3.24). After adjusting for potential confounders, labile INR, dementia, depression, and stroke and remained significant predictors. Conclusions: Fall-related major bleeding is a relatively uncommon event among older adults receiving anticoagulation for AF. However, several factors place patients at increased risk, and optimal management for this high-risk phenotype deserves further study

IMPORTANCE: Epidemiological evidence suggests that physical activity benefits cognition, but results from randomized trials are limited and mixed. OBJECTIVE: To determine whether a 24-month physical activity program results in better cognitive function, lower risk of mild cognitive impairment (MCI) or dementia, or both, compared with a health education program. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial, the Lifestyle Interventions and Independence for Elders (LIFE) study, enrolled 1635 community-living participants at 8 US centers from February 2010 until December 2011. Participants were sedentary adults aged 70 to 89 years who were at risk for mobility disability but able to walk 400 m. INTERVENTIONS: A structured, moderate-intensity physical activity program (n = 818) that included walking, resistance training, and flexibility exercises or a health education program (n = 817) of educational workshops and upper-extremity stretching. MAIN OUTCOMES AND MEASURES: Prespecified secondary outcomes of the LIFE study included cognitive function measured by the Digit Symbol Coding (DSC) task subtest of the Wechsler Adult Intelligence Scale (score range: 0-133; higher scores indicate better function) and the revised Hopkins Verbal Learning Test (HVLT-R; 12-item word list recall task) assessed in 1476 participants (90.3%). Tertiary outcomes included global and executive cognitive function and incident MCI or dementia at 24 months. RESULTS: At 24 months, DSC task and HVLT-R scores (adjusted for clinic site, sex, and baseline values) were not different between groups. The mean DSC task scores were 46.26 points for the physical activity group vs 46.28 for the health education group (mean difference, -0.01 points [95% CI, -0.80 to 0.77 points], P = .97). The mean HVLT-R delayed recall scores were 7.22 for the physical activity group vs 7.25 for the health education group (mean difference, -0.03 words [95% CI, -0.29 to 0.24 words], P = .84). No differences for any other cognitive or composite measures were observed. Participants in the physical activity group who were 80 years or older (n = 307) and those with poorer baseline physical performance (n = 328) had better changes in executive function composite scores compared with the health education group (P = .01 for interaction for both comparisons). Incident MCI or dementia occurred in 98 participants (13.2%) in the physical activity group and 91 participants (12.1%) in the health education group (odds ratio, 1.08 [95% CI, 0.80 to 1.46]). CONCLUSIONS AND RELEVANCE: Among sedentary older adults, a 24-month moderate-intensity physical activity program compared with a health education program did not result in improvements in global or domain-specific cognitive function. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01072500.

OBJECTIVES: To evaluate physician-perceived strengths and limitations of the Thrombolysis in Myocardial Infarction (TIMI) risk scores for use in older adults with acute myocardial infarction (AMI). BACKGROUND: The TIMI risk scores are risk stratification models developed to estimate mortality risk for patients hospitalized for AMI. However, these models were developed and validated in cohorts underrepresenting older adults (>/=75 years). METHODS: Qualitative study using semi-structured telephone interviews and the constant comparative method for analysis. RESULTS: Twenty-two physicians completed interviews ranging 10-30 min (mean = 18 min). Median sample age was 37 years, with a median of 11.5 years of clinical experience. TIMI strengths included familiarity, ease of use, and validation. Limitations included a lack of risk factors relevant to older adults and model scope and influence. CONCLUSIONS: Physicians report that the TIMI models, while widely used in clinical practice, have limitations when applied to older adults. New risk models are needed to guide AMI treatment in this population.

BACKGROUND: An increased resting heart rate (RHR) has long been associated with unhealthy life. Nevertheless, it remains uncertain whether time-varying measurements of RHR are predictive of mortality in older persons. DESIGN: The purpose of this study was to assess the relationship between repeated measurements of RHR and risk of death from all causes among older adults. METHODS: We evaluated repeat measurements of resting heart rate among 5691 men and women (aged 65 years or older) enrolled in the Cardiovascular Health Study. RHR was measured annually for six consecutive years by validated electrocardiogram. All-cause mortality was confirmed by a study-wide Mortality Review Committee using reviews of obituaries, death certificates and hospital records, interviews with attending physicians, and next-of-kin. RESULTS: Of the study cohort, 974 (17.1%) participants died. Each 10 beat/min increment in RHR increased the risk of death by 33% (adjusted hazard ratio, 95% confidence interval (CI) = 1.33, 1.26-1.40). Similar results were observed (adjusted hazard ratio, 95% CI = 2.21, 1.88-2.59) when comparing the upper-most quartile of RHR (mean = 81 beats/min) with the lowest (mean = 53 beats/min). Compared with participants whose RHR was consistently