Faculty Bibliography

BACKGROUND:Oldest-old patients (≥85 years) constitute half the acute myocardial infarction hospitalizations among older adults and more commonly have atypical presentation, under-treatment and functional impairments. Yet this group has not been well characterized. OBJECTIVES/OBJECTIVE:We characterized differences in presentation, functional impairments, treatments, health status, and mortality among middle-old (75-84 years) and oldest-old patients with myocardial infarction. METHODS:We analyzed data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study that enrolled 3041 patients ≥75 years of age from 94 hospitals across the US between 2013-2016. We performed Cox proportional hazards regression to examine the association between the oldest-old (n=831) and middle-old (n=2210) age categories with post-discharge 6-month case fatality rate adjusting for socio-demographic and clinical variables, and mobility impairment. RESULTS:The oldest-old were less likely to present with chest pain (52.7% vs. 57.7%) as their primary symptom or to receive coronary revascularization (58.1% vs. 71.8) (p<0.01 for both). The oldest-old were more likely to have functional impairments and had higher 6-month mortality compared with the middle-old patients (HR 1.78, 95% CI 1.39-2.28). This association was substantially attenuated after adjusting for mobility impairment (HR 1.29, 95% CI 0.99-1.68). CONCLUSIONS:There is considerable heterogeneity in presentation, treatment and outcomes among older patients with myocardial infarction. Mobility impairment, a marker for frailty, modifies the association between advanced age and treatments as well as outcomes.

OBJECTIVE:To develop a 180-day readmission risk model for older adults with acute myocardial infarction (AMI) that considered a broad range of clinical, demographic and age-related functional domains. METHODS:We used data from ComprehenSIVe Evaluation of Risk in Older Adults with AMI (SILVER-AMI), a prospective cohort study that enrolled participants aged ≥75 years with AMI from 94 US hospitals. Participants underwent an in-hospital assessment of functional impairments, including cognition, vision, hearing and mobility. Clinical variables previously shown to be associated with readmission risk were also evaluated. The outcome was 180-day readmission. From an initial list of 72 variables, we used backward selection and Bayesian model averaging to derive a risk model (N=2004) that was subsequently internally validated (N=1002). RESULTS:Of the 3006 SILVER-AMI participants discharged alive, mean age was 81.5 years, 44.4% were women and 10.5% were non-white. Within 180 days, 1222 participants (40.7%) were readmitted. The final risk model included 10 variables: history of chronic obstructive pulmonary disease, history of heart failure, initial heart rate, first diastolic blood pressure, ischaemic ECG changes, initial haemoglobin, ejection fraction, length of stay, self-reported health status and functional mobility. Model discrimination was moderate (0.68 derivation cohort, 0.65 validation cohort), with good calibration. The predicted readmission rate (derivation cohort) was 23.0% in the lowest quintile and 65.4% in the highest quintile. CONCLUSIONS:Over 40% of participants in our sample experienced hospital readmission within 180 days of AMI. Our final readmission risk model included a broad range of characteristics, including functional mobility and self-reported health status, neither of which have been previously considered in 180-day risk models.

The growing population of older adults (age ≥65 years) is expected to lead to higher rates of cardiovascular disease. The expansion of digital health (encompassing telehealth, telemedicine, mobile health, and remote patient monitoring), Internet access, and cellular technologies provides an opportunity to enhance patient care and improve health outcomes-opportunities that are particularly relevant during the current coronavirus disease-2019 pandemic. Insufficient dexterity, visual impairment, and cognitive dysfunction, found commonly in older adults should be taken into consideration in the development and utilization of existing technologies. If not implemented strategically and appropriately, these can lead to inequities propagating digital divides among older adults, across disease severities and socioeconomic distributions. A systematic approach, therefore, is needed to study and implement digital health strategies in older adults. This review will focus on current knowledge of the benefits, barriers, and use of digital health in older adults for cardiovascular disease management.

OBJECTIVE:Electronic health records (EHRs) have become a common data source for clinical risk prediction, offering large sample sizes and frequently sampled metrics. There may be notable differences between hospital-based EHR and traditional cohort samples: EHR data often are not population-representative random samples, even for particular diseases, as they tend to be sicker with higher healthcare utilization, while cohort studies often sample healthier subjects who typically are more likely to participate. We investigate heterogeneities between EHR- and cohort-based inferences including incidence rates, risk factor identifications/quantifications, and absolute risks. MATERIALS AND METHODS/METHODS:This is a retrospective cohort study of older patients with type 2 diabetes using EHR from New York University Langone Health ambulatory care (NYULH-EHR, years 2009-2017) and from the Health and Retirement Survey (HRS, 1995-2014) to study subsequent cardiovascular disease (CVD) risks. We used the same eligibility criteria, outcome definitions, and demographic covariates/biomarkers in both datasets. We compared subsequent CVD incidence rates, hazard ratios (HRs) of risk factors, and discrimination/calibration performances of CVD risk scores. RESULTS:The estimated subsequent total CVD incidence rate was 37.5 and 90.6 per 1000 person-years since T2DM onset in HRS and NYULH-EHR respectively. HR estimates were comparable between the datasets for most demographic covariates/biomarkers. Common CVD risk scores underestimated observed total CVD risks in NYULH-EHR. DISCUSSION AND CONCLUSION/CONCLUSIONS:EHR-estimated HRs of demographic and major clinical risk factors for CVD were mostly consistent with the estimates from a national cohort, despite high incidences and absolute risks of total CVD outcome in the EHR samples.

Background Functional decline (ie, a decrement in ability to perform everyday activities necessary to live independently) is common after acute myocardial infarction (AMI) and associated with poor long-term outcomes; yet, we do not have a tool to identify older AMI survivors at risk for this important patient-centered outcome. Methods and Results We used data from the prospective SILVER-AMI (Comprehensive Evaluation of Risk Factors in Older Patients With Acute Myocardial Infarction) study of 3041 patients with AMI, aged ≥75 years, recruited from 94 US hospitals. Participants were assessed during hospitalization and at 6 months to collect data on demographics, geriatric impairments, psychosocial factors, and activities of daily living. Clinical variables were abstracted from the medical record. Functional decline was defined as a decrement in ability to independently perform essential activities of daily living (ie, bathing, dressing, transferring, and ambulation) from baseline to 6 months postdischarge. The mean age of the sample was 82±5 years; 57% were men, 90% were White, and 13% reported activity of daily living decline at 6 months postdischarge. The model identified older age, longer hospital stay, mobility impairment during hospitalization, preadmission physical activity, and depression as risk factors for decline. Revascularization during AMI hospitalization and ability to walk a quarter mile before AMI were associated with decreased risk. Model discrimination (c=0.78) and calibration were good. Conclusions We identified a parsimonious model that predicts risk of activity of daily living decline among older patients with AMI. This tool may aid in identifying older patients with AMI who may benefit from restorative therapies to optimize function after AMI.

BACKGROUND: Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). However, readmissions from SNFs and immediately after SNF discharge are common. In this study, we examined whether patients with a primary hospital discharge diagnosis of HF may benefit from a HF disease management program (HF-DMP) while undergoing post-acute rehabilitation in SNFs.
METHOD(S): This is a sub-group analysis of a cluster-randomized controlled trial of HF-DMP vs usual care (UC) for patients in SNF (n=671) with a HF diagnosis, regardless of ejection fraction (EF), conducted in 47 SNFs in the Denver-metropolitan area. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by a HF nurse advocate (HFNA). The HFNA directed a 7- component intervention focused on optimizing HF disease management through the following: documentation of EF, symptom and activity assessment, weights 3 times a week with dietary surveillance, recommendations for medication titration, patient/caregiver education, discharge instructions, and 7-day post- SNF discharge follow-up. This sub-group analysis examined patients discharged from hospital to SNF with a primary hospital discharge diagnosis of HF (n=125). The primary outcome was a composite of all-cause hospitalization, emergency department visits, and mortality at 60 days post-SNF admission. The etiology (HF related, non-HF cardiovascular (CV) related, or "other") of the first event was adjudicated by a Clinical Endpoints committee that was blinded to treatment group. Secondary outcomes were the composite outcome at 30 days, and change in health status and self-management from baseline to 60 days measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Self-care of HF Index (SCHFI).
RESULT(S): Of the 125 patients with a primary hospital discharge diagnosis of HF, 50were in the HF-DMP and 75 in UC. Overallmean age was 79+/-10, 53% were women, mean EF was 46+/-15%. At 60 days, the rate of the composite outcome was lower in the HF-DMP group (30%) compared to UC (52%) (p=0.02). Adjudicated events in the HF-DMP group revealed one HF related event, one CV related event, and 12 events classified as "other" within 60 days. In contrast, the UC group had 12 HF related events, 5 CV related events, and 19 events classified as "other" within 60 days. The rate of the composite outcome at 30 days for the HFDMP group was 18% versus 31% in the UC group (p=0.11). Change in KCCQ and SCHFI measures were not significantly different between groups at 60 days.
CONCLUSION(S): Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while receiving rehabilitation in a SNF had lower rates of the composite outcome at 60 days and less HF related events. Standardized HF management during SNF stays may be particularly important for patients with a primary discharge diagnosis of HF

PURPOSE/OBJECTIVE:Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF). METHODS:We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression). RESULTS:Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) (P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31). CONCLUSIONS:Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.

Introduction: Functional decline, i.e., a decrement in performing every day activities necessary to live independently, is common after acute myocardial infarction (AMI) and associated with poor long-term outcomes; yet we do not have a tool to identify older AMI survivors at risk for this important patient-centered outcome.
Method(s): We used data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study, a prospective longitudinal study of 3,041 AMI patients adults age >=75 years, recruited from 94 hospitals across the U.S. Participants underwent a structured interview and assessment during hospitalization and at six months to collect data on demographics, geriatric impairments, psychosocial factors, and activities of daily living (ADLs). Clinical variables were abstracted from the medical record. Functional decline was defined as a decrement in ability to independently perform essential activities of daily living (i.e., bathing, dressing, transferring, ambulation) from baseline to six months post-discharge. Backward selection was used to identify significant predictors of functional decline.
Result(s): Mean age of the sample was 82+/-5 years; 57% were male, 90% were white; and 13% reported ADL decline at six months post-discharge. Factors independently associated with increased risk of decline were older age, longer hospital stay, mobility impairment during hospitalization, higher comorbidity score, fall history, and depression. Revascularization during AMI hospitalization (e.g., PCI, CABG) and ability to walk mile prior to AMI were associated with decreased risk. Model discrimination (c=0.79) and calibration were very good.
Conclusion(s): We identified a parsimonious model that predicts risk of ADL decline among older AMI patients. This tool may aid in identifying older AMI patients who may benefit from physical therapy or cardiac rehab to optimize function after AMI.

Background. Medical and interventional therapies for older adults with acute myocardial infarction (AMI) reduce mortality and improve outcomes in selected patients, but there are also risks associated with treatments. Shared decision making (SDM) may be useful in the management of such patients, but to date, patients' and cardiologists' perspectives on SDM in the setting of AMI remain poorly understood. Accordingly, we performed a qualitative study eliciting patients' and cardiologists' perceptions of SDM in this scenario. Methods. We conducted 20 in-depth, semistructured interviews with older patients (age ≥70) post-AMI and 20 interviews with cardiologists. The interviews were transcribed and analyzed using ATLAS.ti. Two investigators independently coded transcripts using the constant comparative method, and an integrative, team-based process was used to identify themes. Results. Six major themes emerged: 1) patients felt their only choice was to undergo an invasive procedure; 2) patients placed a high level of trust and gratitude toward physicians; 3) patients wanted to be more informed about the procedures they underwent; 4) for cardiologists, patients' age was not a major contraindication to intervention, while cognitive impairment and functional limitation were; 5) while cardiologists intuitively understood the concept of SDM, interpretations varied; and 6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI). Conclusions. Patients viewed intervention as "the only choice," whereas cardiologists saw a need for balancing risks and benefits in treating older adults post-NSTEMI. This discrepancy implies there is room to improve communication of risks and benefits to older patients. A decision aid informed by the needs of older adults could help to better convey patient-specific risk and increase choice awareness.