Faculty Bibliography

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.

Background We sought to examine whether people with a diagnosis of cardiovascular disease (CVD) experienced a greater incidence of subsequent cognitive impairment (CI) compared to people without CVD, as suggested by prior studies, using a large longitudinal cohort. Methods We used biennial data collected on adults age >=50 from the Health and Retirement Study (HRS) to compare the incidence of CI over 8 years in 1,931 participants newly diagnosed with CVD vs. 3,862 age- and gender-matched controls. Diagnosis of CVD was adjudicated with an established HRS methodology. CI was defined as <=11 on the 27-point Telephone Interview for Cognitive Status, based on a previously accepted clinical cutpoint. To examine the incidence of CI, we used a cumulative incidence function accounting for competing risk of death. Results Mean age at study entry was 70 years, and 55% were female. CI developed in 1,335 participants over 8 years. Death was more common among participants with incident CVD (20.4% vs. 13.4%, p <.001). Cumulative incidence analysis for CI, after adjusting for death, showed no significant difference in incidence of cognitive impairment between the CVD and control groups at the end of the study period (Figure). Conclusion We found no increased risk of subsequent cognitive impairment among participants with CVD (compared with no CVD), despite previous research indicating that CVD accelerates cognitive decline. This finding may be due to appropriately accounting for the competing risk of death. [Figure presented]
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Background We developed a risk model to predict hospitalization for bleeding within 6 months of discharge in older adults hospitalized for acute MI (AMI) and discharged on dual antiplatelet therapy (DAPT). Methods SILVER-AMI is a cohort study of 3041 patients age >=75 hospitalized with AMI at 96 U.S. hospitals. Participants underwent in-hospital functional assessment (cognition, vision, hearing, unintentional weight loss, ADLs, grip strength, functional mobility, falls). These analyses focused on participants discharged on DAPT (N=1858). Our outcome was rehospitalization for bleeding within 6 months. We used Bayesian model averaging to develop a risk model with split sample validation. Results Mean age was 81.5 years. Compared with participants not prescribed DAPT, those prescribed DAPT had slightly better functional mobility and lower cognitive impairment. Overall, 150 (8.1%) participants on DAPT experienced hospitalization for bleeding within 6 months; nearly half (48.7%) were gastrointestinal. Rates of functional impairments were similar among participants who did and did not experience bleeding. The final risk model included 8 predictors (Table), had moderate discrimination (C-statistic = 0.66), and good calibration (Hosmer-Lemeshow P value > 0.05). Conclusion Hospitalization for bleeding within 6 months of discharge on DAPT among older AMI patients was not predicted by aging-related functional impairments, but 8 other clinically plausible predictors were identified. [Figure presented]
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With the ubiquity of mobile devices, the availability of mobile health (mHealth) applications for cardiovascular disease (CVD) has markedly increased in recent years. Older adults represent a population with a high CVD burden and therefore have the potential to benefit considerably from interventions that utilize mHealth. Traditional facility-based cardiac rehabilitation represents one intervention that is currently underutilized for CVD patients and, because of the unique barriers that older adults face, represents an attractive target for mHealth interventions. Despite potential barriers to mHealth adoption in older populations, there is also evidence that older patients may be willing to adopt these technologies. In this review, we highlight the potential for mHealth uptake for older adults with CVD, with a particular focus on mHealth cardiac rehabilitation (mHealth-CR) and evidence being generated in this field.

Background/UNASSIGNED:Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts. Objective/UNASSIGNED:To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments. Design/UNASSIGNED:Prospective cohort study. (ClinicalTrials.gov: NCT01755052). Setting/UNASSIGNED:94 hospitals throughout the United States. Participants/UNASSIGNED:3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive. Measurements/UNASSIGNED:Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality. Results/UNASSIGNED:Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer-Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment. Limitation/UNASSIGNED:The model was not externally validated. Conclusion/UNASSIGNED:A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge. Primary Funding Source/UNASSIGNED:National Heart, Lung, and Blood Institute of the National Institutes of Health.

BACKGROUND/OBJECTIVES/OBJECTIVE:The American College of Cardiology (ACC) Geriatric Cardiology Section Leadership Council recently outlined 4 key domains (which are composed of 14 subdomains) that are important to assess in older adults with heart failure (HF). We sought to determine which geriatric domains/subdomains are routinely assessed, how they are assessed, and how they impact clinical management in the care of ambulatory older adults with HF. DESIGN/METHODS:Survey. SETTING/METHODS:Ambulatory. PARTICIPANTS/METHODS:Fifteen active ACC member physicians from the geriatric cardiology community. MEASUREMENTS/METHODS:Electronic survey assessing which domains/subdomains are currently assessed in these selected real-world practices, how they are assessed, and how they are incorporated into clinical management. RESULTS:Of 15 clinicians, 14 responded to the survey. The majority routinely assess 3 to 4 domains (median, 3; interquartile range, 3-4) and a range of 4 to 12 subdomains (median, 8; interquartile range, 6-11). All respondents routinely assess the medical and physical function domains, 71% routinely assess the mind/emotion domain, and 50% routinely assess the social domain. The most common subdomains included comorbidity burden (100%), polypharmacy (100%), basic function (93%), mobility (86%), falls risk (71%), frailty (64%), and cognition (57%). Sensory impairment (50%), social isolation (50%), nutritional status (43%), loneliness (7%), and financial means (7%) were least frequently assessed. There was significant heterogeneity with regard to the tools used to assess subdomains. Common themes for how the subdomains influenced clinical care included informing prognosis, informing risk-benefit of pharmacologic therapy and invasive procedures, and consideration for palliative care. CONCLUSIONS:While respondents routinely assess multiple domains and subdomains and view these as important to clinical care, there is substantial heterogeneity regarding which subdomains are assessed and the tools used to assess them. These observations provide a foundation that inform a research agenda with regard to providing holistic and patient-centered care to older adults with HF.

BACKGROUND:Among older adults (age≥75) hospitalized for acute myocardial infarction, acute kidney injury after coronary angiography is common. Aging-related conditions may independently predict acute kidney injury, but have not yet been analyzed in large acute myocardial infarction cohorts. METHODS:We analyzed data from 2212 participants age≥75 in the SILVER-AMI study who underwent coronary angiography. Acute kidney injury was defined using KDIGO criteria (serum Cr increase ≥0.3mg/dL from baseline or≥1.5 times baseline). We analyzed the associations of traditional acute kidney injury risk factors and aging-related conditions (ADL impairment, prior falls, cachexia, low physical activity) with acute kidney injury, and then performed logistic regression to identify independent predictors. RESULTS:Participants' mean age was 81.3years, 45.2% were female, and 9.5% were nonwhite; 421 (19.0%) experienced acute kidney injury. Comorbid diseases and aging-related conditions were both more common among individuals experiencing acute kidney injury. However, after multivariable adjustment, no aging-related conditions were retained. There were 11 risk factors in the final model; the strongest were heart failure on presentation (OR 1.91, 95% CI 1.41-2.59), BMI >30 (vs. BMI 18-25: OR 1.75, 95% CI 1.27-2.42), and nonwhite race (OR 1.65, 95% CI 1.16-2.33). The final model achieved an AUC of 0.72 and was well calibrated (Hosmer-Lemeshow P=0.50). Acute kidney injury was independently associated with 6month mortality (OR 1.98, 95% CI 1.36-2.88) but not readmission (OR 1.26, 95% CI 0.98-1.61). CONCLUSIONS:Acute kidney injury is common among older adults with acute myocardial infarction undergoing coronary angiography. Predictors largely mirrored those in previous studies of younger individuals, which suggests that geriatric conditions mediate their influence through other risk factors.