Faculty Bibliography

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: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.

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:US guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF), who tolerate an ACEI (angiotensin-converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), be switched to sacubitril/valsartan to reduce morbidity and mortality. We compared characteristics and healthcare utilization between Veterans with HFrEF who were switched to sacubitril/valsartan versus maintained on an ACEI or ARB. METHODS:retrospective cohort study of treated HFrEF (July 2015-June 2017) using Veterans Affairs data. The index date was the first fill for sacubitril/valsartan and if none, for an ACEI or ARB. Treated HFrEF was defined by (1) left ventricular ejection fraction ≤40%, (2) ≥1 in/outpatient HF encounter, and (3) ≥1 ACEI or ARB fill, all within 1-year preindex. Poisson regression models were used to compare baseline characteristics and 1:1 propensity score-matched adjusted 4-month follow-up healthcare utilization between sacubitril/valsartan switchers and ACEI or ARB maintainers. RESULTS:value 0.035). CONCLUSIONS:Few Veterans with treated HFrEF were switched to sacubitril/valsartan within the first 2 years of Food and Drug Administration approval. Sacubitril/valsartan use was associated with a lower risk for all-cause hospitalizations at 4 months follow-up. Reasons for lack of guideline-recommended sacubitril/valsartan initiation warrant investigation and may reveal opportunities for HFrEF care optimization.

Importance/UNASSIGNED:Many older survivors of acute myocardial infarction (AMI) experience functional decline, an outcome of primary importance to older adults. Mobility impairment has been proposed as a risk factor for functional decline but has not been evaluated to date in older patients hospitalized for AMI. Objective/UNASSIGNED:To examine the association of mobility impairment, measured during hospitalization, as a risk marker for functional decline among older patients with AMI. Design, Setting, and Participants/UNASSIGNED:Prospective cohort study among 94 academic and community hospitals in the United States. Participants were 2587 hospitalized patients with AMI who were 75 years or older. The study dates were January 2013 to June 2017. Main Outcomes and Measures/UNASSIGNED:Mobility was evaluated during AMI hospitalization using the Timed "Up and Go," with scores categorized as preserved mobility (≤15 seconds to complete), mild impairment (>15 to ≤25 seconds to complete), moderate impairment (>25 seconds to complete), and severe impairment (unable to complete). Self-reported function in activities of daily living (ADLs) (bathing, dressing, transferring, and walking around the home) and walking 0.4 km (one-quarter mile) was assessed at baseline and 6 months after discharge. The primary outcomes were worsening of 1 or more ADLs and loss of ability to walk 0.4 km from baseline to 6 months after discharge. The association between mobility impairment and risk of functional decline was evaluated with multivariable-adjusted logistic regression. Results/UNASSIGNED:Among 2587 hospitalized patients with AMI, the mean (SD) age was 81.4 (4.8) years, and 1462 (56.5%) were male. More than half of the cohort exhibited mobility impairment during AMI hospitalization (21.8% [564 of 2587] had mild impairment, 16.0% [414 of 2587] had moderate impairment, and 15.2% [391 of 2587] had severe impairment); 12.8% (332 of 2587) reported ADL decline, and 16.7% (431 of 2587) reported decline in 0.4-km mobility. Only 3.8% (30 of 800) of participants with preserved mobility experienced any ADL decline compared with 6.9% (39 of 564) of participants with mild impairment (adjusted odds ratio [aOR], 1.24; 95% CI, 0.74-2.09), 18.6% (77 of 414) of participants with moderate impairment (aOR, 2.67; 95% CI, 1.67-4.27), and 34.7% (136 of 391) of participants with severe impairment (aOR, 5.45; 95% CI, 3.29-9.01). Eleven percent (90 of 800) of participants with preserved mobility declined in ability to walk 0.4 km compared with 15.2% (85 of 558) of participants with mild impairment (aOR, 1.51; 95% CI, 1.04-2.20), 19.0% (78 of 411) of participants with moderate impairment (aOR, 2.03; 95% CI, 1.37-3.02), and 24.6% (95 of 386) of participants with severe impairment (aOR, 3.25; 95% CI, 2.02-5.23). Conclusions and Relevance/UNASSIGNED:This study's findings suggest that mobility impairment assessed during hospitalization may be a potent risk marker for functional decline in older survivors of AMI. These findings also suggest that brief, validated assessments of mobility should be part of the care of older hospitalized patients with AMI to identify those at risk for this important patient-centered outcome.