Faculty Bibliography

BACKGROUND:Studies of sex-based differences in older adults with acute myocardial infarction (AMI) have yielded mixed results. We, therefore, sought to evaluate sex-based differences in presentation characteristics, treatments, functional impairments, and in-hospital complications in a large, well-characterized population of older adults (≥75 years) hospitalized with AMI. METHODS AND RESULTS/RESULTS:=0.02). CONCLUSIONS:Among older adults hospitalized with AMI, women had a higher prevalence of age-related functional impairments and, among the STEMI subgroup, a higher incidence of overall bleeding events, which was driven by higher rates of nonmajor bleeding events and bleeding following percutaneous coronary intervention. These differences may have important implications for in-hospital and posthospitalization needs.

Background Little is known regarding use of cardiac therapies and clinical outcomes among older myocardial infarction (MI) patients with cognitive impairment. Methods and Results Patients ≥65 years old with MI in the NCDR (National Cardiovascular Data Registry) Chest Pain-MI Registry between January 2015 and December 2016 were categorized by presence and degree of chart-documented cognitive impairment. We evaluated whether cognitive impairment was associated with all-cause in-hospital mortality after adjusting for known prognosticators. Among 43 812 ST-segment-elevation myocardial infarction (STEMI) patients, 3.9% had mild and 2.0% had moderate/severe cognitive impairment; among 90 904 non-ST-segment-elevation myocardial infarction (NSTEMI patients, 5.7% had mild and 2.6% had moderate/severe cognitive impairment. A statistically significant but numerically small difference in the use of primary percutaneous coronary intervention was observed between patients with STEMI with and without cognitive impairment (none, 92.1% versus mild, 92.8% versus moderate/severe, 90.4%; P=0.03); use of fibrinolysis was lower among patients with cognitive impairment (none, 40.9% versus mild, 27.4% versus moderate/severe, 24.2%; P<0.001). Compared with NSTEMI patients without cognitive impairment, rates of angiography, percutaneous coronary intervention, and coronary artery bypass grafting were significantly lower among patients with NSTEMI with mild (41%, 45%, and 70% lower, respectively) and moderate/severe cognitive impairment (71%, 74%, and 93% lower, respectively). After adjustment, compared with no cognitive impairment, presence of moderate/severe (STEMI: odds ratio, 2.2, 95% CI, 1.8-2.7; NSTEMI: odds ratio, 1.7, 95% CI, 1.4-2.0) and mild cognitive impairment (STEMI: OR, 1.3, 95% CI, 1.1-1.5; NSTEMI: odds ratio, 1.3, 95% CI, 1.2-1.5) was associated with higher in-hospital mortality. Conclusions Patients with NSTEMI with cognitive impairment are substantially less likely to receive invasive cardiac care, while patients with STEMI with cognitive impairment receive similar primary percutaneous coronary intervention but less fibrinolysis. Presence and degree of cognitive impairment was independently associated with increased in-hospital mortality. Approaching clinical decision making for older patients with MI with cognitive impairment requires further study.

Background Canadian Cardiovascular Society (CCS) angina severity classification is associated with mortality, myocardial infarction, and coronary revascularization in clinical trial and registry data. The objective of this study was to determine associations between CCS class and all-cause mortality and healthcare utilization, using natural language processing to extract CCS classifications from clinical notes. Methods and Results In this retrospective cohort study of veterans in the United States with stable angina from January 1, 2006, to December 31, 2013, natural language processing extracted CCS classifications. Veterans with a prior diagnosis of coronary artery disease were excluded. Outcomes included all-cause mortality (primary), all-cause and cardiovascular-specific hospitalizations, coronary revascularization, and 1-year healthcare costs. Of 299 577 veterans identified, 14 216 (4.7%) had ≥1 CCS classification extracted by natural language processing. The mean age was 66.6±9.8 years, 99% of participants were male, and 81% were white. During a median follow-up of 3.4 years, all-cause mortality rates were 4.58, 4.60, 6.22, and 6.83 per 100 person-years for CCS classes I, II, III, and IV, respectively. Multivariable adjusted hazard ratios for all-cause mortality comparing CCS II, III, and IV with those in class I were 1.05 (95% CI, 0.95-1.15), 1.33 (95% CI, 1.20-1.47), and 1.48 (95% CI, 1.25-1.76), respectively. The multivariable hazard ratio comparing CCS IV with CCS I was 1.20 (95% CI, 1.09-1.33) for all-cause hospitalization, 1.25 (95% CI, 0.96-1.64) for acute coronary syndrome hospitalizations, 1.00 (95% CI, 0.80-1.26) for heart failure hospitalizations, 1.05 (95% CI, 0.88-1.25) for atrial fibrillation hospitalizations, 1.92 (95% CI, 1.40-2.64) for percutaneous coronary intervention, and 2.51 (95% CI, 1.99-3.16) for coronary artery bypass grafting surgery. Conclusions Natural language processing-extracted CCS classification was positively associated with all-cause mortality and healthcare utilization, demonstrating the prognostic importance of anginal symptom assessment and documentation.

BACKGROUND:Early readmissions among older adults hospitalized for acute myocardial infarction (AMI) are costly and difficult to predict. Aging-related functional impairments may inform risk prediction but are unavailable in most studies. Our objective was to, therefore, develop and validate an AMI readmission risk model for older patients who considered functional impairments and was suitable for use before hospital discharge. METHODS AND RESULTS/RESULTS:SILVER-AMI (Comprehensive Evaluation of Risk in Older Adults with AMI) is a prospective cohort study of 3006 patients of age ≥75 years hospitalized with AMI at 94 US hospitals. Participants underwent in-hospital assessment of functional impairments including cognition, vision, hearing, and mobility. Other variables plausibly associated with readmissions were also collected. The outcome was all-cause readmission at 30 days. We used backward selection and Bayesian model averaging to derive (N=2004) a risk model that was subsequently validated (N=1002). Mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. Within 30 days, 547 participants (18.2%) were readmitted. Readmitted participants were older, had more comorbidities, and had a higher prevalence of functional impairments, including activities of daily living disability (17.0% versus 13.0%; P=0.013) and impaired functional mobility (72.5% versus 53.6%; P<0.001). The final risk model included 8 variables: functional mobility, ejection fraction, chronic obstructive pulmonary disease, arrhythmia, acute kidney injury, first diastolic blood pressure, P2Y12 inhibitor use, and general health status. Functional mobility was the only functional impairment variable retained but was the strongest predictor. The model was well calibrated (Hosmer-Lemeshow P value >0.05) with moderate discrimination (C statistics: 0.65 derivation cohort and 0.63 validation cohort). Functional mobility significantly improved performance of the risk model (net reclassification improvement index =20%; P<0.001). CONCLUSIONS:In our final risk model, functional mobility, previously not included in readmission risk models, was the strongest predictor of 30-day readmission among older adults after AMI. The modest discrimination indicates that much of the variability in readmission risk among this population remains unexplained by patient-level factors. CLINICAL TRIAL REGISTRATION/BACKGROUND:URL: https://www.clinicaltrials.gov. Unique identifier: NCT01755052.

Caring for older adults with multiple chronic conditions (MCCs) is challenging. The American Geriatrics Society (AGS) previously developed The AGS Guiding Principles for the Care of Older Adults with Multimorbidity using a systematic review of the literature and consensus (Table 1). The objective of the current work was to translate these principles into a framework of Actions and accompanying Action Steps for decision-making for clinicians who provide both primary and specialty care to older people with MCCs. A workgroup of geriatricians, cardiologists, and generalists: 1) articulated the core MCC Actions and the Action Steps needed to carry out the Actions; 2) provided decisional tips and communication scripts for implementing the Actions and Action Steps, using commonly encountered situations: 3) performed a scoping review to identify evidence-based, validated tools for carrying out the MCC Actions and Action Steps; and 4) identified potential barriers to, and mitigating factors for, implementing the MCC Actions. The recommended MCC Actions include: 1) Identify and communicate patients' health priorities and health trajectory; 2) Stop, start, or continue care based on health priorities, potential benefit versus harm and burden, and health trajectory; and 3) align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory. The tips and scripts for carrying out these Actions are included in the full MCC Action Framework available in the supplement (www.GeriatricsCareOnline.org).

BACKGROUND:The need for mentorship in aging research among postdoctoral trainees and junior faculty across medical disciplines and subspecialties is increasing, yet senior personnel with expertise in aging are lacking to fulfill the traditional dyadic mentorship role. Facilitated peer mentorship is grounded in collaborative work among peers with the guidance of a senior mentor. METHODS AND RESULTS/RESULTS:We evaluated the Columbia University Mentor Peer Aging Research (CoMPAdRE) program, an interprofessional facilitated peer mentorship program for early stage investigators, using the Reach Effectiveness Adoption Implementation and Maintenance framework (RE-AIM). Reach: A total of 15 participants, of which 20% were women, from five states and across six medical specialties participated. Effectiveness: Participants published 183 papers, of which more than 20% were collaborative papers between CoMPAdRE mentees or mentees-mentor. Participants reported developing skills in negotiation, navigating the academic role, organizing a seminar, management, and leadership over the course of the program. According to the qualitative findings, the most important components of the program included alignment around the aging, learning from national leaders, developing leadership skills and career networking. Adoption: Individual-level factors included selecting participants with a research track record, willingness to sign a compact of commitment and involvement in shaping the program. An institutional-level factor that facilitated program adoption included strong commitment from department leaders. IMPLEMENTATION/METHODS:The program cost $3,259 per participant. Maintenance: CoMPAdRE is being maintained and currently incorporating a second cohort of mentees. CONCLUSION/CONCLUSIONS:This RE-AIM evaluation provides lessons learned and strategies for future adoption, implementation, and maintenance of an aging-focused facilitated peer mentorship program.

Background: Among older adults with cardiovascular disease (CVD), cardiac rehabilitation (CR) has multiple benefits including improved quality of life and reduced mortality. Despite the known benefits of CR, early termination (ET) by patients (attending <12/36 recommended sessions) may attenuate these benefits. Our aim was to determine the incidence of ET in our older adult patient population, as well as risk factors associated with this outcome.
Method(s): We reviewed records from 792 consecutive older adult patients (>= 65 years old) enrolled in the NYU Langone Rusk CR program (2013-2017). Sessions attended, demographics, comor-bidities, and primary referral diagnosis were abstracted. We analyzed the overall rate of ET (defined as attending <12 sessions). Categorical variables were described with percentages and continuous variables with mean values. Multivariable logistic regression was subsequently used to analyze predictors of ET, considering age, race, ethnicity, sex, body mass index, diabetes, chronic lung disease, coronary artery disease, heart failure, and stroke.
Result(s): In our total study population, mean age was 74 +/- 7 years, mean BMI was 26 +/- 5, 38% were female, and 18% were nonwhite. Most patients (65%) were referred to CR due to ischemic heart disease (chronic stable angina, post-myocardial infarction, CABG, or elective PCI), with an additional 23% referred for valvular heart disease, 9% for systolic heart failure, and 3% for congenital heart disease. Early termination occurred in 129 patients (16.3%). Patients who terminated early were significantly older (75.6 vs. 73.9, p=0.005) and less likely to have coronary artery disease (13.6% vs. 19.5%, p=0.03). After multivariable logistic regression, the independent risk factors for ET were age (adjusted OR 1.04, 95% CI 1.01-1.07) and Hispanic ethnicity (adjusted OR 2.32, 95% CI 1.01-5.33).
Conclusion(s): Nearly 1 in 6 older adults terminated CR within 1 month (<12/36 sessions), potentially limiting the benefits of CR within this subgroup. Among factors we analyzed, age and Hispanic ethnicity were risk factors for ET, but the overall strength of associ-ation was weak. Further research is necessary to identify novel risk factors for ET in order to better target prevention efforts

We describe a selection process for a multivariable risk prediction model of death within 30 days of hospital discharge in the SILVER-AMI study. This large, multi-site observational study included observational data from 2000 persons 75 years and older hospitalized for acute myocardial infarction (AMI) from 94 community and academic hospitals across the United States and featured a large number of candidate variables from demographic, cardiac, and geriatric domains, whose missing values were multiply imputed prior to model selection. Our objective was to demonstrate that Bayesian Model Averaging (BMA) represents a viable model selection approach in this context. BMA was compared to three other backward-selection approaches: Akaike information criterion, Bayesian information criterion, and traditional p-value. Traditional backward-selection was used to choose 20 candidate variables from the initial, larger pool of five imputations. Models were subsequently chosen from those candidates using the four approaches on each of 10 imputations. With average posterior effect probability ≥ 50% as the selection criterion, BMA chose the most parsimonious model with four variables, with average C statistic of 78%, good calibration, optimism of 1.3%, and heuristic shrinkage of 0.93. These findings illustrate the utility and flexibility of using BMA for selecting a multivariable risk prediction model from many candidates over multiply imputed datasets.

Real-world outcomes in patients with chronic stable angina treated with ranolazine and other antianginal medications as second- or third-line therapy are limited. In a historical cohort study of veterans with chronic stable angina, we compared time with coronary revascularization procedures, hospitalizations, and 1-year healthcare costs between new-users of ranolazine versus conventional antianginals (i.e., calcium channel blockers, β blockers, or long-acting nitrates) as second- or third-line. Weighted regression models calculated adjusted hazard ratios (HR) at up to 8-year follow-up, and adjusted incremental costs in the first year. Weighted groups comprised 4,699 ranolazine users and 31,815 conventional antianginal users. Percutaneous coronary intervention (PCI) occurred more often in ranolazine users compared with conventional antianginal users (HR 1.16; 95% confidence intervals [CI] 1.08 to 1.25, p <0.001), and coronary artery bypass grafting occurred less often (HR 0.82; 95% CI 0.68 to 1.00, p <0.046). All-cause and atrial fibrillation (AF) hospitalizations were less common with ranolazine users compared with conventional users (all-cause: HR 0.94; 95% CI 0.90 to 0.99, p <0.010; AF:HR 0.74; 95% CI 0.67 to 0.82, p <0.001), and acute coronary syndrome was more common (HR 1.13; 95% CI 1.00 to 1.27, p <0.042). Adjusted 1-year costs were $24,517 in ranolazine users and $24,798 in conventional users (difference, $-280; 95% CI $-1,742 to $1,181, p = 0.71). In conclusion, ranolazine users had lower rates of coronary artery bypass grafting and all-cause and AF hospitalizations, but higher rates of percutaneous coronary intervention and hospitalizations due to acute coronary syndrome compared with conventional antianginal users. Healthcare costs were similar between ranolazine and conventional antianginal users.