Geriatric impairments, risk of treatment-related harms, and shared decision-making among older adults with acute myocardial infarction

患有急性心肌梗死的老年人的老年损伤、治疗相关伤害的风险以及共同决策

• 批准号: 9321776
• 负责人: John A Dodson
• 金额: $ 17.38万
• 依托单位: NEW YORK UNIVERSITY SCHOOL OF MEDICINE
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-08-01 至 2020-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9321776
• 关键词: Acute myocardial infarction; Address; Adoption; Adrenergic beta-Antagonists; Age; Aged, 80 and over; Aging; American; Area; Arteries; Benefits and Risks; Cardiac; Cardiology; Cardiovascular system; Caring; Categories; Chronology; Clinical; Clinical Research; Clinical Trials; Cognition; Cohort Studies; Collaborations; Comorbidity; Conflict (Psychology); Coronary; Coronary Artery Bypass; Coupled; Data; Data Analyses; Data Collection; Data Set; Decision Aid; Decision Making; Development; Discrimination; Elderly; Eligibility Determination; Enrollment; Evaluation of Risk Factors; Familiarity; Funding; Future; Geriatric Assessment; Geriatrics; Goals; Guidelines; Health Status; Hemorrhage; Heterogeneity; Hospitals; Impaired cognition; Impairment; Injury; Internist; Kidney; Kidney Failure; Knowledge; Lead; Leadership; Learning; Longitudinal cohort; Measures; Medical center; Memory; Mentors; Methodology; Methods; Mortality Decline; Muscle Weakness; Myocardial Infarction; Online Systems; Outcome; Participant; Patients; Perception; Pharmaceutical Preparations; Physiological; Population; Procedures; Qualitative Methods; Qualitative Research; Research; Research Personnel; Risk; Risk Estimate; Risk stratification; Self Efficacy; Stroke; Subgroup; Teaching Hospitals; Training; United States National Institutes of Health; Walking; Work; age related; aged; base; career; career development; clinical practice; college; disability; experience; improved; improved outcome; innovation; interest; older patient; patient oriented; patient oriented research; percutaneous coronary intervention; primary outcome; prognostic; programs; prospective; public health relevance; randomized trial; shared decision making; skills; trend

 DESCRIPTION (provided by applicant): With the aging of the U.S. population there has been a fundamental shift among patients with acute myocardial infarction (AMI); the typical patient is now older, with more comorbidities, than even 20 years ago. While there has been significant progress in the development of AMI management strategies such as coronary revascularization procedures and antithrombotic medications, their benefits and harms were studied in trials of younger patients or in older adults without aging-related comorbidities. In practice, the average older adult with AMI is now being managed more aggressively with these therapies, although it remains challenging to precisely characterize and explain potential treatment-related harms such as renal failure after percutaneous coronary intervention (PCI), stroke after coronary artery bypass grafting (CABG), and bleeding from dual antiplatelet therapy (DAPT). While an accurate assessment of these potential harms is a critical component of AMI shared decision making (SDM) for older adults, an effective means of prediction is lacking. Physiologic age, which is manifested by "geriatric impairments" in domains such as mobility, strength, and cognition, shows promise as a determinant of post-AMI risk, but most studies have failed to measure it. We propose to address this gap in knowledge by first analyzing data from the SILVER-AMI study, an NIH-funded longitudinal cohort enrolling 3000 participants aged ≥75 with AMI (Aim 1), and subsequently performing primary data collection at NYU Langone Medical Center (Aims 2-3). In Aim 1 we will develop a risk score for in-hospital coronary revascularization-related complications that incorporates geriatric impairments. In Sub-Aim 1 we will then explore the association between geriatric impairments and bleeding related to DAPT within 6 months of AMI. In Aim 2 we will use a qualitative methodology to assess decisional needs related to coronary revascularization, and in Aim 3 we will then develop and pilot a web-based decision aid to be used prior to revascularization. Our proposed work is innovative because it builds on a study (SILVER-AMI) that provides a rigorous assessment of geriatric impairments post-AMI and their prognostic importance. We also incorporate patients' perspectives (through a qualitative methodology), and provide patient-specific risk estimates in our decision aid which will allow for more individualized SDM discussions. My overall career goal is to become an independent investigator and thought leader in geriatric cardiology with the ability to perform research that improves care for older adults. To achieve this goal I will use the training period to gain skills n quantitative methods, qualitative research, decision aid development, and clinical trials, and to build leadership capabilities that can influence practice. I have assembled a team of Mentors with expertise in Geriatrics (Dr. Caroline Blaum, Dr. Daniel Matlock) and Cardiovascular Clinical Research (Dr. Sarwat Chaudhry, Dr. Stuart Katz), which is supplemented by experienced Advisors and Collaborators. In parallel with my 75% research effort, I will build a practice as a geriatric cardiologist and therefore perform clinical work directly relevant to my research.

 描述（由申请人提供）：随着美国人口老龄化，急性心肌梗塞 (AMI) 患者发生了根本性转变；与 20 年前相比，现在的典型患者年龄更大，合并症也更多。在 AMI 管理策略（例如冠状动脉血运重建手术和抗血栓药物）的制定方面取得了重大进展，在针对年轻患者或无衰老相关的老年人的试验中研究了它们的益处和危害在实践中，患有 AMI 的普通老年人现在正在通过这些疗法进行更积极的治疗，尽管准确描述和解释潜在的治疗相关危害（例如经皮冠状动脉介入治疗 (PCI) 后的肾衰竭、冠状动脉术后中风）仍然具有挑战性。虽然准确评估这些潜在危害是老年人 AMI 共同决策 (SDM) 的重要组成部分，但缺乏有效的预测方法。生理年龄表现为活动能力、力量和认知等领域的“老年障碍”，有望成为 AMI 后风险的决定因素，但大多数研究未能对其进行衡量，我们建议解决这一知识差距。首先分析 SILVER-AMI 研究的数据，这是一项由 NIH 资助的纵向队列，招募了 3000 名年龄≥75 岁的 AMI 参与者（目标 1），随后在纽约大学朗格尼医学中心进行主要数据收集（目标 2-3）。在目标 1 中，我们将制定包含老年损伤的院内冠状动脉血运重建相关并发症的风险评分。在子目标 1 中，我们将探讨老年损伤与 DAPT 相关出血之间的关联。 6 个月的 AMI。在目标 2 中，我们将使用定性方法来评估与冠状动脉血运重建相关的决策需求，在目标 3 中，我们将开发并试点基于网络的决策辅助工具。我们提出的工作是创新的，因为它建立在一项研究 (SILVER-AMI) 的基础上，该研究对 AMI 后的老年损伤及其预后重要性进行了严格的评估，我们还纳入了患者的观点（通过定性方法）。 ），并在我们的决策辅助中提供针对患者的风险评估，这将允许进行更个性化的 SDM 讨论。我的总体职业目标是成为老年心脏病学的独立研究者和思想领袖，有能力进行改善老年人护理的研究。 .实现为了实现这一目标，我将利用培训时间来获得定量方法、定性研究、决策辅助开发和临床试验方面的技能，并建立影响实践的领导能力。我组建了一支具有老年病学专业知识的导师团队（Dr. Caroline Blaum 博士、Daniel Matlock 博士）和心血管临床研究（Sarwat Chaudhry 博士、Stuart Katz 博士），并由经验丰富的顾问和合作者补充。在我 75% 的研究工作的同时，我将建立一个实践：一名老年心脏病专家，因此从事与我的研究直接相关的临床工作。