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