For a cardiologist, my interaction with geriatric medicine occurred relatively early in my career. I was an aspiring academic preparing a career development award. I had the good fortune of being involved in a national project sponsored by the Health Care Financing Administration (HCFA, now the Centers for Medicare and Medicaid Services or CMS) to assess the quality of care for Medicare beneficiaries hospitalized with heart failure called the National Heart Care Project. I had settled on what I thought was an important line of research—the epidemiology and outcomes of older persons with heart failure and preserved systolic function. I felt that I had everything I would need for a compelling application to the NIH—an interesting project, excellent career and scientific mentors, and a coherent research plan.
Fortunately, I took the advice of mentors and peers to contact the program officer at the National Heart Lung and Blood Institute (NHLBI), to which I planned to submit my grant. The NHLBI seemed like a natural fit for a cardiologist. At the time, though, cardiovascular outcomes research did not exist as a field, and the program officer at the NHLBI told me frankly that my application stood little chance because of the topic. I was profoundly disappointed, but should have been grateful for her honesty. It occurred to me that the National Institute on Aging (NIA) might be interested. When I called the program officer there—Andre Premen was his name—the reception could not have been more enthusiastic. While a physiologist, he exuded interest in the topic and strongly encouraged me to apply. I was funded on the first submission (one for the “better lucky than good” file). Thanks to the NIA, my academic career was launched.
My early research with the Medicare data from the National Heart Care Project impressed upon me the challenges in treating older persons with cardiovascular disease, which typically occurs in conjunction with many other conditions. Our team characterized the marked discrepancy between the “real world” population treated in clinical practice and those enrolled in trials (Am Heart J 2003); the increasingly complex and costly medication regimens for heart failure in older persons (Arch Intern Med 2005); and the prescription of potentially harmful medications in this vulnerable population (JAMA 2003 and Circulation 2005).
In parallel, my clinical experiences were teaching me that the care of older persons with cardiovascular disease wasn’t all about cardiology and that the reductionist approach implicit to treatment guidelines didn’t fit this population. When listening to older people talk about their experiences, it was clear that cardiovascular disease wasn’t always the most important issue; that some patients prioritized quality of life over longevity for its own sake; that social support and potential threats to independence played an increasingly important role. Taking care of older patients with numerous conditions was clearly nuanced and required a willingness to look beyond the constraints of the data generated from the rarified environs of clinical trials.
The cardiovascular profession is acknowledging these lessons more broadly. The American College of Cardiology (ACC) has a robust Geriatric Cardiology Section, which has advocated for an emphasis on the specific challenges in caring for complex older patients throughout the organization. The ACC has also engaged in the development of instruments to support shared decision-making, which while important for all patients, is often even more important in the older population. The ACC, in partnership with the American Heart Association, are also committed to integrating considerations relevant to the older population in its practice guidelines. The confluence of these efforts is likely to transform how cardiologists approach the care of older persons in clinical practice.
I remember when saying “I’m a cardiologist” in the company of geriatricians felt like a 12-step program confession. Fortunately, those days are behind me. I am optimistic that through collaboration between geriatricians and cardiovascular specialists, like the Patients’ Priorities Care Program, will help all of us deliver the right care to the right patient in accordance with their personal values.
By: Fred Masoudi, MD