NSTEMI Decide: A Decision Aid for Older Adults

Many patients hospitalized with non ST-elevation myocardial infarction (NSTEMI) are over age 75. This condition requires major management decisions – most importantly, whether to pursue invasive coronary angiography. However there is limited evidence about the absolute benefits of this procedure for NSTEMI in older adults; available data indicate certain advantages (reduced risk of another MI) but also risks (bleeding, acute kidney injury). Until ongoing trials provide better evidence, patients and clinicians are left with uncertainty around whether invasive coronary angiography is worth pursuing.

Our previous qualitative research revealed that for many older adults hospitalized with NSTEMI, they expressed a desire to be better informed about their options. In the same study, cardiologists asked for a tool that would help them facilitate discussions with these patients. And both groups endorsed the process of shared decision making, which involves the active participation of patients in health care decisions that have multiple acceptable choices.

In this context, we undertook an iterative process to develop a decision aid for invasive coronary angiography in older adults with NSTEMI. We convened both clinical experts (cardiologists, geriatricians, internists, nurses) and patients, in order to review serial drafts of this decision aid for accuracy and comprehension. Our development methods are now published and freely available on medRxiv.

We adapted the final decision aid, NSTEMI Decide, to a mobile health app to maximize ease of use in clinical settings. This can currently be found in Apple’s App Store and downloaded for use on iPhone or iPad (an Android version is also under development). The app is eleven pages long and can be used in English or Spanish. We used data from available trials to provide estimates of the benefits and risks of cardiac catheterization, and created visual representations (with patient input) to help make the provided estimates understandable.

Sample screenshots from NSTEMI Decide.

To our knowledge, this is the first decision aid developed for NSTEMI in older adults. We are currently studying this decision aid prospectively to evaluate feasibility of use in practice, and how it influences patients’ medical knowledge and feelings of self-efficacy. Our hope is that NSTEMI Decide may eventually be widely disseminated to help patients and clinicians better navigate care decisions together.

Sophie Montgomery is a 2nd year medical student at NYU Grossman School of Medicine.

John Dodson is a Cardiologist and Associate Professor at NYU Grossman School of Medicine.

 

Geriatric Care in Medical Education

In preparation for medical school and my future career in healthcare, I read Being Mortal: Medicine and What Matters in the End by Dr. Atul Gawande. I wasn’t sure what to expect from the book initially, but came to find that it offered insightful, thought-provoking commentary on a “good death”, aging, and geriatric care. In the book Dr. Gawande points out there are not enough existing palliative care specialists or geriatricians to meet the needs of our aging population. He goes on to suggest that every doctor should be trained to work with older patients in some capacity. This led me to wonder if medical schools were hearing this call to action and making the needed changes to their curriculum to adapt to the demands of society and its aging population.

Fast forward a couple years, and I have finished my first year of medical school with a few answers to my curiosities. I have discovered that medical schools across the country are implementing a variety of programs to give students experience working with geriatric patients. At Mayo Clinic College of Medicine, students are required to complete an online geriatric curriculum. At Icahn School of Medicine at Mount Sinai, all the preclinical courses work to incorporate lessons on the care of older adults.

In my personal experience at NYU Grossman School of Medicine, I was part of the inaugural session of the program: Geriatrics Connect. All 100 first-year medical students were given the name and number of a patient from the community that we were to call five times over the course of six months. Each call had a loose agenda for students to follow with the program’s goals in mind: learn about healthy aging, the needs of older adults, and how to take a “life history”.

The patient assigned to me was an 84-year-old woman with a life story that would make for a bestselling biography. With our first phone call, I learned that she and her parents immigrated to the US when she was 12 after surviving Nazi persecution. She told me how they learned to speak English by reading the newspaper as they built a life in New York. She grew up, married a young lawyer, and had children. She spent her time as a librarian at Columbia University, even auditing a course taught by a rotating professor named Ruth Bader Ginsburg. 

In our first chat, I walked away with a more detailed history than with any traditional patient encounter I had ever had. Yes – I learned a lot about her general life story, but I also gained the most in-depth social history I could have ever attempted to take. I think programs like mine offer a great place to start developing our skills for working with older patients, but I hope there continues to be opportunities for learning as we move forward with our education. After all, nearly 10,000 Americans turn 65 each and every day.

Claire Graves is a 2nd year medical student at NYU Grossman School of Medicine.

Introducing GeriKit: A Geriatric Assessment Toolkit

Introducing GeriKit: A Geriatric Assessment Toolkit

By 2050, the number of older adults in the United States is projected to increase considerably, which mirrors trends in other developed countries.

What does this mean? All clinicians, not just geriatric specialists, will be working with more older adults, and will need to be familiar with elements of the comprehensive geriatric assessment (which includes domains such as cognitive impairment, physical function, and polypharmacy). To meet this rising need, the elements of geriatric assessment need to be readily available for students, trainees (interns, residents, fellows), and practicing clinicians to help them better serve their patients.

Technological innovation has made a universe of information accessible on our smartphones and tablet computers, but this information is often not organized in an easily usable way. In our review of available products focused on geriatric assessment, we found that many either focused on only a single domain (e.g. cognition), were time-intensive to use, or had components that existed behind a paywall.

We started thinking– what if we created an app to educate clinicians and trainees on all aspects of comprehensive geriatric assessment, provided it for free, and used it to help people take better care of older adults? Out of these conversations came the idea for GeriKit.

We have now released GeriKit in Apple’s App Store, and an Android version is under development. In brief, GeriKit is a geriatric assessment app that is:

  • A “one-stop” app to facilitate geriatric assessment by students, trainees, and practicing clinicians
  • Linked to original source materials to enable education on fundamental principles of geriatrics
  • Created by practicing clinicians with broad expertise in geriatric assessment
  • Simple and interactive for the user
  • Free!

In its current version, GeriKit includes resources to assess the following domains: cognition, depression, function, strength, fall risk, nutrition, polypharmacy, and advance care planning. We are collecting user feedback on other domains that may be worth incorporating in future versions.

Currently, GeriKit is available here in the App Store, and will be available soon in the Google Play store.

Ambika Viswanathan is a 2nd-year medical student at the University of North Carolina-Chapel Hill School of Medicine. This summer, Ambika was a Medical Student Training in Aging Research (MSTAR) Program scholar at NYU Grossman School of Medicine, where she helped to develop GeriKit in collaboration with Dr. Nina Blachman and Dr. John Dodson.

Mind the Gap: Anticoagulation in Older Adults with Atrial Fibrillation

All adults with atrial fibrillation (AF) over age 75 meet CHA2DS2-VASc criteria-based guidelines for long-term oral anticoagulation. In reality, about 60% of these people are anticoagulated. Although the risks of anticoagulation outweigh its benefits for some, for many the net clinical benefit remains high. So what’s driving this 40% gap between guidelines and real-world practice?

Prescribers are hesitant to anticoagulate these patients for systemic reasons like the need for individualized decision-making and limited evidence, as well as patient-specific reasons like fear of bleeding risk, falls, and inability to adhere to therapy.

Image by Suad Kamardeen

Let’s start with the systemic factors. Conventional risk stratification tools for stroke and bleeding have limited use in older adults. This is not only because anyone over age 75 starts with a CHA2DS2-VASc of 2 and HAS-BLED of 1, but also because those scores increase in parallel for older adults with comorbidities. The ATRIA risk score does account for increasing age after 75, and has been found in some studies to perform better than CHA2DS2-VASc, however, it is less widely used in part due to its more recent development.

Decision making is made even more difficult by the relative paucity of evidence. Older adults were underrepresented in many of the large trials that demonstrated the better risk-benefit profile of warfarin compared to aspirin and that of DOACs compared with warfarin. Many of the observational and retrospective studies that have attempted to fill this gap unfortunately suffer from selection bias that could favor anticoagulation, as people perceived to be healthier are more likely to be prescribed anticoagulants.

Recent observational data on the clinical benefit of anticoagulation in this age group are mixed. Chao and others compared 11,064 Taiwanese patients with AF with 14,658 patients without, all of whom were above age 90. They found a positive net clinical benefit of warfarin compared with no treatment and antiplatelet therapy, and that DOACs conferred the same benefit as warfarin with a lower risk of intracranial hemorrhage. Shah and colleagues explored this question using decision analysis techniques, and found that the net clinical benefit of warfarin and apixaban decreased with age beyond 75 years in part due to the competing risk of death. Warfarin reached minimal net benefit for the median patient at age 87 while Apixaban reached the same threshold at 92.

While these studies can help guide shared decision-making, they do not address the many patient-specific factors upon which these choices often hinge. Specifically, frailty and cognitive impairment are among the most commonly cited reasons for anticoagulant non-prescription. Studies have shown widely varying rates of anticoagulant prescription in frail older adults with AF, with most hospital-based studies finding under-prescription compared with those who are not non-frail. Cognitive impairment is another concern, as it may inhibit adherence to a daily oral regimen or increase the risk of adverse events such as falls. Paradoxically though, AF is associated with increased risk for cognitive impairment and dementia, and Gaita and colleagues have described and found that among people with AF there is more silent cerebral ischemia and lower mean cognitive performance compared with those without AF. This suggests that anticoagulation may be beneficial in preventing progressive cognitive decline, although more definitive data are needed.

So how can we improve treatment for older adults going forward? First and foremost, we need randomized clinical trials that focus on the “oldest old” and have relatively few exclusion criteria, in order to reflect real-world clinical practice. The recent ELDERCARE-AF trial is therefore relevant since it only enrolled patients over age 80 with AF. Among people assigned to received low-dose edoxaban (15 mg PO daily), rates of stroke and systemic embolism were reduced compared with placebo, without significantly increasing major bleeding events. Second, we need better tools to support individualized decision-making, both better risk stratification criteria that incorporate geriatric impairments, as well as decision aids to help patients and clinicians align their priorities and make fully informed decisions. Given the aging of the population in the U.S. and elsewhere, these efforts are timely and essential.

By Aaron Troy, MPH

Should my dad be taking Lipitor?

I recently received a text from my friend asking, “Should my dad be on Lipitor? His cardiologist hold him that all of his numbers looked good. And at the end of the visit, they told him that he should start taking Lipitor. Seemed kind of like as an afterthought as he was walking out the door.”

It’s an incredibly common situation: a doctor recommends a statin and a patient wonders whether any thought when into the decision at all. After all, doctors often say, “everything looks good” when things are suboptimal as long as there isn’t anything that puts you in imminent danger. Plus, it’s easier to just tell someone that they need to be on a medication than to counsel them about their individual risk factors and how best to modify them?

This decision is generally straightforward if you’ve had a heart attack – being on a statin is probably the right choice.

But for preventing a first heart attack? It’s a more difficult decision and one that’s fraught with a lot of misinformation as well as doctors who don’t interpret cholesterol panels with depth or nuance (or more importantly, don’t order the correct tests to begin with).

Wrong decision making goes in both directions here – there are a lot of people who are taking statins who do not need to be on them and a lot of people who should be on them that aren’t taking them.

How do we think about risk?

There are a number of standard heart disease risk factors that every doctor looks at – blood pressure, blood sugar, cholesterol, family history, smoking, obesity. Some of these are modifiable through lifestyle choices and some are not.

There are also a number of non-standard risk factors that we evaluate – metabolic syndrome, chronic kidney disease, autoimmune disease or chronic infection (diseases with increased inflammation), lipoprotein (a), premature menopause, and preeclampsia.

Huge amounts can be written on all of these individually, but I think that most of the medical decision making (and personal decision making!) about what to do boils down to the decision my friend asked me about above – should you be on a statin?

Statins are the most prescribed drugs in the world and Lipitor (atorvastatin) alone has made Pfizer almost $100 billion in revenue over the past 20 years. Even now that Lipitor has been off-patent for 8 years, it still generates $2 billion a year in revenue.

The numbers are insane. I suspect the fact that there are so many people prescribed statins who haven’t manifested heart disease helps to explain the proliferation of skeptics about their widespread use.

The ways we measure risk are imperfect

We use a few different methods to attempt to quantify a patient’s individual cardiac risk. There are a number of calculators that can be used to calculate approximate 10 year cardiovascular risk – meaning estimate your chance of having a heart attack over the next 10 years.

There’s one from the American Heart Association and American College of Cardiology (AHA/ACC). There are other ones based on large cardiovascular clinical trials such as the Multi Ethnic Study of Atherosclerosis (MESA) or Framingham.

While these are great for predicting risk across a population, they miss a lot of important aspects of individual risk. None of them incorporate all of the factors that increase your own personal risk. We certainly have a good sense of accuracy on the very high end and the very low end, but it’s the folks in the middle where the risk stratification becomes less reliable.

And when you’re thinking about taking a medicine everyday indefinitely, you really want information to personalize your own risk.

So when I’m talking to my patients about this decision – the ones who haven’t had a heart attack but may have some risk factors – I generally recommend additional individualized stratification.

A coronary calcium score is a great tiebreaker for this decision

A coronary artery calcium (CAC) score is a low radiation CT scan that lets us look to see if there is any calcium built up in the arteries around the heart.

You may have heard the term “hardening of the arteries” before. That’s calcification.

Any calcium in the coronary arteries – that is, a calcium score of any number over 0 – implies heart disease is present. Of course, there is a gradation in risk based on the amount of calcium (hence, calcium score), where higher numbers = greater risk.

CAC is better at reclassifying someone’s risk as either low (maybe ok to hold off on meds) or high (maybe it’s time to start something) than any other test that we have. Since it provides quantitative information about your own cardiac anatomy, this test can help to frame your own personal risk-benefit analysis.

So back to my friend’s question, “should my dad be on a statin?”

The answer is: it depends on a lot of factors – your own values and risk tolerance as well as all of your biomarkers and family history – but getting a coronary artery calcium score is a helpful piece of figuring out your own personalized risk.

by Gregory Katz, MD

This post originally appeared on gregorykatzmd.com on 07/15/2020.