Statins for Primary Prevention

dodson%20headshotA recent review article in JACC highlights the conundrum of primary cardiovascular disease prevention with statins among older adults. We often face this dilemma in our outpatient practices: specifically, whether patients age ≥75 without overt cardiovascular disease should be prescribed a medication to reduce their future risk, where the benefits of prevention may not accrue for several years. We are operating in a field with scant data: patients in this age group have been underrepresented in clinical trials showing benefit, and recommendations therefore need to be extrapolated from younger individuals. Accordingly there is a discrepancy in guidelines – while the UK NICE guidelines provide a strong recommendation for primary prevention statin therapy in this age group, other societies (ACC/AHA in the U.S., ESC/EAS in Europe) provide a weak recommendation, and the USPSTF in the U.S. provides no recommendation.

The authors highlight several issues to take into consideration when prescribing statins for primary prevention in this age group, including frailty, comorbidities, and polypharmacy (all of which may increase the risk of adverse drug effects), as well as limited life expectancy (which may prevent long-term benefits from accruing). They also discuss the importance of shared decision making with patients, taking into account their values and goals. Notably, statin decision aids already exist which may facilitate this process.

Several years ago we had written a piece on primary prevention for ACC.org which stated “statins are probably both under- and over-utilized in older adults,” and in my opinion this statement remains accurate. For an older patient who is functionally independent, with few life-limiting comorbidities and a strong desire to reduce their cardiovascular risk, a low to intermediate dose statin makes sense. For a patient with a major life-limiting illness, who wants to reduce their medication burden, it’s reasonable to not prescribe or even “de-prescribe” statins. Ultimately, the variation in guidelines described by Mortensen and Falk in their JACC article highlights that in the absence of consensus, care needs to be individualized – which is a central principle of geriatric cardiology.

 

By: John Dodson, MD, MPH

Glucose Monitoring in Older Adults: How Much Is Too Much?

Wilcox_TanyaMy 90-year-old grandfather was the first person to teach me how to use a glucometer. He developed diabetes thirty years after his 3-vessel CABG, and the necessity of daily blood glucose checks seemed like an inevitable aspect of managing his new disease. As a diligent patient, he underwent the painful experience of pricking his finger and recording his measurements daily, and taught me how to help him as he lost dexterity with age. The experience left me questioning whether glucose monitoring is necessary for all patients with diabetes, especially older patients with late-onset, stable disease like my grandfather.

Diabetes mellitus is common disease among older adults; in the U.S., 1 in 4 persons over age 65 are affected. Cardiologists recognize diabetes management as integral to overall cardiovascular health. However in older adults, aggressive glycemic control can be burdensome and at times dangerous. Evidence from large randomized control trials including ADVANCE, ACCORD and VADT suggests that avoiding dangerously low blood sugars (hypoglycemia) may be more beneficial than achieving aggressively low hemoglobin a1c (HbA1c) targets. Based on available evidence, the American Geriatrics Society recommends higher Hba1c targets for older adults –  between 7-8.5% depending on comorbidity burden and prognosis. There remains, however, a lack of strong evidence on the optimal frequency of home glucose monitoring in this group of patients. An individualized discussion the benefits, risks and alternatives provides a framework for this discussion.

There is a clear need to avoid hypoglycemia, and self-glucose monitoring may provide a mechanism to screen for low blood sugars. Accordingly, the Endocrine Society indicates that glucose monitoring may benefit type 2 diabetics taking medications that put them at risk for hypoglycemia, including insulin or sulfonylureas. This may be especially important during medication initiation or uptitration. However, in patients with stable disease with no clear risk for hypoglycemia, the Endocrine Society and the Society of General Internal Medicine both recommend against routine multiple daily self-glucose monitoring. Home monitoring is nonetheless overprescribed; CDC health behavior data indicate that a majority (63%) of non-insulin dependent diabetics are checking finger sticks at home at least daily, and Veterans Affairs data found that test strips were prescribed to a large number of patients with stable non-insulin type-2 diabetes. Potential harms associated with daily self-monitoring of blood glucose monitoring include pain of needle sticks, cost, and general therapeutic burden, all of which can adversely influence quality of life. While needle-free glucose monitors are a potentially promising alternative, they remain under development.

In summary, in the absence of clear guidelines, decisions about initiation, frequency and discontinuation of self-monitoring of blood glucose in older adults with type 2 non-insulin dependent diabetes requires an informed discussion between clinician and patient, with particular attention to patient goals. For most older patients with cardiovascular disease, in whom sulfonylureas should be avoided, routine glucose monitoring is reasonable for a brief period during medication titration, and subsequent intermittent monitoring may be helpful to determine whether symptoms of hypoglycemia correlate with low blood glucose. However, for most patients with stable disease on oral agents, discontinuing routine (daily) home glucose checks can improve quality of life and reduce health care costs.

 

By: Tanya Wilcox, MD

Improving the Patient and Family Experience: A Caregiver’s Perspective

authors.pngAs our country’s population ages at an unprecedented rate, we must be prepared to care for them, both as loved  ones/caregivers and health care professionals. For aging patients with chronic illnesses such as heart disease, this is particularly important. This topic impacted the two of us in a very personal way. Although we have spent both of our careers in clinical and leadership health care positions, we were stunned by events surrounding our patient with heart failure, as she was a beloved mother to one of us, and a sister and best friend to the other. The symptoms of her congestive heart failure came on suddenly and crept along forebodingly for a year and a half before the one-two punch came out of nowhere – a cardiac arrest while she was driving her car to a routine medical appointment. Miraculously, she was rescued and resuscitated by bystanders, including several physicians who happened to be nearby.

The seven months that followed were the most painful and difficult that we have ever experienced. Three cardiac arrests within 24 hours led to therapeutic hypothermia, extracorporeal membrane oxygenation (ECMO), left ventricular assist device (LVAD) implantation, tracheostomy, GI tube placement, and multiple complications including femoral hemorrhaging, GI bleeding, kidney failure, crippling deconditioning and serious infection after infection. During this time, she was shuttled back and forth between the ICU and a long-term acute rehab hospital. As we look back on that time through the lens of both healthcare professional and dedicated caregiver, we have identified a significant number of clinical processes and decisions that beg for improvements. Ultimately, she died not from her heart failure, but from a massive infection and septic shock, one of many complications that were a result of the extended amount of time that she was hospitalized and the expensive technology that initially saved her, if only for a few months. Our experience as her primary caregivers throughout her long and complex hospitalization, and the many system and process failures that occurred, have spurred us to communicate these issues in several formats, as well as seek to partner with healthcare organizations to improve the patient and family/caregiver experience. There are so many factors to consider when making health care decisions for our aging patients and family members, especially those with conditions that require costly treatments and interventions that cause complications that are equally as severe as the primary diagnosis itself.

These issues also underscore the importance of having a strong advocate at the bedside for those patients who can’t advocate for themselves, especially our compromised and/or elderly loved ones. Here are some of the key areas that we identified as needing improvement, and that an effective patient advocate must be prepared to address:

  1. Coordination of Care – The transition of care from one care setting to another is one of the most vulnerable points during a patient’s care, leading to quality and patient safety issues. During our sister/mother’s hospitalization, she experienced multiple transitions of care. We were alarmed at the lack of communication of critical information, as well as the absence of a coordinated plan of care between these care settings. We frequently had to step in and act as the care coordinator and educator, although we also found that many clinicians were initially reluctant to listen to us.The importance of the presence and active involvement of family members and other caregivers to a patient’s well-being and recovery cannot be underestimated. We are the people who know the patient most intimately, and can tell when something is not right. Most often, we are also present through the numerous physician visits and change of shifts, keeping track of changing and sometimes conflicting treatment plans, and alerting other clinicians to any issues.
  1. Shared Decision Making – With our sister/mother unconscious and on life support during her initial hospitalization, we were forced to make immediate decisions on life-altering procedures, such as putting her on ECMO to keep her alive until she could regain consciousness to participate in the decision to move forward with what was considered her only hope, an LVAD. Ginny knew from previous conversations that she did not want to consider an LVAD if her heart failure progressed, and we struggled with the decision. This was compounded by inadequate educational materials and pressure by the medical team to implant the LVAD, as they felt it was the only option. After taking a firm stance to wait for her to regain consciousness before we made these medical decisions without her, she awoke enough for us to convince the medical team to include her in the discussion, and she agreed to the surgery. However, looking back we realized how severely impaired her cognition and comprehension about her condition was at the time.Much work has been done recently on determining standards for decision aids to help inform patients of their options and help them take a more active role in decisions about their healthcare treatment options that reflect their personal goals. Research has shown that the use of these decision aids improves patient outcomes.
  1. Palliative Care – Patients must be fully informed of the pros and cons of any treatments, with palliative care offered as an option if appropriate. For patients with life-threatening conditions, such as our sister/mother, a discussion with a palliative care team to develop an Advanced Care Plan should have happened early on, and should have included a discussion about how her advance directives and preferences may change after having an LVAD implanted. As it was, we had to make the heart-wrenching decision to turn off her LVAD after she became comatose as a result of severe septic shock, with no chance of recovery – something we were not prepared for, and that had never been discussed with either her or any of us.

We hope that by relaying some of the challenges we faced during this extremely difficult time, we can help future patients and their caregivers enjoy a better healthcare experience, as well as assist healthcare providers to provide the safest, most efficient and dignified patient and family-centered care.

 

By: Melinda Kane, MS-HCM and Ginny Meadows, MSHI, RN-BC

 


Reference to our longer article: “Finding A Better Way” published in Circulation: Cardiovascular Quality and Outcomes.

Limited function, high costs, and the need for a better approach

dodson%20headshotA recent article in the New York Times described the “High Price of Failing America’s Costliest Patients.” The author highlights the disproportionate healthcare costs incurred by a small percentage of patients in the U.S. (for example, 5% of the population accounts for 50% of the costs). These costs are not simply attributable to traditional disease entities that we learn in medical school – for example, patients with a chronic illness plus functional limitation (inability to care for themselves or perform routine daily tasks) have four times higher medical costs, according to the Commonwealth Fund. With an aging U.S. population, these functional limitations, which complicate already difficult management decisions in patients with chronic illnesses, are going to become more common in clinical practice over the coming decades.

We clearly need better models of care for functionally limited, complex older patients including those with cardiovascular disease. The Times article highlights several models already underway – including a Medicare Advantage Plan which spends more upfront time on team-based care (including physicians, nurse practitioners, and social workers) to achieve the aim of reduced downstream costs. These models are most likely to be successful if they focus on the “whole patient” rather than a single disease. For example, hospital readmissions in older patients (which are a major driver of healthcare costs) are usually for something other than the index condition, including in patients with heart failure (where fewer than half of 30-day readmissions are for heart failure). Efforts focused on a single disease entity (for example, diuretic management for heart failure) therefore may miss the larger picture. Another innovative approach to management involves incorporating patient goals into care plans, which moves beyond traditional disease-based management, and may be especially relevant in the setting of functional limitations. Ongoing work by Mary Tinetti, Caroline Blaum, and others is helping to incorporate goal elicitation, and alignment of treatment plans with these goals, into routine clinical care.

In my opinion there’s unlikely to be a “one size fits all” approach that solves the challenge of improving care in older patients with functional limitations. However I think the general principle of working beyond our silos, both by participating in teams with other clinicians and by directly eliciting goals from patients, will make a difference.

 

By: John Dodson, MD, MPH

A Healthy Old Age

karen-alexanderMaintaining a healthy lifestyle in our 30s, 40s or 50s is an important determinant of how we will age. New information confirms this association between lifestyle and healthy aging has no expiration date. Healthier lifestyles in our 70s and beyond continue to yield benefits as demonstrated by the Three Cities Study. In 2010, the American Heart Association released Life’s Simple 7, which is a 7-step list of ideal lifestyle modification goals that target improved cardiovascular health. AHA Life’s Simple 7 are a mix of behavioral (healthy diet, nonsmoking, moderate to vigorous physical activity more than 150 min/week) and biological (total cholesterol <200 mg/dl, blood pressure <120/80 mm Hg, fasting glucose <100 mg/dl, and body mass index <25 kg/m2) targets, with each goal having levels of ideal, intermediate, and poor attainment. Attainment of Life’s Simple 7 goals is associated with better cardiovascular health, better general health, less cancer, depression, cognitive impairment, diabetes, frailty, and all-cause mortality.

Better attainment of the American Heart Association’s Life’s Simple 7 goals among 9,294 men and women from France (mean age of 73.8 years) was associated with better health outcomes a decade later. Older adults who met at least 5 of 7 ideal goals at baseline had a 35% lower risk of all-cause mortality. Adults who met 3 to 5 ideal goals (intermediate health) had a 17% lower risk of all-cause mortality. Even better news is that outcomes improved with each goal attained; even intermediate goal attainment had a beneficial association with outcomes. Now for the bad (if predictable) news: only 1 participant met all 7 goals at ideal status, 5% met at least 5 of 7, and 15% met all behavioral goals. This attainment is comparable to similarly low rates in much younger populations around the US and world. Even though aging biology impacts non-attainment of ideal status on some measures (e.g. blood pressure and cholesterol), healthier behaviors were more likely among longer lived adults. Since healthy behaviors may prevent cognitive impairment and frailty, better goal attainment in older populations is important for optimizing survival and quality of life, while limiting time spent with illness and disability. This article has emboldened me to push my older patients to continue to shoot for Life’s Simple 7, giving few a “pass” based solely on age. Even more relevant for the older population, working to achieve these goals is likely to yield benefits before attaining ideal status. A favorite Tibetan proverb applies to those age 70 and beyond: “The secret to living well and longer is to eat half, walk double, laugh triple, and love without measure.”

 

By: Karen Alexander, MD