Shared Decision-Making in Acute Myocardial Infarction

Headshot_Grant_2018Several weeks ago I had the pleasure of presenting our findings from a qualitative research study we conducted at the AGS 2018 annual meeting, investigating cardiologists’ perspectives and familiarity with shared decision-making (SDM) in older adults after hospitalization for acute myocardial infarction (AMI). SDM has emerged in the literature as a way to move towards patient-centered care and has significant potential to enhance patient adherence, reduce undesired treatments, and improve overall satisfaction with care. In our study, we sought to discover the degree to which practicing cardiologists understood SDM, and whether it was applicable to their practice with older adult patients – particularly in the setting of cardiac catheterization and percutaneous coronary intervention. Five major themes emerged from these interviews:

  1. Age alone is not a major contraindication to intervention.

Our respondents consistently stated that age would not deter them from sending a patient to cardiac catheterization. Instead, they generally brought up “what kind of 80,” distinguishing chronological and biological age. Further, cardiologists generally reported treating older adults similarly to how they would treat their younger counterparts.

  1. SDM is important in the setting of NSTEMI, and not practical in STEMI:

Respondents felt that SDM was useful among patients hospitalized for NSTEMI (who represent the largest proportion of older adults with AMI). Conversely, due to the acuity of STEMI (with system-wide pressures on prompt reperfusion therapy), there was near-universal agreement that SDM was not practical in this setting.

  1. Dementia and functional status emerged as the major contraindications to intervention:

While age was not itself a major contraindication to intervention, age-related impairments such as dementia and functional status were consistently noted as reasons cardiologists would adopt a more conservative approach to care.

  1. There was some variation in cardiologists’ interpretation of SDM:

While most cardiologists saw SDM as a move away from paternalism towards patient-centered care, there was some variation in what the meaning of “shared” was among our respondents. While some respondents felt it was shared between the cardiologist and her patient, others thought it was between the patient and family members, and still others thought it was between the provider and her colleagues.

  1. A personalized (and geriatric-informed) risk calculator may help to facilitate SDM in this population for cardiologists:

Cardiologists continually highlighted the paucity of data to guide their care in the older adult population, and emphasized that a risk calculator tailored to these patients would allow them to give more specific and personalized information in order to promote SDM with accurate calculations of risk and benefit.

Our findings have several implications. The take-home message was that cardiologists generally accepted SDM as an optimal model of care, particularly in settings where the risk/benefit ratio was uncertain, but experienced some challenges with accurate prognostication. Future efforts at personalized risk calculators, tailored to older patients’ phenotypes, may help to promote SDM in practice.


By: Eleonore Grant, BA

Eleonore Grant was an Associate Research Coordinator at NYU Langone Health and coordinated studies on shared decision-making. She will be matriculating at medical school this Fall. 

Cardiac Rehabilitation – Effective and Underutilized

bostromTreadmills, elliptical machines, and tennis shoes; objects commonly associated with leisure time and fitness training are abundant on the 16th floor of the NYU Ambulatory Care Center, home to the NYU Cardiac Rehabilitation Program. Cardiac rehabilitation (CR) programs involve regimented, structured physical activity and are typically employed over the course of many weeks; at NYU, the standard schedule involves supervised activity three times per week for three months.

Evidence suggests that participation in CR programs after hospitalization for a variety of cardiac conditions and procedures (including stable ischemic heart disease, heart failure, and following coronary revascularization) imparts real benefits including decreased cardiovascular-related mortality, reduced hospital admissions, and improvement in health-related quality of life. ACC/AHA guidelines accordingly assign a Class I recommendation for the prescription of CR programs to patients after hospitalization for acute coronary syndrome, post-revascularization, or heart failure.

Despite these recommendations, CR programs are underutilized. Studies (here and here) have noted that many patients who could benefit from participation in a CR program are not referred upon discharge, and under-referral is even more pronounced in older patients. Given that adults over the age of 65 have the highest rates of mortality related to acute myocardial infarction and heart failure, lack of referral for these patients may represent a glaring missed opportunity for significant impact.

Notably, in a recent observational study by Flint et. al. of patients aged ≥65 with acute myocardial infarction, those with slow gait speed – a marker of frailty – were less frequently referred to CR programs. While reasons for this phenomenon are likely multifactorial (e.g. transportation, lack of available facilities, physical limitations), an important and addressable factor is referral bias; clinicians may feel that a patient who is “too frail” may be unlikely to benefit from a program that includes frequent structured exercise. Notably, in the study by Flint et al., patients with slow gait speed who participated in a CR program garnered similar benefits in outcomes (mortality, maintenance of activities of daily living) when compared their less frail counterparts. These data (which build on previous observations) suggest that even older adults who are considered frail or have significant medical comorbidities benefit from standardized referral to CR.

Initial referral is just one of many potential barriers to participation in CR programs: economic and social factors contribute to reduced rates of participation and adherence. Time commitment, including distance from home to a CR program, has also been mentioned as a barrier to utilization. In this context, mobile health (mHealth) companies are rapidly moving to develop home-based CR programs that leverage existing technologies (smartphones, tablet devices, wearable monitors) with the promise that they can serve as either a substitute or adjunctive therapy to traditional ambulatory CR programs. If successful, they may fill a significant gap in our current care paradigms for older adults by reducing a number of barriers to participation in CR programs; but rigorous trials will be ultimately required to evaluate their efficacy.

By: John Bostrom, MD