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The past month has been a crash course for me in telemedicine, as my geriatric cardiology practice went from fully in-person to fully “virtual” in light of the COVID-19 pandemic. Despite the abrupt startup and inevitable bumps along the way, many of my older patients have successfully transitioned to video encounters for the time being. And I’ve noticed a recurring theme during many of these video conversations: people tell me that they’re terrified of coming to the hospital, even in an emergency.

This fear has been reported in both the scientific literature and the lay press – with a precipitous drop in hospitalizations for emergent conditions ranging from acute coronary syndrome (ACS) to stroke. For example, Metzler et al. reported that in Austria, from the beginning to the end of March 2020, ACS hospitalizations decreased by nearly 40% – far outside the range of normal variation. The authors hypothesized that “the strict instructions to stay at home as well as the fear of infection in a medical facility may have…prevented patients with an ACS from going to a hospital.” Similarly, a study in the U.S. of several high-volume cardiac catheterization laboratories found a 38% reduction in emergent activations for ACS due to ST segment elevation myocardial infarction after March 1. In the setting of ACS, failure to present due to fear of hospitals may lead to multiple consequences including fatal arrhythmias, heart failure, and death. And based on the data, it’s highly likely that many patients are suffering through ACS and other emergent conditions at home.

What steps can we take? COVID-19 has created an unprecedented challenge to modern healthcare, and there’s no consensus even among experts. In my own practice, I emphasize to my patients there are certain symptoms – persistent chest pain, shortness of breath at rest, new speech difficulty – that require them to go to the emergency room; the consequences of failing to act are too great. Letting patients know about new telemedicine options (e.g. virtual “urgent care” 24 hours a day) may help them to know there are options between staying home and calling an ambulance, so that their symptoms can be appropriately triaged. Finally, as the effects of social distancing take hold and COVID-19 cases decline, fear of hospitals may decrease. But for now, the problem is very real, and can be considered as one of the many negative consequences of the pandemic.

 

By: John Dodson, MD

On March 11, 2020 the World Health Organization declared COVID-19 a global pandemic. SARS-CoV-2, the virus that causes COVID-19, was initially recognized in China in December 2020 then over the course of three short months has brought the hustle and bustle of NYC to a grinding halt. Terms such as “social distancing”, “flattening the curve”, and “hydroxychloroquine”, are now spoken causally in everyday conversation. The rapid evolution and spread of the virus has been accompanied by a mounting body of experimental protocols aimed to treat those infected, a large proportion who are over the age of 65.

One such treatment protocol is the use of azithromycin and hydroxychloroquine to treat symptomatic hospitalized patients with supplemental oxygen requirements. This treatment strategy is currently off label and is based on a small French study showing decreased viral burden. Additionally, the use of hydroxychloroquine alone is based on limited data including a study showing inhibition of the virus in vitro, meaning in the laboratory. These off label treatments, based on limited evidence, are being widely used across the United States to treat patients hospitalized with COVID-19. While there is hope for benefit, there is also potential harm due to adverse drug events, especially in older adults. While large randomized trials of these medications will provide definitive evidence, they will also require more time.

In those age 65 years and older it is necessary to critically examine the potential deadly cardiac side effect commonly known to be associated with azithromycin and hydroxychloroquine, QTc prolongation. This prolongation can lead to deadly ventricular arrhythmias. The QTc is the QT interval on an ECG corrected for heart rate. Studies have shown that, as chronological age increases, so does the QTc interval. Theories for this phenomenon include increased myocardial fibrosis altering the myocardium and changes to the sympathetic and parasympathetic tone effecting myocardial repolarization. This can result in increased susceptibility to events and medications, which may further prolong the QT interval.

Figure 1. ECG Phases

Recently the Canadian Heart Rhythm Society published a treatment guideline aimed to minimize the risk of drug-induced ventricular arrhythmias. The article acknowledged that the use of certain antimicrobials to treat COVID-19 has uncertain benefits but may increase the risk of QT prolongation. They proposed an algorithm that included obtaining a baseline ECG and electrolyte panel, as well as a subsequent ECG 48 hours after initiation of therapy. The guidelines recommend that QT prolonging antimicrobial agents should generally be stopped in the setting of a QTc >500. An article in press from investigators at the Mayo Clinic makes similar recommendations.

The rapid spread and deadly devastation of COVID-19 has resulted in clinical momentum to find a definitive treatment. However, combining two medications, azithromycin and hydroxychloroquine, in the off label treatment of COVID-19 and administering them to a vulnerable patient population must be performed with extreme caution, even if the risk to the general population is low. We must continue to uphold the principles of evidence-based medicine even in a time of a global pandemic.

 

By: Megan E. Rau, MD, MPH

Dr. Rau is a practicing physician at NYU Langone Health who specializes in geriatrics and palliative care & hospice. 

 

My 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

A 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

Maintaining 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