Need for Evidence-Based Decision Making in the Older Adult Population

Rich MW, Chyun DA, Skolnick AH, et al.
Knowledge Gaps in Cardiovascular Care of the Older Adult Population: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol 2016;Apr 11:[Epub ahead of print].

The following are 10 points to remember from a Scientific Statement intended to summarize current guideline recommendations as they apply to older adults, and identify critical gaps in knowledge that preclude informed evidence-based decision making:

  1. Cancer is the leading cause of death among U.S. adults 18-74 years of age, and it is only after age 75 that cardiovascular disease becomes the dominant cause of mortality.
  2. Due to age-related changes in cardiovascular structure and function, coupled with changes in other organ systems, including the kidneys, liver, skeletal muscle, and brain, older patients are at increased risk for complications related to pharmacological and nonpharmacological interventions.
  3. In general, the studies upon which American College of Cardiology/American Heart Association (ACC/AHA) guidelines are based enrolled few older adults and/or included older patients with few comorbidities. Older patients with comorbidities, frailty, and cognitive deficits should be included in clinical studies when feasible and in compliance with local Institutional Review Board policies. Furthermore, future studies should incorporate a range of outcomes, including quality of life, functional capacity, maintenance of independence, and cognitive function.
  4. According to the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes (NSTE-ACS), “management decisions for older patients with NSTE-ACS should be patient-centered, and consider patient preferences/goals, comorbidities, functional and cognitive status, and life expectancy.” Additional studies should define the risks and benefits of conservative versus invasive care in older patients with ACS.
  5. More than one-third of patients with atrial fibrillation (AF) are older than 80 years of age. While most AF trials have enrolled patients without an upper age limit, the mean age of the study cohorts is 5 years less than the average age of patients with AF in the general population. In particular, older patients are not well represented in the ablation literature.
  6. While indications for pacemaker implantation and for cardiac resynchronization therapy are similar in older and younger patients, remote device monitoring is recommended after 2 weeks following the implant.
  7. Age is not a contraindication to aortic valve replacement. Multiple series demonstrate favorable outcomes in elderly patients undergoing surgical or transcatheter AVR (TAVR).
  8. That said, current guidelines provide a Class III recommendation for TAVR in patients in whom existing comorbidities would preclude the expected benefit from correction of aortic stenosis.
  9. Advanced age is a risk factor for adverse outcomes, and age ≥80 years is considered a relative contraindication to mechanical circulatory support as destination therapy.
  10. There are many evidence gaps regarding the management of common cardiovascular disorders with a high prevalence in older adults. There is a critical need for evidence from population-based studies that include older adults and incorporate patient-centered outcomes.

Keywords: Acute Coronary Syndrome, Aortic Valve Stenosis, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Resynchronization Therapy, Cardiovascular Diseases, Cognition Disorders, Comorbidity, Geriatrics, Life Expectancy, Muscle, Skeletal, Neoplasms, Pacemaker, Artificial, Quality of Life, Risk Assessment, Risk Factors, Transcatheter Aortic Valve Replacement

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