Geriatric impairments, risk of treatment-related harms, and shared decision-making among older adults with acute myocardial infarction

 描述（由申请人提供）：随着美国人口老龄化，急性心肌梗死（AMI）患者发生了根本性变化;与20年前相比，现在的典型患者年龄更大，合并症更多。虽然在AMI管理策略（如冠状动脉血运重建术和抗血栓药物）的开发方面取得了重大进展，但在年轻患者或无年龄相关合并症的老年人的试验中研究了其获益和危害。在实践中，一般的老年AMI患者目前正在接受更积极的治疗，尽管精确描述和解释潜在的治疗相关危害仍然具有挑战性，例如经皮冠状动脉介入治疗（PCI）后的肾衰竭，冠状动脉旁路移植术（CABG）后的卒中和双重抗血小板治疗（DAPT）引起的出血。虽然对这些潜在危害的准确评估是老年人AMI共享决策（SDM）的关键组成部分，但缺乏有效的预测手段。生理年龄，表现为在活动性、力量和认知等领域的“老年损伤”，显示出作为AMI后风险决定因素的前景，但大多数研究未能对其进行测量。我们建议首先分析SILVER-AMI研究的数据，以解决这一知识缺口。SILVER-AMI研究是一项由NIH资助的纵向队列研究，招募了3000名年龄≥75岁的AMI患者（目标1），随后在NYU Langone Medical Center进行原始数据收集（目标2-3）。在目标1中，我们将制定一个包含老年损伤的院内冠状动脉血运重建相关并发症的风险评分。在子目标1中，我们将探讨老年损伤与AMI后6个月内DAPT相关出血之间的相关性。在目标2中，我们将使用定性方法来评估与冠状动脉血运重建相关的决策需求，在目标3中，我们将开发和试点基于网络的决策辅助工具，用于血运重建之前。我们提出的工作是创新的，因为它建立在一项研究（SILVER-AMI），提供了一个严格的评估老年损伤后AMI及其预后的重要性。我们还纳入患者的观点（通过定性方法），并在我们的决策辅助中提供患者特定的风险估计，这将允许更多的个性化SDM讨论。我的总体职业目标是成为一名独立的研究者和老年心脏病学的思想领袖，有能力进行研究，改善老年人的护理。为了实现这一目标，我将利用培训期间获得定量方法，定性研究，决策辅助开发和临床试验的技能，并建立能够影响实践的领导能力。我组建了一个具有老年医学专业知识的导师团队（Caroline Blaum博士、丹尼尔马特洛克博士）和心血管临床研究（Sarwat Chaudhry博士、Stuart Katz博士），并由经验丰富的顾问和合作者补充。在我75%的研究工作的同时，我将建立一个老年心脏病专家的实践，因此执行与我的研究直接相关的临床工作。

 DESCRIPTION (provided by applicant): With the aging of the U.S. population there has been a fundamental shift among patients with acute myocardial infarction (AMI); the typical patient is now older, with more comorbidities, than even 20 years ago. While there has been significant progress in the development of AMI management strategies such as coronary revascularization procedures and antithrombotic medications, their benefits and harms were studied in trials of younger patients or in older adults without aging-related comorbidities. In practice, the average older adult with AMI is now being managed more aggressively with these therapies, although it remains challenging to precisely characterize and explain potential treatment-related harms such as renal failure after percutaneous coronary intervention (PCI), stroke after coronary artery bypass grafting (CABG), and bleeding from dual antiplatelet therapy (DAPT). While an accurate assessment of these potential harms is a critical component of AMI shared decision making (SDM) for older adults, an effective means of prediction is lacking. Physiologic age, which is manifested by "geriatric impairments" in domains such as mobility, strength, and cognition, shows promise as a determinant of post-AMI risk, but most studies have failed to measure it. We propose to address this gap in knowledge by first analyzing data from the SILVER-AMI study, an NIH-funded longitudinal cohort enrolling 3000 participants aged ≥75 with AMI (Aim 1), and subsequently performing primary data collection at NYU Langone Medical Center (Aims 2-3). In Aim 1 we will develop a risk score for in-hospital coronary revascularization-related complications that incorporates geriatric impairments. In Sub-Aim 1 we will then explore the association between geriatric impairments and bleeding related to DAPT within 6 months of AMI. In Aim 2 we will use a qualitative methodology to assess decisional needs related to coronary revascularization, and in Aim 3 we will then develop and pilot a web-based decision aid to be used prior to revascularization. Our proposed work is innovative because it builds on a study (SILVER-AMI) that provides a rigorous assessment of geriatric impairments post-AMI and their prognostic importance. We also incorporate patients' perspectives (through a qualitative methodology), and provide patient-specific risk estimates in our decision aid which will allow for more individualized SDM discussions. My overall career goal is to become an independent investigator and thought leader in geriatric cardiology with the ability to perform research that improves care for older adults. To achieve this goal I will use the training period to gain skills n quantitative methods, qualitative research, decision aid development, and clinical trials, and to build leadership capabilities that can influence practice. I have assembled a team of Mentors with expertise in Geriatrics (Dr. Caroline Blaum, Dr. Daniel Matlock) and Cardiovascular Clinical Research (Dr. Sarwat Chaudhry, Dr. Stuart Katz), which is supplemented by experienced Advisors and Collaborators. In parallel with my 75% research effort, I will build a practice as a geriatric cardiologist and therefore perform clinical work directly relevant to my research.