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

 描述(申请人提供)：随着美国人口的老龄化，急性心肌梗死(AMI)患者的情况发生了根本性的变化；与20年前相比，现在的典型患者年龄更大，合并疾病也更多。虽然在开发急性心肌梗死治疗策略方面取得了重大进展，如冠状动脉血管重建术和抗血栓药物，但它们的益处和危害是在年轻患者或没有与衰老相关的并发症的老年人的试验中研究的。在实践中，普通老年急性心肌梗死患者现在使用这些治疗方法进行更积极的管理，尽管准确描述和解释潜在的与治疗相关的损害仍然具有挑战性，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)后的中风和双重抗血小板治疗(DAPT)的出血。虽然对这些潜在危害的准确评估是老年人急性心肌梗死共享决策(SDM)的关键组成部分，但缺乏有效的预测手段。生理年龄，表现为行动能力、力量和认知等方面的“老年损害”，显示出作为急性心肌梗死后风险决定因素的前景，但大多数研究都未能衡量它。我们建议通过首先分析白银-急性心肌梗死研究的数据来解决这一知识差距，该研究是由美国国立卫生研究院资助的纵向队列研究，招募了3,000名年龄为75岁的≥急性心肌梗死患者(目标1)，然后在纽约大学朗格内医学中心进行初步数据收集(目标2-3)。在目标1中，我们将制定包含老年损伤的住院冠状动脉血运重建相关并发症的风险评分。在次目标1中，我们将探讨老年损伤与急性心肌梗死后6个月内DAPT相关出血之间的关系。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，然后在目标3中，我们将开发并试行基于网络的决策辅助工具，以在血运重建之前使用。我们提出的工作是创新的，因为它建立在一项研究(银质急性心肌梗死)的基础上，该研究提供了对急性心肌梗死后老年损害及其预后重要性的严格评估。我们还结合了患者的观点(通过定性方法)，并在我们的决策辅助工具中提供了患者特定的风险估计，这将允许进行更个性化的SDM讨论。我的整个职业目标是成为老年心脏病学的独立研究员和思想领袖，有能力进行改善老年人护理的研究。为了实现这一目标，我将利用培训时间获得定量方法、定性研究、决策辅助开发和临床试验方面的技能，并建立能够影响实践的领导能力。我组建了一支在老年病学(Caroline Blaum博士、Daniel Matlock博士)和心血管临床研究(Sarwat Chaudhry博士、Stuart Katz博士)方面具有专业知识的导师团队，并辅之以经验丰富的顾问和合作者。在我75%的研究努力的同时，我将建立一个老年心脏病专家的实践，因此进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.