Individualizing Anticoagulant use in Older Adults with Atrial Fibrillation

项目摘要/摘要 这是比森(K76)职业发展奖，授予Sachin J Shah，医学博士，公共卫生硕士，医生兼研究员 受过内科、临床流行病学和衰老研究方面的培训。沙阿博士是 加州大学旧金山分校医院医学部。沙阿博士的长期目标是 建立证据，为面临高风险、高收益的老年人提供个性化治疗建议 使用新的流行病学方法和老年学研究原则的治疗决定。决定使用 老年房颤患者的抗凝治疗是一项高风险治疗决策的范例 因为虽然抗凝剂可以预防中风，但它们增加了出血并发症的风险。指南使用 一刀切的方法；对于老年人，他们建议使用几乎普遍的抗凝剂。不计其数 在临床实践的研究中，医生报告了对当前方法的担忧，表示需要 为老年人提供个性化的治疗建议。这项建议解决了以下迫切需要 通过两个目标使患有房颤的老年人的抗凝治疗决定个体化。目标1：发展和 抗凝药物预防缺血性卒中治疗效果的个体化评估 患有房颤的老年人。这个目标将使用临床试验和观察数据来开发和验证一种治疗方法。 将估计个人水平的治疗收益的效果模型。目标2：确定术后功能结果 严重的颅外出血，有短期的也有长期的。主要疾病后的功能结果 出血是抗凝治疗的一个关键不良事件，目前尚不清楚，尤其是在老年人中。通过两个 研究表明，这一建议将决定大出血后的短期和长期功能结果。 沙阿博士出类拔萃的多学科指导团队由全国公认的玛格丽特·方博士领导 在肯尼斯博士的共同指导下，她研究了抗凝剂在老年人中的临床结果 科文斯基，他的国家认可的研究计划促进了我们对预测因素的理解 以及老年人的残疾后果。这一职业发展奖将支持沙阿博士向 通过指导和集中培训实现研究的独立性(1)测量异质治疗 使用新的流行病学工具的效果，(2)初步数据收集，以建立预期的老年人队列， (3)设计决策辅助工具；(4)领导跨学科、多机构的领导力发展 研究团队。这项提案将支持一项开发拨款，以设计和试行临床决策工具 考虑使用抗凝剂的老年人和一项评估异种治疗效果的项目赠款 老年房颤患者的程序性干预。拟议的研究和培训目标将为Shah博士提供 拥有数据、培训和经验来支持竞争对手的R系列应用。

Project Summary/Abstract This is a Beeson (K76) career development award for Sachin J Shah, MD, MPH, a physician-investigator trained in internal medicine, clinical epidemiology, and aging research. Dr. Shah is an Assistant Professor in the Division of Hospital Medicine at the University of California, San Francisco. Dr. Shah's long-term goal is to build evidence to individualize treatment recommendations for older adults facing high-risk, high-benefit therapeutic decisions using new epidemiologic methods and geriatric research principles. The decision to use anticoagulants in older adults with atrial fibrillation (AF) is the paradigm of a high-stakes therapeutic decision because while anticoagulants prevent stroke, they increase the risk of bleeding complications. Guidelines use a one-size-fits-all approach; for older adults, they recommend near-universal anticoagulant use. In numerous studies of clinical practice, physicians report concern with the current approach voicing the need to individualize treatment recommendations for older adults. This proposal addresses the pressing need to individualize anticoagulant treatment decisions in older adults with AF through two aims. Aim 1: Develop and validate individualized estimates of the treatment effect of anticoagulants for ischemic stroke prevention in older adults with AF. This aim will use clinical trial and observational data to develop and validate a treatment effect model that will estimate individual-level treatment benefit. Aim 2: Ascertain functional outcomes after major extracranial hemorrhage, both short-term and longer-term. The functional outcomes following major hemorrhage, a key adverse event of anticoagulant therapy, are unclear, especially in older adults. Through two studies, this proposal will determine the short- and long-term functional outcomes following major hemorrhage. Dr. Shah's exceptional, multidisciplinary mentoring team is led by Dr. Margaret Fang, nationally recognized for her work studying the clinical outcomes of anticoagulants in older adults and co-mentored by Dr. Kenneth Covinsky, whose nationally recognized research program has advanced our understanding of the predictors and outcomes of disability in older adults. This career development award will support Dr. Shah's transition to research independence through mentorship and focused training in (1) measuring heterogeneous treatment effects using novel epidemiologic tools, (2) primary data collection to build prospective cohorts of older adults, (3) designing decision aids and (4) leadership development to lead cross-disciplinary, multi-institutional research teams. This proposal will support a development grant to design and pilot a clinical decision tool for older adults considering anticoagulant and a project grant to measure heterogeneous treatment effects of procedural interventions in older adults with AF. The proposed research and training aims will provide Dr. Shah with the data, training, and experience to support competitive R-series applications.