Re-thinking the Role of Stress Imaging for Symptomatic Older Adults with Stable Coronary Artery Disease

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PROJECT SUMMARY/ABSTRACT More than a quarter of all adults older than 75 years have symptomatic stable ischemic heart disease. Stress nuclear imaging is the one of the most common tests performed for diagnosis and management of coronary artery disease in these older adults. Older adults are more likely to have co-existing impairments in function, cognition and multimorbidity, which may limit their benefit from imaging tests and post-test treatment, alike. Although stress testing is often used to evaluate symptoms, clinicians are less likely to refer older adults for revascularization or to optimize their medical therapy, even if stress test results are severely abnormal. In turn, this can result in overuse of testing, increased complications and cost of care without improving patient outcomes. To help older patients presenting with suspected ischemic symptoms make a well-informed decision, clinicians should contextualize the benefits of imaging and treatment strategies post imaging in context of elicited goals of care, clinical impairments. It is critical to understand presentation, cardiac risk factors and potential age-related how to improve shared decision making among older adults and identify areas of imaging test overuse or underuse among older adults with symptomatic stable ischemic heart disease. In this project, I use a multi-stakeholder approach to understand post-stress test decision making from patient, caregiver and physician perspectives and study its association with outcomes among symptomatic older adults with suspected or known CAD. My research aims are to (a) understand older patient and caregiver attitudes about post-imaging treatment choice in context of their preferred outcomes and age-related impairments through focus group interviews and (b1) examine the association between cardiovascular and geriatric risk factors on post-imaging treatment choice (i.e., invasive referral vs. medical optimization); and (b2) compare the association of treatment received post-imaging and patients' symptoms, function and quality of life among symptomatic older adults  75 years undergoing clinically indicated stress nuclear imaging within our health system. This study will help inform my future work aimed at developing and testing personalized decision aids to guide choice of testing and treatment for symptomatic older adults with CAD. This GEMSSTAR award will also provide me with the support, mentorship and training required to become a leader in field of cardiovascular imaging and shared decision-making for older adults with stable ischemic heart disease.