Risk Stratification in Older Persons with Acute Myocardial Infarction: SILVER-AMI

描述（由申请人提供）：在急性心肌梗死（AMI）患者中，30%为75岁或以上，预计这种患病率将随着婴儿潮一代的老龄化而增加。他们的高共病负担和伴随的较低的生理储备使这一组更复杂，从根本上不同于年轻的AMI患者。风险分层模型有助于AMI后时期的医疗决策，因为被判定为风险较高的患者可能会接受更积极的监测和/或更早的治疗，而被估计为风险较低的患者可能会得到保证和较低的积极性管理。目前可用的AMI后风险模型是使用来自年轻患者的数据开发的，并且它们在老年患者中表现不佳。尽管人们对了解老年疾病（包括认知和肌肉力量障碍）与心血管结局的关系越来越感兴趣，但目前还没有标准的、可行的老年AMI患者评估方法，可以对他们随后的发病率和死亡率风险进行分层。此外，当前可用的风险模型仅被设计为预测临床事件（例如，死亡率）。这不足以与老年患者共同决策，老年患者始终将维持良好的健康状况（包括身体功能）作为首要任务。该提案将通过融合老年医学和心脏病学的原则来解决这些差距，以创建专为老年患者设计的AMI后风险模型。我们提出了第一个，大型（N=3000），观察性，混合方法研究（结合定量和定性方法）的老年AMI人群，银- AMI。本研究的总体目标是为老年AMI患者开发和验证危险分层工具。我们将连续筛选年龄在75岁及以上的AMI住院患者，以招募来自全国医院网络的参与者，这些医院正在与我们合作进行一项即将完成的年轻人AMI大规模观察性研究（VIRGO）。出院前将评估所有风险因素，6个月后将评估所有结局。由于缺乏了解医生使用风险分层工具的信息，我们将对医生进行深入访谈，以评估促进者和 采用新的风险分层工具的障碍。这些信息将指导我们开发的工具的开发，以最大限度地提高它们在临床实践中使用的可能性。我们开发的工具将适用于常规临床护理（即，计算分数需要15分钟或更短时间），考虑以前被忽视的风险因素，预测临床和以患者为中心的结果，并将通过最终用户的见解（即，护理AMI住院老年患者的医生）。为了满足人口老龄化的需求，需要一种新的临床模式--从全面评估临床和以患者为中心的结局的风险开始，然后根据每个患者的风险定制治疗和监测。这是基础性工作：为老年患者定制AMI后恢复策略的先决条件。

DESCRIPTION (provided by applicant): Among patients presenting with acute myocardial infarction (AMI), 30% are 75 years or older, and this prevalence is expected to increase with the aging of the baby-boomer generation. Their high burden of comorbid conditions and concomitant lower physiologic reserve render this group more complex and fundamentally different from younger AMI patients. Risk stratification models are helpful for medical decision making in the post-AMI period as patients judged to be at higher risk may receive more aggressive surveillance and/or earlier treatment, while patients estimated to be at lower risk may be reassured and managed less aggressively. Currently available post-AMI risk models were developed using data from younger patients, and they do not perform well in older patients. While there is emerging interest in understanding the role of geriatric conditions (including impairments in cognition and muscle strength) as they pertain to cardiovascular outcomes, there is no standard, feasible assessment of older patients with AMI that can stratify their risk of subsequent morbidity and mortality. Furthermore, currently available risk models are designed solely to predict clinical events (e.g., mortality). This is insufficient for shared decison making with older patients, who consistently rate maintenance of favorable health status (including physical function) as a top priority. This proposal will address these gaps by melding principles from geriatrics and cardiology to create post-AMI risk models specifically designed for older patients. We propose the first, large (N=3000), observational, mixed- methods study (combining both quantitative and qualitative methodology) of the older AMI population, SILVER- AMI. The overall objective of this study is to develop and validate risk stratification tools for oder adults with AMI. We will consecutively screen men and women age 75 years and older hospitalized with AMI to enroll participants from a national network of hospitals that are working with us in a nearly completed large-scale observational study of AMI in younger persons (VIRGO). All risk factors will be assessed prior to hospital discharge, and all outcomes will be assessed 6-months later. Given the dearth of information to understand use of risk stratification tools by physicians, we will conduct in-depth interviews with physicians to assess facilitators and barriers to adoption of new risk stratification tools. This information will guide the development f the tools we develop to maximize the likelihood that they are used in clinical practice. The tools we develop will be feasible for use in routine clinical care (i.e. take 15 minutes or less to calculate scores), consider previously neglected risk factors, predict both clinical and patient-centered outcomes, and will be informed by insights of the end-users (i.e., physicians caring for older patients hospitalized with AMI). To meet the needs of the aging population, a new clinical paradigm is needed- one that starts with a comprehensive assessment of risk for clinical and patient-centered outcomes, and then tailors therapy and surveillance to each patient's risk. This is foundational work: a prerequisite to tailoring post AMI recovery strategies for older patients.