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

描述(申请人提供)：在出现急性心肌梗死(AMI)的患者中，30%的患者年龄在75岁或以上，预计随着婴儿潮一代的老龄化，这一患病率将会增加。他们合并疾病的高负担和伴随的较低的生理储备使这一群体更加复杂，从根本上不同于年轻的急性心肌梗死患者。风险分层模型有助于急性心肌梗死后的医疗决策，因为被判断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，而被估计风险较低的患者可能会得到安抚和较不积极的管理。目前可用的急性心肌梗死后风险模型是使用年轻患者的数据开发的，它们在老年患者中表现不佳。虽然人们对了解老年疾病(包括认知和肌肉力量受损)与心血管结果有关的作用越来越感兴趣，但目前还没有对老年急性心肌梗死患者进行标准的、可行的评估，以对他们随后的发病率和死亡率进行分层。此外，目前可用的风险模型仅设计用于预测临床事件(例如，死亡率)。这对于与老年患者共同做出决定是不够的，老年患者始终将维持良好的健康状态(包括身体功能)作为首要任务。这项提案将通过融合老年病学和心脏病学的原理来解决这些差距，以创建专门为老年患者设计的急性心肌梗死后风险模型。我们提出了第一个大规模(N=3000)的观察性混合方法研究(结合定量和定性方法)老年急性心肌梗死患者--银色急性心肌梗死。这项研究的总体目标是开发和验证成人急性心肌梗死的风险分层工具。我们将连续筛查75岁及以上的急性心肌梗死住院患者，从与我们合作的全国医院网络招募参与者，进行一项即将完成的关于年轻人急性心肌梗死的大规模观察性研究(Virgo)。所有风险因素将在出院前进行评估，所有结果将在6个月后进行评估。鉴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。我们开发的工具将可用于常规临床护理(即，只需15分钟或更少的时间来计算分数)，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，并将根据最终用户(即，护理老年急性心肌梗死患者的医生)的见解进行了解。为了满足老龄化人口的需求，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果的风险开始，然后针对每个患者的风险进行量身定制的治疗和监测。这是基础性工作：为老年患者量身定制急性心肌梗死后康复策略的先决条件。

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.