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%的患者年龄在75岁以上，随着婴儿潮一代的老龄化，这一患病率预计会增加。他们的高合并症负担和伴随的较低的生理储备使这一群体更复杂，与年轻AMI患者根本不同。风险分层模型有助于ami后时期的医疗决策，因为判断为高风险的患者可能会接受更积极的监测和/或更早的治疗，而估计为低风险的患者可能会放心并进行不那么积极的治疗。目前可用的ami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）与心血管预后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，可以对其随后发病和死亡的风险进行分层。此外，目前可用的风险模型仅用于预测临床事件（如死亡率）。这对于与老年患者共同决策是不够的，他们始终将保持良好的健康状态（包括身体功能）作为首要任务。该提案将通过融合老年病学和心脏病学的原则来解决这些差距，创建专门为老年患者设计的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）老年AMI人群，SILVER- AMI。本研究的总体目标是开发和验证老年AMI患者的风险分层工具。我们将连续筛选75岁及以上AMI住院患者的男性和女性，从全国医院网络中招募参与者，这些医院正在与我们合作进行一项几乎完成的大规模年轻人AMI观察性研究（VIRGO）。出院前评估所有危险因素，6个月后评估所有结果。鉴于缺乏了解医生使用风险分层工具的信息，我们将与医生进行深入访谈，以评估促进者和

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.