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.

Public Health Relevance

Patients 75 years of age and older make up a large and growing segment of the heart attack (acute myocardial infarction) population, but they have historically been under-studied. The overall objective of this work is to create tools to predict te risk of subsequent adverse outcomes among older patients hospitalized with myocardial infarction. The results of this study can inform decision-making about therapies and surveillance after myocardial infarction, and the development of interventions to improve the outcomes of this patient population.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Project (R01)
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Cardiovascular and Sleep Epidemiology (CASE)
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Cooper, Lawton S
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Yale University
Internal Medicine/Medicine
Schools of Medicine
New Haven
United States
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Chaudhry, Sarwat I; Khan, Rabeea F; Chen, Jersey et al. (2014) National trends in recurrent AMI hospitalizations 1 year after acute myocardial infarction in Medicare beneficiaries: 1999-2010. J Am Heart Assoc 3:e001197
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