With the aging of the U.S. population there has been a fundamental shift among patients with acute myocardial infarction (AMI); the typical patient is now older, with more comorbidities, than even 20 years ago. While there has been significant progress in the development of AMI management strategies such as coronary revascularization procedures and antithrombotic medications, their benefits and harms were studied in trials of younger patients or in older adults without aging-related comorbidities. In practice, the average older adult with AMI is now being managed more aggressively with these therapies, although it remains challenging to precisely characterize and explain potential treatment-related harms such as renal failure after percutaneous coronary intervention (PCI), stroke after coronary artery bypass grafting (CABG), and bleeding from dual antiplatelet therapy (DAPT). While an accurate assessment of these potential harms is a critical component of AMI shared decision making (SDM) for older adults, an effective means of prediction is lacking. Physiologic age, which is manifested by geriatric impairments in domains such as mobility, strength, and cognition, shows promise as a determinant of post-AMI risk, but most studies have failed to measure it. We propose to address this gap in knowledge by first analyzing data from the SILVER-AMI study, an NIH-funded longitudinal cohort enrolling 3000 participants aged ?75 with AMI (Aim 1), and subsequently performing primary data collection at NYU Langone Medical Center (Aims 2-3).
In Aim 1 we will develop a risk score for in-hospital coronary revascularization-related complications that incorporates geriatric impairments. In Sub-Aim 1 we will then explore the association between geriatric impairments and bleeding related to DAPT within 6 months of AMI.
In Aim 2 we will use a qualitative methodology to assess decisional needs related to coronary revascularization, and in Aim 3 we will then develop and pilot a web-based decision aid to be used prior to revascularization. Our proposed work is innovative because it builds on a study (SILVER-AMI) that provides a rigorous assessment of geriatric impairments post-AMI and their prognostic importance. We also incorporate patients' perspectives (through a qualitative methodology), and provide patient-specific risk estimates in our decision aid which will allow for more individualized SDM discussions. My overall career goal is to become an independent investigator and thought leader in geriatric cardiology with the ability to perform research that improves care for older adults. To achieve this goal I will use the training period to gain skills n quantitative methods, qualitative research, decision aid development, and clinical trials, and to build leadership capabilities that can influence practice. I have assembled a team of Mentors with expertise in Geriatrics (Dr. Caroline Blaum, Dr. Daniel Matlock) and Cardiovascular Clinical Research (Dr. Sarwat Chaudhry, Dr. Stuart Katz), which is supplemented by experienced Advisors and Collaborators. In parallel with my 75% research effort, I will build a practice as a geriatric cardiologist and therefore perform clinical work directly relevant to my research.

Public Health Relevance

Acute myocardial infarction (heart attack) is common in older patients and there are a variety of procedures and treatments for it, including opening blocked arteries (revascularization). Revascularization procedures carry risks of complications that may be higher in patients with impairments such as poor memory, difficulty walking, or low strength. Our proposed research will generate knowledge about how such impairments are associated with complications, and we will then develop an interactive web-based program to help clinicians and patients to make more informed decisions about their treatment options.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Mentored Patient-Oriented Research Career Development Award (K23)
Project #
5K23AG052463-02
Application #
9321776
Study Section
Clinical Aging Review Committee (NIA-C)
Program Officer
Salive, Marcel
Project Start
2016-08-01
Project End
2020-04-30
Budget Start
2017-05-15
Budget End
2018-04-30
Support Year
2
Fiscal Year
2017
Total Cost
$137,536
Indirect Cost
$10,188
Name
New York University
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
121911077
City
New York
State
NY
Country
United States
Zip Code
10016
Dodson, John A; Hochman, Judith S; Roe, Matthew T et al. (2018) The Association of Frailty With In-Hospital Bleeding Among Older Adults With Acute Myocardial Infarction: Insights From the ACTION Registry. JACC Cardiovasc Interv 11:2287-2296
Grant, Eleonore V; Skolnick, Adam H; Chodosh, Joshua et al. (2018) Improving Care Using a Bidirectional Geriatric Cardiology Consultative Conference. J Am Geriatr Soc 66:1415-1419
Dodson, John A; Chaudhry, Sarwat I; Krumholz, Harlan M (2017) Time for a New Approach to Studying Older People with Ischemic Heart Disease. J Am Geriatr Soc 65:2349-2351
Dodson, John A; Williams, Mathew R; Cohen, David J et al. (2017) Hospital Practice of Direct-Home Discharge and 30-Day Readmission After Transcatheter Aortic Valve Replacement in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry. J Am Heart Assoc 6:
Ó Hartaigh, Bríain; Lovato, Laura C; Pahor, Marco et al. (2016) Effect of a Long-Term Physical Activity Intervention on Resting Pulse Rate in Older Persons: Results from the Lifestyle Interventions and Independence for Elders Study. J Am Geriatr Soc 64:2511-2516
Dodson, John A; Matlock, Daniel D; Forman, Daniel E (2016) Geriatric Cardiology: An Emerging Discipline. Can J Cardiol 32:1056-64