ACC, AHA, AGS recommend trials examine older adults with cardiovascular disease

After reviewing current guidelines, researchers have found a lack of evidence to guide clinical decision making in older adults with cardiovascular disease and a lack of data on the impact diagnostic and therapeutic interventions have on quality of life, physical function and other outcomes.

The American College of Cardiology (ACC), American Heart Association (AGS) and American Geriatrics Society (AGS) detailed their review and concerns in a scientific statement released on April 11. The scientific statement was simultaneously published in the Journal of the American College of Cardiology and Circulation.

Michael W. Rich, MD, of the Washington University School of Medicine in St. Louis, and Deborah A. Chyun, PhD, of New York University, were co-chairs of the writing group.

The group mentioned that people older than 65 years old account for more than half of cardiovascular hospitalizations and procedures and approximately 80 percent of all cardiovascular deaths in the U.S. Although only 6 percent of the population is older than 75 years old, more than half of cardiovascular deaths occur in that age group.

Still, most randomized trials exclude older adults or include only relatively health older adults who have few comorbidities or functional impairments, according to the researchers.

“The present scientific statement summarizes vital knowledge and evidence gaps relevant to common cardiovascular disorders with high prevalence in older adults,” they wrote. “To overcome these deficiencies, there is a critical need for a multitude of large population-based studies and clinical trials using novel study designs that incorporate patient-centered outcomes relevant to older patients and, most importantly, that include a broad mix of older patients typical of those seen in clinical practice. The results of these studies will enable translation of key findings into future evidence-based guidelines, thereby transforming care and enhancing outcomes for the growing population of older people with [cardiovascular disease] in the United States and around the world.”

For this review, the researchers analyzed the ACA/AHA and American Stroke Association guidelines. Each of the 11 members of the writing committee reviewed the initial manuscript. Next, 16 context experts from the ACC, AHA and AGS reviewed the document and sent comments and suggestions back to the writing committee, which incorporated them before submitting the document for publication.

The researchers mentioned efforts should be made to recruit older adults into clinical trials and assess health status, quality of life, functional capacity, maintenance of independence and cognitive function of patients as well as the cost-effectiveness, value and resource utilization of medications and treatments.

They provided recommendations in the following areas: coronary artery disease; stable ischemic heart disease, PCI and CABG; heart rhythm disorders; ventricular arrhythmias and prevention of sudden cardiac death; device-based therapy for cardiac rhythm abnormalities; valvular heart disease and aortic stenosis; heart failure; peripheral arterial disease; cerebrovascular disease and stroke; and perioperative management for noncardiac surgery.

“The importance of assessing relevant domains beyond chronological age, such as frailty and cognitive function, and the incorporation of patient preferences into shared decision making have not been assessed adequately,” the committee wrote. “The utility of all cardiac preventative measures, diagnostic tests, and therapeutic interventions, including medications, invasive procedures, and other programs (e.g., cardiac rehabilitation) in the management of older patients with [cardiovascular disease] warrants careful scrutiny, especially in the context of multimorbidity, polypharmacy, functional limitations, and frailty.”