COMMENTARY

Long Life vs Living Well: AHA Addresses Elderly With CVD

AHA Scientific Statement on Functional Capacity in Older Patients With CVD

Ileana L. Piña, MD, MPH; Daniel E. Forman, MD

Disclosures

April 26, 2017

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Ileana L. Piña MD, MPH: Hello. I am Ileana Piña from Albert Einstein College of Medicine in Montefiore Medical Center in the Bronx.

Today, my guest is Dr Dan Forman, who is chair of geriatric cardiology and professor of medicine at University of Pittsburgh Medical Center. Thank you, Dan, for being here with us. Dan is also the chair of our Cardiovascular Disease in Older Populations Committee at the American Heart Association.

Many of you may not realize that the Council on Clinical Cardiology of the American Heart Association has a series of committees that are dedicated to different aspects of clinical cardiology, and older adults is one of them.

Dan, you have a very important paper published from your committee. Do you want to tell us a little bit about it and why it came to be?

Seduction of Longevity

Daniel E. Forman, MD: Yes. Thanks for inviting me.

We are coming out with a statement that talks about functional outcomes as a priority of care for older adults with cardiovascular disease. As our listeners know, the focus on longevity has really been one of the great achievements of the American College of Cardiology; the American Heart Association; and research-funding bodies, such as the National Institutes of Health (NIH). The reality is that people are living longer and have different consequences as a function of age. The average length of life is about 30 years longer than it was about a century ago.

Longer lives mean new challenges. In addition to the association of age with cardiovascular disease, age has other liabilities and vulnerabilities. We help you live longer, but being functionally impaired is one of the risks that arises out of that age dimension.

Function Goes Beyond Cardiorespiratory Fitness

Dr Piña: Is that physical function, or it could be any kind of functional impairment?

Dr Forman: In cardiology, we have tended to focus on cardiorespiratory fitness as a notion of what we think of as function, but physical function goes beyond just the heart. It is elements of skeletal muscle, strength, balance, and even cognition. When you ask, "What is function?", it is all of those points.

We think it is a great achievement when people live longer with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors or other drugs. But they are left with the consequences—more is going on other than just longevity. In cardiology, we are seduced by longevity as such a great thing, but I would argue that there is a holistic perspective. As people live longer, what else is going on?

We measure cardiorespiratory fitness using cardiopulmonary exercise testing (CPET). It is a big part of my career, and we think it is important. It is based on not only cardiac output, but also peripheral manifestations. It is skeletal muscle.

Dr Piña: Also balance. They need to balance on a treadmill or a bike.

Dr Forman: Exactly. Peripheral endurance, balance—all of these things are points that we have to embrace. A beta-blocker has chronotropic impact; a statin may have myopathic impact. Treatments can affect balance and other manifestations of endurance that really become, in many cases, the bane of people's existence. They struggle with quality of life in addition to longevity.

A Broader Perspective of Outcome

Dr Forman: The point of this statement, which I really regard as a tremendous step for cardiologists, is that we have to think about this broader perspective of outcome. All the bravado of PCSK9 inhibitors or Entresto™ (sacubitril/valsartan) is not enough—we really have to think of impact on quality of life. We share tremendous interest in cardiac rehabilitation and in other aspects of care, which, in my experience, are not as embraced with quite the same sense of excitement as the new drug.

Dr Piña: Yes; we sort of put this into the trial as almost a second thought, and sometimes the data are missing. We try to make it up as we go, and it does not work.

Dr Forman: I agree. Both aspects of care—longevity and reduced events—are tremendously valuable. But also important is how they affect physical function, balance, strength, and cognition.

This paper will be useful to the community. It helps the clinician with a set of tools that he or she can use to measure cardiorespiratory function, and goes beyond that with measures for strength, balance, and composite measures. There is a whole list that talks about applications not only in clinical environments, but also in research environments because, as is clear from the NIH's perspective, these notions of broader outcomes are really seen as a priority of care for responding to population dynamics.

Dr Piña: I am sure that the Centers for Medicare & Medicaid Services (CMS) would also be very interested in quality of life and function. It is costly when you have to put patients into nursing facilities because they no longer have balance and function or mental health. I think the number of patients going into these facilities is actually going up.

Dr Forman: It is going up. I think that the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is relevant, because the notion of patient-reported outcomes is one of the metrics that is going to determine reimbursement. A patient living longer who is moribund and miserable is not a good outcome. The fact is, transcatheter aortic valve replacements (TAVRs) are wonderful for a subset of patients, but they may not be terrific for another subset who have no improvement in New York Heart Association class or quality of life.

Goals for Skilled Nursing Facilities

Dr Forman: [The statement provides] a better sense of predicting which patients will do better. It [discusses] reinforcing function with cardiac rehabilitation, modifying medical regimens, [adding] supplements, and even other things we could do within skilled nursing facilities (SNFs) in nursing homes to give rigorous thought of how to increase function.

One of the big problems that this article describes is that within SNFs, rehabilitation has really not been prioritized. We help people stand up, perhaps, but not really become mobile so that they can go back home and have a reasonable quality of life.

Dr Piña: I think some of these SNFs have staff with low-level education. They give medicine, maybe weigh patients in the morning, and that is it. Physical therapists at our institution will back off if they see the patient getting a little tachycardic. I say, "Tachycardia is a sign of being out of shape. Get them out of bed and get them moving."

The sense of safety with activity really needs to come into focus. Not only is the activity safe, it is beneficial for them. But it is always easier to just turn your back and let them go. I hate to be so negative, but that is what it is.

Dr Forman: I agree. It is a complicated issue.

The one other dimension this paper does well is that it brings forward some of the signs that have been a part of this community for a while. It focuses that this is not just at the system level; it goes down to a molecular level. It is a mitochondrial issue. It is an issue of skeletal muscle health on a very biological, fundamental basis. These really become relevant in terms of what we do and do not do in SNFs as part of standard care. Again, just as we are excited about new drugs or new procedures, I would think the system of care has to embrace all these complexities.

Conclusion

Dr Piña: It is a wonderful addition to our armamentarium, and I am hoping that researchers see some of the evaluation tools that you have provided and use and test them in our trials and in our large populations. I know I am going to be pushing for that and probably even start earlier, because by the time [that patients] get to that age, if they have been deconditioned most of their lives, we are losing ground. The American Heart Association has a big focus right now on brain health, and this comes right into the functional cognition aspect of the older patients.

Thank you for coming and for your contribution. This is going to be a very important paper. Give us the full name of the paper.

Dr Forman: "Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease," and it will appear in Circulation.

Dr Piña: Look for this paper in Circulation or online. Thank you for joining me today. Hopefully, we will have more from ACC.17. This is Ileana Piña, singing off. Have a great day.

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