Pharmacotherapy in Older Adults With Cardiovascular Disease

Report From an American College of Cardiology, American Geriatrics Society, and National Institute on Aging Workshop

Janice B. Schwartz, MD; Kenneth E. Schmader, MD; Joseph T. Hanlon, PharmD, MS; Darrell R. Abernethy, MD, PhD; Shelly Gray, PharmD, MS; Jacqueline Dunbar-Jacob, PhD, RN; Holly M. Holmes, MD, MS; Michael D. Murray, PharmD, MPH; Robert Roberts, MD; Michael Joyner, MD; Josh Peterson, MD, MPH; David Lindeman, PhD; Ming Tai-Seale, PhD, MPH; Laura Downey, DVM, MSM; Michael W. Rich, MD

Disclosures

J Am Geriatr Soc. 2019;67(2):371-380. 

In This Article

Abstract and Introduction

Abstract

Objectives: To identify the top priority areas for research to optimize pharmacotherapy in older adults with cardiovascular disease (CVD).

Design: Consensus meeting.

Setting: Multidisciplinary workshop supported by the National Institute on Aging, the American College of Cardiology, and the American Geriatrics Society, February 6–7, 2017.

Participants: Leaders in the Cardiology and Geriatrics communities, (officers in professional societies, journal editors, clinical trialists, Division chiefs), representatives from the NIA; National Heart, Lung, and Blood Institute; Food and Drug Administration; Centers for Medicare and Medicaid Services, Alliance for Academic Internal Medicine, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, pharmaceutical industry, and trainees and early career faculty with interests in geriatric cardiology.

Measurements: Summary of workshop proceedings and recommendations.

Results: To better align older adults' healthcare preferences with their care, research is needed to improve skills in patient engagement and communication. Similarly, to coordinate and meet the needs of older adults with multiple comorbidities encountering multiple healthcare providers and systems, systems and disciplines must be integrated. The lack of data from efficacy trials of CVD medications relevant to the majority of older adults creates uncertainty in determining the risks and benefits of many CVD therapies; thus, developing evidence-based guidelines for older adults with CVD is a top research priority. Polypharmacy and medication nonadherence lead to poor outcomes in older people, making research on appropriate prescribing and deprescribing to reduce polypharmacy and methods to improve adherence to beneficial therapies a priority.

Conclusion: The needs and circumstances of older adults with CVD differ from those that the current medical system has been designed to meet. Optimizing pharmacotherapy in older adults will require new data from traditional and pragmatic research to determine optimal CVD therapy, reduce polypharmacy, increase adherence, and meet person-centered goals. Better integration of the multiple systems and disciplines involved in the care of older adults will be essential to implement and disseminate best practices.

Introduction

The pathogenesis and incidence of cardiovascular disease (CVD) are mechanistically linked to aging and to exposure to conventional cardiovascular disease risk factors.[1–3] A high prevalence of coronary heart disease, heart failure, valvular heart disease, arrhythmias, peripheral arterial disease, and other CVD processes will inevitably burden the expanding population of older adults, but multiple comorbid conditions and common geriatric syndromes that fundamentally alter the risk:benefit relationship for virtually all diagnostic procedures and therapeutic interventions, including medications proven to be effective in younger, healthier individuals, often complicate caring for older adults with CVD. The multiple healthcare providers involved in managing older adults with multiple conditions further complicates care. Optimal person-centered care for the growing population of older adults thus demands that these multiple complex interactions be better delineated and more fully integrated into routine clinical decision-making and drug prescribing for older adults with CVD.[4]

These issues were the impetus for a series of workshops supported by the National Institute on Aging (NIA), the American College of Cardiology (ACC), and the American Geriatrics Society (AGS) to identify critical knowledge gaps and research priorities for optimizing person-centered care and outcomes for older adults with CVD. The first workshop, in 2015, focused on multimorbidity in older adults with CVD and identified challenges to and opportunities for advancing principles of multimorbidity, identified research opportunities and resources for integration of multimorbidity into research and clinical care, and identified targets such as practice guidelines and methods to assess and record people's goals and priorities as part of a paradigm shift from disease-focused to person-centered care. A product of the conference was a comprehensive state-of-the-art review on multimorbidity in older adults with CVD targeted to the cardiology community.[5] The workshop also stimulated conceptualization of a rationale and vision for geriatric cardiology that would infuse cardiology practice with expanded proficiencies in diagnosis, risks, care coordination, communications, end-of-life, and other competencies required to best manage older adults with CVD.[6]

The second workshop, "Pharmacotherapy in Older Adults with CVD,", took place February 6 to 7, 2017, in Washington, District of Columbia. The main objective was to identify knowledge gaps and research priorities for optimizing pharmacotherapy in older adults with CVD within the areas of polypharmacy, adverse drug effects (ADEs), medication adherence, aligning therapy with individuals' goals, and novel approaches to drug prescribing. Drs. Joseph Hanlon, Kenneth Schmader, and Janice Schwartz co-chaired the workshop. Attendees included leaders from the cardiology and geriatrics communities (officers in professional societies, journal editors, clinical trialists, prominent division chiefs) and representatives from the NIA; National Heart, Lung, and Blood Institute; Food and Drug Administration (FDA); Centers for Medicare and Medicaid Services, Alliance for Academic Internal Medicine, Patient-Centered Outcomes Research Institute (PCORI), Agency for Healthcare Research and Quality, pharmaceutical companies, and selected trainees and junior faculty with interests in geriatric cardiology. This article briefly summarizes the conference proceedings, highlighting challenges to optimal outcomes of medical management related to knowledge gaps, too much medication (age-related changes in medication pharmacokinetics (PK) and pharmacodynamics (PD), multimorbidity, polypharmacy, ADEs), and too little medication (adherence, underprescribing). A discussion of the top priorities for research that workshop participants identified follows. Supplementary Appendix S1 details the topics and speakers, and the presentations are available at https://www.acc.org/membership/sections-and-councils/geriatric-cardiology-section/section-initiatives/workshops.

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