TAVR in Older Adults: Moving Toward a Comprehensive Geriatric Assessment and Away From Chronological Age

Calcific aortic stenosis can be considered a model for geriatric cardiovascular conditions due to a confluence of factors. The remarkable technological development of transcatheter aortic valve replacement was studied initially on older adult populations with prohibitive or high-risk for surgical valve replacement. Through these trials, the cardiovascular community has recognized that stratification of these chronologically older adults can be improved incrementally by invoking the concept of frailty and other geriatric risks. Given the complexity of the aging process, stratification by chronological age should only be the initial step but is no longer sufficient to optimally quantify cardiovascular and noncardiovascular risk. In this review, we employ a geriatric cardiology lens to focus on the diagnosis and the comprehensive management of aortic stenosis in older adults to enhance shared decision-making with patients and their families and optimize patient-centered outcomes. Finally, we highlight knowledge gaps that are critical for future areas of study

The impact of National Institutes of Health funding on U.S. cardiovascular disease research.

BACKGROUND: Intense interest surrounds the recent expansion of US National Institutes of Health (NIH) budgets as part of economic stimulus legislation. However, the relationship between NIH funding and cardiovascular disease research is poorly understood, making the likely impact of this policy change unclear. METHODS: The National Library of Medicine's PubMed database was searched for articles published from 1996 to 2006, originating from U.S. institutions, and containing the phrases "cardiolog," "cardiovascular," or "cardiac," in the first author's department. Research methodology, journal of publication, journal impact factor, and receipt of NIH funding were recorded. Differences in means and trends were tested with t-tests and linear regression, respectively, with P < or = 0.05 for significance. RESULTS: Of 117,643 world cardiovascular articles, 36,684 (31.2%) originated from the U.S., of which 10,293 (28.1%) received NIH funding. The NIH funded 40.1% of U.S. basic science articles, 20.3% of overall clinical trials, 18.1% of randomized-controlled, and 12.2% of multicenter clinical trials. NIH-funded and total articles grew significantly (65 articles/year, P < 0.001 and 218 articles/year, P < 0.001, respectively). The proportion of articles receiving NIH funding was stable, but grew significantly for basic science and clinical trials (0.87%/year, P < 0.001 and 0.67%/year, P = 0.029, respectively). NIH-funded articles had greater journal impact factors than non NIH-funded articles (5.76 vs. 3.71, P < 0.001). CONCLUSIONS: NIH influence on U.S. cardiovascular research expanded in the past decade, during the period of NIH budget doubling. A substantial fraction of research is now directly funded and thus likely sensitive to budget fluctuations, particularly in basic science research. NIH funding predicts greater journal impact

Trends in NIH-funded and overall U.S. cardiovascular disease articles, 1996–2006, selected methodologies.

<p>Data were normalized to 1996 levels. All article types depicted here had statistically significant growth except all U.S. general research articles. Furthermore the ratio of NIH-funded to overall articles increased significantly for general research articles and clinical trials, indicating a proportionally increasing role played by the NIH for these article types.</p

Worldwide, U.S., and U.S. NIH-funded cardiovascular research articles, 1996–2006, by article study characteristics and methodology.

<p>Articles may belong to more than one category, thus the sum of the categories do not necessarily equal the total. <i>Unspecified, general research</i> are research articles with no specified subtype. <i>Miscellaneous articles</i> are journal articles without scientific content, such as bibliographies, biographies, comments, letters, historical articles, guidelines, editorials, news, indices, legal cases, interviews, and consensus statements. Additional information on publication characteristics and methodologies is available at the National Library of Medicine website, at <a href="http://www.nlm.nih.gov/mesh/pubtypes2008.html" target="_blank">http://www.nlm.nih.gov/mesh/pubtypes2008.html</a>.</p

Mean journal impact factor of NIH-funded and non-NIH-funded U.S. cardiovascular disease articles, 1997 to 2006, by article methodology.

<p><i>P</i>-values denote the difference between NIH-funded and non NIH-funded journal impact factors when means were compared with two-tailed t-tests. There was insufficient data for comparisons of Phase III and Phase IV clinical trials.</p

Contemporary Management of Patients with Stable Ischemic Heart Disease

The overall goals of therapy for patients with stable ischemic heart disease are to minimize the likelihood of death while maximizing health and function. Initial risk assessment with noninvasive testing is indicated to determine whether invasive evaluation is needed in addition to medical therapy. All patients with stable ischemic heart disease need optimal medical therapy, which includes risk factor management with lifestyle modifications and pharmacologic therapy. First-line pharmacologic therapy is focused on preventing myocardial infarction and death with antiplatelet agents, lipid-lowering therapy, and antihypertensive therapies. In addition, antianginal therapy and anti-ischemic therapy are indicated to alleviate symptoms, reduce ischemia, and improve quality of life. The commonly used antianginal agents include nitrates, beta-blockers, calcium channel blockers, and ranolazine. When medical therapy is not adequate to relieve angina, revascularization with percutaneous coronary intervention or coronary artery bypass grafting is indicated. We review the indications and evidence for antianginal agents and other therapies for angina

Sponsored articles in cardiovascular disease research from individual NIH institutes, 1996–2006, with 11-year annualized growth rates.

<p>Individual articles may have received support from more than one institute, thus the sum of the percentiles from each institute exceeds 100%.</p><p>*The National Institute of Biomedical Imaging and Bioengineering (NIBIB) was created in December 2000, and thus no data were available for the first 5 years of the study. Trend analysis was performed on the 6 years for which data were available, 2001 to 2006.</p

Annual growth in total U.S., U.S. NIH-funded, and relative NIH-funded cardiovascular research articles, 1996–2006.

<p>All U.S. and NIH-funded U.S. growth rates are expressed in terms of articles per year, with relative growth expressed as a percentage of the 1996 level. The proportional growth in NIH-funded articles is expressed as the annual change in the ratio of NIH-funded to all articles, e.g. growth from 30% NIH-funded in 1996 to 41% NIH-funded in 2006 corresponds to a yearly growth of approximately 0.01, or 1 percent per year. Figures normalized to 1996 for this proportion are also depicted. Insufficient numbers of phase-type clinical trials were published to allow meaningful analysis of trend for these methodologies.</p

Detection of Atherosclerotic Cardiovascular Disease in Patients with Advanced Chronic Kidney Disease in the Cardiology and Nephrology Communities

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality among patients with chronic kidney disease (CKD) with a glomerular filtration rate of < 60 mL/min/1.73 m2 body surface area. The availability of high-quality randomized controlled trial data to guide management for the population with CKD and ASCVD is limited. Understanding current practice patterns among providers caring for individuals with CKD and CVD is important in guiding future trial questions. A qualitative survey study was performed. An electronic survey regarding the diagnosis and management of CVD in patients with CKD was conducted using a convenience sample of 450 practicing nephrology and cardiology providers. The survey was administered using Qualtrics® (https://www.qualtrics.com). There were a total of 113 responses, 81 of which were complete responses. More than 90% of the respondents acknowledged the importance of CVD as a cause of morbidity and mortality in patients with CKD. Outside the kidney transplant evaluation setting, 5% of the respondents would screen an asymptomatic patient with advanced CKD for ASCVD. Outside the kidney transplant evaluation scenario, the respondents did not opt for invasive management strategies in advanced CKD. The survey results reveal a lack of consensus among providers caring for patients with advanced CKD about the management of ASCVD in this setting. Future randomized controlled trials will be needed to better inform the clinical management of ASCVD in these patients. The limitations of the study include its small sample size and the relatively low response rate among the respondents