Improving Care Using a Bidirectional Geriatric Cardiology Consultative Conference

Aspirin, Statins, and Primary Prevention: Opportunities for Shared Decision Making in the Face of Uncertainty

PURPOSE OF REVIEW

The utility of aspirin and statins for primary prevention of atherosclerotic cardiovascular disease remains ambiguous in older adults. Current guidelines and recent data are vague and inconclusive. This review seeks to summarize the landscape of primary prevention of cardiovascular disease in older adults and explore the role of shared decision making.

RECENT FINDINGS

Observational data suggest potential benefit of statin therapy in older adults. Aspirin is presently not recommended for primary prevention based on evidence from recent clinical trials. The implementation of shared decision making and decision aids in routine clinical practice remains challenging but may rise in coming years. Clinical trial data on the horizon may aid in solidifying guideline therapy for statin use. However, in the face of uncertainty, shared decision making between provider and patient should be utilized to determine whether pharmacotherapy may benefit older adults. Decision aids are an effective tool to guide this process.

Shared decision-making for older adults with cardiovascular disease

Shared decision-making is appropriate for clinical decisions involving multiple reasonable options, which occur frequently in the cardiovascular care of older adults. The process includes the communication of relevant factual information between the patient and the clinician, elicitation of patient preferences, and a mutual agreement on the best course of action to meet the patient's personal goals. For older adults, there are common challenges and considerations with regard to shared decision-making, some of which (eg, cognitive impairment) may be biologically linked to cardiovascular disease. There are tools designed to facilitate the shared decision-making process, known as decision aids, which are broadly effective although have shortcomings when applied to older adults. Novel approaches in clinical research and health systems changes will go some way toward improving shared decision-making for older adults, but the greatest scope for improvement may be within the grass roots areas of communication skills, interdisciplinary teamwork, and simply asking our patients what matters most.