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Fermini B, Bell DC. On the perspective of an aging population and its potential impact on drug attrition and pre-clinical cardiovascular safety assessment. J Pharmacol Toxicol Methods 2022; 117:107184. [PMID: 35618160 DOI: 10.1016/j.vascn.2022.107184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 12/17/2022]
Abstract
There is no refuting that America's population is growing older: for the first time in US history, by 2034 older adults (defined as >65 years of age) are projected to outnumber children under the age of 18, representing approximately 70 million people or almost 25% of the population (Lloyd-Jones et al., 2010). Described as the "silver tsunami", this flood of older adults is driven by the baby boomers (people born after World War II, from 1946 to 1964): they are now reaching old age, living longer due to significant advances in healthcare coupled with a record low birth rate, resulting in a skewed elderly population demographic. Unfortunately, older adults are also becoming increasingly unhealthy. Many often suffer from several chronic disorders requiring the use of multiple medications at a level higher than any other age group, resulting in an increased risk of drug-drug interactions (DDIs) and adverse drug reactions (ADRs). Indeed, because of age-related changes in pharmacokinetics (PK) and pharmacodynamics (PD), older adults are also more vulnerable to drug toxicity. Prescribed drugs certainly improve a range of health outcomes, but also often cause considerable ADRs, leading to devastating consequences for patients, clinicians, and manufacturers. Therefore, safe and effective pharmacotherapy remains one of the greatest growing challenges in geriatric medicine. In this review we examine the effects of aging and its impact on the increased risk of experiencing ADRs, resulting in devastating consequences for patients and manufacturers. We assess the current regulatory considerations related to the development of drugs for this population and highlight issues, concerns, and propose alternatives to the standard battery of tests focused on assessing cardiovascular (CV) safety in an attempt to develop safer and efficient new drugs for the growing elderly demographic.
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Affiliation(s)
| | - Damian C Bell
- Sophion Bioscience A/S, Ballerup, Copenhagen, Denmark.
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2
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Alexander KP. Meaningful Evidence for Anticoagulation in the Gray (Elder) Zone. JAMA Cardiol 2022; 7:581-582. [PMID: 35416911 DOI: 10.1001/jamacardio.2022.0477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Karen P Alexander
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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3
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Bawazeer G, Alsaad S, Almalag H, Alqahtani A, Altulaihi N, Alodhayani A, AlHossan A, Sales I. Impact of Specialized Clinics on Medications Deprescribing in Older Adults: A Pilot Study in Ambulatory Care Clinics in a Teaching Hospital. Saudi Pharm J 2022; 30:1027-1035. [PMID: 35903532 PMCID: PMC9315319 DOI: 10.1016/j.jsps.2022.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/26/2022] [Indexed: 12/03/2022] Open
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Research engagement and experiences of patients pre- and post-implant of a left ventricular assist device from the mechanical circulatory support measures of adjustment and quality of life (MCS A-QOL) study. Qual Life Res 2022; 31:2457-2470. [PMID: 35258804 PMCID: PMC10284295 DOI: 10.1007/s11136-022-03111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Adults living with mechanical circulatory support (MCS) present with unique challenges (e.g., left ventricular assist device [LVAD]-related self-care, adverse events) to research study enrollment, engagement, and completion. The purpose of this study was to understand the experiences of adults with MCS who were eligible for and enrolled in a study of health-related quality of life (HRQOL). METHODS In a secondary analysis of data from the Mechanical Circulatory Support: Measures of Adjustment and Quality of Life study, we used a mixed-methods approach to evaluate research engagement and experiences among adults preparing to undergo or currently living with MCS implant. First, we assessed the cascade of study engagement. Second, we assessed research experiences using a structured interview developed for this study. RESULTS Of 1011 participants approached for the study, 86.7% enrolled, 12.7% declined, and 0.6% were ineligible. Of 877 participants enrolled, 272 were pre-implant (of whom 88% completed assessments; "respondents") and 605 were post-implant (of whom 74% completed assessments). Only 14% of respondents reported difficulty completing the questionnaires, 54% had previously used an iPad to complete questionnaires, and 62% reported that their experience was "as expected." Respondents qualitatively described both positive (e.g., value of research) and negative (e.g., too much time) research experiences, difficulties completing questionnaires (e.g., online platform, health literacy issues), and provided recommendations for the questionnaires and delivery. CONCLUSIONS Participants enjoyed participating in HRQOL research focused on MCS and had unique perspectives for improving the questionnaires. It is important to minimize the burden of participation and critical to be flexible to meet participant preferences for research engagement. TRIAL REGISTRATION NCT03044535 (accessible at https://clinicaltrials.gov/ct2/show/NCT03044535 ), registered February 7, 2017.
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5
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Liu Q, Schwartz JB, Slattum PW, Lau SWJ, Guinn D, Madabushi R, Burckart G, Califf R, Cerreta F, Cho C, Cook J, Gamerman J, Goldsmith P, van der Graaf PH, Gurwitz JH, Haertter S, Hilmer S, Huang SM, Inouye SK, Kanapuru B, Pirmohamed M, Posner P, Radziszewska B, Keipp Talbot H, Temple R. Roadmap to 2030 for Drug Evaluation in Older Adults. Clin Pharmacol Ther 2021; 112:210-223. [PMID: 34656074 DOI: 10.1002/cpt.2452] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/04/2021] [Indexed: 12/17/2022]
Abstract
Changes that accompany older age can alter the pharmacokinetics (PK), pharmacodynamics (PD), and likelihood of adverse effects (AEs) of a drug. However, older adults, especially the oldest or those with multiple chronic health conditions, polypharmacy, or frailty, are often under-represented in clinical trials of new drugs. Deficits in the current conduct of clinical evaluation of drugs for older adults and potential steps to fill those knowledge gaps are presented in this communication. The most important step is to increase clinical trial enrollment of older adults who are representative of the target treatment population. Unnecessary eligibility criteria should be eliminated. Physical and financial barriers to participation should be removed. Incentives could be created for inclusion of older adults. Enrollment goals should be established based on intended treatment indications, prevalence of the condition, and feasibility. Relevant clinical pharmacology data need to be obtained early enough to guide dosing and reduce risk for participation of older adults. Relevant PK and PD data as well as patient-centered outcomes should be measured during trials. Trial data should be analyzed for differences in PK, PD, effectiveness, and safety arising from differences in age or from the presence of conditions common in older adults. Postmarket evaluations with real-world evidence and drug labeling updates throughout the product lifecycle reflecting new knowledge are also needed. A comprehensive plan is needed to ensure adequate evaluation of the safety and effectiveness of drugs in older adults.
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Affiliation(s)
- Qi Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Janice B Schwartz
- Departments of Medicine, Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Patricia W Slattum
- Department of Pharmacotherapy and Outcomes Science and Virginia Center on Aging, Virginia Commonwealth University, Richmond, Virginia, USA
| | - S W Johnny Lau
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Daphne Guinn
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rajanikanth Madabushi
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Califf
- Verily and Google Health (Alphabet), South San Francisco, California, USA
| | - Francesca Cerreta
- Portfolio office, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Carolyn Cho
- Oncology Early Development and Translational Research, Merck & Co., Kenilworth, New Jersey, USA
| | - Jack Cook
- Department of Clinical Pharmacology, Pfizer Global Research and Development, Groton, Connecticut, USA
| | - Jamie Gamerman
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Paul Goldsmith
- Lilly Exploratory Medicine and Pharmacology, Bracknell, UK
| | | | - Jerry H Gurwitz
- Meyers Health Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA
| | - Sebastian Haertter
- Boehringer Ingelheim Pharma, Translational Medicine & Clinical Pharmacology, Ingelheim, Germany
| | - Sarah Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Shiew-Mei Huang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sharon K Inouye
- Marcus Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School, Boston. Massachusetts, USA
| | - Bindu Kanapuru
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Phil Posner
- Patient-Centered Outcomes Research Institute Ambassador, Gainesville, Florida, USA
| | - Barbara Radziszewska
- National Institute of Aging, National Institute of Health, Bethesda, Maryland, USA
| | - H Keipp Talbot
- Departments of Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert Temple
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Slattum PW, Schwartz JB. A challenge: The American Geriatric Society needs to address the lack of inclusion of older adults in new drug evaluation. J Am Geriatr Soc 2021; 69:2684-2688. [PMID: 34062612 DOI: 10.1111/jgs.17294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Patricia W Slattum
- School of Pharmacy, Pharmacotherapy and Outcomes Science, Geriatrics Workforce Enhancement Program, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Janice B Schwartz
- School of Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Gaspar-Marques J, Palmeiro T, Caires I, Leiria Pinto P, Neuparth N, Carreiro-Martins P. Ventilatory defects and treatable traits in very elderly patients. Sci Prog 2021; 104:368504211013171. [PMID: 33929910 PMCID: PMC10305819 DOI: 10.1177/00368504211013171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Though the approach used to classify chronic respiratory diseases is changing to a treatable-traits (TT) approach, data regarding very elderly patients is lacking. The objectives of this study were to assess TT frequency in very elderly patients and to study the link between extrapulmonary TT and ventilatory defects. Individuals (≥75 years) residing in elderly care centres answered a standardised questionnaire, underwent spirometry, atopy and fractional exhaled nitric oxide assessments and had their blood pressure and peripheral pulse oximetry measured. Pulmonary, extrapulmonary and behavioural TT were evaluated. Outcome variables were an airflow limitation (post-bronchodilator z-score FEV1/FVC<-1.64) and a restrictive spirometry pattern (z-score FEV1/FVC ≥ +1.64 and z-score FVC<-1.64). Seventy-two percent of the individuals who took part in the study (n = 234) were women, and the median age of participants was 86 (IQR: 7.4). At least one pulmonary TT was identified in 105 (44.9%) individuals. The most frequent extrapulmonary TTs were: persistent systemic inflammation (47.0%), anaemia (34.4%), depression (32.5%) and obesity (27.4). Airflow limitation was exclusively associated with smoking (OR 5.03; 95% CI 1.56-16.22). A restrictive spirometry pattern was associated with cognitive impairment (OR: 3.89; 95% CI: 1.55-9.79). A high frequency of various TTs was found. The novel association between a restrictive spirometry pattern and cognitive impairment highlights the urgency of clinical research on this vulnerable age group.
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Affiliation(s)
- João Gaspar-Marques
- NOVA Medical School/Comprehensive
Health Research Centre (CHRC), Lisbon, Portugal
- Immunoallergology Service, Dona
Estefânia Hospital, Central Lisbon Hospital Centre, EPE, Lisbon, Portugal
| | - Teresa Palmeiro
- NOVA Medical School/Comprehensive
Health Research Centre (CHRC), Lisbon, Portugal
| | - Iolanda Caires
- NOVA Medical School/Comprehensive
Health Research Centre (CHRC), Lisbon, Portugal
| | - Paula Leiria Pinto
- NOVA Medical School/Comprehensive
Health Research Centre (CHRC), Lisbon, Portugal
- Immunoallergology Service, Dona
Estefânia Hospital, Central Lisbon Hospital Centre, EPE, Lisbon, Portugal
| | - Nuno Neuparth
- NOVA Medical School/Comprehensive
Health Research Centre (CHRC), Lisbon, Portugal
- Immunoallergology Service, Dona
Estefânia Hospital, Central Lisbon Hospital Centre, EPE, Lisbon, Portugal
| | - Pedro Carreiro-Martins
- NOVA Medical School/Comprehensive
Health Research Centre (CHRC), Lisbon, Portugal
- Immunoallergology Service, Dona
Estefânia Hospital, Central Lisbon Hospital Centre, EPE, Lisbon, Portugal
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Khan MZ, Munir MB, Khan SU, Subramanian CR, Khan MU, Asad ZUA, Talluri S, Madhanakumar A, Lone AN, Khan MS, Michos ED, Alkhouli M. Representation of women, older patients, ethnic, and racial minorities in trials of atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:423-431. [PMID: 33512027 DOI: 10.1111/pace.14178] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/28/2020] [Accepted: 01/18/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Representation trends of women, older adults, and ethnic/racial minorities in randomized controlled trials (RCTs) of atrial fibrillation (AF) are uncertain. METHODS We systematically reviewed 134 AF related RCTs (phase II and III) encompassing 149,162 participants using Medline and ClinicalTrials.gov through April 2019 to determine representation trends of women, older patients (≥75 years), and ethnic/racial minorities. Weighted data on the prevalence of AF from epidemiological studies were used to compare the representation of the studied groups of interest in AF RCTs to their expected burden of the disease. RESULTS Only 18.7% of the RCTs reported proportion of older patients, and 12.7% RCTs reported ethnic/racial minorities. The proportions of women in RCTs versus general population were 35.2% and 35.1%, of Hispanics were 11.9% and 5.2%, of Blacks were 1.2% and 5.7%, of American Indian/Alaskans were 0.2% and 0.2%, of Asians were 14.2% and 2.4%, of native Hawaiian/Pacific Islanders were 0.05% and 0.1% and of non-Whites were 19.5% and 22.5%, respectively. The weighted mean age (SD) across the trials was 65.3 (3.2) years which was less than the corresponding weighted mean age of 71.1 (4.5) years in the comparative epidemiological data. CONCLUSION The reporting of older patients and ethnic/racial minorities was poor in RCTs of AF. The representation of women and American Indian/Alaskan natives matched their expected population share of disease burden. Hispanics and Asians were over-represented and Blacks, native Hawaiian/Pacific Islanders and non-Whites were under-represented in RCTs of AF.
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Affiliation(s)
- Muhammad Zia Khan
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California, USA
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | | | - Muhammad Usman Khan
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Zain Ul Abideen Asad
- Cardiovascular Disease Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Swapna Talluri
- Department of Medicine, Guthrie Health System/Robert Packer Hospital, Sayre, Pennsylvania, USA
| | - Aarthi Madhanakumar
- Department of Cardiovascular Medicine, Allegheny General hospital, Pittsburgh, Pennsylvania, USA
| | - Ahmad Naeem Lone
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Muhammad Shahzeb Khan
- Department of Medicine, John H. Stroger Cook County Hospital, Chicago, Illinois, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Goyal P, Anderson T, Bernacki GM, Marcum ZA, Orkaby A, Kim D, Zullo A, Krishnaswami A, Weissman A, Steinman MA, Rich MW. Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults. J Am Geriatr Soc 2020; 68:78-86. [PMID: 31509233 PMCID: PMC7061460 DOI: 10.1111/jgs.16157] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVES Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties. DESIGN National cross-sectional survey. SETTING Ambulatory. PARTICIPANTS Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians. MEASUREMENTS Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases. RESULTS In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists). CONCLUSIONS While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine (New York, NY)
| | - Timothy Anderson
- Department of Medicine, University of California-San Francisco (San Francisco, CA)
| | - Gwen M. Bernacki
- Cardiology Division, University of Washington (Seattle, WA), Cambia Palliative Care Center of Excellence (Seattle, WA)
| | | | - Ariela Orkaby
- New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA; Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Dae Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA
| | - Andrew Zullo
- Departments of Epidemiology and Health Services, Policy, and Practice, Brown University School of Public Health (Providence, RI); Center of Innovation in Long Term Services and Supports, Providence VA Medical Center (Providence, RI)
| | - Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center (San Jose, CA); Department of Epidemiology and Biostatistics, University of California (San Francisco, CA)
| | | | - Michael A. Steinman
- Department of Medicine, University of California-San Francisco (San Francisco, CA)
- San Francisco Veterans Affairs Medical Center, (San Francisco, CA)
| | - Michael W. Rich
- Cardiovascular Division, Washington University School of Medicine (St. Louis, MO)
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Perreault S, Denus S, White‐Guay B, Côté R, Schnitzer ME, Dubé M, Dorais M, Tardif J. Oral Anticoagulant Prescription Trends, Profile Use, and Determinants of Adherence in Patients with Atrial Fibrillation. Pharmacotherapy 2019; 40:40-54. [DOI: 10.1002/phar.2350] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy Université de Montréal Montreal Quebec Canada
| | - Simon Denus
- Faculty of Pharmacy Université de Montréal Montreal Quebec Canada
- Montreal Heart Institute Montreal Quebec Canada
| | - Brian White‐Guay
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
| | - Robert Côté
- Department of Neurology and Neurosurgery McGill University Montreal Quebec Canada
| | | | - Marie‐Pierre Dubé
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
- Department of Neurology and Neurosurgery McGill University Montreal Quebec Canada
| | - Marc Dorais
- StatSciences Inc. Notre‐Dame‐de‐l’Île‐Perrot Quebec Canada
| | - Jean‐Claude Tardif
- Montreal Heart Institute Montreal Quebec Canada
- Faculty of Medicine Université de Montréal Montreal Quebec Canada
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Goyal P, Gorodeski EZ, Marcum ZA, Forman DE. Cardiac Rehabilitation to Optimize Medication Regimens in Heart Failure. Clin Geriatr Med 2019; 35:549-560. [PMID: 31543185 PMCID: PMC7233375 DOI: 10.1016/j.cger.2019.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cardiac rehabilitation (CR) is an inherently patient-centered program that provides holistic care to adults with cardiovascular conditions to promote lifelong health and fitness, facilitate self-care and self-efficacy, and improve clinical outcomes. CR offers an excellent platform for patient-centered optimization of medication regimens for older adults with heart failure through its potential to address several aspects of care that have historically served as major challenges to clinicians-diuretic management, the use of guideline-directed medical therapy, review and reconciliation of noncardiovascular medications, and optimization of medication adherence. In this review, these challenges are described and strategies offered for leveraging CR toward addressing them.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA; Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, 3rd floor. LH340, New York, NY 10021, USA.
| | - Eiran Z Gorodeski
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Desk J3-4, 9500 Euclid Avenue, Cleveland, OH 44195, USA. https://twitter.com/EiranGorodeski
| | - Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, 1959 Northeast Pacific Street Box 357630, Seattle, WA 98195, USA. https://twitter.com/ZacharyAMarcum
| | - Daniel E Forman
- Section of Geriatric Cardiology, Cardiac Rehabilitation and GeroFit, VA Pittsburgh Healthcare System, University of Pittsburgh, 3471 Fifth Avenue, Suite 500, Kaufmann Medical Building, Pittsburgh, PA 15213, USA
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Nguyen QD, Peters E, Wassef A, Desmarais P, Rémillard-Labrosse D, Tremblay-Gravel M. Evolution of Age and Female Representation in the Most-Cited Randomized Controlled Trials of Cardiology of the Last 20 Years. Circ Cardiovasc Qual Outcomes 2019; 11:e004713. [PMID: 29853466 DOI: 10.1161/circoutcomes.118.004713] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/08/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Older adults and women have historically been underrepresented in randomized controlled trials of cardiology. Recent temporal evolution and factors influencing representation are incompletely investigated. We aimed to contrast age and female representation in the most influential randomized controlled trials in cardiology of the last 20 years to population prevalence and to assess the study factors affecting representation. METHODS AND RESULTS Using Web of Science, we selected the 25 most-cited cardiology articles each year between 1996 and 2015, and extracted mean age, percentage of women, funding source, sample size, disease condition, intervention type, and exclusion criteria. The outcomes were the evolution of the mean age and the percentage of women over time. Protocol design elements and year of publication were assessed as predictors of outcomes in multivariable regressions. A total of 500 studies were analyzed, where the mean age was 62.6±7.4 years and the median percentage of women was 28.6% (22.2-40.5). Compared with population prevalence derived from National Health and Nutrition Examination Survey 2015-2016, gaps in representation were apparent and more pronounced for coronary artery disease (-5.0 years; -27.2% women) and heart failure (-6.0 years; -25.4% women). The mean age (0.15 year per year; 95% confidence interval, 0.04-0.26) and percentage of women (+0.29% per year; 95% confidence interval, 0.07-0.50), slightly but significantly increased over time. Private funding, small sample size, and exclusions pertaining to maximal age, atrial fibrillation, and diabetes mellitus were associated with a decreased mean age in multivariable linear regressions. Age and life expectancy exclusions were associated with lower female percentage. CONCLUSIONS Although age and female representation increased over time, the modest trends are unlikely to resolve the persistently wide gaps with actual populational prevalence, especially for coronary artery disease and HF. Representation is modulated by the cardiovascular condition studied and some modifiable protocol elements.
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Affiliation(s)
- Quoc Dinh Nguyen
- Division of Geriatrics, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Canada (Q.D.N., P.D.).
| | | | | | - Philippe Desmarais
- Division of Geriatrics, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Canada (Q.D.N., P.D.)
| | - Delphine Rémillard-Labrosse
- Faculty of Medicine, Université de Montréal, Canada. Department of Family Medicine, Hôpital Cité-de-la-Santé, Laval, Canada (D.R.-L.)
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13
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Alexander KP, Alexander JH. Safe and Effective Anticoagulation: What Does Drug Concentration Add? J Am Geriatr Soc 2019; 67:1772-1773. [DOI: 10.1111/jgs.15981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Karen P. Alexander
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute Duke University School of Medicine Durham North Carolina
| | - John H. Alexander
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute Duke University School of Medicine Durham North Carolina
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Goyal P, Bryan J, Kneifati-Hayek J, Sterling MR, Banerjee S, Maurer MS, Lachs MS, Safford MM. Association Between Functional Impairment and Medication Burden in Adults with Heart Failure. J Am Geriatr Soc 2018; 67:284-291. [PMID: 30488944 DOI: 10.1111/jgs.15654] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 09/15/2018] [Accepted: 09/17/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine whether the number of medications taken by adults with heart failure (HF) and impairment in activities of daily living (ADL)-a subpopulation in whom the risks of a high medication burden may outweigh the benefits-differs from the number taken by those without impairment in ADLs. DESIGN Cross-sectional. SETTING National Health and Nutrition Examination Survey (NHANES; 2003-2014), a cross-sectional survey that produces national estimates of adults in the United States. PARTICIPANTS Adults aged 50 and older (mean 70) with self-reported HF (N= 947; representing 4.6 million adults with HF in the United States. MEASURMENTS We assessed ADL impairment and medication count based on self-report. ADL impairment was defined as having difficulty with or being unable to dress, feed oneself, or get in and out of bed. To determine the independent association between ADL impairment and medication count, we performed sequential Poisson multivariable regression analyses. All analyses were cross-sectional in nature and accounted for the complex survey design of NHANES. RESULTS Mean medication count was 7.2, and 74% of participants were taking 5 or more medications (polypharmacy). In a multivariable model, ADL impairment was not independently associated with medication count. These findings were similar for those with 3 or more hospitalizations in the prior year, declining health status, and cognitive impairment. CONCLUSION After adjusting for confounders including comorbidity, we found that adults with HF and ADL impairment take as many medications as those without ADL impairment. This suggests that providers may not sufficiently consider functional impairment when prescribing medications to adults with HF and thus may unnecessarily expose individuals to risk of adverse outcomes. J Am Geriatr Soc 67:284-291, 2019.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, New York.,Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Joanna Bryan
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jerard Kneifati-Hayek
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Madeline R Sterling
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Samprit Banerjee
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Mathew S Maurer
- Center for Advanced Cardiac Care, Columbia University Medical Center, New York, New York
| | - Mark S Lachs
- Division of Geriatrics, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Monika M Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
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Dodson JA, Chaudhry SI, Krumholz HM. Time for a New Approach to Studying Older People with Ischemic Heart Disease. J Am Geriatr Soc 2017; 65:2349-2351. [PMID: 28493548 PMCID: PMC5681380 DOI: 10.1111/jgs.14923] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This editorial comments on the article by Bourgeois et al.
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Affiliation(s)
- John A. Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
- Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, New York
| | - Sarwat I. Chaudhry
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Sharma A, Alexander KP. Natriuretic Peptides in Older Patients With Heart Failure: A Look Into the Seeds of Time. J Am Geriatr Soc 2017; 65:691-692. [PMID: 28176304 DOI: 10.1111/jgs.14762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Abhinav Sharma
- Duke Clinical Research Institute, Duke University, Durham, North Carolina.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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