Multimorbidity in Older Adults With Cardiovascular Disease

Forman, Daniel E.; Maurer, Mathew S.; Boyd, Cynthia M.; Brindis, Ralph G.; Salive, Marcel E.; Horne, Frances Mc Farland; Bell, Susan P.; Fulmer, Terry; Reuben, David B.; Zieman, Susan J.; Rich, Michael W.

doi:10.1016/j.jacc.2018.03.022

Cited by 241 publications

(218 citation statements)

References 70 publications

(81 reference statements)

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“…Patients with CVD tend to have greater multimorbidity than individuals who are free from CVD 195 . Diseases most often associated with multimorbidity are diabetes, chronic kidney disease, anaemia, chronic pulmonary disease, depression, and dementia, which all involve inflammageing as an important risk factor 3,138,139,142,143,196 .…”

Section: Consequences Of Inflammageing For Cvdmentioning

confidence: 99%

“…The resulting syndromes present clinical challenges whose complexity is often ignored in clinical practice guidelines for single diseases, which are based on randomized clinical trials in which patients with multimorbidity are under-represented, including most of the trials cited above that targeted inflammation 195 . The degree of clinical complexity is even higher when the comorbid medical condition is frailty.…”

Section: Consequences Of Inflammageing For Cvdmentioning

confidence: 99%

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Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty

2018

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Most older individuals develop inflammageing, a condition characterized by elevated levels of blood inflammatory markers that carries high susceptibility to chronic morbidity, disability, frailty, and premature death. Potential mechanisms of inflammageing include genetic susceptibility, central obesity, increased gut permeability, changes to microbiota composition, cellular senescence, NLRP3 inflammasome activation, oxidative stress caused by dysfunctional mitochondria, immune cell dysregulation, and chronic infections. Inflammageing is a risk factor for cardiovascular diseases (CVDs), and clinical trials suggest that this association is causal. Inflammageing is also a risk factor for chronic kidney disease, diabetes mellitus, cancer, depression, dementia, and sarcopenia, but whether modulating inflammation beneficially affects the clinical course of non-CVD health problems is controversial. This uncertainty is an important issue to address because older patients with CVD are often affected by multimorbidity and frailty — which affect clinical manifestations, prognosis, and response to treatment — and are associated with inflammation by mechanisms similar to those in CVD. The hypothesis that inflammation affects CVD, multimorbidity, and frailty by inhibiting growth factors, increasing catabolism, and interfering with homeostatic signalling is supported by mechanistic studies but requires confirmation in humans. Whether early modulation of inflammageing prevents or delays the onset of cardiovascular frailty should be tested in clinical trials.

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Section: Consequences Of Inflammageing For Cvdmentioning

confidence: 99%

Section: Consequences Of Inflammageing For Cvdmentioning

confidence: 99%

Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty

2018

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“…Even when cardiovascular clinical trials do include older adults, they may not include participants with multiple coexisting chronic conditions. Among adults over 80 years of age, multimorbidity is more common than any single disease, and just over half have four or more chronic conditions . The older adult sitting in front of you likely does not resemble those in clinical trials.…”

Section: Challenges Of Shared Decision‐making With Older Adultsmentioning

confidence: 99%

Shared decision‐making for older adults with cardiovascular disease

Backman

Levine

Wenger

et al. 2019

Clinical Cardiology

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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.

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“…Demographic changes with increasing life expectancy will lead to a growing number of patients with multiple chronic conditions in the near future . Multimorbidity is commonly accompanied by the use of multiple drugs in a single patient, a condition known as polypharmacy, most often defined as a constant intake of more than four drugs by a patient.…”

mentioning

confidence: 99%

Relevance of Polypharmacy for Clinical Outcome in Patients Receiving Vitamin K Antagonists

Eggebrecht

Nagler

Göbel

et al. 2018

J American Geriatrics Society

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BACKGROUND Although polypharmacy is associated with a negative clinical outcome in various settings and commonly observed in patients receiving oral anticoagulation therapy, evidence on the relevance for the clinical outcome of anticoagulated patients is currently limited. The aim of the study was to investigate the effect of polypharmacy on the clinical outcomes among patients taking phenprocoumon. DESIGN Prospective cohort study. SETTING Regular medical care. PARTICIPANTS Information on 2011 individuals receiving vitamin K antagonists was available for analysis from the prospective multicenter thrombEVAL study. MEASUREMENTS Data were obtained from clinical visits, computer‐assisted interviews, and laboratory measurements. Information on clinical outcome was obtained during a 3‐year follow‐up period and subsequently validated via medical records. RESULTS The prevalence of polypharmacy (five drugs or more) was 84.1% (n = 1691). Quality of anticoagulation therapy assessed by time in therapeutic range was lower in individuals on five to eight drugs and nine drugs or more (70.7% and 64.7%, respectively) compared with subjects without polypharmacy (73.4%). In addition, a significantly higher variability of international normalized ratio measurements was found in the presence of polypharmacy. The cumulative incidence of bleeding, hospitalization, and all‐cause mortality, but not for thromboembolic events, increased across groups of medication. In adjusted Cox regression analysis, polypharmacy is an independent risk factor for bleeding (hazard ratio [HR]≥ 9 drugs vs 1‐4 drugs = 1.62; 95% confidence interval [CI] = 1.04‐2.52; p = .033); hospitalization (HR≥ 9 drugs vs 1‐4 drugs = 1.60; 95% CI = 1.26‐2.03; p < .001; and all‐cause mortality (HR≥ 9 drugs vs 1‐4 drugs = 2.16; 95% CI = 1.43‐3.27; p < .001) in a dose‐dependent relationship. Per additional drug, bleeding risk was increased by 4%. CONCLUSIONS Polypharmacy influences the quality of anticoagulation therapy and translates into an elevated risk of adverse events in anticoagulated patients. This suggests that additional medication intake in such patients should be critically reviewed by physicians, and it highlights the importance of initiating investigations aimed at reducing multiple medication intake. J Am Geriatr Soc 67:463–470, 2019.

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Multimorbidity in Older Adults With Cardiovascular Disease

Cited by 241 publications

References 70 publications

Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty

Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty

Shared decision‐making for older adults with cardiovascular disease

Relevance of Polypharmacy for Clinical Outcome in Patients Receiving Vitamin K Antagonists

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