Increasing the focus on older patients in cardiology research
Authors: None The Lancet Healthy Longevity
Journal: The Lancet Healthy Longevity (2022)

The American College of Cardiology hosted its 71st annual meeting in early April, 2022, bringing together global researchers from various areas of expertise. With an acute awareness of the increasing burden of cardiovascular disease worldwide and with consideration of changes in health care in the aftermath of the pandemic, a theme of discussions was promoting equitable access and leveraging technology to provide cost-effective treatments. Clinical trials showed promising results for treatment options; for example, the POISE-3 trial revealed the effectiveness of tranexamic acid in decreasing postoperative bleeding, a particularly common adverse effect with increasing age. Other trials were geared towards empowering patients to pursue healthy lifestyles; the SUPERWIN trial (NCT03895580) showed that a dietary intervention for grocery store shopping, which combined individualised purchasing education with training on technologies, including online shopping platforms, resulted in increased purchasing of healthy foods. However, notably, despite cardiovascular disease predominantly affecting older people, very few presentations were centred specifically on this population. Although trials mostly included a broad age range, including older patients (with subgroup analyses done to assess effects by age), this inclusion appeared to be more a by-product of the mean age of patients, rather than a deliberate aim. The uniquely heterogenous profile of older patients, including different risk levels according to frailty, multimorbidity, and immune function, renders it imperative to assess differential effects by these risk factors. For example, the SCORED trial yielded impressive results showing reductions in major adverse cardiovascular events in outpatients with diabetes and chronic kidney disease taking sotagliflozin, compared with patients receiving placebo. Although patients had a median age of 69 years, analyses were not tailored to older patients, in part reflected by an absence of measurements of comorbidities or any frailty assessments. Because previous research has shown that SGLT2 inhibitors are associated with an increased risk of diabetic ketoacidosis in older patients, and as this risk is further elevated in older patients with comorbidities, assessing pre-existing conditions and how they might modulate the effectiveness and safety of therapies such as sotagliflozin in older patients is crucial. Another dominating theme was telemedicine. Although telemedicine is accompanied by challenges regarding the regulation of data and determining the cost of services, the challenge of ensuring inclusivity is equally pertinent. Professor Carl Lavie from the University of Queensland School of Medicine (Ochsner Clinical School, the University of Queensland School of Medicine, New Orleans, Louisiana) discussed the benefits of digital management of hypertension, including regular home readings and monthly report cards given to both patients and physicians on progress, in improving systolic blood pressure variability. Similarly, Dr Erica Spatz from the Yale School of Medicine (New Haven, Connecticut) discussed the utility of remote physiological monitoring to promote self-management of hypertension, which circumvents the limitations inherent to in-clinic testing by allowing for more reliable blood pressure readings, recording of lifestyle behaviours and sleep activity, and geocoded data of social determinants in the community. However, it is important not to assume that all older people have sufficient digital skills to navigate these tools. Although research on digital health might include older participants, these participants might be self-selecting as more digitally literate compared with the general older population. Telehealth has great potential to be a useful resource for older patients by empowering them to take control over their own health, removing access barriers due to mobility difficulties, and allowing patients and their families to meet with physicians from the comfort of their own homes. These tools must therefore be trialled specifically in older people to ensure their patient feedback can be used in the design of these tools, otherwise the potential of telehealth to alleviate the growing burden of cardiovascular disease might be squandered. There have been remarkable recent advances in cardiology, particularly in the context of competing demands during the pandemic. However, as population ageing is paralleled by a growing burden of cardiovascular disease, it is important that such advances do not exclude or discount the specialist needs of older patients.