Age only one consideration in post-MI drug therapy

Although the term “elderly” is often defined as ages 65 years or older in the medical literature, there is a tremendous heterogeneity among older adults.

“We should not be thinking of adults as a homogeneous group where everyone above a certain age should be treated the same,” said Michael Steinman, MD, FACP, professor of medicine in the division of geriatrics at University of California, San Francisco.

He and his colleagues published a study in the February 2017 JAMA Internal Medicine looking at the association between beta-blockers and functional decline, mortality, and rehospitalization in adults ages 65 years or older who were hospitalized for acute myocardial infarction (MI) and lived in a nursing home. Among this population, use of beta-blockers in the weeks and months following MI conferred a considerable mortality benefit, but those adults with moderate to severe cognitive impairment or severe functional dependency were at increased risk for functional decline.

“For many frail older patients in these situations, improving quality of life may be more important than improving quantity of life,” Dr. Steinman said. “In particular, many older people of an advanced age may put a high priority on maintaining their ability to do day-to-day activities like dressing themselves or getting in and out of bed, rather than living longer.”

After MI, most patients are prescribed a combination of drugs that commonly include aspirin, a P2Y12 platelet receptor antagonist such as clopidogrel, a beta-blocker, a statin, and either an angiotensin-converting (ACE) inhibitor or an angiotensin-receptor blocker.

“There are sentences in the guidelines stating that physicians should make sure the use of these drugs make sense in each individual patient. All things considered, and in general, the above medications are often routinely used,” said Ashok Krishnaswami, MD, a cardiologist in San Jose, Calif., who is affiliated with Kaiser Permanente San Jose Medical Center.

For example, the 2013 American College of Cardiology Foundation/American Heart Association guideline for the management of ST-elevation MI specifies that elderly patients make up a population that presents special challenges for management. However, the guideline also states that “treatments that are effective in younger populations usually are indicated in older adults, with the caveat that older adults more often have absolute or relative contraindications to their use.”

Know the patient

To determine the best therapy for elderly patients after MI, it is very important for physicians to know them and have a sense of who they are in the context of their life and their life trajectory, said Jennifer Tjia, MD, MSCE, professor of population and quantitative health science at University of Massachusetts Medical School in Worcester, Mass.

“For a primary care physician who has known a patient a long time, this can be easier,” Dr. Tjia said. “For someone catching a patient at only one point in time, it will be helpful to talk to a patient and the family about what their goals are for life.”

This conversation might include questions about their goals for medical therapy and where they see themselves in six months or one year, she said.

“A frail older patient or their caregiver may tell you that living forever is not a key goal but maximizing function is. If that person has moderate or severe functional or cognitive impairment, in many cases I would recommend not taking the beta-blocker because it may increase risks of further functional decline,” Dr. Steinman said. “Conversely, that patient might say that they want to stay alive in order to see a grandchild's wedding, and in that case, use of the medication would increase the patient's chances of meeting that goal.”

Try to get away from the idea that starting a new medication means continuing it for the rest of a patient's life, Dr. Tjia advised.

“It is more appropriate to say that this is for ‘right now’, but what is ‘right’ now may not be right for the future,” she said.

There is a definite need for more evidence about and discussion of appropriate modification and withdrawal of cardiovascular medications, especially in older adults, according to ACP Member Parag Goyal, MD, MSc, assistant professor of medicine at Weill Cornell Medicine in New York City.

“I don't think there is any process in the community for review of these medications,” Dr. Krishnaswami agreed. “The view is pretty much if you start these medications, you are required to take it indefinitely.”

One recently published observational study by Shavadia and colleagues in Circulation: Cardiovascular Quality and Outcomes examined whether beta-blockers had any benefit beyond three years of use post-MI in elderly patients. Among patients ages 65 years or older, regardless of the dose, beta-blocker use was not associated with improved outcomes such as all-cause mortality, hospitalization for recurrent MI, stroke, or heart failure.

“The problem is that a lot of these studies looking at harm are observational studies, and cardiology guidelines put randomized clinical trials at the top of the evidence hierarchy,” Dr. Krishnaswami said. “People are very wedded to these drugs and may not see harms associated with them.”

Medication for older adults should be reviewed regularly, according to Dr. Tjia, particularly with respect to goals of care. “On the simplest level, you should look at whether the indication is still valid or not,” she said. “But you should also look at whether or not the patient is really taking the drugs, whether or not they are working, and whether they are having any adverse effects.”

Cardiology comanagement

In the case of beta-blockers, Dr. Goyal said that he considers discontinuation in a good number of patients.

“If someone is several years post-MI, from my standpoint, it may be reasonable to titrate off beta-blockers in the absence of other compelling indications, especially if the patient is having side effects,” Dr. Goyal said.

There is not much guidance on how best to do this, Dr. Goyal said. Unlike statins, where there is no rebound effect, with beta-blockers that is not the case.

“When taking a beta-blocker there is an upregulation of beta receptors,” Dr. Goyal said. “When you stop beta-blockers, there are more receptors available for binding, and that could lead to rebound symptoms like hypertension, tachycardia, or diaphoresis in some if not done carefully.”

A recent study in the January Journal of the American Geriatrics Society showed that among a group of surveyed geriatricians, general internists, and cardiologists, many had recently considered deprescribing a cardiovascular medication, often because of adverse drug reactions.

“One of the primary barriers to deprescribing that emerged among geriatricians, internists, and cardiologists was that they were concerned that if they deprescribed a cardiovascular medication that they would be interfering with the treatment plan of another doctor,” Dr. Goyal said.

Use of comanagement would hopefully alleviate some of those concerns but would require collaboration and communication to figure out the best way forward based on patients' individual risk, benefit, and preference profile, he said. Even with comanagement, Dr. Krishnaswami encouraged primary care physicians to trust their knowledge of the patient and their preferences.

“The problem is that cardiologists tend to be very therapy-focused, and the primary care physician may be left feeling pressure from the cardiologist to continue medications based on guideline recommendations,” he said.

For example, the study by Dr. Goyal and his colleagues showed that geriatricians were the most likely and cardiologists the least likely to deprescribe cardiovascular medications in the face of limited life expectancy such as cancer or significant functional impairment.

Balancing these subspecialists in the comanagement of older patients may just be the next frontier of medicine, according to Dr. Tjia. This may be especially true given the fact that the average age of first myocardial infarction is now 65.6 years in men and 72.0 years in women.

“We are trying to figure it out, but don't yet know what the answer is,” Dr. Tjia said. “From the geriatrician's point of view, when you are applying guidelines to older adults, we like to take a holistic view, and that should always include information about the patient's goals, level of function, existing medication burden, and life expectancy.”