Rich Michael W, Chyun Deborah A, Skolnick Adam H, Alexander Karen P, Forman Daniel E, Kitzman Dalane W, Maurer Mathew S, McClurken James B, Resnick Barbara M, Shen Win K, Tirschwell David L
J Am Coll Cardiol. 2016 May 24;67(20):2419-2440. doi: 10.1016/j.jacc.2016.03.004. Epub 2016 Apr 11.
The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.
大多数心血管疾病的发病率和患病率随年龄增长而增加，心血管疾病是75岁及以上成年人死亡和严重残疾的主要原因；然而，尽管心血管疾病对老年人的生活质量、发病率和死亡率有重大影响，但在大多数主要的心血管试验中，75岁及以上的患者代表性明显不足，而且几乎所有试验都排除了患有复杂合并症、有明显身体或认知残疾、身体虚弱或居住在养老院或辅助生活设施中的老年患者。因此，目前的指南无法为日常临床实践中常见的老年患者的诊断和治疗提供基于证据的建议。本科学声明的目的是总结当前适用于老年人的指南建议，识别妨碍做出明智的基于证据决策的关键知识空白，并建议未来开展研究以填补现有知识空白。为实现这些目标，我们对美国心脏病学会/美国心脏协会以及美国中风协会的现行指南进行了详细审查，以确定明确针对老年患者的内容和建议。我们发现，普遍缺乏指导老年心血管疾病患者临床决策的证据，而且关于诊断和治疗干预对老年患者尤为重要的关键结局（如生活质量、身体功能和保持独立）影响的数据也很匮乏。因此，迫切需要开展大量基于人群研究和临床试验，纳入广泛的、代表临床实践中所见老年患者的样本，并在研究设计中纳入对老年患者重要的相关结局。这些研究结果将为未来适用于老年患者的基于证据的指南奠定基础，从而加强美国乃至全球以患者为中心的老年心血管疾病患者的循证护理。
