Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.
Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands.
BMC Geriatr. 2022 May 5;22(1):394. doi: 10.1186/s12877-022-03082-8.
In clinical practice and science, there is debate for which older adults the benefits of cardiovascular preventive medications (CPM) still outweigh the risks in older age. Therefore, we aimed to assess how various clinical characteristics influence the judgement of appropriateness of CPM in older adults.
We assessed the appropriateness of CPM for adults ≥75 years with regard to clinical characteristics (cardiovascular variables, complexity of health problems, age, side effects and life expectancy) using the RAND/ University of California at Los Angeles Appropriateness Method. A multidisciplinary panel, including 11 medical professionals and 3 older representatives of the target population, received an up-to-date overview of the literature. Using 9-point Likert scales (1 = extremely inappropriate; 9 = extremely appropriate), they assessed the appropriateness of starting and stopping cholesterol lowering medication, antihypertensives and platelet aggregation inhibitors, for various theoretical clinical scenarios. There were two rating rounds, with one face-to-face discussion in between. The overall appropriateness judgments were based on the median panel ratings of the second round and level of disagreement.
The panelists emphasized the importance of the individual context of the patient for appropriateness of CPM. They judged that in general, a history of atherosclerotic cardiovascular disease strongly adds to the appropriateness of CPM, while increasing complexity of health problems, presence of hindering or severe side effects, and life expectancy < 1 year all contribute to the inappropriateness of CPM. Age had only minor influence on the appropriateness judgments. The appropriateness judgments were different for the three types of CPM. The literature, time-to-benefit, remaining life expectancy, number needed to treat, and quality of life, were major themes in the panel discussions. The considerations to stop CPM were different from the considerations not to start CPM.
Next to the patients' individual context, which was considered decisive in the final decision to start or stop CPM, there were general trends of how clinical characteristics influenced the appropriateness, according to the multidisciplinary panel. The decision to stop, and not start CPM, appeared to be two distinct concepts. Results of this study may be used in efforts to support clinical decision making about CPM in older adults.
在临床实践和科学研究中，对于哪些老年患者使用心血管预防药物（CPM）的获益仍超过风险存在争议。因此，我们旨在评估各种临床特征如何影响老年患者使用 CPM 的适宜性判断。
我们使用 RAND/加利福尼亚大学洛杉矶分校适宜性方法，根据临床特征（心血管变量、健康问题的复杂性、年龄、副作用和预期寿命）评估≥75 岁成年人使用 CPM 的适宜性。一个由 11 名医疗专业人员和 3 名目标人群的老年代表组成的多学科小组，收到了最新的文献综述。他们使用 9 分李克特量表（1=极不适当；9=极适当），对各种理论临床情况开始和停止使用降胆固醇药物、抗高血压药物和血小板聚集抑制剂的适宜性进行评估。有两轮评分，中间进行了一次面对面讨论。第二轮的中位数面板评分和意见分歧程度决定了整体适宜性判断。
小组成员强调了患者个体情况对 CPM 适宜性的重要性。他们判断，一般来说，动脉粥样硬化性心血管疾病病史强烈增加了 CPM 的适宜性，而健康问题的复杂性增加、存在阻碍或严重副作用以及预期寿命<1 年都增加了 CPM 的不适当性。年龄对适宜性判断的影响较小。三种 CPM 的适宜性判断不同。文献、获益时间、预期剩余寿命、需要治疗的人数和生活质量是小组讨论的主要主题。停止 CPM 的考虑因素与不开始 CPM 的考虑因素不同。
除了患者的个体情况，这被认为是最终决定开始或停止 CPM 的决定性因素外，多学科小组还确定了临床特征影响适宜性的一般趋势。停止和不开始 CPM 的决定似乎是两个不同的概念。本研究的结果可用于支持对老年患者使用 CPM 的临床决策。
