Background. Medical and interventional therapies for older adults with acute myocardial infarction (AMI) reduce mortality and improve outcomes in selected patients, but there are also risks associated with treatments. Shared decision making (SDM) may be useful in the management of such patients, but to date, patients’ and cardiologists’ perspectives on SDM in the setting of AMI remain poorly understood. Accordingly, we performed a qualitative study eliciting patients’ and cardiologists’ perceptions of SDM in this scenario. Methods. We conducted 20 in-depth, semistructured interviews with older patients (age ≥70) post-AMI and 20 interviews with cardiologists. The interviews were transcribed and analyzed using ATLAS.ti. Two investigators independently coded transcripts using the constant comparative method, and an integrative, team-based process was used to identify themes. Results. Six major themes emerged: 1) patients felt their only choice was to undergo an invasive procedure; 2) patients placed a high level of trust and gratitude toward physicians; 3) patients wanted to be more informed about the procedures they underwent; 4) for cardiologists, patients’ age was not a major contraindication to intervention, while cognitive impairment and functional limitation were; 5) while cardiologists intuitively understood the concept of SDM, interpretations varied; and 6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI). Conclusions. Patients viewed intervention as “the only choice,” whereas cardiologists saw a need for balancing risks and benefits in treating older adults post-NSTEMI. This discrepancy implies there is room to improve communication of risks and benefits to older patients. A decision aid informed by the needs of older adults could help to better convey patient-specific risk and increase choice awareness.
RashidMFischmanDLGulatiM, et al. Temporal trends and inequalities in coronary angiography utilization in the management of non-ST-elevation acute coronary syndromes in the U.S. Sci Rep. 2019;9:240.
2.
PageMDoucetMEisenbergMJ, et al. Temporal trends in revascularization and outcomes after acute myocardial infarction among the very elderly. Can Med Assoc J. 2010;182(13):1415–20.
3.
RoffiMPatronoCColletJPMuellerC, et al. 2015ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2015;37(3):267–315.
4.
KeeleyECBouraJAGrinesCL.Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13–20.
5.
MehtaSRCannonCPFoxKAA, et al. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA. 2005;293(23):2908–17.
6.
BudnitzDSLovegroveMCShehabN, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–12.
7.
AronowHDSteinhublSRBrennanDM, et al. Bleeding risk associated with 1 year of dual antiplatelet therapy after percutaneous coronary intervention: insights from the Clopidogrel for the Reduction of Events During Observation (CREDO) trial. Am Heart J. 2009;157(2):369–74.
8.
ManganoCMDiamondstoneLSRamsayJG, et al. Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. Ann Intern Med. 1998;128(3):194.
9.
NdrepepaGBergerPBMehilliJ, et al. Periprocedural bleeding and 1-year outcome after percutaneous coronary interventions. J Am Coll Cardiol. 2008;51(7):690–7.
10.
BachRGCannonCPWeintraubWS, et al. The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes. Ann Intern Med. 2004;141(3):186–95.
11.
ElwynGFroschDThomsonR, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–7.
12.
TinettiMENaikADDodsonJA.Moving from disease-centered to patient goals—directed care for patients with multiple chronic conditions. JAMA Cardiol. 2016;1(1):9.
13.
SpatzESSpertusJAMontoriVM.Shared decision making: a path toward improved patient-centered outcomes. Circ Cardiovasc Qual Outcomes. 2012;5(6):e75–7.
14.
MatlockDDNowellsCTMasoudiFA, et al. Patient and cardiologist perceptions on decision making for implantable cardioverter-defibrillators: a qualitative study. Pacing Clin Electrophysiol. 2011;34(12):1634–44.
15.
ThompsonJSMatlockDDMcIlvennanCK, et al. Development of a decision aid for patients with advanced heart failure considering a destination therapy left ventricular assist device. JACC Hear Fail. 2015;3(12):965–76.
16.
MishraSRHaldarSPollackAH, et al. “Not just a receiver”: understanding patient behavior in the hospital environment. Proc SIGCHI Conf Hum Factor Comput Syst. 2016;2016:3103–14.
FeredayJMuir-CochraneE.Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5(1):80–92.
19.
GlaserBGStraussAL.The discovery of grounded theory. Int J Qual Methods. 1967;5:1–10.
20.
CurryLANembhardIMBradleyEH.Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. 2009;119(10):1442–52.
IsaacsCGKistlerCHunoldKM, et al. Shared decision making in the selection of outpatient analgesics for older individuals in the emergency department. J Am Geriatr Soc. 2013;61(5):793–8.
23.
FederSLSchulman-GreenDDodsonJA, et al. Risk stratification in older patients with acute myocardial infarction. J Aging Health. 2016;28(3):387–402.
24.
HessEPHollanderJESchafferJT, et al. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ. 2016;355:i6165.
25.
GreenARJenkinsAMasoudiFA, et al. Decision-making experiences of patients with implantable cardioverter defibrillators. Pacing Clin Electrophysiol. 2016;39(10):1061–9.
26.
DodsonJAChaudhrySIKrumholzHM.Time for a new approach to studying older people with ischemic heart disease. J Am Geriatr Soc. 2017;65(11):2349–51.
27.
AmsterdamEAWengerNKBrindisRG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64(24):e139–e228.
28.
WilsonTMillerJTeareS, et al. Patient perspectives on engagement in decision making in early management of non-ST elevation acute coronary syndrome: a qualitative study. BMC Med Inform Decis Mak. 2017;17(1):153.
29.
WieringaTHRodriguez-GutierrezRSpencer-BonillaG, et al. Decision aids that facilitate elements of shared decision making in chronic illnesses: a systematic review. Syst Rev. 2019;8(1):121.
30.
FederSLSchulman-GreenDGedaM, et al. Physicians’ perceptions of the Thrombolysis in Myocardial Infarction (TIMI) risk score in older adults with acute myocardial infarction. Heart Lung. 2015;44(5):376–81.
31.
WennbergJEO’ConnorAMCollinsED, et al. Extending the P4P agenda, part 1: how Medicare can improve patient decision making and reduce unnecessary care. Health Aff. 2007;26(6):1564–74.
32.
SpatzESSpertusJA.Shared decision making: a path toward improved patient-centered outcomes. Circ Cardiovasc Qual Outcomes. 2012;5(6):e75–7.
