Cardiovascular Procedures That Push the Line: High-Risk or Futility of Care? Interview with:

Adam Skolnick, MD Cardiologist Associate professor of medicine NYU Langone Medical Center

Dr. Adam Skolnick

Adam Skolnick, MD
Associate professor of medicine
NYU Langone Medical Center What is the background for this study? What are the main findings?

Response: I am privileged to serve on the ACC Program Planning Committee and helped to design this important session that seeks to determine the line between when a cardiovascular procedure is high risk and when it is futile.    I am co-chairing the session with the incoming chair of the section on Geriatric Cardiology for the ACC, Dr. Karen Alexander from Duke.

We are practicing medicine at one of the most extraordinary times when there are so many devices and procedures to prolong and improve quality of life.    It is critical to assess a patient’s goals of care for a given intervention.   In some patients, particularly those who are multiple degenerative chronic conditions, are frail and/or have cognitive impairment it is difficult to know when a given procedure multiple medical conditions will achieve a patient’s goals.   When is a procedure high risk, and when is it simply futile?    This is the fine line upon which many cardiologists often find themselves.

The speakers present case examples of high risk patients considering TAVI, high risk PCI or CABG and mechanical support devices and with interaction from the audience work through when each procedure is high risk and when it is unlikely to achieve a patient’s goals of care.   We also have a dedicated talk on high risk procedures in patients with cognitive impairment, such as advanced dementia. What should readers take away from your report?

Response: There are now excellent risk scoring systems that may inform one’s decision about when a procedure has such a high prohibitive risk that it is unlikely to accomplish a patient’s goals of life prolongation or improved quality of life.   When we speak with patients and their families, they are desperate to find hope for their condition.   It is critical to always be positive and kind and supportive of a patient’s goals but also to set clear expectations about how likely a given procedure will achieve those goals.    We hope that those attending our session will walk away with a set of tools and strategies to approach these difficult patient decisions. What recommendations do you have for future research as a result of this study?

Response: The TAVI investigators have done a great job of including frailty and cognitive metrics in their studies but more research is needed on the impact of frailty and cognitive dysfunction in high risk PCI/CABG and mechancial support devices.   It is also critical to develop research strategies to help identify those patients who will be extremely unlikely to benefit from a given procedure a priori.     Finally the definition of frailty must be consistent across studies; I think one of the most important research avenues is to work on harmonization of the frailty indices so that we can compare frailty assessments across studies.

No disclosures. Thank you for your contribution to the community.

Citation: Seminar presentation at the March 2017 ACC

 This seminar will review the data supporting the use of common invasive cardiovascular procedures in older adults. It will review the decision criteria to perform the procedure, procedural nuances and post-procedural care unique to high risk patients (particularly older adults). Discussion will focus the comparative lessons across procedure types to enhance the concepts.

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on March 19, 2017 by Marie Benz MD FAAD