Cardiovascular Biomarkers and Imaging in Older Adults: JACC Council Perspectives

Abstract

Whereas the burgeoning population of older adults is intrinsically vulnerable to cardiovascular disease, the utility of many management precepts that were validated in younger adults is often unclear. Whereas biomarker- and imaging-based tests are a major part of cardiovascular disease care, basic assumptions about their use and efficacy cannot be simply extrapolated to many older adults. Biology, physiology, and body composition change with aging, with important influences on cardiovascular disease testing procedures and their interpretation. Furthermore, clinical priorities of older adults are more heterogeneous, potentially undercutting the utility of testing data that are collected. The American College of Cardiology and the National Institutes on Aging, in collaboration with the American Geriatrics Society, convened, at the American College of Cardiology Heart House, a 2-day multidisciplinary workshop, "Diagnostic Testing in Older Adults with Cardiovascular Disease," to address these issues. This review summarizes key concepts, clinical limitations, and important opportunities for research.

Keywords: aging; biomarkers; cardiovascular testing; imaging; shared decision making; stress testing.

FIGURE 1. Age and Sex Differences in hs-cTnT to Diagnose MI

In an age-stratified analysis of the DHS (Dallas Heart Study), ARIC (Atherosclerosis Risk in Communities) study, and CHS (Cardiovascular Health Study), the 99th percentile value for high-sensitivity cardiac troponin T (hs-cTnT) varied markedly by age and sex, with the manufacturer’s reported cutpoint (14 ng/l) being higher than the observed 99th percentile value in younger women <50 years old, but lower than the observed 99th percentile value for men and women 65 to 74 and particularly those >75 years (19). Data for men are shown in blue and women in red. MI = myocardial infarction.

FIGURE 2. Diagnostic Performance of the ESC hs-cTnT 0/1 h Algorithm According to Age

Specificity of high-sensitivity cardiac troponin T (hs-cTnT) decreases modestly across age ranges, but the positive predictive value for rule-in was similar in the older group due to a higher prevalence of myocardial infarction. NSTEMI = non-ST-segment elevation myocardial infarction.

FIGURE 3. Utility of NT-proBNP and cTnT to Predict Short-Term Risk for CVD Events in Older Adults Without Known CVD

N-terminal pro-B-type natriuretic peptide (NT-proBNP) was used to predict short-term risk for cardiovascular disease (CVD) events in conjunction with cTnT in a cohort of older adults without known CVD at baseline. Over 4 years, higher NT-proBNP and hs-cTnT predicted relatively more CVD events in models adjusted for traditional CVD risk factors in the pooled cohort equation (48). Abbreviations as in Figures 1 and 2.

FIGURE 4. Changes in LVED Measurements With Age in Men and Women

For men (left) and women (right), the 95% confidence intervals for the following measurements are presented: left ventricular end-diastolic dimension (LVEDD) measured from a parasternal long-axis window on the basis of body surface area (BSA) (top), BSA-indexed left ventricular end-diastolic volume (LVEDV) measured from an apical 4-chamber view on the basis of age (middle), and BSA-indexed biplane LVEDV on the basis of age (bottom) (61). LVESV = left ventricular end-systolic volume.

CENTRAL ILLUSTRATION. The Increased Importance of Shared Decision Making When Considering Testing for Older Adults With or at Risk for CVD

Whereas diagnostic, prognostic, and surveillance testing is often perceived as relatively straightforward and fundamental in the care of younger adults with or at risk for cardiovascular disease (CVD), testing strategies and cardiovascular therapies in older adults tend to become less clearly aligned with what many older adults describe as their goals of care. Shared decision making is especially important when considering diagnostic testing as the value of each test is more likely to be shaped by each older adult’s preferences, particularly amid the confounding effects of multimorbidity, frailty, polypharmacy, cognitive decline, and reduced life expectancy. Age-related differences in the burden a patient may associate with testing as well as in the interpretability of results may also have an impact on the perceived value of testing to older adults as well as to their clinicians.