Clinical practice patterns among older multimorbid adults presenting with suspected ischemic symptoms: A multi-center survey

Background: When patients with suspected or known coronary artery disease (CAD) present with new or worsening ischemic symptoms, initial referral to imaging or optimization of guideline directed medical therapy (GDMT) with deferral of testing are both acceptable management approaches. Methods: In this 12-center study, a 19-item survey exploring preferred management strategy for symptomatic older adults (≥75 years) with or without known CAD, and major patient and clinical factors driving this decision making was administered to clinicians. Results: There were 96 respondents (70.8 % cardiologists, 20.9 % primary care physicians/geriatricians). Among patients without known CAD, 59 (61.4 %) respondents favored early referral to testing, 6 (6.3 %) opted for initial GDMT and 23 (24.0 %) preferred both. For patients with known CAD, 27 (28.1 %) prioritized initial GDMT optimization, 37 (38.6 %) would refer for early testing and 19.8 % both. Key factors influencing initial preference for GDMT optimization were unoptimized anti-anginal medications, patient preference, increased complication risk, frailty, cognitive impairment and comorbidities. Key factors influencing preference for initial imaging were increasing symptom severity, already optimized GDMT, and electrocardiogram changes. When imaging revealed ischemia, clinicians reported weighing symptom severity, ischemic burden, current medications, comorbidities, frailty, and procedural risks before referring for invasive cardiac angiography. Conclusion: Both initial GDMT optimization and referral for imaging are frequently used approaches for the symptomatic older patient with suspected or known CAD. The survey highlighted the importance of patient characteristics such as frailty, cognitive impairment, multimorbidity and the gap in clinical guidance on how to optimally manage symptomatic older adults with CAD.