When Krishna Patel, MD, ordered a cardiac stress test for an 80-year-old patient, she did not expect how the move — the standard of care for patients with elevated coronary artery calcium — would change her patient’s life.

When the stress test results came back as abnormal, Patel, an assistant professor of cardiology at the Icahn School of Medicine at Mount Sinai in New York City, ordered catheterization. The man had multiple blocked coronary arteries, requiring coronary artery bypass surgery.

“The surgery was technically successful, but the recovery was long and difficult,” Patel said.

His recovery entailed multiple hospitalizations, complications with medicine, and ultimately, ended his ability to live independently. Throughout multiple postsurgical conversations, Patel learned that she had missed something during those initial tests.

“It became clear that what he valued most was being able to remain at home comfortably, not undergoing aggressive procedures, or spending extended time in the hospital,” Patel said. “A single test can start a cascade that reshapes a patient’s final years in ways they may not have chosen, had their goals and preferences guided the decision from the beginning.”

If a geriatric patient shows signs of ischemia, the standard route of care is to administer a stress test. But whether these patients will benefit from this test or the potential treatment afterward is far more complicated.

A new study published in JAMA Network Open found doctors are not talking with older patients about the implications of having a stress test or their choice to receive one.

Physicians must take time to discuss goals with their patients, experts say. And sometimes the best approach is not to treat disease but to make whatever years are left the most comfortable.

About one quarter of adults aged 75 years or older have heart disease compared with less than 15% of people aged 64-74 years and just 1% of adults younger than 45 years. These geriatric patients often have different goals when it comes to managing their disease.

“When you are dealing with geriatric patients, it’s not always about longevity. It’s often about maintaining independence and quality of life,” said William Cornwell, MD, an associate professor of medicine-cardiology at the University of Colorado Anschutz School of Medicine in Aurora, Colorado, who was not involved with the new study.

The qualitative analysis of 29 patients aged 75 years or older showed patients consistently reported having no conversation with their cardiologist regarding how their age or comorbidities would be affected by their treatment options. For example, a blood thinner might make their cognitive impairment worse. Nearly three quarters of patients had multiple chronic conditions, such as hypertension, kidney disease, or arterial fibrillation.

“Most of the time, when we discuss our treatment recommendations or test results with patients, especially as specialists, we just kind of do a one-size-fits-all because that is what we are trained to do,” said Patel, who is also a professor of population health science and the lead author of the study.

“We don’t really go into how the treatment we’re recommending fits into the grand scheme of things they care about like quality of life,” she said.

Patients said they also wanted more than one office visit to decide on an option.

“They want time to process information and to bring a caregiver into the conversation,” Patel said.

Using Patient-Centered Goals

Some older adults in the study said they wished they were told why they needed the test, what the results could show, and potential treatment options. Several people said they did not know they had a choice in the matter or could request more information.

“A lot of times that isn’t done because it’s a noninvasive test, but patients do want to know why they are getting this test and what to expect after,” Patel said. “It’s important to set the expectations early.”

Cardiologists should think about stress tests differently for an older patient, said Daniel Forman, MD, chair of the section of geriatric cardiology at the University of Pittsburgh Medical Center, Pittsburgh. In geriatric patients, stress tests can tell physicians a lot about their patient’s physical function in daily life, helping to tailor treatment to support a patient’s independence and quality of life.

“It can tell you why someone is struggling when living their routine lives — cleaning the kitchen, walking from the car to the grocery store, taking a shower, those kinds of things,” Cornwell said.

Cardiologists might want to call the patient’s referring physician to get a good idea of the patient’s health, frailty, and physical fitness before the first office visit, Forman said.

These factors can inform how a cardiologist designs the stress test, Cornwell said. Evaluating how a patient functions when moderately exerting themselves can be much more powerful in geriatric patients than how their body responds to peak exertion, he said.

Cornwell said specialists should collaborate with a patient’s primary care clinician over the phone or messaging and both should share detailed notes of their conversations with the patient and their family or caregiver. Cardiologists are also responsible for communicating any follow-up care the primary care clinician will need to manage.

“If you are starting a new medication, maybe blood tests need to be done in a couple months, or maybe there are side effects that are of concern that the primary physician should be looking out for,” Cornwell said.

At the very least, cardiologists should document the patient’s goals in their chart and the “why” behind which treatment has been chosen.

Physicians should also protect themselves from any potential legal ramifications of a patient refusing a test or treatment by thoroughly documenting every conversation they have with a patient and their caregivers, said Sean Domnick, a personal injury lawyer and partner at Rafferty Domnick Cunningham & Yaffa, a law firm in Palm Beach Gardens, Florida.

Cardiologists should clearly state what a patient’s diagnosis is, the treatment options, and the pros and cons of each, Domnick said. Patients should receive a paper copy with this information, potentially with links to more information about the procedures online, he added.

Cardiologists can avoid any potential miscommunication — or legal accusations — by getting family members involved in conversations early on and using dictation software to have a transcript on file of the conversations.

During these conversations, Domnick recommends physicians ask patients to articulate back to them what they understand about what the physician has told them.

If a patient or their family does take legal action, “What often happens is there is a dispute over what was said,” Domnick said.

Patients should also sign an Against Medical Advice form if they are choosing to not undergo a life-saving treatment.

“Sometimes you will be in a position where a doctor says you need to have this done, a stent for example, and the patient says, ‘no I don’t want to do that,’” Dominick said. “Absolutely they should be signing paperwork.”

Tailored Medicine

Tailoring treatment can be much more complex in older patients but having thorough conversations with patients and their caregivers can illuminate the best treatment option.

“When their doctors explain to them their test results, they also want to understand the bigger picture of how it will affect their overall health, which is largely dependent on the other comorbidities they have in addition to the heart,” Patel said. “Most of our patients [in the study] said that wasn’t brought up.”

For some patients, a stress test may not be the best road forward, or something they do not want to do, Forman said. For these people, taking a step-up approach, starting with medication, can be a good treatment plan.

“It is essential to begin by hearing what matters most to patients,” Forman said.

Treatment should come down to shared decision-making, which can only happen when a patient fully understands the potential consequences of each treatment option, Cornwell said.

“We might need to put them on beta-blockers and those can make people feel lightheaded: If you have an older person who is frail and already prone to falling, we ultimately haven’t helped them,” he said.

Time and time again, patients in the study responded with the same sentiment regarding what they want out of their medical care.

“If they had to make a tradeoff on a treatment strategy that would make them live longer but inhibit their independence, they would much rather choose something that allowed them to keep their independence and quality of life,” Patel said.

What cardiologists often miss is that older adults care about living well, Patel said. For these patients, treatment might go against a physician’s primary goal of preventing a heart attack or death.

“Staying active, avoiding hospitalizations or procedures that may leave them weaker, and maintaining their independence, those things are more important to them than living longer,” she said.