What Matters Most to Older Adults Referred for Stress Testing

Cardiovascular disease (CVD) management continues to advance, with increasing insights into the pathophysiology of disease, as well as breakthroughs in diagnosis, prognosis, and treatment.Yet, whether these advances benefit all patients, particularly older adults, is less certain.Most adults with CVD are now older, such that CVD typically occurs in a context of multimorbidity, polypharmacy, frailty, sarcopenia, cognitive impairment, functional declines, falls, and other geriatric concerns.These broader health concerns can dominate a patient's personal priorities for care, to the extent that CVD-specific management may seem less meaningful or desirable.Therapeutic burden, iatrogenic risks, prolonged time to benefit, and other implications of treatment may also outweigh its perceived value.Conversely, older adults with CVD often present with nonspecific or atypical symptoms.This ambiguity often increases reliance on diagnostic testing to guide care.However, optimal testing and management cannot be fully determined without first understanding each patient's personal care priorities.In this study of patient perspectives on cardiac stress testing, Patel et al 1 touch on some of these themes by interviewing adults aged 75 years or older who had undergone cardiac stress testing.Patel et al 1 present a compelling qualitative study using in-depth focus groups with 29 patients, addressing key patient-centered topics, such as communication, decision-making, and how geriatric impairments shape decision-making preferences.Patients emphasized inadequate patient-physician communication regarding age-related challenges and expressed a preference for quality of life over longevity.While these insights seem to suggest actionable next steps, the challenges of implementation remain substantial.Aligning care to patient preferences remains an ideal that is difficult to realize in practice.Clinicians face time constraints, fragmented continuity, and pressure to follow disease-specific guidelines that may conflict with personalized care.Specialists in particular are often consulted to provide guideline-based management and may feel limited in deviating from customary standards, especially amidst institutional, peer, and medicolegal expectations.As a result, testing is frequently equated with appropriate care, regardless of context or patient preference.Furthermore, reduced patient-physician continuity and shorter office visits undermine opportunities to build trust and personal insights as foundations for shared decision-making.In addition, shared decision-making is often underemphasized in training, particularly among specialists whose focus tends to remain centered on rapid advances in their specialty field.Patel et al 1 note communication challenges across both primary care and cardiology settings, although clinician perspectives are not included.Generalist and specialist perspectives could reveal additional insight, with prior studies reporting that clinicians may avoid deviating from guidelines due to fear of liability. 2Primary care physicians, with their more established relationships, may be wellpositioned to initiate goal-aligned care discussions.Likewise, specialists could request such background information from referring clinicians as a prerequisite to specialty care.In addition, as geriatric conditions increasingly shape every facet of chronic disease care, subspecialists should develop greater expertise in geriatric domains. 3However, this would require a broader transformation in health system structure, payment models, and resource allocation within a system that still largely centers on specialty procedures.It is notable that Patel et al 1 focused on patients referred for stress imaging for suspected ischemia-implying that symptoms prompted testing and that further intervention (eg,