WASHINGTON (Sept. 11, 2014) — A quarter of adults in the U.S. have two or more chronic medical conditions, as do more than two-thirds of seniors, yet there are few clinical practice guidelines for cardiologists that take such comorbid conditions and their treatment into consideration.
An article jointly developed by the American College of Cardiology, the American Heart Association, and the U.S. Department of Health and Human Services hopes to raise awareness and provide advice for cardiologists treating cardiovascular disease patients who are taking drugs for a range of other common health problems, especially the elderly.
The authors reviewed Medicare claims for 2012 to determine the extent to which cardiovascular patients were filing claims for a range of other conditions such as pulmonary dysfunction, diabetes mellitus, arthritis and mental health disorders.
The analysis focused on four major cardiovascular conditions: ischemic heart disease, heart failure, atrial fibrillation, and stroke. In all, 8,678,060 patients had claims for ischemic heart disease; 4,366,489 with heart failure; 2,556,839 with atrial fibrillation; and 1,145,719 with stroke.
As was expected, hypertension and high cholesterol were the most common comorbidities for most of the major cardiovascular conditions. Notably, diabetes and arthritis were also very common in individuals with these conditions. For example, diabetes was a comorbidity in 41.7 percent of those with ischemic heart disease, 47.1 percent among heart failure patients, 37.1 percent in atrial fibrillation patients, and 41.5 percent in stroke patients. Arthritis was a comorbidity in 40.6 percent of those with ischemic heart disease, 45.6 percent among heart failure patients, 41.7 percent in atrial fibrillation patients, and 44.2 percent in stroke patients. The analysis also revealed the presence of comorbidities such as chronic kidney disease, chronic obstructive pulmonary disease, Alzheimer’s disease/dementia, and depression among individuals with these cardiovascular conditions. For example, 26.3 percent of heart failure patients had Alzheimer’s disease/dementia, and 29.7 percent of stroke patients had depression.
“Although data in the medical literature is somewhat limited, some medications given to patients with these other conditions can interfere with those used for cardiovascular disease and, in some cases, even pose serious health risks,” said William A. Zoghbi, MD, director of cardiovascular Imaging at the Houston Methodist DeBakey Heart and Vascular Center, past president of the American College of Cardiology and an author of the article.
“We have to become better at addressing more of these comorbid conditions in cardiovascular patients, especially older individuals,” he said. “Dynamic changes in the population, treatments and the introduction of new drugs, pose substantial implications for organizations that develop clinical practice guidelines, including the increasing prevalence of chronic conditions in all adults. In older Medicare beneficiaries the prevalence is even higher, with more than two thirds, or 68 percent, having more than two chronic conditions, and 14 percent with six or more.”
Donna K. Arnett, M.S.P.H., Ph.D., professor and chair of the Department of Epidemiology in the School of Public Health at University of Alabama Birmingham and past president of the American Heart Association, who helped develop the article, said that the increase in so many comorbidities in aging patients with cardiovascular disease is an important clinical problem and makes developing new guidelines critical.
“Incorporating major comorbidities into future clinical practice guidelines will be challenging, however this large analysis helps by identifying those comorbidities which are most prevalent,” she said, noting that ischemic heart disease is most common in the elderly, with nearly 9 million individuals over the age of 65 estimated to have the disease, while 81 percent have comorbid hypertension and 69 percent have hyperlipidemia.
Some existing cardiovascular guidelines include consideration of special treatment and potential complications due to these factors, such as patient age and problems affecting pharmacokinetics, notably kidney and liver function. But as a whole, with the exception of atrial fibrillation and heart failure, formal clinical practice guidelines have never before systematically identified and made recommendations on how common comorbidities in cardiovascular disease might affect care and management of patients.
“We want to ensure that we are addressing all of these potential comorbidities while developing and implementing future guidelines—but all of them are different,” Arnett said.
“We must try to better address many of the comorbidities that require special consideration,” said Jeffrey L. Anderson, M.D., chair of the ACC/AHA Task Force on Practice Guidelines, and associate chief of cardiology at Intermountain Health Care, in Murray, Utah. “For example, arthritis is very common in older individuals who take analgesics that can make them more vulnerable to stomach bleeding, and blood thinners can cause serious consequences if stomach bleeding occurs, as can bladder complications.”
He said the ACC and AHA are working to provide cardiologists with a better understanding of how many drugs used to treat many conditions in older patients might react with current cardiovascular medications.
“Physicians often do not address these other conditions in making treatment decisions,” Anderson said. “This is intended as a wake-up call, since therapeutic decision making is getting more complicated because so many new drugs, devices and therapeutic strategies for these other conditions are constantly coming into clinical practice. There is a lack of general awareness and even good clinical evidence available on possible interactions with cardiovascular and non-cardiovascular drugs.”
Developing and implementing clinical practice guidelines that address comorbidities is difficult because evidence that might serve to help in developing generalizable recommendations is limited, in part because such patients are often excluded from clinical trials, Anderson said. U.S. Food and Drug Administration (FDA) internal policy now suggests that a closer examination of the populations be included in clinical trials should be a regular part of FDA’s assessment of clinical trials. The FDA expects the development plans proposed by drug developers to include patients with multiple chronic conditions.
The full document is publishing today on the websites for the ACC (www.cardiosource.org) and AHA (www.americanheart.org) and will be published in the Journal of the American College of Cardiology and Circulation.
About the American College of Cardiology
The mission of the American College of Cardiology is to transform cardiovascular care and improve heart health. The College is a 47,000-member medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers. The College is a leader in the formulation of health policy, standards and guidelines. The ACC provides professional education, operates national registries to measure and improve quality of care, disseminates cardiovascular research, and bestows credentials upon cardiovascular specialists who meet stringent qualifications.
About the American Heart Association
The American Heart Association is devoted to saving people from heart disease and stroke – America’s No. 1 and No. 4 killers. We team with millions of volunteers to fund innovative research, fight for stronger public health policies, and provide lifesaving tools and information to prevent and treat these diseases. The Dallas-based association is the nation’s oldest and largest voluntary organization dedicated to fighting heart disease and stroke.