News | September 16, 2014

New Analysis Addresses Cardiovascular Patients With Other Conditions

First attempt to tackle clinical decisions compounded by other treated comorbidities

September 16, 2014 — A quarter of adults in the United States 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 (ACC), the American Heart Association (AHA) and the U.S. Department of Health and Human Services (HHS) 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, M.D., director of cardiovascular imaging at the Houston Methodist DeBakey Heart and Vascular Center, past president of the ACC and an author of the article.

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 AHA, 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.

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