AHA/ACC/HHS Release Strategies to Enhance CVD and Comorbid Condition Guidelines

With a growing number of U.S. adults with more than one chronic condition, the ACC, American Heart Association (AHA) and the U.S. Department of Health and Human Services (HHS) have released an analysis aimed at providing guidance around effective management of cardiovascular patients with comorbidities.

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The "AHA/ACC/HHS Strategies to Enhance Application of Clinical Practice Guidelines in Patients With Cardiovascular Disease and Comorbid Conditions," published Sept. 11 in the Journal of the American College of Cardiology, is based on a review of 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 for heart failure; 2,556,839 for atrial fibrillation; and 1,145,719 for stroke.

Overall, the review found 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. Data also showed that 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. In addition, the presence of comorbidities such as chronic kidney disease, chronic obstructive pulmonary disease, Alzheimer’s disease/dementia, and depression was found 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 are 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, MACC, director of Cardiovascular Imaging at the Houston Methodist DeBakey Heart and Vascular Center, past president of the ACC 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."

Jeffrey L. Anderson, MD, FACC, chair of the ACC/AHA Task Force on Practice Guidelines, and associate chief of cardiology at Intermountain Health Care, in Murray, UT, noted that moving forward, the ACC and AHA are trying 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. He also stressed the importance of considering comorbidities during the development process of future disease-specific clinical practice guidelines.

"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, and there is a lack of general awareness and even good clinical evidence available on possible interactions with cardiovascular and non-cardiovascular drugs."

The study authors do note that 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. However, U.S. Food and Drug Administration (FDA) internal policy now instructs that a closer examination of the populations to be included in clinical trials should be a regular part of FDA’s assessment of clinical trials and the FDA expects the development plans proposed by drug developers to include patients with multiple chronic conditions.

It is important that the ACC and AHA partner with various organizations to determine how best to highlight and address the complex issues arising from comorbidities in clinical medicine moving forward.

Keywords: Protestantism, Comorbidity, Cholesterol, Prevalence, United States Food and Drug Administration, Filing, Medicare, Mental Health, Hypertension, Depression, Myocardial Ischemia, Stroke, Heart Function Tests, Decision Making, Social Change, Pulmonary Disease, Chronic Obstructive, Cardiovascular Agents, Perioperative Care, Heart Failure, Diabetes Mellitus, Renal Insufficiency, Chronic

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