ACC's newest Expert Consensus Decision Pathway offers a comprehensive and integrative framework for treating patients with atherosclerotic cardiovascular disease (ASCVD) and multimorbidity. The document, published Oct. 25 in JACC, encourages making treatment decisions for patients based on life expectancy and "4 domains": medical, mind and emotion, physical functioning, and social and physical environment.

"Patients with ASCVD often have multiple chronic conditions. Clinical practice guidelines frequently address a single condition and do not provide sufficient guidance for patients with multimorbidity," said Writing Committee Chair Kim K. Birtcher, PharmD, MS, FACC, Vice Chair Larry A. Allen, MD, FACC, et al. They note that the document aims to provide "clinicians and members of the care team with a multidimensional understanding of the patient to better promote care optimization."

Specifically, the Pathway provides recommendations for stacking clinical practice guidelines and the burden of cumulative recommendations; categorizing patients by phase of life; and sequencing treatments from highest to lowest patient value (Figure). Additionally, it provides insights into the characteristics of ideal therapy and how to discuss health goals and document advance care planning. A checklist tool for optimizing treatment is also included, with the aim of helping clinicians best determine and incorporate patient preferences and care goals into shared decision-making.

Birtcher, Allen and colleagues also stress the importance of health systems promoting a team-based approach to care for this patient population, whether leveraging interconnected electronic health records to facilitate implementation of the domain framework or establishing a process to "formally evaluate the impacts of implementing the domain framework and the tools from this [Expert Consensus Decision Pathway] on patients, clinicians, and the health system itself." They add that professional organizations like the ACC should also play a role in terms of "advocating for legislative efforts to reward holistic, patient-centered care."

According to the document: "As patients acquire more chronic conditions, the burdens of available therapy intensify while life expectancy shortens. Accordingly, care for patients must shift from recommending all evidence-based options to an approach that prioritizes therapies with the greatest expected benefit/harm profile, while aligning with patients' goals and preferences."