Typically, people with cardiovascular disease have one or more comorbid conditions, which challenges treatment and can greatly impact the burden of disease
Recent data suggests that more than four million Australians are living with cardiovascular disease (CVD), which represents 16.6% of the population. According to the Heart Foundation, CVD is a leading cause of death across the globe. In Australia, it represents one in four of all adult deaths, claiming the life of one person every 13 minutes.
There are numerous challenges in the care and management of CVD. A key issue is the prevalence of comorbidities, which challenges clinical care and is associated with worse health outcomes.
“We know that people with comorbidities, compared to people without comorbidities, experience a decreased quality of life. They access healthcare services more often, which includes hospitalisation,” says Natalie Raffoul, clinical pharmacist and risk reduction manager at the Heart Foundation.
“They are also at increased risk of mortality. We know that chromic heart disease is the single biggest cause of death in Australia,” she says.
“Globally, evidence suggests that over the last few decades there’s been an increased trend in the burden of comorbidities. A growing number of people have chronic comorbid conditions and this has a lot to do with the ageing population.”
Being aware of risk factors
Comorbid conditions are very common in patients with CVD. Moreover, comorbidity is much higher among the older population (65+) with 80% of this cohort having three or more chronic conditions.
Some of the most common cardiovascular comorbidities include hypertension, ischemic heart disease, atrial fibrillation (flutter) and stroke.
Among the most prevalent non-cardiovascular comorbidities are diabetes, COPD and chronic kidney disease.
Ms Raffoul explains, “It’s important to recognise that the most common types of overlapping comorbidities with CVD are other diseases that share the same pathophysiology for their condition.
Things like chronic kidney disease, diabetes and CVD, which covers multiple types of cardiac diseases, all share the same risk factors. Some would argue that cancer also shares many of the same risk factors as well.
“The only way to prevent other related conditions or comorbidities is to tackle the risk factors. We need to take a holistic approach in addressing these risk factors.
“We know that cardiometabolic risk factors are related to many of the common cardiovascular comorbidities, so there’s blood pressure, cholesterol levels and obesity. You also have lifestyle related factors, such as food, physical inactivity and smoking. Then there are other factors such as mental illness. While we’re unsure how this affects chronic disease, we know it plays a role somewhere along the line.
“Taking an integrated and holistic approach and dealing with the risk factors that we know contribute to multiple chronic conditions is our most reliable course of action,” says Ms Raffoul.
Consultant clinical pharmacist Debbie Rigby adds, “A less commonly considered cardiovascular comorbidity or risk factor is gout.
Indeed, a study published in the Journal of the American Heart Association found that gout was linked to worse cardiovascular outcomes for people being treated for coronary artery disease (CAD).
Among the patients with gout who were receiving medical therapy for CAD, their risk of dying of cardiovascular disease or having a heart attack or stroke was 15% higher than those patients who didn’t have gout.
“The fact that many people don’t recognise the link between gout and cardiovascular problems highlights the need to educate patients on CVD risk factors.
“We need to consider gout not only as a comorbidity but as a risk factor for CVD. It’s prevalent in younger men and much more common in Maori and Pacific people, due to genetic predispositions,” Ms Rigby explains.
Overcoming the challenge of comorbidities
“Particularly in the comorbidity space, it’s important for pharmacists to understand what they can expect to see in their patients. Recognising which of their patients are likely to be at the highest risk of having indirect consequences of polypharmacy or a greater burden of disease because of their comorbidity is important,” says Ms Raffoul.
“Easy wins in my mind are people with heart failure, for example. Of the patients with CVD, the ones with heart failure will have the highest number of other comorbidities, which can be cardiac or non-cardiac.
“So if you have someone with heart failure, they’re very likely to have coronary heart disease or have had a heart attack. All the other non-cardiac comorbities are also common here too.
“Being able to identify your high gains patients is important. In community pharmacy, and even in hospital, we can’t see every patient. We can’t be the ‘perfect pharmacist’, due to time pressures among other things.
“Other than the number of conditions a person has, the number of medicines they’re prescribed is a good indicator of who needs your help.”
An interesting study by Claire Lawson and colleagues into comorbidity in heart failure (HF) patients looked into why these people often have persisting symptoms and poor health-related quality of life despite receiving optimal treatment.
She discovered that non-cardiovascular comorbidities were linked with much higher symptom burden and severity than cardiovascular comorbidities.
The leading symptoms for non-cardiovascular comorbidities included shortness of breath, fatigue and leg swelling—which are also common symptoms of heart failure. However, her study showed that for some patients these symptoms might be driven by conditions such as diabetes and renal disease, rather than heart failure. While pain and anxiety were found to be more common symptoms for cardiovascular comorbidities, as opposed to shortness of breath and fatigue.
She says treatment guidelines need to consider the optimal management of the most prevalent comorbidities and take a more individualised approach to patient care. Interventions should aim to address the comorbidities and the associated symptoms that have the greatest impact on health.
Ms Rigby says, “Across the whole spectrum of CVD there are multiple classes of drugs that can be used to treat the condition. This is the choice of the prescriber, but while they might choose a drug based on its efficacy, it’s also important to consider comorbidities, and the potential for harm but also for benefit.
“SGLT2 inhibitors (dapagliflozin, empagliflozin and canagliflozin), for example, have a cardiorenal benefit. Not only do they lower blood glucose levels, but they also have a protective effect on heart and kidneys.”
“Pharmacists play a critical role in reviewing medications, both formally or informally. We are practically one of the only healthcare professionals in the community that are dedicated to this process,” Ms Raffoul says.
“Conducting regular reviews with high gain patients and understanding what warrants more of your attention in this type of setting is essential.
“We know there are commonalities between these types of conditions, we know that diabetes, CKD and CVD can overlap with each other so that quickly indicates you need to look out for medications that are renally cleared and understand, especially for narrow therapeutic indexed drugs, what medicines need to be changed or need special attention in a review.
“Keep a special eye on anticoagulants, antiarrhythmics and antipsychotics, for example, and look out for the interactions that you know can exist in this setting.”
Ms Rigby says pharmacists are ideally placed to contribute to the care of patients because of the depth and breath of their medicine knowledge.
“Home medicines reviews and residential medication management reviews are a key service, both of which are underutilised. They are not top of mind among many GPs when considering multi-disciplinary care for their patients.
“I strongly support the multidisciplinary approach; pharmacists can contribute greatly in regards to discussing the differences within the class of drugs and the choices of different classes of drugs to treat hypertension or high cholesterol.
“There’s also the complexity of the drug regime; we now have many fixed dose combination products that can help reduce pill burden and the intricacy of taking multiple doses per day. This has been shown to have a benefit on adherence and cost to the patient.
“Deprescribing is another area where we can at least start the conversation or enforce what GPs might be saying to patients.
“Certainly, polypharmacy is common in the palliative population. However, there is evidence to support the safety of stopping certain medicines. Among those classes of medications deemed appropriate to consider deprescribing are antihypertensives and statins.
“Community pharmacists probably don’t have many conversations around deprescribing. However, home medicines reviews play an important role. We can recommend a HMR to the GP, but we can also help patients to weigh up the risks and benefits of stopping certain medications, as well as talk about the trade offs.
“Pharmacists can help a patient to understand that yes, the medication is lowering their blood pressure to target but it’s leaving them feeling dizzy and at risk of falls. It’s about helping the person to understanding that trade off.
“Typically, during a HMR or simply in the pharmacy setting, pharmacists talk to patients longer and more frequently than other healthcare professionals. So if a patient tells you they’re concerned about falls or feeling weak and they’re on medicines that could potentially be ceased, pharmacists can assist in this area.”
Ms Raffoul adds, “Once you get to the point of recognising that a medicine may need to be deprescribed this must be an equal decision between the patient and the prescriber, and the pharmacist can certainly play an important role here.
“In practice, discussing deprescribing can be tricky. You can have very different types of patients. There are some that value your input and others that are less receptive.
“Depending on the medicine you’re thinking of changing, there are some great patient decision aids that you can use to guide your discussion and walk patients through the different options at hand.
“This tool helps the patient to weigh up in more of an objective way the decision to initiate or deprescribe a medicine.”
A more integrated approach
“One of the biggest challenges we face is that most of the recommendations that guide clinical practice are based on a singular disease state,” says Ms Raffoul.
“The problem for pharmacists and clinicians lies in trying to translate specific data to the care of a patient that’s sitting in front of you with multiple comorbidities,” “In community pharmacy we tend to break up our services into disease-specific services, such as a diabetes check or a respiratory check,” she added.
“While it’s good to target the screening for those specific conditions, we have to be mindful of the fact the people that present to us are likely to have at least one other comorbidity—especially as they age.
“We really need a more integrated approach for screening, prevention and even management of care.”
Ms Raffoul says that given Australia’s ageing population, she’s hopeful that new guidelines will be developed that aren’t so focused on individual disease states and risk factors, but are instead more comprehensive.
“As a professional I feel pharmacists need to push ourselves forward in this area,” she says.
“I’d love to see pharmacists move towards taking a more integrated and holistic approach to risk factor assessment and the management of comorbidities.”
Heart Foundation. Key statistics: cardiovascular disease. Available here
Pagidipati NJ, Clare RM, Keenan RT, et al. Association of gout with long-term cardiovascular outcomes among patients with obstructive coronary artery disease. J Am Heart Assoc. 2018 Aug 21;7(16):e009328.
Lawson CA, Solis-Trapala I, Dahlstrom U, et al. Comorbidity health pathways in heart failure patients: a sequences-of-regressions analysis using cross-sectional data from 10,575 patients in the Swedish Heart Failure Registry. PLoS Med. 2018 Mar 27;15(3): e1002540.