Comorbidities will be considered in future ACC/AHA guidelines

American College of Cardiology/American Heart Association clinical practice guidelines in the future will discuss the applicability and quality of recommendations for the most frequent comorbidities related to the CV condition addressed, according to a new statement from the ACC, the AHA and the US Department of Health and Human Services.

To achieve that, the ACC, AHA and HHS will collaborate on development of comorbidity data for selected CV conditions and will “partner with various organizations to determine how best to highlight and address the complex issues arising from comorbidities in clinical medicine,” Donna K. Arnett, MSPH, PhD, AHA past president, and colleagues wrote.

Donna K. Arnett

With the exception of recent guidelines on atrial fibrillation and HF, ACC/AHA guidelines have not systematically addressed how common comorbidities might affect the care of patients with a particular CV condition. However, that must change, given that 68% of Medicare beneficiaries have at least two chronic conditions and 14% have at least six chronic conditions, Arnett and colleagues wrote.

Hypertension, hyperlipidemia common

Using 2012 CMS data, the statement authors determined the most common comorbid conditions among Medicare fee-for-service beneficiaries aged 65 years or older with four index CV conditions: ischemic heart disease, HF, AF and stroke. For all, the most common comorbidity was hypertension. For all but HF, the second-most common comorbidity was hyperlipidemia; for HF, it was ischemic heart disease, according to the statement.

The most common combination among individuals with at least two comorbidities was high cholesterol and high BP; the most common combination among those with at least three comorbidities was high cholesterol, high BP and ischemic heart disease.

“Two general, but important, points emerge from the CMS data,” Arnett, professor and chair of the department of epidemiology at the University of Alabama School of Public Health, and colleagues wrote. “First, a beneficiary with [CVD], but without at least one comorbid condition, is the exception rather than the rule. Second, whereas common risk factors such as hypertension and hyperlipidemia are associated with index [CV] conditions, the index conditions are associated with a constellation of comorbidities, the pathophysiology of which may be distinct from the index condition and for which prevalence increases with age or other factors.”

Potential barriers

Therefore, the statement calls for more attention to comorbidities in CV guidelines. “Comorbidities may constitute barriers to adherence to [clinical practice guidelines], and caring for patients with multiple comorbidities can affect patient safety if recommendations for diagnosis and treatment in one [clinical practice guideline] conflict with those for another condition,” the statement authors wrote.

Patients should be more involved in the clinical practice guideline development process, and more patients with comorbidities should be included in the randomized clinical trials that provide much of the basis for guideline development, according to the statement. In addition, “the increasing use of electronic health records and clinical registries would also allow a longitudinal evaluation of the management strategies and clinical outcomes of patients with [CVD] and comorbidities, which often is not afforded by randomized clinical trials,” they wrote.

For more information:

Arnett DK. Circulation. 2014;doi:10.1161/CIR.0000000000000128.

Arnett DK. J Am Coll Cardiol. 2014;doi:10.1016/j.jacc.2014.07.012.

Disclosure: The members of the writing panel and the reviewers report no relevant financial disclosures.