CVD and co-morbidities

What are the priorities?

G.J. Geersing, General Practitioner MD PhD

Julius Center UMC Utrecht

EPCCS conference 2014

Groningen

This presentation

Multi-morbidity and primary care medicine

Consultation: farmer Loeks, 82 years of age.

Implications for clinical research

What are the priorities?

Miss Sparrow, 76 years

Eccentric personality

Severe presbyacusis

Recurrent UTI / incontinence

Hypertension

Severe osteoarthritis

Atrial fibrillation

eGFR 35 ml/min

Possible heart failure (NT-proBNP = 236 pg/ml )

Medication:

Omeprazol 20 mg

Lisinopril 10 mg

Digoxin 0,0125 mg

Metoprolol 50 mg

Aspirin 80 mg

BAFTA ≠ ASA!!Renal function!!Bad doctor!

Miss Sparrow and randomized trials

Eccentric personality

Severe presbyacusis

Recurrent UTI / incontinence

Hypertension

Severe osteoarthritis

Atrial fibrillation

eGFR 35 ml/min

Possible heart failure (NT-proBNP = 236 pg/ml )

Medication:

Omeprazol 20 mg

Lisinopril 10 mg

Digoxin 0,0125 mg

Metoprolol 50 mg

Aspirin 80 mg

BAFTA ≠ ASA!!Renal function!!

EBM in crisis?

Multi-morbidity and its causes.

Epidemiology of multimorbidity and implications for health care, research, and medical education. K. Barnett et.al. Lancet 2012

Lower SES 10-15 years earlier

Multi-morbidity: the price of succes?

Multi-morbidity in COPD

Prognostic studies in COPD

Example I in COPD (sec care).

Comorbidity and risk of mortality in patients with COPD. M. Divo, et.al. Am. J. Respir. Crit. Care Med. 2012

Example II in COPD (prim care).

The importance of cardiovascular disease for mortality in patients with COPD: a prognostic cohort study. J. Zangh et.al. Family Practice 2011.

Multi-morbidity in heart failure

Prognostic studies in HF

Example in heart failure.

Noncardiac comorbidity increases preventable hospitalizations and mortality among medicare beneficaries with chronic heart failure. J.B. Braunstein. JACC 2003.

Multi-morbidity in AF

IPD Rx studies in AF

Beta-blockers in AF with heart failure

Summary so far:

Multi-morbidity: frequent, notably with increasing age

Low SES: 10-15 years earlier.

Important for patients!

Consultation: farmer Loeks, 82 years

65 years: myocardial infarction, CABG

Depression

‘Chronic bronchitis’, history of smoking

Hypertension

72 years: TKP, post-operative DVT

Renal impairment, eGFR 30 ml/min.

Medication: ASA 80 mg, simva 40 mg, HCT 12.5 mg, metoprolol 50 mg mga, atrovent, pcm zn.

Farmer Loeks 82 years.

“Doc, for some time now I am experiencing shortness of breath. About 10 days ago it suddenly got worse. I also started to cough, and had some pain on inspiration. Fever? No, I don’t think so doc…”

RR 160/90, HR 105/min.

Lungs: rales, some wheezing. COPD with pneumonia?

Heart failure?

Pulmonary embolism?

What tests and/or biomarkers do I need to perform?

TESTSCDR and BNP in heart failure

721 patients with suspicion of heart failure, referred by GP to ‘rapid-access clinic’.

The diagnostic values of physical examination and additional testing in primary care patients with suspected heart failure. J.C. Kelder, et.al. Circulation 2011

TESTSCDRs/decision tools in COPD.

173/357 (48%) patients ‘low risk’

NPV in ‘low risk’ group 94%

TESTS… CRP added value in suspected pneumonia.

c-statistic ‘only’ signs and symptoms = 0.70

combined with CRP: increase of c-statistic to 0.78

TESTS… and for suspected pulmonary embolism.

272/598 (45%) patients ‘low risk’

NPV in ‘low risk’ group 98.5%

Wells ≤ 4 plus D-dimeer negative PE unlikely

CDRs and biomarkers; implications for clinical research

Performance often summarized in one or two values (c-statistic, sens/spec, predictive values)

Only true for average patient!

Influence age and co-morbidity?

Age-dependent cut-off D-dimer.

OUTCOMEConcurrent presence of COPD and HF

405 patients with GP diagnosis of COPD (65+).

Screening for unknown heart failure.

Diagnostic model to recognize HF in COPD patients

Recognizing heart failure in elderly patients with stable COPD in primary care: cross sectional diagnostic study. F.H. Rutten, et.al. BMJ 2005

Unrecognized HF diagnosed in 83 patients (21%!)

PE diagnosis in COPD patients …

“Our study findings suggest that one in four patients with an acute exacerbation of COPD may have PE. Thus, clinicians should consider PE in the diagnostic work-up of COPD exacerbations , especially in patients where the underlying etiology is not apparent.”

Back to our patient

What do we know:CDRs/tools: COPD, pneumonia, HF, and PE

Biomarkers: BNP, CRP, D-dimerCOPD, HF and PE simultaneously present

COPD / PneumoniaAgeMaleHistory of smokingHistory of CVDWheezingCRP?

Heart failureAgeHistory of CVDTachycardiaRalesBNP?

Pulmonary embolismHistory of DVTTachycardiaD-dimer?

Back to our patient

What we do not know yet / challenges:Influence age and co-morbidityIntegral strategy‘typical’ GP problem

So, what are our priorities?

Multi-morbidity important for patients …

… for diagnosis, prognosis and treatment

Challenge for clinical research!

Let us help miss Sparrow and become ‘good doctors’!