Case discussion Practical challenges in CV risk management: Managing patents with comorbidities Professor Konradi A.O., PhD, FESC Almazov Federal North-West Medical Research Centre, St.Petersburg konradi@almazovcentre.ru
Comorbidity – the growing importance in 21 st century? • Patients have multiple diseases and risk factors • Risk stratification and risk reduction in comorbidity is unclear • The is an uncertainty in different guidelines • Evidence-based medicine is a poor tool, because lack of good evidence in comorbidity • Goal-oriented care is very important
Causes of growing burden of comorbidity • Aging population • Better medical care – better survival in many conditions • Medicines that can accelerate atherosclerosis (cancer, antipsychotics, etc)
Ageing Percentage of population in age 60 or over by region, 2000-2050 35 2000 2050 Percentage of population 30 age 60 and over 25 20 15 10 5 0 World Africa Asia Europe Latin Northern Oceania total America & America Caribbean http://www.un.org/esa/socdev/ageing/agewpop1.htm (2002).
Proportion of subjects over 70 years in Russia 10,5 10 9,5 9 % 8,5 8 7,5 2005 2006 2007 2008 2009 2010 2011 2012 Rosstat, official website
Number of chronic disorders by age-group null, Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study Volume 380, Issue 9836, 2012, 37 – 43
Selected comorbidities in people with four common, important disorders in the most affluent and most deprived deciles Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study null, Volume 380, Issue 9836, 2012, 37 – 43
Deaths attributed to major cardiometabolic risk factors The Lancet Diabetes & Endocrinology 2014 2, 634-647
Risk of specific deaths according to different risk-factors The Lancet Diabetes & Endocrinology 2014 2, 634-647
Cardiac, renal and brain comorbidity Kidney Brain Heart
RCT and real-life • Mostly selected patients less that 75 years • Predominately males • Comorbidities are usually excludes, especially cancer • Reflects less that 50% of population • Included selected clinics and selected specialists
Paradigm of medicine Medicine- based evidence Evidence- based medicine Pre-evidence- based empiric medicine
Case 1. An obese lady with diabetes
Female 55 yrs • Hypertension for 10 years, no medication • Preeclampsia during last pregnancy • Farther – MI at the age of 60, sister – stroke at the age of 55 • Smoking for 20 years • BMI 32 kg/m2, WC 98 cm • Sedentary lifestyle • Atypical chest pain after exercise or emotional stress
Examination • Blood pressure 160/90 mmHg, HR 70 min -1 • Plasma glucose 7,6 mmol/l repeated • HgA1C 7,2%, GFR 70 mL/min/1,73 m2 • Total cholesterol 6,5, LDL 4,3, HDL 1,0 mmol/l • ECG – LVH
Questions • What is the risk of the patients and which scale to use? • What is the target BP level? • Which preferable drugs? • What is the target LDL level? • Do we need to perform an exercise test to confirm CAD? • Do we need to perform Echo? • Options to treat DM
The patients is unique – factors that can affect management • Gender – she is a female with specific risk factor • Comorbidities – obesity, diabetes, metabolic syndrome • Family history • More than 1 CVD risk factor and TOD
Female-specific risk factors of CVD Risk factor CVD CGD HTN STROKE DM PSOS * * *** POI ** ** PIH ** * *** * ** Preeclampsia ** ** *** ** ** GDM ** ** *** *** Parity ** Miscarriage ** Preterm birth ** * * ** ** SGA ** ** ** Stillbirth ** Adapted from Appelman Y. et al. Atherosclerosis 2015; 241:211-218
Pre-eclampsia increases CVD risk by 1.5-2.5
Who should not use SCORE for risk assessment • There are subjects, who can be considered at high risk for starting interventions (already enough) • Established atherosclerotic CVD • Hypertension stage 2 or more with TOD • DM • Renal dysfunction • Familial hyperlipidemia • People over 75 yrs (especially hypertensive and smoking)
Why Is Echocardiography Useful In Hypertensive Patients? “No other biological variable (except advancing age) predicts cardiac risk better than left ventricular hypertrophy”. (De Simone et al, J Hypertens 12;1129, 1994)
LVH is associated with a 2.5-fold increase in the relative risk of all-cause mortality Relative risk 0 1 2 3 4 5 6 7 8 9 All Studies Sokolow † * CDP †# * Kannel (m) † * Kannel (w) † * Boden † * Dunn (m) † Dunn (w) † SPRINT † * Sullivan † * Larsen †# * Kahn † BIRNH † Levy (m) ‡ Levy (w) ‡ Parfrey ‡# * Koren ‡ * Ghali -CAD ‡ Ghali CAD ‡ Mensah ‡ * Liao (m) ‡ Liao (w) ‡ Foley ‡ 0 1 2 3 4 5 6 7 8 9 † Electrocardiographic LVH; ‡ Echocardiographic LVH; # unadjusted; (m) men; (w) women; CAD=coronary artery disease; *P<0.05 Vakili et al. Am Heart J 2001;141:334 – 341
Left ventricular remodeling patterns (Ganau et al.,1992) LVH - LVH + RWT<0,45 Normal geometry Eccentric LVH RISK RWT>0,45 increased Concentric remodelling Concentric LVH
CAD and diabetes
Do we need to perform exercise test to check for CAD? • There are data that suggest exercise tests less informative in diabetic patients and having lower prognostic value (Daddy trial) Eur J Internal Med 2015; 26:417-426
Prognostic value of stress- echocadiography in diabetic and non- diabetic patients JACC 2006; 47:606-610
Case 1. Examination results • Echocardiography – concentric LVH, LVMI 145 g/m2, diastolic dysfunction, no other structural abnormalities • ECG stress test – negative according to both symptoms and ECG criteria
LDL target Risk Recommended LDL-C goals intervention VERY HIGH RISK Lifestyle and drug initiation <1,8 mmol/l or >50% Established CVD reduction DM type 2 (> 40 yrs with 1 or more risk factors or TOD) SCORE>10% HIGH RISK Lifestyle and drug initiation <2,5 mmol/l SCORE 5-10% MODERATE RISK Lifestyle and drug initiation <3 mmol/l SCORE>1%, <5% if no control EHJ 2011;32: 1769-1818
Case 1. Treatment • Hypertension . ACE inhibitors. Combinations if necessary. Goal 140/85 mmHg. Enalapril 40 mg, CCB or D or ARB • Lipids – statins for target – 1,8 mmol/l Atorvastatin 40-80 mg • Antithrombotic. Aspirin 100 mg • Diabetes – metformin 1000 mg for target HbA1c <7,0%
A problem of multiple goals BP HbA1c LDL BMI Lifestyle interventions are crucial – smoking cessation, diet, weight reduction, exercising
Look-AHEAD study 5145 patients, DM+obesity lifestyle interventions for risk reduction
Alas… Combined end point – CV death+MI+stroke+hospitalization No outcome benefit Life is so disappointing
Predictors of statin failure (resistance) • Under-dosing • Low compliance • Other risk factors and multiple gals • ACVD events • Internet
2 years later • Poor compliance with lifestyle • Smoking, BMI 31kg/m2 • HbA1c – never re-checked • BP more or less controlled, taking AH drugs • Atorvastatin stopped 3 months after prescription (saving lever from side effects) • Only one visit o cardiologist, no aspirin • Non-fatal MI at the age of 57
Optimal therapy is therapy that is taken by the patient
Case 2 Female patient with non-fatal stroke A cornerstone in cardiology • A non-fatal MI is an inconvenience • A non-fatal stroke is a catastrophe
Background – the burden of stroke • In the European Union stroke is the second cause of mortality (10.9%) immediately after coronary heart disease (18.1%), accounting for approximately 200,000 deaths yearly. • Stroke accounts for 5.27% of the total burden of illness, but because of aging of the population it has been calculated that, by the year 2020, stroke will account for 6.2% of the total illness burden. • Among patients above the age of 65 years and surviving a stroke, 50% have some residual hemiparesis, 30% are unable to walk without assistance, 26% are dependent on others for help with daily living, 19% have aphasia, 35% depressive symptoms and 26% are being cared for in a nursing home.
Special attention to stroke in females • About 425 000 cases of stroke in females annually • Women have higher lifetime risk of stroke and higher rates of mortality • Female stroke patients have higher prevalence of hypertension compared to male • Even prehypertension increases risk of stroke in females up to 2 times. • Women have a high risk of stroke in peripartum period • Women have higher risk of intracranial hemorrhage • Females after stroke are more likely to be disabled
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