CVD and co-morbidities What are the priorities? G.J. Geersing, General Practitioner MD PhD Julius...
-
Upload
curtis-powers -
Category
Documents
-
view
217 -
download
0
Transcript of CVD and co-morbidities What are the priorities? G.J. Geersing, General Practitioner MD PhD Julius...
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’!