Dr. C. V. Alert, MB BS, DM. (Family Medicine), FCCFP.
Family Physician.
Fellow, Caribbean College of Family Physicians.
There have been advances in a number of specific clinical areas of cardiovascular disease prevention and management over the last two decades that offer the Caribbean Family Physician the opportunity to improve the management in Caribbean patients, and improve the quality, and sometimes the quantity, of lives of our patients. However, the evidence that significant numbers of primary care physicians have embraced some of these advances is scarce, as suggested by our national morbidity and mortality statistics.
Cardiovascular Risk tables.
For a long time the concept of ‘the metabolic syndrome’ has been recognized. When a combination of obesity, diabetes, hypertension and dyslipidemia occur in one patient, then ‘metabolic syndrome’ can be diagnosed, and with this diagnosis comes knowledge of an increased risk of a major adverse cardiovascular event, or MACE. However, the magnitude of this risk was never quantified, and, apart for treating the individual components, mainly the diabetes and the hypertension, no specific therapeutic options were offered.
The term atherosclerotic cardiovascular disease (ASCVD) involves the buildup of cholesterol plaque in arteries. Risk factors include the traditional ‘metabolic syndrome’ components, but also include inactivity, smoking, and family history of premature cardiovascular disease. These risk factors, along the low-density lipoprotein cholesterol (LDL-C) accelerate the progression og ASCVD. Calculating a patient’s 10-year ASCVD risk is fundamental in establishing appropriate medical management, especially cholesterol-lowering medications. Traditional tests for markers such as lipid profile, particularly low density lipoprotein (LDL), are needed for the evaluation of ASCVD risk; such testing is also used for screening and monitoring.
Modern guidelines for ‘primary prevention’ attempts to quantify the degree of cardiovascular risk in patients who have not suffered a MACE, and to initiate a level of treatment designed to minimize cardiovascular disease progression. These guidelines for cardiovascular disease management incorporate risk tables to support the management of patients before they develop a MACE, as well as identify specific treatment targets depending on the calculated degree of individual risk. These tables aim to improve the quality of care by rationalizing decisions on identification and management of patients at various levels of risk.
Cardiovascular risk calculations emphasize the role of (LDL) cholesterol of accelerating the risk of MACE, and are better predictors of developing MACE than, say, the magnitude of the blood pressure or the blood sugar. And since ‘cholesterol’ is not associated with specific symptoms, the cardiovascular risk calculations can serve as an important guide in slowing the progression from asymptomatic to symptomatic disease.
The asymptomatic state seems to be closely associated with ‘therapeutic inertia’, a condition that affects both health care workers and patients, and is associated with poor clinical outcomes for the patients only. Studies have been done to encourage individual patients to monitor specific clinical indicators, and to self-titrate medication doses and sometimes even medications, to achieve specific targets. It is important to develop and implement successful strategies to combat ‘therapeutic inertia’, and patient empowerment is one part of this.
In this regard, WHO/PAHO have introduced Cardiocal for physicians, a free cardiovascular risk calculator with country-specific considerations for multiple countries in Latin America and the Caribbean. Cardiocal is part of the “Hearts of the Americas” initiative, a model for cardiovascular disease risk management. The Family Physician of today, and tomorrow, will put increased emphasis on the primary care management of NCD risk factors, and the “Heart of the Americas” seeks to provide a roadmap for this journey.
So there has been a paradigm shift. No longer is there a focus on treating individual cardiovascular risk factors only, but the total patient cardiovascular risk status has to be taken into account. Results from studies like the ASCO-LLA (7) and the HOPE-3 (8) studies support this concept. The Family Physician 2.0 will use cardiovascular risk calculations to optimize patient management.
Chronic Kidney Disease.
There has been recent attention on chronic kidney disease (CKD) for a number of reasons. Treating chronic kidney disease is costly: in 2017 approx thirteen percent of the budget of the Queen Elizabeth Hospital (QEH), the main tertiary hospital in Barbados, was spent on treating chronic kidney disease (1). The risk factors for chronic kidney disease include diabetes, hypertension, obesity, and heart disease. We know that many of these diseases preside in our population, in relatively high numbers. To the extent that it is theoretically possible to control many of these risk factors, we should be able to save a lot of money, and we should be able to minimize the progression to CKD. Unfortunately, t we have no national screening program for CKD.
We have known about classes of anti-hypertensive medications called the renin-angiotensin inhibitors (RAAS inhibitors), which includes both the angiotensin converting enzyme (ACE) inhibitors and the angiotensin receptor blockers (ARBs), and actually use them here. These drugs, when used appropriately in hypertensive patients, not only lower the blood pressure, but can slow the progression to CKD. A newer class of drugs, the sodium-glucose co-transporter 2 (SGLT-2) inhibitors, initially developed for treating diabetes, has also been shown to be able to slow the progression to CKD, in patients with or without diabetes. A cost evaluation should be done locally, as these drugs offer the possibility of reducing the high costs associated with treating CKD and slowing the progression to end-stage renal disease (ESRD).
But CKD, which rarely appears on lists of primary care diagnoses, is important for another reason. Most patients with CKD do not progress to ESRD, requiring dialysis or renal transplant, but instead succumb to MACE. So ‘controlling’ CKD, apart for saving money, may also save lives, a detail appreciated by most patients and their families. Therefore, reducing CV and renal risk is now a major focus of diabetes guidelines with prioritized use of therapeutic agents with proven cardio-renal benefits regardless of glycemic control.
To determine the status of kidney function in any individual, all that is required is the patients age, gender, the serum creatinine (blood test), and the urine albumen to creatinine ratio, UACR (urine test). These figures can be plugged into the Kidney Disease to Improve Global Outcomes (KDIGO) CKD calculator ( free online) to give an estimated Glomerular Filtration Rate (e-GFR), to determine the stage of kidney disease, e.g. CKD Stage 3a/G1, and KDIGO guidelines also offer advice on ‘what/when’ to do next.
Patients with early stages of CKD are more likely to die of CVD than they are to progress to ESKD (2), and CVD is the leading cause of death in people with diabetes (3). Early screening and detection of CKD, followed by risk stratification and early treatment, may potentially reduce morbidity and mortality from adverse kidney and CV outcomes.
Chronic Heart Failure.
Heart failure seems to exist under the radar, as it is never mentioned in the same breath as heart attacks and/or strokes. But for both the patients and their physicians, it is a very difficult disease.
Fig 1: 5-year death rates USA statistics.(5)
It is hardly recognized that heart failure, for example, may be ten times more deadly than breast cancer.
Chronic heart failure is a disease that staging, diagnosis and management has seen significant evolution in recent years. The ACC/AHA classification, which does not replace but complements the older (symptom-based) New York Heart Association (NYHA) classification, recognizes four stages:
Stage A: At high risk for heart failure but without structural heart disease or symptoms of heart failure;
Stage B: Structural heart disease but without symptoms or signs of heart failure;
Stage C: Structural heart disease with prior or current symptoms of heart failure;
Stage D: Refractory Heart failure requiring specialist interventions.
All patients can be put into one of these stages, and many patients seen by their Family Physicians can be placed into either stage A or B. Certainly, for Stages C and D, the totality of evidence suggests that patients should be treated early with a combination of the four drugs: an angiotensin receptor/neprilysin inhibitor (ARNI), beta-blocker, non-steroidal mineralo-corticoid receptor antagonist (ns-MRA), and SGLT2 inhibitor in order to benefit from substantial and sustained reductions of mortality, heart failure hospitalizations, and symptoms. Because of the significant morbidity and mortality associated with chronic heart failure, Family physicians need to aggressively diagnose, and initiate optimum treatment, of this progressive and deadly disease. This suggests that we will need easier access to these drugs, easier access to NT-BNP testing, and echocardiograms, as only a fraction of these patients can be managed by our relatively small number of cardiologists.
Summary.
There are many areas, apart from those outlined in this three-part article, than Caribbean Family should adopt and adapt, to optimally serve Caribbean patients, and to prepare Caribbean communities for pandemics now and in the future. “Therapeutic inertia” is not an option. As Sir William Osler noted, we should already know what type of patients we have, our tasks is to make sure we equip ourselves with the tools and adequate resources to change the current trajectory of health in the Caribbean. We need the Family Physician 2.0.
References:
- Kidney Worry- Barbados Today Online newspaper.
https//barbadostoday.bb/2018/03/03/kidney-worry
2. de Boer IH, et al: Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care 2022;45: 3075-3090
3. Briasoulis A, et al. Chronic kidney disease as a coronary artery disease risk equivalent. Curr Cardiol Resp; 2013: 15-340
4. Shalipak MG, et al: Conference Participants. The case for early identification and intervention of chronic kidney disease; conclusions from a kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2021; 99: 34-47
5. National Institute of Health (NIH):National Cancer Institute. Cancer stats fact sheet. Surveillance, Epidemiology, and End Results Program (SEER) https://seer.concer/gov
6. PAHO/WHO Stepwise approach to non communicable disease (NCD) risk factor surveillance (STEPS) to non-communicable disease (NCD) risk factor surveillance (STEPS).https://iris.PAHO.org/handle/10665
7. Gupta A, Mackay J, Whitehouse A, et al. Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomized factorial trial. Lancet 2018: Aug 26
8. Yusuf S, et al: Cholesterol Lowering in Intermediate-Risk Persons without Cardiovascular Disease. N Engl J Med 2016; 374:2021-2031