Carga de morbilidad cardiovascular en pacientes con multimorbilidad y control farmacológico de la hipertensión arterial, la diabetes mellitus y la hipercolesterolemia en Atención primaria

Abstract

Background Few studies that have analyzed the burden of cardiovascular disease in the multimorbid population. Hypertension, diabetes and hypercholesterolemia are highly prevalent and there is little knowledge about the simultaneous control of these combinations in people with multimorbidity. Aim of the study Identify and describe the cardiovascular diseases among the patients with multimorbidity and to determine which drug combinations achieve better control in comorbidities: hypertension, diabetes and hypercholesterolemia, in a pragmatic sample of primary health care (PC) patients. Methods Cross-sectional study in patients ≥19 years old assigned to 251 PC centres in Catalonia, Spain. The main outcome was cardiovascular morbidity burden (≥1 chronic cardiovascular diseases), in multimorbid patients (≥2 chronic conditions). Two groups were defined, with and without multimorbidity; the multimorbidity group was further divided into cardiovascular and non-cardiovascular subgroups. The secondary outcomes were: cardiovascular risk factors (smoking, hypertension, hypercholesterolemia, diabetes) and cardiovascular risk score. Other variables analysed were: sex, age, number of chronic diseases, urban setting, active toxic habits (smoking and alcohol), physical parameters and laboratory tests. Good control criteria were established as glycated haemoglobin ≤7%, blood pressure <140/90mmHg, and LDL cholesterol <130 mg/dl. Antihypertensive, hypoglycaemic and hypolipemiant drugs and treatment adherence were analysed in relation to their association with good control. Results A total of 1,749,710 individuals were included (mean age, 47. 4 years; 50. 7% women), of which nearly half (46. 8%) had multimorbidity. In patients with multimorbidity, the cardiovascular burden was 54. 1 % of morbidity, uncomplicated hypertension (75. 3%) was the most prevalent cardiovascular disease. In the cardiovascular morbidity subgroup, 38. 2 % had more than one cardiovascular disease. The most prevalent duet and triplet combinations were uncomplicated hypertension & lipid disorder (38. 8%) and uncomplicated hypertension & lipid disorder & non-insulin dependent diabetes (11. 3%), respectively. Patients with multimorbidity showed a higher cardiovascular risk profile than the non-multimorbidity group. The more prevalent comorbidities that accomplished selection criteria were: hypertension & diabetes 44% (n= 46,309 patients; mean age, 71. 7 years); hypertension & hypercholesterolemia 34% (n=31. 039 patients; mean age, 71. 0 years); diabetes & hypercholesterolemia 13% (n=10. 312, mean age,70. 8 years) and hypertension & diabetes & hypercholesterolemia 9% (n=9. 635 patients; mean age, 70. 9 years). Good control was achieved in 31. 6%; 35. 0%; 40. 1% and 23. 9% respectively. Biguanides & diuretics; calcium channel blockers & statins; biguanides & statins and biguanides & calcium channel blockers & statins were the combinations that achieved the highest association with good control. Adherence to pharmacological treatment was more difficult in hypercholesterolemia and diabetes than in hypertension. Some clinical and sociodemographic variables were found to be significantly associated with low control, age (<65 years) and sex (women) were coincident in the three groups. Conclusions More than 50% of patients with multimorbidity had cardiovascular diseases, the most frequent being hypertension. The presence of cardiovascular risk factors and the cardiovascular risk profile were higher in the multimorbidity group than the non-multimorbidity group. Hypertension, diabetes and hypercholesterolemia are common conditions in multimorbidity group. Good control of these hypertension, diabetes and hypercholesterolemia comorbidities with pharmacological treatment are challenging. Some drug combinations achieved better control than others. The greatest effort should focus on improving the low adherence to hypercholesterolemia and diabetes treatment.

Date of Award	30 Oct 2020
Original language	Spanish
Supervisor	Miguel Luis Martin Mateo (Tutor) & Quintí Foguet-Boreu (Director)