Clinical Practice Consensus on Integrating ASCVD and Multimorbidity Treatment

Clinicians who care for individuals with atherosclerotic cardiovascular disease (ASCVD) need to take into account a patient’s multimorbidities and advancing age, according to the 2022 American College of Cardiology (ACC) Expert Consensus Decision Pathway (ECDP) for Integrating Atherosclerotic Cardiovascular Disease and Multimorbidity Treatment, which was published in the Journal of the American College of Cardiology.

When managing individuals with ASCVD, the need exists among health care professionals for improved guidance on how to mitigate progression of the condition and the development of major adverse cardiovascular events within the context of other chronic conditions, multiple guideline-directed medical treatments, shifting prognoses, and patient preferences regarding care.

Although the current decision pathway is applicable to patients of all ages with ASCVD and multimorbidities, it is designed to integrate evidence-based therapies into a broader value-based care framework that incorporates the principles of the American Geriatric Society regarding the care of older adults with multimorbidities. This includes the 4Ms (what Matters most, Medication, Mentation, Mobility) from the Age-Friendly Health System; the 4-domain framework (medical, min and emotion, physical functioning,  social and physical environmental) of care for older adults with heart failure; and social determinants of health.

It is well known that as patients develop more chronic conditions, the burden of available treatments increases, whereas life expectancy declines. The care and management of patients must shift from the recommendation of all evidence-based options to an approach that prioritizes those treatments with the greatest anticipated benefit/harm profile, while supporting each patient’s goals and preferences.

On December 10, 2019, the ACC’s Heart House Roundtable entitled “Navigating Treatment Decisions for Patients with ASCVD and Multiple Comorbidities” convened in an effort to bring together expert clinicians, along with stakeholders from patient advocacy groups, drug manufacturers, health systems, and health plans. At the roundtable, discussions were focused on real-world challenges associated with the management of patients with ASCVD and multimorbidities.

In 2020, a writing committee was convened to develop an ECDP that was intended to provide guidance on the treatment and management of individuals with ASCVD and multimorbidities. The Heart House Roundtable offered valuable insight into issues and gaps in care, but the clinical policy was designed specifically to address all questions that were raised at the meeting.

The importance of avoiding any real or perceived relationships with industry or other entities that may impact clinical policy is recognized by the ACC and the Solution Set Oversight Committee. ECDPs follow the ACC relationships with industry policy when establishing what constitutes a relevant relationship, with additional vetting carried out by the Solution Set Oversight Committee.

The term “ASCVD” in the decision pathway is defined as “A condition defined by a history of acute coronary syndrome or myocardial infarction, stable or unstable angina, coronary heart disease with or without revascularization, other arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease (PAD) including aortic aneurysm, all of which are atherosclerotic in origin.”

The term “multimorbidity” is defined as “When 2 or more chronic medical conditions coexist within one person, and one of the chronic conditions is not more important than another.” Other terms defined within the decision pathway include “deprescribing,” “domain model of care for the patient with ASCVD and multimorbidity,” “financial toxicity,” “guideline stacking,” “shared decision-making,” and “social determinants of health.”

“Health systems should formally evaluate the impacts of implementing the domain framework and the tools from this ECDP on patients, clinicians, and the health system itself,” the study authors wrote. “Professional organizations should advocate for legislative efforts to reward holistic, patient-centered care.”

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.