A recent study found that the proportion of patients in the Netherlands with chronic obstructive pulmonary disease (COPD) who are being assessed for cardiovascular (CV) risk does not align with Dutch guideline recommendations.
Despite guidelines recommending assessment of the risk of cardiovascular (CV) death for all patients with chronic obstructive pulmonary disease (COPD) in the Netherlands, a recent study found that 1 in 6 patients have not been assessed and many patients at high risk have not been enrolled in CV management programs.
Investigators said that the results, which were published in BJBP Open, show that in the 36.1% of patients who have not had a CV risk (CVR) assessment, there is “room for improvement,” which can be accomplished by completing CVR profiles and enrolling high-risk and very-high-risk patients in CV care programs directed at chronic disease management.
“The results may help to draw clinical attention to patients with COPD, especially to those with (potential) quantitatively high or very high CVRs,” wrote the investigators.
CV events, such myocardial infarction, are the primary cause for approximately 30% to 50% of deaths for patients with COPD. Patients with COPD have a 2.5 times higher risk of CV morbidity compared to patients without COPD, regardless of CVR factors.
In May 2019, the Dutch College of General Practitioners published updated guidelines on CVR management that recommended estimating the risk of CV death in patients with COPD and promoted the use of chronic disease management strategies as an early treatment for patients who are most at risk for CV. The investigators set out to establish current adherence to the guidelines and to gain insight into what proportion of patients should have their treatments intensified.
From September 1, 2014, to August 31, 2019, investigators collected data from the electronic medical records of 5 Dutch primary health care centers. Also, on August 31, 2019, the rates of enrollment for CV care programs were collected.
Data on 391 patients with COPD were included in the study. The mean (SD) age of all patients was 67.5 (10.8) years, and 45.5% of them were male. Overall, 43.5% of patients were current smokers and three-fourths of the COPD population were 60 years or older.
Data on risk assessment were present for 84.1% (n = 329) of patients with COPD. Investigators noted the positive finding that the majority of patients had received an CVR assessment. However, they said that the results underline “the urgency of assessment of CVR in all patients with COPD, to reduce the incidence of CVD in these patients over the next decades.”
Patients were categorized into groups based on their CVR, which were estimated using a qualitative risk assessment based on patient comorbidities and the quantitative Systematic Coronary Risk Evaluation (SCORE). Very high risk was defined as having a risk of 10% or greater. Patients with a risk between 5% and 10% were classified as having high risk, and those with a CVR of less than 5% were labeled as having low-to-moderate risk.
A total of 32 (9.7%) patients had a low-to-moderate CVR and 297 (84.1%) patients either had a high or very high CVR, of whom 178 (59.9%) had a very high risk and 119 (40.1%) had a high risk.
Of the patients classified as high risk, 73.4% (218) received guidance-based follow-up. Overall, 208 (95.4%) of the high-risk patients who were enrolled in a CV care program were enrolled in primary care and 10 (4.6%) were enrolled in secondary care.
The remaining 79 (26.6%) high-risk patients were not enrolled in a program to manage CVR “as they should be.”
The main study limitation that researchers identified was that assumptions were made when a patient’s SCORE was not applicable. Receiving a CV medication was used as an indication of enrollment in a CV care program and it was assumed that patients receiving those medications had a high CVR. In these cases, researchers were uncertain whether a physician assessed CVR prior to prescribing the drug.
Additionally, the use of the SCORE assumed that patients younger than 40 years had a low-to-moderate CVR and that patients 70 years or older had a very high CVR.
Nies LN, Looijmans-van den Akker I, Rozendaal L, Baar B, Vos RC, Hart HE. The impact of the new Dutch guideline on cardiovascular risk management in patients with COPD: a retrospective study. BJGP Open. Published online January 27, 2021. doi:10.3399/bjgpopen20X101139