Canadian researchers and clinicians have collaborated on a new guideline aimed at making it easier for primary care physicians (PCPs) to assess comorbid brain and heart conditions in their older patients.

The document provides several screening and treatment recommendations and encourages the use of a shared-decision model to promote the patient’s active participation in guiding treatment. The document was developed in recognition of the need to create a more holistic approach to the screening and treatment of cardiovascular risk factors and common cardioneurovascular conditions (eg, atrial fibrillation and hypertension) that are associated with cognitive decline.

“The way the system is currently set up, to evaluate and treat patients in silos, is impractical,” lead author Jodi D. Edwards, PhD, director of the Brain and Heart Nexus Research Program at the University of Ottawa Heart Institute, Ottawa, told Medscape News Canada. “The truth is, they have multiple chronic conditions and need a holistic approach to their care and management.”

The document was published on March 30 in CMAJ.

Targeting Patient-Centered Priorities

Edwards emphasized the role that PCPs play in the early recognition and treatment of comorbid brain and heart conditions that become chronic in aging patients. Many of these conditions confer reciprocal increased risk (eg, hypercholesterolemia and heart attack in patients with a history of stroke).

The guideline discusses a concept that many PCPs are aware of but might not have the time or resources to implement: targeting patient-centered priorities in management.

“We had patients involved in every step of the development of these recommendations, and we even have a recommendation around the importance and role of shared decision-making,” said Edwards.“We were hoping that the recommendations would be a conversation with physicians, families, and caregivers to prioritize what’s important to patients: meaning the part of the condition impacting them most,” she said.

The document includes the following recommendations:

• Screen for risk for cognitive impairment in patients with atrial fibrillation using a validated screening tool.
• In patients with systolic blood pressure between 130 mm Hg and 180 mm Hg and increased cardiovascular risk (ie, having clinical or subclinical cardiovascular disease, chronic kidney disease, Framingham Risk Score of ≥ 15%, or age ≥ 75), initiate intensive blood pressure lowering to < 120 mm Hg to reduce cognitive impairment risk.
• In patients with low-density lipoprotein cholesterol (LDL-C) > 1.8 mmol/L, intensify therapy to bring LDL-C below the target to prevent stroke and reduce cardiovascular risk.
• PCPs are advised to routinely offer patients, especially those older than 65 years, influenza vaccination to reduce the risk for cardiovascular mortality, stroke, and dementia; pneumococcal vaccine to reduce the risk for myocardial infarction and stroke; and herpes zoster vaccination to reduce the risk for myocardial infarction, stroke, and possibly dementia.
• Use evidence-based decision aids to facilitate the shared decision-making process.

Knowledge Gaps Remain

Christopher C. Frank, MD, professor of medicine at Queen’s University in Kingston, Ontario, likened shared decision-making to universal goal setting. “I try to use the concept of universal goals, especially with people of older age or with lots of clinical frailty, where there’s a lot of trade-offs in treatment,” he told Medscape News Canada. “This concept explores questions like ‘Will the treatment help me live longer? Is it going to make me feel better? Is it going to help me do better?’” he said. Frank, a family physician with a certificate of added competency in elderly and palliative care, was not involved in developing the guidelines. 

For example, the guideline recommends that PCPs consider screening patients with coronary artery disease for depression using a validated screening tool. If a diagnosis is confirmed, it’s important to initiate treatment with a selective serotonin reuptake inhibitor or explore cognitive behavioral therapy, depending on severity.

But it’s just as important to consider the crushing fatigue that many patients with depression experience, said Frank. Shared decision-making in these patients might entail conversations that explore how depression has been affecting their lives and explore strategies that target these manifestations.

Screening tools are helpful, but so is being alert to possible symptoms of depression, said Frank. For example, fatigue can be a symptom for many patients with depression, and making the link with heart disease can be important, he added. Shared decision-making in these patients might entail conversations that explore how depression has been affecting their lives and that explore strategies that target these manifestations.

“The guideline is relevant for clinicians seeing a wide age range of patients, especially when considering how best to improve healthspan. The guideline gives doctors food for thought for identifying factors that, if prevented, might pay off through a variety of benefits,” said Frank. 

Significant knowledge gaps related to sex and gender analyses remain, partly because several trials cited within the guideline had underrecruitment of female participants, Edwards emphasized.

“The data aren’t there, but we know that women aren’t just small men. Treatment may vary, and there are sex-specific risk factors to be taken into account,” she said. “We really need to do more research on how these recommendations apply to women.”

Uncertainty also results from the “lesser degree or uncertain evidence for people in their late 80s and older,” said Frank. “We can’t purely extrapolate from people in their 70s.”

The guideline was funded by the University of Ottawa’s Brain-Heart Interconnectome program. Edwards and Frank reported having no relevant financial relationships.

Liz Scherer is an independent medical/health journalist. She frequently reports on Canadian and European health news.