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6.7 Multimorbidity

The older adult population is growing fast and survival after acute CVD has improved,820 leading to an increasing number of older patients with CVD and multimorbidity.821,822 This development is associated with high healthcare costs,823,824 worse outcome measures, higher readmission rates,825 and mortality.826 Up to 70% of patients aged >_70 years have at least one CVD and two-thirds also develop non-CVD comorbidities. Multimorbidity is important in patients with CVD.823 The prevailing CV conditions in patients aged >60 years are hypertension, hyperlipidaemia, ischaemic heart disease, arrhythmia, DM, and CAD.823 Other frequent comorbidities include anaemia and arthritis. Low vision, back and neck problems, osteoarthritis, COPD, depression, and cancer are the most common non-CV comorbidities in CVD patients. Most studies have found no sex differences in the number of comorbidities. However, men have more CVD comorbidities and women have more non-CVD comorbidities (in particular more depression).822,826,827 So far, guidance for the treatment of CVD has focused mainly on single CVDs. In multimorbid patients, application of a single guideline for one CVD is often not feasible as therapeutic competition is highly prevalent (22.6%)820 and treatment for one condition can worsen a coexisting condition. The challenges for managing CVD and multimorbidity are disease-disease, disease-drug, and drug-drug interactions.820 Further, pharmacokinetics can be different in patients with comorbidities, and life expectancy has to be taken into account when starting a new medication. A value-based approach should always be discussed and proposed when possible.820 The incremental benefit of medication when added to an already complex regimen is often uncertain.828 Moreover, care for multimorbid CVD patients is often fragmented and given by multiple providers, complicating decisionmaking and adherence to recommended treatment.820

Multimorbid CVD patients have been underrepresented in most clinical trials that underlie the guidelines. Trials including patients with multimorbidity and endpoints that matter to patients, pragmatic trials, and the use of registries and big data could help elucidate how to optimize treatment and care for patients with CVD and multimorbidity.820 There is a plea for a paradigm shift from disease-focused to patient-centred care for multimorbid CVD patients, with a central place for patients’ overarching goals of care.828 ‘What matters to you?’ should be the central question, instead of ‘what is the matter?’. Patient-centred care should include assessment of patients’ preferences, interpretation of the evidence and its application to the specific patient, consideration of overall prognosis, including life expectancy, functional status, and quality of life, and clinical feasibility. Adherence to treatment, the occurrence of adverse drug events, the economic burden, and the stress experienced by caregivers should be taken into account when optimizing therapies and care plans where adherence to essential medication is emphasized and nonessential drugs are stopped.828 Furthermore, advanced care planning should be initiated early. Multidisciplinary teams and close collaboration between primary care workers and specialists is needed. Finally, automated decision support systems for multimorbidity and CVD could help in aligning the relevant evidence and making adequate decisions.829

7 Key messages

Risk factors and risk classification

• The major risk factors for ASCVD are cholesterol, BP, cigarette smoking, DM, and adiposity. • Risk factors are treated in a stepwise approach to reach the ultimate treatment goals in apparently healthy people, patients with established ASCVD, and patients with DM. • 10-year CVD risk is estimated in apparently healthy people aged 4069 years with SCORE2, and in people aged >_70 years with SCORE2-OP. • Age-specific 10-year CVD risk thresholds—together with consideration of risk modifiers, frailty, comorbidities, lifetime CVD risk, treatment benefit, polypharmacy, and patient preferences— guide treatment decisions for lipid and BP treatment. • There are various options of communicating the (residual) CVD risk, and this should be tailored to the individual patient.

Recommendations for lifestyle interventions and management of risk factors and concomitant diseases in patients with atrial fibrillation215

Recommendations Classa Levelb

Identification and management of risk factors and concomitant diseases are recommended to be an integral part of treatment.795 I B Modification of unhealthy lifestyle and targeted therapy of intercurrent conditions is recommended to reduce AF burden and symptom severity.216,795802 I B Attention to good BP control is recommended in AF patients with hypertension to reduce AF recurrences and risk of stroke and bleeding.800,801 I B In obese patients with AF, weight loss together with management of other risk factors should be considered to reduce AF incidence, AF progression, AF recurrences, and symptoms.795797 IIa B Advice and management to avoid alcohol excess should be considered for AF prevention and in AF patients considered for oral anticoagulant therapy.798,803,804 IIa B PA should be considered to help prevent AF incidence or recurrence, with the exception of excessive endurance exercise, which may promote AF.805812 IIa C Optimal management of OSA may be considered to reduce AF incidence, AF progression, AF recurrences, and symptoms.813816 IIb C

AF = atrial fibrillation; BP = blood pressure; OSA = obstructive sleep apnoea; PA = physical activity. aClass of recommendation. bLevel of evidence. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026