Although most cardiologists and other healthcare professionals agree that diet and lifestyle are important factors in cardiovascular (CV) risk reduction and should be discussed with patients, many say they lack the necessary tools to advise patients effectively, according to a survey conducted by Medscape in collaboration with the American College of Cardiology (ACC).
The ACC and American Heart Association will release a revised clinical practice guideline for primary cardiovascular disease prevention on March 17, 2019, during the ACC's 2019 Annual Scientific Session in New Orleans, Louisiana.
Medscape and ACC asked 621 full-time practicing clinicians involved in the diagnosis and/or treatment of patients with or at risk for cardiovascular disease (CVD) for their views on diet/lifestyle, hypertension, and type 2 diabetes. Responses came from 204 cardiologists; 101 endocrinologists; 166 primary care physicians (PCPs); and 150 allied healthcare professionals comprising nurse practitioners (NPs), physician assistants (PAs), and registered nurses (RNs).
Diet/Lifestyle Tools Lacking
Most healthcare professionals responding to the Medscape/ACC survey agree that they have a role to play in advising patients on diet and lifestyle factors to promote heart health. Overall, 81% of healthcare professionals say diet/lifestyle modification is the most important treatment for CV risk reduction, with slightly more PCPs (84%) and NPs/PAs/RNs (86%) holding this view than cardiologists (77%) and endocrinologists (77%).
However, only two thirds (66%) of all providers surveyed believe they have the necessary tools to make lifestyle recommendations to their patients. Allied healthcare professionals (74%) and endocrinologists (71%) were more comfortable with the tools they have to give diet/lifestyle advice than were PCPs (69%) or cardiologists (54%).
Overall, healthcare providers surveyed said that only about 10% of their obese patients are receiving a prescription drug to treat their obesity. Endocrinologists are most likely (18%) and cardiologists least likely (3%) to prescribe an antiobesity agent.
About one third of all providers say they always or frequently refer their obese patients to specialists for weight loss treatment. PCPs and NPs/PAs/RNs (34% each) are most likely to refer, and cardiologists (24%) and endocrinologists (21%) are least likely.
In treating patients with type 2 diabetes, less than half of all respondents said they rely on the 2018 American Diabetes Association (ADA) guidelines, ranging from 57% of endocrinologists to 28% of cardiologists. Not surprisingly, endocrinologists also commonly use the 2018 American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice (57%).
Close to 80% of endocrinologists surveyed routinely prescribe diabetes medication to lower CV risk among patients with type 2 diabetes, as do 64% of PCPs and 47% of NPs/PAs/RNs. Only a minority of cardiologists surveyed prescribe medication for diabetes (18%)—about 10% say they don't treat diabetes at all.
Excluding endocrinologists, over half of the healthcare providers surveyed say they are familiar with product data for the sodium-glucose cotransporter type 2 (SGLT2) inhibitors empagliflozin (Jardiance) and canagliflozin (Invokana) and the glucagon-like peptide-1 (GLP-1) analog (Victoza). Familiarity with these diabetes medications is nearly universal among endocrinologists.
Most endocrinologists (81%) are also familiar with the newer long-acting GLP-1 receptor agonist semaglutide (Ozempic), compared with just 10%-20% of other healthcare providers surveyed. Among all providers except cardiologists, those familiar with these medications are very comfortable prescribing them to lower CV risk.
Room for Improvement on Hypertension
When it comes to managing hypertension, many providers reported using more than one guideline. Most (72% overall) use the 2017 ACC/American Heart Association (AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults, including 83% of cardiologists but only 61% of PCPs.
About half of family and internal medicine physicians surveyed use the 2014 Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 8).
Guideline adherence leaves some room for improvement, according to the survey.
Overall, fewer than half (47%) of healthcare professionals surveyed report that they always or most of the time record BP in both arms at first visit. Cardiologists are most adherent to this recommendation (66%) with endocrinologists lagging behind (27%).
Sixty percent of all providers surveyed say they routinely have patients sit on a chair with their feet on the ground for more than 5 minutes before recording their blood pressure. Allied health professionals (NPs/PAs/RNs) were most likely to abide by this recommendation (68%), followed by cardiologists (58%).
The recommendation to use an average of two or more BP readings from two or more occasions is adhered to by 72% of all provider respondents; endocrinologists were the least adherent, at 62%.
The biggest barrier to following to the 2017 ACC/AHA hypertension guidelines, according to our survey respondents, is the time allotted for patient visits, cited by 49% overall.
The second biggest barrier is hitting the BP target of < 130/80 mm Hg; 43% of all providers, including half of cardiologists, said this target is unrealistic for most patients.
When asked what resources they would like available to help address CV risk in their patients, healthcare providers often mentioned patient education material (dietary guidelines, exercise), patient weight management resources (weight loss programs/coaching, dietitians) and assessment tools (calculators/app calculators).
The survey was conducted June 21, 2018, to October 8, 2018. Cardiologists were recruited from the ACC and Medscape memberships, and all other healthcare professionals were recruited from Medscape members. As expected, cardiologists see the greatest number of patients with CVD or CV risk factors on a monthly basis, at 259, compared with 158 for endocrinologists, 138 for PCPs, and 93 for allied healthcare professionals. More than half of all patients seen by survey participants have multiple concomitant conditions.
© 2019 American College of Cardiology & Medscape
Cite this: Addressing CV Risk: What Clinicians Told Us - Medscape - Feb 25, 2019.