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Other conditions

This information is common to all 5 diseases.

Click for more information on the following conditions:

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic disabling disease associated with an increased risk of cardiovascular disease, low mood and depression. It may also worsen the effect of other long term conditions. It is a powerful independent risk factor for increased mortality from cardiovascular disease. The increased risk appears to be due to both an increased prevalence of traditional risk factors, such as smoking, in addition to inflammation.

Most existing CVD risk assessment models do not treat RA as an independent risk factor for CVD and therefore the scores underestimate the person’s risk.

Expert opinion suggests that the risk weighting for presence of rheumatoid arthritis is similar to that for diabetes mellitus.

It is recommended that the CVD risk assessment is repeated annually, unless patients have established CVD (for example, CHD, stroke and transient ischemic attack), or familial hypercholesterolemia, because lipid levels have an impact on the risk of developing CVD. Also lipids may not be constant in patients with RA and therefore can change over a course of a year. RA treatment for the control of inflammations may alter lipid levels.

 
Hypertension

A major overview of randomised trials showed that a reduction of 5–6 mmHg in blood pressure sustained over five years reduces coronary events by 20–25 per cent in patients with CHD.

In one major overview, a long-term difference of 5-6 mmHg in usual diastolic blood pressure (DBP) is associated with approximately 30–40 per cent less stroke over five years. The PROGRESS trial demonstrated that blood pressure lowering reduces stroke risk in patients with prior stroke or TIA.

Blood pressure lowering in patients with diabetes reduces the risk of macrovascular and microvascular disease.

In QOF, DM003 sets a target of 140/80 mmHg as per the target recommended by NICE70; while the target of 150/90 mmHg has been set for those patients who cannot manage this, such as those with retinopathy, micro-albuminuria or cerebrovascular disease.

 Mental Health

Around 30% of all people with a long term condition also have a mental health problem, especially those who have multiple long term conditions. The combination of mental health problems with other long term conditions has serious implications, including:

- poorer clinical outcomes
- lower quality of life
- reduced ability to manage their condition effectively.

In both coronary heart disease and diabetes, there is also evidence of earlier death in patients with co-morbid mental health conditions. It is important to detect (and even more important to manage effectively) mental health problems as part of the chronic disease management process.

Patients with schizophrenia have mortality between two and three times that of the general population and most of the excess deaths are from diseases that are the major causes of death in the general population.

A recent prospective record linkage study of the mortality of a community cohort of 370 patients with schizophrenia found that the increased mortality risk is probably life-long and it suggested that cardiovascular mortality of schizophrenia has increased over the past 25 years relative to the general population.

The NICE clinical guideline on bipolar disorder also states that the standardised mortality ratio for cardiovascular death may be twice that of the general population but appears to be reduced if patients adhere to long-term medication.

Hypertension in people with schizophrenia is estimated at 19 per cent compared with 15 per cent in the general population.

There is evidence to suggest that physical conditions such as cardiovascular disorders go unrecognised in psychiatric patients. A direct comparison of cardiovascular screening (blood pressure, lipid levels and smoking status) of patients with asthma, patients with schizophrenia and other attendees indicated that general practice were less likely to screen patients with schizophrenia for cardiovascular risk compared with the other two groups.

Recording (and treating) cardiovascular risk factors are therefore very important for patients with a serious mental illness.

Chronic Kidney Disease

Chronic kidney disease often co-exists with diabetes and hypertension. Management of patients with these co-morbidities require good coordination of all aspects of their care, to help manage often complex comorbidities, optimise medication, monitor and respond to laboratory parameters to minimise the risk of disease progression.

Studies have shown that in patients aged 65 or over and in patients with diabetes, normal blood pressure is hard to achieve but is important.

The NICE clinical guideline on CKD recommends that in patients with CKD the clinician aims to keep the systolic blood pressure below 140 mmHg (target range 120-139 mmHg) and the DBP below 90 mmHg. In patients with CKD and diabetes
and also in people with an ACR 70 mg/mmol or more (approximately equivalent to PCR 100 mg/mmol or more, or urinary protein excretion 1g/24hr or more) the clinician aims to keep the systolic blood pressure below 130 mmHg (target range 120-129 mmHg) and the DBP below 80 mmHg.

The SIGN clinical guideline on CKD recommends that blood pressure be controlled to slow the deterioration of the glomerular filtration rate and reduce proteinuria. Patients with >1 g/day of proteinuria (approximately equivalent to a PCR of 100 mg/mmol) have a target maximum systolic blood pressure of 130 mmHg.

The lower the blood pressure achieved the better for patient care .


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