Rheumatologists or primary care: Who bears 'responsibility' for CV risk?
SCOTTSDALE, Ariz. —Rheumatologists, focused as they are on inflammatory symptoms, are often less familiar with cardiovascular management, according to M. Elaine Husni, MD, MPH, of the Cleveland Clinic.
Meanwhile, primary care providers tend to under-recognize cardiovascular risk among patients with inflammatory arthritis, she added.
When it comes to assessing and managing cardiovascular risk in autoimmune diseases, the answer, according to Husni, may be a matter of “thinking globally, but acting locally.” That is, a systematic approach that recommends preventative cardiology for all patients with certain types of arthritis or vasculitis.
“Who is responsible for managing all these risk factors? When you see your patient, what is your responsibility, as a rheumatologist? As a primary care provider? As a family medicine provider?” asked Husni, addressing attendees at the Basic and Clinical Immunology for the Busy Clinician annual symposium.
“We know that cardiovascular management is complex,” she added. “We have all these studies about the microbiome and novel markers — are we supposed to check them all? Some are not even ready for prime time. The way I think about it is that we think globally about this disease, but also have to act locally.”
As one example of this, Husni pointed to the EPIC system at the Cleveland Clinic. Initiated in 2009, the system uses electronic medical records to flag patients with high-risk conditions, such as rheumatoid arthritis or psoriatic arthritis, during assessments. An automatic pop-up window in the electronic chart prevents any further input until the physician answers the question, “Would you like to refer this patient to preventative cardiology?”
According to Husni, this system frees rheumatologists to focus on their specialty while also ensuring that their patients receive all aspects of the care they need.
“Much of this is due to the fact that we don’t think we have the time, or possibly the expertise, for assessing cardiovascular risk,” Husni said. “Even if I got a lipid level and it was elevated, do I even know how to treat it? So, we thought this would be a nice way to highlight and mark these patients, and give them an automatic referral for a cardiovascular consult.”
However, the system is not perfect, Husni cautioned. Although most staff members are compliant, some reflexively answer “No” to the question to clear the pop-ups quickly.
“There is some variability,” Husni said. “Maybe they know a local cardiologist and they don’t choose to refer to the one here. There is still more that needs to be done, but this is what we are doing locally.” – by Jason Laday
Husni ME. Sorting out cardiovascular risk in autoimmune disease — whose job is it? Presented at Basic and Clinical Immunology for the Busy Clinician; Feb. 28-29, 2020; Scottsdale, Arizona.
Disclosure: Husni reports consulting fees and advisory board membership with AbbVie, Amgen, Janssen, Eli Lilly and Regeneron; consulting fees, advisory board membership and teaching and speaking fees from Novartis; advisory board membership with Pfizer; consulting fees from UCB; and consulting and teaching and speaking fees from WebMD.