248 Underestimation of Cardiovascular Risk in Patients With Elevated Cardiometabolic Risk in the Canadian Primary Care Setting

Abstract

Primary care offers a unique opportunity for early identification and preventive management of patients at elevated cardiometabolic risk (CMR). We evaluated the risk assessment patterns employed by primary care physicians in patients at elevated CMR. Between April 2011 and March 2012, data from 88 individual physicians from British Columbia, Ontario and Québec, and from multiple physicians from 6 Family Health Teams (FHTs) in Ontario and Québec were collected on the current health profile and management of patients >40 years old with no clinical evidence of cardiovascular (CV) disease and diagnosed with at least one of the following - dyslipidemia, type 2 diabetes mellitus (T2DM) or hypertension as per the current Canadian Clinical Practice Guidelines (CPGs). Key patient characteristics from the 1864 patient charts are shown in the Table. Incidences of dyslipidemia, T2DM and hypertension were higher in individuals with a BMI ≥25 kg/m2 (84.7%) relative to those with a BMI <25 kg/m2. Waist circumference (WC) data, available from solo-physician practice assessments only, revealed that patients with WCs greater than their ethnic-specific cut-offs (41.8%) relative to patients with WCs below the thresholds also demonstrated higher occurrences of dyslipidemia, T2DM and hypertension. Approximately half (54.5%) of the patients managed by physicians in solo-physician practices had the metabolic syndrome based on the Harmonized Definition for the metabolic syndrome. CV risk was estimated in clinic in 52.2% of the 781 patients without T2DM with 98.8% of the physicians indicating that they used the Framingham Risk Score (FRS) and 0.5% the Reynolds Risk Score. Our own FRS analysis based on the complete data sets from 690 patients without T2DM implied that 57.0%, 30.7% and 12.3% of these individuals were actually at high, moderate and low CV risk respectively before invoking the 1.5- to 2-fold multiplier to determine absolute CMR. Notably, this suggests that 44.8% of the patients without T2DM who had their CV risk estimated in clinic were misclassified by their physicians into a lower risk category.Tabled 1 Current Canadian CPGs emphasize the importance of early identification of CMR in order to facilitate preventative measures against CMR factors. In this practice assessment program, CV risk using traditional CV risk algorithms was often underestimated. While the underlying reasons are unknown, this misclassification may have led to an inappropriate selection of therapeutic strategies contributing to a care gap.