A Prospective Observational Study on Medication Use Management and Prevalence of Cardiovascular Disease with Comorbidities in a Tertiary Care Hospital

Introduction

Non-communicable diseases (NCDs) such as cardiovascular diseases (CVD) are the main cause of death worldwide, accounting for 32% of all fatalities. Despite highly improved healthcare facilities, CVDs have a higher mortality rate and lower quality of life than other NCDs.¹

Numerous cardiovascular drugs, such as beta blockers, diuretics, ACE inhibitors, calcium channel blockers, lipid-lowering medicines, antiplatelet, thrombolytic, anticoagulants, and β-Hydroxy β-methylglutaryl-CoA (HMG-CoA) reductase inhibitors, have been utilised to control CVDs (statins).^2,3

Prescriptions that are irrational and pointless are common and have become a significant issue in health care. Medication use management can be employed as a method to identify any drug-related issues that patients may have come across while seeking medical care for their condition. Medication use management is a set of guidelines and analytical techniques for defining, comprehending, and assessing the prescription, dispensing, and consumption of medicines, as well as for evaluating interventions to improve the efficacy of these processes.⁴ The main causes of irrational drug use which can result in insufficient therapeutic effects, undesirable drug events, and adverse drug interactions are a lack of knowledge by patients regarding dosing schedules, misunderstanding of brand names, cost issues, unpredictable drug supply, and the absence of a hospital formulary, and issues with cost and availability of drugs. Understanding prescription patterns is an important factor in determining the rationality of drug therapy and to enhance the utilization.⁵

Comorbidity is the occurrence of one or more chronic diseases next to an index disease that co-occurs.⁶ Cardiovascular and non-cardiovascular comorbidities can be divided into different groups. The first group consists of arrhythmias, valvular heart disease, hypertension, coronary artery disease, peripheral artery disease,and cerebrovascular disease. Respiratory, endocrine, metabolic, nutritional, renal, haematological, neurological, and musculoskeletal diseases are examples of non-cardiovascular comorbidities.⁷ Comorbidity may result in decreased functional status, worse quality of life, and even higher mortality. 

The known risk factors for CVDs include smoking, harmful alcohol use, reduced physical activity, consumption of unhealthy food, obesity, hypertension, diabetes, and hyperlipidemia. According to estimates,smoking accounts for almost 10% of all CVDs, followed by inactivity (6%), overweight, and obesity (5%).⁸

Patient characteristics and comorbid conditions are two additional factors that are linked to lower Health-related Quality of Life (HRQOL). The term "HRQOL" refers to a person's general opinion of health and well-being as well as their current state of health, which is considered as a progression of very complicated health outcomes. It is referred to as the (in) compatibility between the desired and actual functional capacity, and it is especially significant for Coronary heart disease (CHD) patients.⁹

In clinical settings, HRQOL surveys, such as the SF-36, a short form 36-item health survey, are frequently employed as indicators of function. The SF 36 instrument is brief, simple to use, and can be finished in 5 to 10 minutes, but it contains a large amount of information on patient self-reports regarding how they view their own functioning in life. The SF-36 evaluates eight concepts of health: restriction in physical activity due to health concerns; reduced social activity because of emotional or physical issues; limitations in regular activities due to physical health problems; bodily pain; general mental health (psychological distress and well-being); limitations in regular activities because of emotional issues; vitality (energy and fatigue); and perceptions regarding general health.¹⁰ 

Materials and Methods

A prospective observational study was conducted in the Department of Medicine, Chigateri District Hospital, Davangere. The study was carried out for a duration of six months (April 2022 to September 2022) after receiving the clearance and approval from the Institutional Ethics Committee. Patients having CVD and comorbidities were included in our study. Patients admitted in paediatric, emergency ward and pregnant women were excluded in the study along with patients having insufficient data. Relevant data was collected on data collection form which included patient demographics, laboratory results, diagnosis, comorbid conditions and prescription analysis. Information was collected using SF-36 questionnaire to assess HRQOL.

Results

Demographic data

Data related to demographic details of around 204 patients were collected and analysed. The calculated percentages are tabulated in Table 1. It was observed that among the 204 patients, 117 (57.35%) were males and 87 (42.64%) were females. From the Figure 1, it can be observed that majority patients were in the age range of 58-67 years (n=67, 32.84%).

Distribution of CVD among study population

Figure 2 shows that the most commonly seen CVDs were HTN (n=107, 28.23%), followed by MI (n=88, 23.21%).

Risk associated with CVD patients

The risk of developing CVD was more in patients having HTN (N=99, 16.92%), followed by patients who were smokers (n=98, 16.75%). The various risk factors are summarized in Figure 3.

Comorbidities associated with CVD

In this study, out of 204 CVD cases, HTN (n=87, 32.17%) was the most prominent comorbidity followed by diabetes mellitus (DM) (n=76, 28.57%) (Table 2).

Prescribing indicators

Among 204 prescriptions analysed, a total of 2009 drugs were used of which 799 were CVD drugs, constituting 39.72% (Table 3).

Polypharmacy assessment

Out of 204 prescriptions, 172 (84.31%) were analysed as polypharmacy (Table 4).

Utilization pattern of CVD drugs prescribed

Among 204 CVD cases, the most prescribed class of drugs was antiplatelet (n=227, 28.41%) and the most prescribed drug was furosemide (n=107, 13.39%). 

Prescribing pattern of drugs as fixed dose combination (FDCs) in patients

In the present study, there were 102 combination therapies noted, out of which Ecosprin gold (n=36, 35.29%), followed by Ecosprin AV gold (n=25, 24.50%) was the most prescribed fixed dose combination.

HRQOL assessment

In SF 36, the highest score was in the physical functioning domain (62.89), whereas the lowest was in the social functioning domain (49.15) (Table 7). 

Discussion

The term "CVD" refers to a wide range of illnesses that affect the heart and blood vessels and cause comorbid conditions that can be fatal.¹¹ Management of CVD patients in the primary care setting is significant since patients are associated with increased mortality, decreased QOL and increased use of health services.¹² The purpose of this prospective observational study involving 204 patients with CVD over the course of six months in the inpatient general medicine department was to evaluate the management of medication usage, prevalence, comorbidities, risk factors, and HRQOL in CVD patients.

In this study, out of 204 patients enrolled, the proportion of males with CVD was significantly higher (n=117, 57.35%) compared to females (n=87, 42.64%) which is in accordance with the results of study conducted at Punjab by Gaur et al. ⁴ The results of the present study showed that the majority of patients belonged to the age group of 58-67 years (n=67, 32.84%) indicating direct relationship of age with incidence of CVD which is in agreement with the studies conducted in Ethiopia by Tefera et al. ³ CVD were reported along with other comorbidities showing that the patients simultaneously suffered with more than one disease. In this study, HTN (n=87, 32.17%) was found to be the most prevalent comorbid illness as suggested by the results of study conducted in Western Maharashtra by Vakade K et al.¹³ Also anaemia (n=5, 1.87%) was the least observed comorbidities which is in agreement with the results of study conducted in Bihar by Ram B et al. ¹⁴

Hypertension (n=107, 28.23%) was found to be the most prevalent CVD disease as suggested by the results of the study conducted in Bangladesh by Muhit et al. ² Also arrhythmia (n=2, 0.52%) was least prevalent disease observed which is in agreement with studies conducted in Western Maharashtra by Vakade K et al. ¹³ HTN (n=99,16.92%) was found to be the most common risk factor and liver disease (n=5,0.85%) was the least common risk factor in the study population. The study conducted at Nevadans by Tran D et al.,¹¹ showed BMI as the highest prevalent risk factor and least was heavy drinking. This variation could be due to the change in the study population. While assessing the prescribing indicators of the 204 prescriptions analysed, the total number of drugs prescribed were 2009 and the average number of drugs per prescription constituted 9.84, which is lower than that reported by Adhikari K et al.,¹⁵ in Assam which showed that the average number of drugs per prescription was 12.4.

The current study demonstrated the prevalence of polypharmacy as 84.31% which is in agreement with the results of the study done in Pakistan by Saqlain M et al. ¹⁶ According to the present study, antiplatelet drugs (n=227, 28.41% ) were the most prescribed class of drugs which is in agreement with the findings reported by Sreelekshmi V et al., in their study conducted in Kerala.¹⁷ The most prominent CVD drug prescribed was found to be furosemide (n=107, 13.39%) and the least was lasilactone (n=1, 0.12%), which is not in agreement with the results of study conducted at Tiruchengode by Rangapriya M et al. ¹¹ According to their result, the most prescribed drug was atorvastatin and the least prescribed was dilitiazem.

In this study, antiplatelet drugs were the most prescribed class of drugs in combination therapy [aspirin+clopidogrel (n=36, 35.29%)], which is supported by the results of the study conducted in South India by Veeramani V et al. ¹⁸ While assessing the HRQOL, the PCS was 56.94 and MCS was 54.24, which is very much similar to the results of the study conducted by Zhang J et al. ¹⁰

Conclusion

A prospective observational study on assessment of medications used in the management of CVD with comorbidities concluded that men outnumbered women implying that men are more likely to develop CVD. In the age range of 58 to 67 years, CVD was observed to be somewhat more prevalent. HTN was the common illness found among the 204 participants included in the research. HTN and DM were observed as the typical comorbid conditions in this investigation. Patients with hypertension and smokers are more likely to be susceptible to CVD. We evaluated 204 prescriptions and discovered that the average number of drugs per prescription was 9.84. This supports the finding that the majority of the prescriptions were polypharmacy. Among the study population, most prescribed class of drug was antiplatelet and the most prescribed drug was Furosemide. The most frequently prescribed combination therapy was Ecosprin gold (Aspirin + Clopidogrel). PCS and MCS were in a modest range when HRQOL was evaluated. Effective CVD management is crucial for life-saving. Our thesis will serve as a future resource to identify the medication use management in CVD patients.

Ethics declaration

The protocol was verified and approved by the Institutional Ethics Committee of SCS College of pharmacy, Harapanahalli on 15th April 2022.

Author’s contribution

Sherin Anna Shaji, Sofy Sunny, Stefi A Mathew contributed equally.

Consent for publication

All authors have given their consent for publication.

Competing Interest

The authors declare that they have no competing interest

Authors funding

The authors hereby declare that no financial support was taken from anyone for research, authorship and for publication of this article.

Conflict of interest

All the authors declare no conflict of interest.

Acknowledgements

The authors are thankful to Dr. Nagendra Rao, Principal, SCS College of Pharmacy, Harpanahalli, for the encouragement and the valuable support throughout the study.