Multimorbidity and cardiovascular prevention in primary care: a cohort study in New Zealand

Stina Mannheimer; Yeunhyang Catherine Choi; Katrina Poppe; Jingyuan Liang; Vanessa Selak; Allan Moffitt; Sue Wells

doi:10.3399/BJGP.2025.0798

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Multimorbidity and cardiovascular prevention in primary care
Stina Mannheimer

Published on: 25 August 2026
Beyond the label of multimorbidity: individualising cardiovascular prevention
Muhammad Mukarrum Saleh and Mehak Fatima

Published on: 17 August 2026

Published on: (25 August 2026)
Page navigation anchor for Multimorbidity and cardiovascular prevention in primary care
Multimorbidity and cardiovascular prevention in primary care
Stina Mannheimer, General Practitioner, University of Gothenburg
We agree that our findings suggest the greatest opportunity to improve cardiovascular prevention lies in treatment initiation. Although only 40% of people at high estimated cardiovascular risk received guideline-recommended dual therapy, maintenance was high once treatment had been initiated, suggesting that future efforts should focus on understanding and addressing barriers to treatment initiation.

As the authors note, our study was not designed to determine why eligible patients did not receive treatment. Administrative health data cannot distinguish between appropriate individualised decisions based on clinical judgement, patient preferences, frailty, treatment burden, or contraindications, and unwarranted undertreatment. Understanding these mechanisms is an important direction for future research.

We also agree that multimorbidity is heterogeneous. While defining multimorbidity as two or more long-term conditions is appropriate for large population-based studies, it cannot capture differences in disease combinations, severity, or patient priorities. Notably, diabetes was the strongest predictor of dual therapy across all cardiovascular risk groups in our study, supporting the importance of considering the composition, as well as the presence, of multimorbidity. However, our study very clearly demonstrated that using this very broad definition was associated with increased initiation of cardiovascular preventive medications.

Competing Interests: None declared.
Published on: (17 August 2026)
Page navigation anchor for Beyond the label of multimorbidity: individualising cardiovascular prevention
Beyond the label of multimorbidity: individualising cardiovascular prevention
Muhammad Mukarrum Saleh, General Physician, Sharifa Bibi Memorial Hospital
Other Contributors:
Mehak Fatima, General Physician
We read with interest Mannheimer et al.’s cohort study examining multimorbidity and cardiovascular prevention in primary care.¹ The finding that only 40% of patients in the high-cardiovascular-risk group received combined blood-pressure- and lipid-lowering therapy highlights an important evidence–practice gap. Yet, among those already receiving dual therapy, two-year maintenance was high (88–89%). This raises an important question: does the principal gap lie in treatment initiation rather than subsequent maintenance? The study cannot determine whether non-initiation reflected clinician decision-making, patient preferences, treatment intolerance, competing illness, treatment burden, or other factors.¹

We believe the broader concept of multimorbidity also warrants closer consideration. Defining multimorbidity simply as two or more conditions may obscure clinically important heterogeneity. A patient with hypertension and osteoarthritis differs substantially from one with diabetes, hypertension and chronic kidney disease, despite both meeting the same multimorbidity definition. Indeed, previous primary-care research found that the composition of multimorbidity, particularly the presence of diabetes, was more strongly associated with appropriate statin prescribing than multimorbidity itself.²

This distinction is important for cardiovascular prevention. Guidelines recommend that management of multimorbidity account for inter...
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We read with interest Mannheimer et al.’s cohort study examining multimorbidity and cardiovascular prevention in primary care.¹ The finding that only 40% of patients in the high-cardiovascular-risk group received combined blood-pressure- and lipid-lowering therapy highlights an important evidence–practice gap. Yet, among those already receiving dual therapy, two-year maintenance was high (88–89%). This raises an important question: does the principal gap lie in treatment initiation rather than subsequent maintenance? The study cannot determine whether non-initiation reflected clinician decision-making, patient preferences, treatment intolerance, competing illness, treatment burden, or other factors.¹

We believe the broader concept of multimorbidity also warrants closer consideration. Defining multimorbidity simply as two or more conditions may obscure clinically important heterogeneity. A patient with hypertension and osteoarthritis differs substantially from one with diabetes, hypertension and chronic kidney disease, despite both meeting the same multimorbidity definition. Indeed, previous primary-care research found that the composition of multimorbidity, particularly the presence of diabetes, was more strongly associated with appropriate statin prescribing than multimorbidity itself.²

This distinction is important for cardiovascular prevention. Guidelines recommend that management of multimorbidity account for interactions between conditions, treatment burden, competing risks, frailty, polypharmacy, and individual patient goals and preferences rather than applying single-disease recommendations in isolation.³,⁴

Thus, rather than asking simply whether multimorbidity is present, future studies should examine which combinations and severity of conditions influence preventive treatment initiation, and why eligible patients remain untreated. Such a more granular approach could help distinguish genuine undertreatment from appropriate individualisation of care and better balance cardiovascular risk reduction against treatment burden.

References
1.Mannheimer S, Choi YC, Poppe K, Liang J, Selak V, Moffitt A, Wells S. Multimorbidity and cardiovascular prevention in primary care: a cohort study in New Zealand. Br J Gen Pract 2026;76(769):e673-e680. doi:10.3399/BJGP.2025.0798.
2.Dumont R, Haller DM, Maisonneuve H, et al. Multimorbidity and statin prescription for primary prevention of cardiovascular diseases: a cross-sectional study in general practice in France. Front Med (Lausanne) 2022;9:1089050. doi:10.3389/fmed.2022.1089050.
3.National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management. NICE guideline NG56. London: NICE; 2016. www.nice.org.uk/Guidance/ng56.
4.National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification. NICE guideline NG238. London: NICE; 2023. www.nice.org.uk/guidance/ng238.

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Competing Interests: None declared.

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