When Complexity Becomes the Norm: Cardiovascular Multimorbidity

Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality worldwide, accounting for one-third of global deaths.1 The coexistence of multiple cardiovascular disorders within an individual—cardiovascular multimorbidity—is increasingly prevalent2 and associated with lower quality of life, disproportionate healthcare use, and worse clinical outcomes.2,3 Multimorbidity is also associated with challenges such as polypharmacy, complicated care coordination, and difficulty applying clinical guidelines designed for single diseases.3 Cardiovascular multimorbidity demands a shift from single disease focus to integrated, person-centered care, where nurses specifically can serve as key coordinators who manage complex medication regimens, provide patient education across conditions and needs, support self-care in the context of competing health needs and priorities, and help navigate often fragmented health care systems. These realities underscore the importance of innovative approaches to the prevention and management of CVD and multimorbidity. Specifically, prevention of cardiovascular multimorbidity has two complementary aims: preventing the first cardiovascular event (primary prevention) and preventing the accumulation of further cardiovascular conditions among those with existing conditions (secondary and tertiary prevention). This Progress in Prevention column summarizes recent advances across the prevention spectrum, with an emphasis on innovations that could support personalized, scalable, and equitable strategies for cardiovascular and multimorbidity care, highlighting the role of nurses and future directions. Epidemiology and Shared Risk Pathways Multimorbidity prevalence exceeds 30% to 40% in many settings globally, is substantially higher in older adults,3,4 and disproportionately affects females and those with lower socioeconomic conditions.5 Common clusters of cardiovascular multimorbidity include cardiometabolic conditions (hypertension, diabetes, dyslipidemia, and obesity), cardiovascular-renal-metabolic syndrome (heart failure, chronic kidney disease, and diabetes), and atrial fibrillation with ischemic heart disease.6–8 Cardiovascular multimorbidity often coexists with non-CVD, which further complicates care. Many CVD share underlying etiologic pathways driven by hypertension-induced vascular remodeling, endothelial dysfunction, atherosclerosis, chronic systemic inflammation, oxidative stress, and metabolic dysregulation,9–13 fueled by genetic predisposition, behavioral factors (smoking, unhealthy diets, and physical activity), and social/environmental determinants (socioeconomic deprivation, air pollution, noise, and chronic psychological stress).14–16 Specifically for nurses, understanding these shared pathways is essential for implementing holistic prevention strategies, recognizing overlapping symptom presentations, and addressing upstream social determinants, particularly critical given the higher burden among at-risk populations. Progress in Risk Stratification and Primary Prevention Advances Traditional risk calculators like the Framingham Risk Score, ASCVD Risk Estimator, and Pooled Cohort Equations are widely used in daily practice, where newer tools such as PREVENT and Framingham-30 represent refinements to incorporate lifetime risk and work more effectively for diverse patient populations.17,18 Additional tools to refine risk assessments are biomarkers like high-sensitivity cardiac troponins, brain and natriuretic peptides (BNP/NT-proBNP), inflammatory markers (high-sensitivity C-reactive protein), lipoprotein (a), and genomic polygenic risk scores,19,20 along with imaging like coronary artery calcium scoring and carotid intima-media thickness/plaques.21,22 Machine learning is also a valuable tool in analyzing data from electronic health records, wearables, and complex datasets to catch patterns predicting multimorbidity, though their performance needs careful assessment and testing for clinical usefulness.20,23,24 Nurses often use or interpret findings from these tools at bedside or in clinics, helping patients understand numbers and meaning for prevention and management. Informed by risk stratification, proven effective primary prevention strategies include approaches such as quitting smoking, adopting healthier diets such as Mediterranean or DASH, increasing physical activity, and managing weight, which are increasingly supported by Apps, wearable devices, and digital programs to enhance reach.25,26 Based on risk profile, earlier use of medications such as statins and polypills that combine blood pressure medications, statins, and sometimes aspirin into one pill is also found to be helpful with adherence and reduce cardiovascular events.27 Further, evidence found that increased uptake of Flu and pneumonia vaccines is associated with reduced cardiovascular events in high-risk patients, and broader efforts such as reducing air pollution, workplace hazards, and policies around tobacco, trans-fats, and salt all contribute to prevention at community level.16,28,29 Nurses are on the frontlines of all this, from risk assessments to implementing preventive strategies through involvement in practice, education, research, policy, and advocacy. Secondary and Tertiary Prevention Advances Integrated care has been continuously advocated as a multidisciplinary, patient-centered approach to manage existing conditions, reduce recurrence risk, and mitigate the long-term impact of comorbid conditions, which can prevent disease progression and multimorbidity as well as reduce health care utilization and costs.30,31 Key strategies for this include managing smooth care transitions, optimizing medications, and supporting sustainable lifestyle changes through tailored personalized care plans. Further, it has been identified that getting patients on appropriate guideline-directed therapies such as statins, beta-blockers, angiotensin-converting enzyme inhibitors, and appropriate polypills can help manage existing conditions and prevent new cardiovascular conditions.32 Additionally, cardiac rehabilitation programs have been identified as effective ways to reduce recurrent events, improve functional capacity, and help patients stick with lifestyle changes and medications long-term.32,33 Secondary and tertiary prevention isn’t a one-time and one intervention but requires years of sustained and coordinated support between multidisciplinary teams, where nurses have significant role in helping maintain that continuity of care and advocating for patients and families, catching medication needs and problems early, reinforcing education, monitoring progress, encouraging patients when they struggle, and making sure nothing slips through the cracks in fragmented healthcare systems. Innovative Approaches to Support Prevention of Cardiovascular Multimorbidity Several innovations for cardiovascular care have been identified. Wearables and implantable devices are now helpful in detecting arrhythmias, tracking lifestyle activity, and providing continuous blood pressure/heart rate trends,34,35 alerting providers and patients to early warning signs. Digital health, telemedicine, and mobile health Apps offer remote consultations, coaching, and adherence support that have been crucial in rural areas, resource-limited settings, and during pandemic.36 Electronic health record integrated tools can be used to prompt guideline-based prevention, risk calculation, and medication optimization, and when combined with team-based approaches and shared decision-making, can help reach more patients on preventive therapies aligned with their priorities.37 Equity has moved front and center, with growing recognition that it is impossible to prevent CVD without addressing social determinants like income, education, food security, housing, and structural racism; programs combining medical care with social support are showing real promise.15 Community-based approaches through faith organizations, workplaces, and peer networks were effective, culturally relevant prevention and reaching people where they are,38 while health system innovations like task-shifting expand nurses’, pharmacists’, and community health workers’ roles in delivering prevention services such as blood pressure management, protocol-driven medication adjustments, and counseling to enhance reach and improve outcomes.39 There is also movement toward value-based care, shared decision-making, efforts ensuring universal access to essential preventive medications, and better data systems enabling population tracking and targeted interventions. Research is shifting toward pragmatic trials testing interventions in real-world settings using implementation and dissemination frameworks for scalability, sustainability, and impact on disparities. Nurses are central to these innovations, providing value-based integrated care, connecting patients to resources and health systems, implementing research and quality improvements, advocating for policy changes, and providing a consistent presence holding fragmented systems together. Challenges, Gaps, and Future Direction Despite progress, significant challenges in preventing and managing cardiovascular multimorbidity remain. Most evidence comes from single-disease studies, not trials conducted among those living with multimorbidity.3 The complexity of multimorbidity makes both trial design and applying results difficult. Many risk prediction tools have not been validated across diverse populations and do not adequately capture social and environmental risk factors. Even with evidence on effective approaches, implementation is slow, especially in low-resource settings facing cost, supply chain, and workforce barriers. Moving forward requires adequately preparing the nursing and healthcare workforce, conducting research and trials among individuals with multimorbidity, ensuring equitable access to proven interventions, and keeping equity central; only by addressing challenges at individual, provider, health system, and economic levels can meaningfully reduce the growing burden of cardiovascular multimorbidity. Precision prevention is needed combining clinical data, imaging, biomarkers, genetics, and social context to match prevention intensity to individual needs; building social needs and upstream determinants into care and research, evaluating programs connecting medical care and social determinants; focusing on implementation at scale across diverse health systems sustainably while monitoring equity effects; and strengthening economic research quantifying long-term returns to guide policy decisions about prevention investments. Priorities should include integrated care emphasizing multidisciplinary teamwork, aligned financing, digital health infrastructure, workforce development, patient partnership, and robust monitoring and evaluation40 of outcomes that matter for multimorbidity, like development of additional conditions, functional status, quality of life, healthcare use, and healthcare costs. Fundamentally, as multimorbidity is more widespread, there is a need to shift the entire approach in education, research, practice, and policy from a single-disease-focused to a multimorbidity-focused framework. Conclusion Preventing cardiovascular multimorbidity can be supported by the advances in improved risk prediction, digital health technologies, health system innovations such as integrated team-based care and task-shifting, and effective population policies. Yet substantial gaps remain: most evidence comes from single-disease trials that do not reflect multimorbidity complexity, interventions are not implemented equitably, and there are limited integrated approaches that also combine clinical and social interventions. As prevention of cardiovascular multimorbidity requires more than clinical care alone, nurses are positioned at the frontline, educating patients, coordinating complex regimens, navigating fragmented systems, leading, and advocating for change. Preventing cardiovascular multimorbidity demands coordinated action across clinical practice, public health, policy, and community sectors, combining person-centered integrated care interventions and structural changes addressing social determinants.