HFA Committee on Comorbidities-report of a meeting on physiological monitoring in the complex multi-morbid heart failure patient.

Abstract

One of the largest and most active committees of the Heart Failure Association (HFA) is the Committee on Comorbidities, which I have the honour to chair. It is in fact multiple committees, because its remit is so broad, covering study groups looking at Cardio-Oncology (Alex Lyon), Diabetes & Hypertension (Giuseppe Rosano), Cardiorenal Dysfunction (Wilfried Mullens), Heart & Brain (Andrew Coats), Cachexia, Sarcopenia and Frailty (Ewa Jankowska), and Lung Disease and Sleep Disorders (Mitja Lainscak). Co-morbidities are increasingly recognized as crucial components of the heart failure (HF) syndrome, especially in typical older patients (unlike the very highly selected patients who make in into randomized controlled trials). There has been much work published about these issues in the European Journal of Heart Failure recently.1-7 February 28, 2019 saw many of the members of the Committee on Comorbidities come together to tackle a very clinically relevant topic, that of producing an official position paper on how to monitor all these co-morbidities (using simple physiological measurements) in the typical HF patient, if such a person exists. Getting together in the wonderful setting of the eternal city of Rome, we saw the following members work on this topic, along with many more who could not attend in person: Andrew Coats, Maurizio Volterrani, Loreena Hill, Massimo Piepoli, Ovidiu Chioncel, Ewa Jankowska, Mitja Lainscak, Stefan Anker, Marco Metra, Piotr Ponikowski and Petar Seferovic. ECG – patterns, rhythms and conduction - Should we simply do opportunistic ECGs or should we recommend routine ECGs on regular follow-up and should we recommend wearable devices for ECG recordings, looking for example for things such as We then turned our attention to ventricular function, the most important of course being left ventricular function, discussing the role of echocardiography and other imaging techniques, when they should be used and how frequently, and important clinical questions such as what are the recommendations for routine echo follow-up in HFrEF or HFpEF, for valve lesions complicating HF, and whether other circumstances justify routine echo during follow-up, e.g. looking for forms of amyloid, myocarditis etc., and whether we should re-check echo after cardiac resynchronization therapy or drug therapy changes. Another important and frequently clinically relevant topic in transplant and ventricular assist device assessment clinics is that of monitoring of functional capacity, covering topics such as the prognostic value of exercise tolerance, and especially of peak oxyen uptake and other measurements derived from formal cardiopulmonary exercise testing (CPET), such as VE/VCO2 slope, exercise oscillatory ventilation, along with a discussion of the potential for wearable devices and the possibility of daily activity monitoring. Under the heading of advanced forms of monitoring, we considered plasma biomarkers, including their diagnostic role, prognostic value, value as inclusion criteria for certain therapies (e.g. sacubitril/valsartan) and the choice of the optimal biomarkers for HFrEF or HFpEF. Another large topic was the role of remote monitoring and telemedicine—both non-invasive and using implanted technologies (pulmonary artery pressure monitoring and loop recorders). What should we say about recommending remote non-invasive telemonitoring, given the recent TIM-HF2 trial?8, 9 A very important question that will be addressed on the final paper is the issue of what clinical trials and with what endpoints will be needed to get the proof we need to routinely recommend monitoring by implantable devices, and who will pay for this on-going monitoring effort. We finished by reviewing the specific challenges of monitoring the advanced HF patient—given that we all agreed sicker patients need more intense monitoring. This covered emerging topics such as lung congestion or total body water monitoring, along with prevalent co-morbidities, renal impairment, haemoglobin and serum iron, transferrin and transferrin saturation, sodium, potassium (with the advent of potassium binders into our treatment options), sleep disordered breathing, where differentiating central from obstructive sleep apnoea is essential to choose the right therapy for a HF patient with sleep disordered breathing, and of course monitoring diabetic control. We then finished with a discussion about the growing incidence of co-existing cancer and heart disease and need to develop evidence-based strategies for monitoring and protecting cardiac function during many modern anti-cancer regimes. The one thing that became increasingly obvious was that this area is enormously complex and the need for future reach is growing ever more urgent. Andrew J.S. Coats University of Warwick, Coventry, UK ajscoats@aol.com