Comorbidity In Heart Failure Patients Research Articles

The effectiveness of cognitive-behavioral therapy for heart failure patients: a narrative review.

Heart failure (HF) remains a major cause of morbidity, mortality and healthcare costs, despite available treatments. Psychological issues such as depression, anxiety and poor self-care are prevalent in HF patients. Such issues adversely affect patients' daily lives and increase hospitalization and mortality rates; therefore, effective approaches to address these are needed. Cognitive-behavioral therapy (CBT) has been proposed as potentially useful for psychological comorbidities in HF patients, but its efficacy is not well-established. This narrative review aimed to summarize the evidence on the effectiveness of CBT for HF patients. A search was conducted using PubMed and Google Scholar for randomized controlled trials (RCTs) on CBT for HF patients. Ten studies (nine RCTs and one case study) were included in the review. CBT was found to be an effective intervention for managing depression, anxiety, low quality of life, and impaired social and physical functioning in HF patients. The results suggest that CBT can improve psychological well-being and enhance the benefits of rehabilitation programs. Face-to-face CBT appears to be superior to conventional therapy and can be implemented in cardiac rehabilitation settings. Further research is needed to evaluate the efficacy of internet-based CBT for cardiac patients and identify factors that promote treatment adherence.

The Prevalence of Depression and Anxiety in Heart Failure Patients in Saudi Arabia: An Original Study.

Background Depression is a severe comorbidity that is often detected in patients with chronic diseases. Poor prognosis may eventuate high mortality risk. Up to 30% of heart failure patients have been documented with depression and the majority upholds depression-related symptoms that may have serious clinical implications, such as hospital readmissions and fatalities. To mitigate depression-induced harms among heart failure patients, studies are being conducted to determine the prevalence, risk factors, and interventions. Objectives The current investigation is envisioned to examine the prevalence of depression and anxiety among the Saudi heart failure population. Also, it will help to explore the risk factors that will subsequently facilitate the analysis of preventive measures. Methodology The cross-sectional epidemiologic research was conducted at King Khalid University, Hospital with the recruitment of 205 participants. Each participant underwent a 30-question screening for depression, anxiety, and related risk factors. The "Hospital, Anxiety, and Depression Scale" (HADSscore) was used to score subjects for the assessment of both comorbidities. The data points were subsequently analyzed by descriptive statistics and regression analysis. Results Among 205 participants, 137 (66.82%) were male and 68 (33.17%) were female with a mean age of 59.71 years. Our sample reflects a prevalence of 52.7% depression and 56.9% anxiety in Saudi heart failure patients. High depression scores were positively related to age, female gender, hospital readmissions, and pre-existing comorbidities in heart failure patients. Conclusion The study manifested high depression scores among the Saudi heart failure cohort compared to the previous survey. In addition, a substantial interrelationship of depression and categorical variables has been identified that accentuates predominating risks that can potentially promote depression and anxiety in heart failure patients.

Restoring myocardial infarction-induced long-term memory impairment by targeting the cystic fibrosis transmembrane regulator.

Cognitive impairment is a serious comorbidity in heart failure patients, but effective therapies are lacking. We investigated the mechanisms that alter hippocampal neurons following myocardial infarction (MI). MI was induced in male C57Bl/6 mice by left anterior descending coronary artery ligation. We utilised standard procedures to measure cystic fibrosis transmembrane regulator (CFTR) protein levels, inflammatory mediator expression, neuronal structure, and hippocampal memory. Using invitro and invivo approaches, we assessed the role of neuroinflammation in hippocampal neuron degradation and the therapeutic potential of CFTR correction as an intervention. Hippocampal dendrite length and spine density are reduced after MI, effects that associate with decreased neuronal CFTR expression and concomitant microglia activation and inflammatory cytokine expression. Conditioned medium from lipopolysaccharide-stimulated microglia (LCM) reduces neuronal cell CFTR protein expression and the mRNA expression of the synaptic regulator post-synaptic density protein 95 (PSD-95) invitro. Blocking CFTR activity also down-regulates PSD-95 in neurons, indicating a relationship between CFTR expression and neuronal health. Pharmacologically correcting CFTR expression invitro rescues the LCM-mediated down-regulation of PSD-95. Invivo, pharmacologically increasing hippocampal neuron CFTR expression improves MI-associated alterations in neuronal arborisation, spine density, and memory function, with a wide therapeutic time window. Our results indicate that CFTR therapeutics improve inflammation-induced alterations in hippocampal neuronal structure and attenuate memory dysfunction following MI. Knut and Alice Wallenberg Foundation [F 2015/2112]; Swedish Research Council [VR; 2017-01243]; the German Research Foundation [DFG; ME 4667/2-1]; Hjärnfonden [FO2021-0112]; The Crafoord Foundation; Åke Wibergs Stiftelse [M19-0380], NMMP 2021 [V2021-2102]; the Albert Påhlsson Research Foundation; STINT [MG19-8469], Lund University; Canadian Institutes of Health Research [PJT-153269] and a Heart and Stroke Foundation of Ontario Mid-Career Investigator Award.

Cost-effective heart failure management: Meta-analysis of IV iron therapy in iron-deficient heart failure patients

BackgroundIron deficiency is an important co-morbidity in heart failure patients. IV iron may improve quality of life and reduce heart failure hospitalizations, but the results of the clinical trials are varied. ObjectiveThe purpose of this meta-analysis is to assess not only the effect of IV iron in iron-deficient heart failure patients but also the quality of evidence. MethodsPubMed and Cochrane databases were searched from inception to Oct 2021. Randomized clinical trials in iron-deficient, heart failure patients assessing the effect of IV iron versus placebo and with at least 12 weeks of follow-up were included. The outcomes were pooled and analyzed using a random-effect model. The quality of evidence was assessed using the GRADE approach. ResultsSeven studies were included in our meta-analysis. IV iron was associated with a 13.8 % decreased risk of HF hospitalizations (OR 0.59; 0.35–0.98, p = 0.040, GRADE = Low). All-cause mortality and CV mortality were not different between IV iron and placebo. But a composite outcome of HF hospitalizations or CV mortality was 17.5 % lower with IV iron (OR 0.51;0.31–0.84, p = 0.008, GRADE = Moderate). ConclusionsAmong heart failure patients with iron deficiency, IV iron is associated with lower HF hospitalizations. It is a relatively inexpensive regimen that can potentially improve quality of life and decrease healthcare expenditure.

Assessing The Clinical Benefits Of Iv Iron-only In Heart Failure Patients: A Meta-analysis

<h3>Introduction</h3> The cost of heart failure (HF) continues to be a huge burden on the healthcare system, with recurrent hospitalizations and mortality being major contributors.¹ Iron deficiency (ID) is a commonly undertreated comorbidity in HF patients, despite research showing its association with increased mortality and hospitalization rates.² <h3>Objective</h3> We aim to perform a meta-analysis of randomized controlled trials (RCT) assessing the clinical benefits of treating iron deficiency in heart failure patients. <h3>Methods</h3> We searched Pubmed, Cochrane, EMBASE and NIH databases from 2005-2020. The result was limited to RCT's comparing intravenous (IV) iron-only to placebo, in HF patients with ID. We identified 7 RCT's for inclusion.^3-9 Intervention used in selected trials was IV iron (iron sucrose or ferric carboxymaltose). The primary outcome was the incidence of HF hospitalization, and the secondary outcome was all-cause mortality at maximum follow-up time. A random-effects model was used. The bias of included studies was assessed using the Cochrane bias assessment for RCT's. The analysis was performed using Cochrane Revman version 5.3. <h3>Results</h3> Seven studies were included, with 2,164 participants (1,167 IV Iron group, 997 Placebo group). There were no significant differences in the baseline characteristics of the groups. Follow-up time ranged from 12-52 weeks. Compared to placebo, IV iron significantly reduces the odds of HF hospitalization events in HF patients with ID (OR: 0.54; 95% CI: 0.32 to 0.91; p=0.02) [Figure 1]. Rates of all-cause mortality in the IV iron group were no different than in the placebo group (OR: 0.92; 95% CI: 0.68 to 1.24; p=0.60) [Figure 2]. <h3>Conclusion</h3> Treatment with IV iron compared to placebo significantly reduces the incidence of HF hospitalization in HF patients with ID. Conversely, there was no mortality benefit with using IV iron over placebo in HF patients with ID. Our study represents the largest number of meta-analyzed patients and expands on the recent meta-analysis by Osman et al.¹⁰ by including all types of HF (HFpEF and HFrEF) patients. Further study of the use of IV iron with longer follow-up time is needed to further explore the clinical benefits of IV iron in HF patients with ID.

C61. Managing Acute Decompensated Heart Failure with Exacerbation of Chronic Obstructive Pulmonary Disease in Rural Area: A Case Report

Abstract Background COPD is one of the comorbidities in heart failure patients with a prevalence of around 10-41%. The mortality and morbidity increase in patients with concomitant HF and COPD. Case Description A-54-year-old man, smoker, complained dyspnea that worsen for 48 hours, orthopnea, worsening productive cough with thick phlegm for 1 week, diaphoresis, and fatigue. History of untreated COPD since 2014, dyslipidemia, heart attack, and hypertension since 2018. Examination: Obesity, HR 54x/min, RR 30 x/min, BP 140/90 mmHg, SpO2 96% on O2 4 lpm. JVP was increased, gallops, bilateral crackles, wheezing, and pre-tibial edema. WBC count was 15.000, Inferior OMI and LVH on ECG. Signs of pulmonary congestion, cardiomegaly, and increased Broncho-vascular pattern on chest X-ray. Echocardiography and cardiac marker testing were unavailable. The patient was diagnosed with ADHF and AECOPD. The patient was initially given furosemide IV, ramipril, spironolactone but didn’t improve. SABA-anticholinergic nebulization was added then and improved the symptoms. These medications were continued and added corticosteroid IV, antibiotics, aspirin in inward room. After 5 days of treatment, the patient improved, considered as outpatient and advised to control after 3 days. Discussion In the limited setting, manages patients with heart disease is challenging. History of untreated COPD, heart attack, hypertension, and dyslipidemia led the patient to this condition. There was no consensus in managing HF in the COPD population. Clinical consideration based on the dominant patient condition was suggested by some studies. This patient had significant improvement after combining diuretic, nebulization, and corticosteroid.

C61. Managing Acute Decompensated Heart Failure with Exacerbation of Chronic Obstructive Pulmonary Disease in Rural Area: A Case Report

Abstract Background COPD is one of the comorbidities in heart failure patients with a prevalence of around 10-41%. The mortality and morbidity increase in patients with concomitant HF and COPD. Case Description A-54-year-old man, smoker, complained dyspnea that worsen for 48 hours, orthopnea, worsening productive cough with thick phlegm for 1 week, diaphoresis, and fatigue. History of untreated COPD since 2014, dyslipidemia, heart attack, and hypertension since 2018. Examination: Obesity, HR 54x/min, RR 30 x/min, BP 140/90 mmHg, SpO2 96% on O2 4 lpm. JVP was increased, gallops, bilateral crackles, wheezing, and pre-tibial edema. WBC count was 15.000, Inferior OMI and LVH on ECG. Signs of pulmonary congestion, cardiomegaly, and increased Broncho-vascular pattern on chest X-ray. Echocardiography and cardiac marker testing were unavailable. The patient was diagnosed with ADHF and AECOPD. The patient was initially given furosemide IV, ramipril, spironolactone but didn’t improve. SABA-anticholinergic nebulization was added then and improved the symptoms. These medications were continued and added corticosteroid IV, antibiotics, aspirin in inward room. After 5 days of treatment, the patient improved, considered as outpatient and advised to control after 3 days. Discussion In the limited setting, manages patients with heart disease is challenging. History of untreated COPD, heart attack, hypertension, and dyslipidemia led the patient to this condition. There was no consensus in managing HF in the COPD population. Clinical consideration based on the dominant patient condition was suggested by some studies. This patient had significant improvement after combining diuretic, nebulization, and corticosteroid.

Non-cardiovascular comorbidities in heart failure patients and their impact on prognosis.

With the aging of the population and improvement of life expectancy of patients with heart disease, there is an increase in non-cardiovascular (CV) comorbidities affecting chronic heart failure (HF) patients. The increased prevalence of different CV and non-CV comorbidities is a rising problem in the management of patients with HF, mostly because these comorbidities may lead to poor prognosis, increase of hospitalizations and mortality rate. Recently, important data from multicenter randomized studies point to diabetes mellitus or iron deficiency as new pharmacological targets, and this highlights the need of broad expertise for the 21st-century cardiologist. The management of HF should take into account non-CV comorbidities. In this review, we discuss novel aspects of non-CV comorbidities in HF patients and emphasize the impact on prognosis.

Heart Failure Optimize Clinic: Improving Quality of Care In Heart Failure Patients In An Academic Medical Center

Background While heart failure (HF) is a leading cause of mortality and readmissions, only a small percentage of patients are optimized on guideline-directed medical therapy (GDMT). We developed a multidisciplinary HF clinic to optimize medications, provide education and resources and screen for medical co-morbidities in HF patients. Methods A multidisciplinary clinic composed of Advanced Practice Providers (APPs), pharmacist, nutritionists and nurses was developed and targeted patients with a 30-day HF readmission, ≥ 2 HF-related hospitalizations in last 12 months or new HF diagnosis. The OPTIMIZE clinic consisted of a total of 6 visits approximately two weeks apart seeing an APP at each visit along with pharmacy and nutrition evaluation. Echocardiographic, 6-minute walk, and health related quality of life (EQ5D) outcomes were measured at baseline and at the end of the 12 weeks. Results A total of 62 patients with heart failure with reduced ejection fraction (HFrEF) completed OPTIMIZE clinic over an average of 11.6 weeks. Patients were primarily white (62.3%) males (56.5%) with an average age of 59.1 (±15.3) years. HF etiology was primarily non-ischemic (65%) and patients had typical cardiac comorbidities - hypertension 54%, hyperlipidemia 33%, diabetes 23%, sleep apnea 15%, and chronic kidney disease 24%. Completion of OPTIMIZE clinic resulted in significant improvements in 6-minute walk distance, left ventricular ejection fraction (LVEF), and patient reported quality of life measures as assessed by the EQ5D along with significant reductions in brain natriuretic peptide (BNP) and left ventricular internal diameter in diastole (LVIDd) (Figure 1a). We also saw improved utilization of GDMT with completion of the OPTIMIZE clinic (Figure 1b). During the course of the clinic, only 7 (11%) patients were admitted for CHF exacerbation and 44 referrals were made to various other cardiology or internal medicine subspecialities, the most common being sleep clinic (14 referrals). A total of 13 (21%) patients had enough improvement in LVEF on GDMT as a result of this clinic that they no longer met criteria for implantable cardioverter defibrillator implantation. Conclusion Successful implementation of a multidisciplinary HF optimization clinic can help improve GDMT utilization, HF education, comorbidity recognition, and markers of HF severity. An OPTIMIZE clinic model can be considered in other centers as a way to increase GDMT optimization and improve clinical and functional markers of HF.

Prognostic Significance of Diastolic Dysfunction With Multiple Comorbidities in Heart Failure Patients.

BackgroundHeart failure poses a significant burden on health care and economy. In recent years, diastolic dysfunction has been increasingly recognized as a significant predictor of readmission in heart failure patients.ObjectivesWe aimed to identify factors predicting readmission in patients with clinical heart failure at 30 days and six months.MethodsA retrospective chart review was performed at a single urban medical center, including 208 patients in our final analysis.ResultsA higher Charlson comorbidity index (CCI) and moderate anemia (hemoglobin [Hb] < 10 g/dL) were significant predictors of readmission at both 30 days and six months. In addition, advanced chronic kidney disease (CKD) stage (4 or 5) and follow-up in a cardiology clinic were significant predictors at six months. During multivariate analysis, worsening diastolic dysfunction (grade 3 or 4) (OR: 2.09; 95% CI: 1.03 to 4.23), higher CCI (OR: 1.18; 95% CI: 1.03-1.36), and Hb < 10 g/dL (OR: 3.42; 95% CI: 1.44-8.13) were independent predictors of readmission at 30 days. Higher CCI (OR: 1.37; 95% CI: 1.19-1.58) and CKD stage 4 or 5 (OR: 3.05; 95% CI: 1.40-6.62) were independent predictors of readmission at six months.ConclusionsWorse diastolic dysfunction (grade 3 or 4) was a significant predictor of all-cause readmission at 30 days post-discharge in heart failure patients. Higher CCI precisely predicted readmission as an independent variable at 30 days and six months. Anemia (Hb < 10 g/dL) and CKD stage 4 or 5 were significant predictors of readmission at 30-days and six months, respectively.

Survival among Heart Failure Older Adults with Three Highest Impact Comorbidities in the United States

Introduction Heart failure (HF) mortality remains high in the United States in spite of the decline in HF incidence in recent decades. HF patients are more likely to suffer from multiple comorbidities, contributing to increased mortality. It is important to identify the most predictive comorbidities of mortality and promote treatment for HF patients with these comorbidities. Objective We describe the prevalence of several comorbidities in HF patients and quantify their impact on mortality. Methods Sample (31,126) included adult (50 + years of age) participants from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) and 2015 linked mortality data. Presence of HF is defined based on the subject's response to the question: ‘Have you ever been told by a physician that you had heart failure?’ Prediction of mortality among HF patients with comorbidities is obtained by using Cox proportional hazards regression, after the adjustment of gender, age, and race. Results The prevalence of self-reported comorbidity among 512 HF subjects is: emphysema (12.5%), kidney weakness or failure (13.1%), diabetes mellitus (34.8%), CHD (44.3%), stroke (20.9%), and anemia (11.7%). The HF subjects with the three highest impact commodities (emphysema, kidney weakening or failure, and diabetes mellitus) are associated with increased hazards of mortality compared to subjects without commodities. The hazard ratios (HR) and 95% confidence intervals (CI) are: emphysema (1.87: 1.35-2.60), kidney weakness or failure (1.50: 1.08-2.08), and diabetes mellitus (1.42: 1.12-1.80). Subsequently, subjects are classified into 4 groups according to these 3 comorbidities and their hazard of mortality is compared. Group 1 is the reference group consisting of subjects without any of the three comorbidities. Group 2 consists of subjects with all three comorbidities. Group 3 consists of subjects with emphysema only. Group 4 consists of subjects without emphysema. The three groups each have a significantly higher hazard of mortality than the reference group, with HR and 95% CI as 5.07 (1.22, 21.0), 1.99 (1.31, 3.03) and 1.59 (1.08, 2.36), respectively. Conclusion Three comorbidities, emphysema, kidney weakness or failure, and diabetes mellitus, are considered to be the major predictors of mortality in HF subjects. Health providers should prompt care for the three comorbidities in order to improve survival in HF patients.

Sleep apnea detection by a cardiac resynchronization device integrated thoracic impedance sensor: A validation study against the gold standard polysomnography.

BackgroundSleep disordered breathing is a common but often undiagnosed comorbidity in heart failure patients. Cardiac implantable electronic devices used for cardiac resynchronization therapy (CRT) may detect sleep apnea by use of a transthoracic impedance sensor. Validation of the AP scan® algorithm (Boston Scientific®) was performed by using the diagnostic gold standard polysomnography (PSG).MethodsForty-one patients with impaired left ventricular ejection fraction, frequent right ventricular pacing due to atrioventricular block and heart failure symptoms despite optimal medical therapy underwent upgrading to biventricular pacing. Within one month after left ventricular lead implantation, sleep apnea was assessed by single-night PSG and AP scan® measurements.ResultsAP scan® measurements were valid in only 21 of 41 (51.2%) patients in the index night of the PSG. The PSG determined apnea-hypopnea index did not correlate statistically significant with the AP scan® measurements (r = 0.41, 95% confidence interval -0.05–0.72, p = 0.07). The degree of overestimation is displayed by using the Bland-Altman method: mean difference -12.4, standard deviation ± 15.8, 95% confidence interval -43.3–18.6.ConclusionsIn heart failure patients receiving CRT upgrading, the AP scan® algorithm may need further improvement before it can be recommended for sleep apnea detection.

Diagnosis of sleep apnea in patients with stable chronic heart failure using a portable sleep test diagnostic device.

ApneaLink is a portable device for the screening of sleep apnea, a prevalent and underdiagnosed comorbidity in heart failure patients. A prospective cross-sectional study in patients with chronic heart failure was carried out to assess the sensitivity and specificity of apnea-hypopnea index (AHI) measurements using ApneaLink against the standard polysomnography test. Adult patients with a prior hospitalization in an acute heart failure hospital unit were recruited for the study. All participants were tested for sleep apnea using ApneaLink and polysomnography simultaneously during an overnight stay at a sleep laboratory. Global sleep apnea was evaluated according to the AHI, which was analyzed and compared. Subpopulation comparison based on ejection fraction was not realized due to population size. Thirty-five patients with stable chronic heart failure completed the study (mean age 70.9 ± 10.5years and body mass index 30.0 ± 4.7kg/m2). Two patients were excluded due to insufficient study duration. ApneaLink had a sensitivity greater than 80% for all AHI measurements, and a specificity greater than 80% for all AHI measurements, except for AHI ≥ 5 events/h (61.5%). The results showed higher sensitivities and specificities at AHI values of ≥ 10 events/h (sensitivity 81.3% and specificity 84.2%) and ≥ 15 events/h (sensitivity 83.3% and specificity 91.3%). Correlation analysis showed that AHI measurements using ApneaLink and polysomnography had a strong and significant correlation (r = 0.794; P < 0.001). Our results suggest that ApneaLink could be used in clinical practice to identify heart failure patients with high (AHI ≥ 15 events/h) and low (AHI < 5 events/h) probability of having sleep apnea, sparing the need for a diagnostic polysomnography and thus potentially impacting prognosis by providing a more cost-effective and timely diagnosis of this non-cardiac comorbidity.

Patients with heart failure and concomitant chronic obstructive pulmonary disease participating in the Heart Failure Pilot Survey (ESC-HF Pilot) - Polish population.

IntroductionThere is an increasing interest in comorbidities in heart failure patients. Data about chronic obstructive pulmonary disease (COPD) in the Polish population of heart failure (HF) patients are scarce. The aim of this study was to investigate the clinical characteristics, treatment differences and outcome according to COPD occurrence in the Polish population of patients participating in the ESC-HF Pilot Survey Registry.Material and methodsWe analyzed the data of 891 patients with HF recruited in 2009–2011 in Poland: 648 (72.7%) hospitalized patients and 243 (27.3%) patients included as outpatients.ResultsThe COPD was documented in 110 (12.3%) patients with HF in the analyzed population. Patients with – compared to those without COPD were older, more often smokers, had higher NYHA class, and higher prevalence of hypertension. Ejection fraction (EF) was higher in hospitalized patients with COPD compared to patients without COPD (40.5 ±14.6% vs. 37.2 ±13.7%, p < 0.04), without a significant difference in the outpatient group. There was a significant difference in β-blocker use between patients with and without COPD (81.8% vs. 94.7%, p < 0.0001). Most patients received them below target doses. At the end of the 12-month follow-up, there was no significant difference in mortality between COPD and no-COPD patients (10.9% vs. 11.1%, p = 0.66).ConclusionsThe findings from the Polish part of the ESC-HF registry indicate that COPD in patients with HF is associated with older age, smoker status, hypertension and higher NYHA class. The use of β-blockers was significantly lower in patients with than without COPD. There were no significant differences in mortality between groups.

Increased comorbidities in heart failure patients ≥ 85 years but declined from > 90 years: Data from the Swedish Heart Failure Registry

ObjectivesEpidemiological studies of elderly heart failure (HF) patients (≥85years) are limited with inconsistent findings. Our objective is to confirm and extend epidemiological study in elderly (≥85years) patients using the Swedish Heart Failure Registry database. MethodsThis retrospective study included 8,347 HF patients aged ≤65years and 15,889 HF patients aged ≥85years. Elderly population was further divided into two subgroups: 11,412 patients were 85–90years and 4,477 patients were >90years. ResultsThe ≥85year group was characterized by more women, higher systolic blood pressure (SBP), lower body-mass index (BMI), more than twice as many HF with normal left ventricular ejection fraction (HFNEF), higher incidence of cardiovascular and non-cardiovascular comorbidities and less use of proven therapeutics compared with the ≤65year group. Compared with the 85–90year subgroup, the >90year subgroup had a decline in cardiovascular and non-cardiovascular comorbidities except renal insufficiency and anaemia which continued to increase with ageing (p<0.01). Tendency was the same regardless of gender but slightly different between systolic HF (SHF) and HFNEF. In the group with HFNEF, there were more women, higher SBP, lower N-terminal pro-B-type natriuretic peptide levels, less ischaemic heart disease, more hypertension and left bundle branch block regardless of age. Atrial fibrillation was more frequent in patients with HFNEF than with SHF in the elderly group (p<0.01). Patients with HFNEF in the >90year subgroup had increasing incidence of ischaemic heart disease compared to 85–90year group (p<0.01). ConclusionsHF patients ≥85years had increased cardiovascular and non-cardiovascular comorbidities but with a decline from >90years.

Heart failure comorbidities at the end of life

To review the impact of comorbidity in heart failure patients who are approaching the end of life and consider current treatment options in alleviating symptom burden. Renal failure, respiratory disease, anaemia, cognitive impairment, falls and urinary incontinence are common comorbidities in heart failure patients approaching the end of life. This review describes the impact of these comorbidities and gives practical advice to aid clinicians in their management. Limited evidence exists for how best to manage the majority of comorbidities in heart failure patients at the end of life. As a result a comprehensive assessment and a patient-centred approach should be sought. Prevention of many complications such as falls or delirium is likely to be possible with this approach and hence reduce the burden of these problems at the end of life.

Metabolic remodelling in human heart failure

In addition to the typical abnormalities in myocardial structure and function, it is well established that the cardiac metabolism is abnormal in patients with heart failure (HF). Insulin resistance is a common co-morbidity in HF patients and also modulates cardiac metabolism in HF. The notion that an altered myocardial metabolism may contribute to the disease pathogenesis and optimizing it may serve therapeutic purposes underscores the importance of identifying the metabolic characteristics of HF patients. In this paper, the literature on the metabolic changes in human HF is reviewed, and the effects of metabolic modulators on patients with HF are discussed.

Herzinsuffizienz und Komorbiditäten

Noncardiac Comorbidities are frequent and may be overlooked during routine CHF management. They have great impact on hospitalisations and mortality. The most important comorbidities in heart failure patients are renal insufficiency, diabetes mellitus, chronic obstructive pulmonary disease, sleeping disorders like obstructive and central apnea syndrom, and anemia. The most powerful predictor for mortality is renal insufficiency. It's important to recognize the different causes of renal failure. Defining the volume status and the cardiac output is crucial for the guidance of therapy. The management of diuretic resistance is of special interest and often challenging. Diabetes mellitus is an independent risk factor for heart failure. The benefit of ACE inhibitors and Angiotensin receptor blockers for HF and DM is accepted. The management of Diabetes in HF depends on side-effect profiles of the numerous anti-diabetic drugs. Metformin is safe even in HF patients. Thiazolidinediones should be avoided in NYHA class III/IV because of fluid retention. In COPD patients there is an underuse of betablockers and the prediction of mortality with this comorbidity could be partially caused by that. The principle goal of treatment of sleeping disorders is to avoid hypoxia during night. CPAP therapy improves live quality and HF symptoms. Anemia is often diagnosed, the best therapy - erythropoetin plus iron or iron alone - remains controversial. Iron supplementation without anemia could be an option for better quality of life. To handle all these comorbidities in heart failure patients becomes more and mor complex. Heart failure nurses can help us to manage these growing population.

Management of Anemia and Iron Deficiency in Heart Failure

Anemia is independently associated with an increased risk of mortality and morbidity in patients with heart failure (HF). The diagnosis of anemia should prompt assessment of the underlying cause(s), first by using routine laboratory measurements (i.e., serum creatinine and estimated glomerular filtration rate [eGFR], serum iron, transferrin saturation, ferritin, vitamin B12, folic acid, and thyroid stimulating hormone). In clinical practice, it remains unclear whether using levels of the soluble transferrin receptor in HF patients to assess iron deficiency is warranted. Further investigation should follow these simple tests when judged appropriate (e.g., if occult gastrointestinal blood losses are suspected). Hemodilution may contribute significantly to anemia in patients with advanced HF and may be suspected when signs of hypervolemia are present. Euvolemia should be the first goal in such cases (as always), followed by optimization of the disease-modifying therapies used in HF (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, or aldosterone antagonists and cardiac resynchronization therapy in selected cases). Erythropoiesis-stimulating agents (ESA) can be used to improve functional capacity in patients with significant chronic kidney disease (CKD), a frequent comorbidity in HF patients. ESA and iron therapy is recommended in patients with moderate-to-severe CKD (eGFR < 60mL/min/1.73m(2)), with a target hemoglobin level of 11.0g/dL. In a recent randomized, placebo-controlled clinical trial, weekly administration of intravenous iron significantly improved symptoms, New York Heart Association class, quality of life, and exercise capacity in both anemic and non-anemic HF patients. A trend toward fewer hospitalizations was seen in the group treated with intravenous iron. The rates of adverse events were similar in the treatment and the placebo groups. Larger-scale and longer-term studies are needed to establish the safety and efficacy profile of intravenous iron in non-CKD HF patients and in HF patients without anemia. Studies designed to further unravel the pathophysiology of anemia in HF are essential in order to determine 1) novel treatment targets and 2) whether and how the treatment of anemia could improve outcomes.

Relationship of Paroxysmal Atrial Tachyarrhythmias to Volume Overload

Background— Clinical experience suggests that atrial tachyarrhythmias (ATs) are a frequent comorbidity in heart failure patients with left ventricular systolic dysfunction and that volume overload may increase AT susceptibility. However, substantiating this apparent relationship in free-living patients is difficult. Recently, certain implantable cardioverter-defibrillators provide, by measuring transpulmonary electric bioimpedance, an index of intrathoracic fluid status (OptiVol index [OI]). The goal of this study was to determine whether periods of greater intrathoracic fluid congestion (as detected by OI) correspond with increased AT event frequency. Methods and Results— This analysis retrospectively assessed the relation between AT events and OI estimate of volume overload in patients with left ventricular systolic dysfunction and OI-capable implantable cardioverter-defibrillators. OI values were stratified into 3 levels: group 1, &lt;40; group 2, 40 to 60; and group 3, &gt;60. An OI threshold-crossing event was defined as OI≥60, a value previously associated with clinically significant volume overload. Findings in 59 patients (mean left ventricular ejection fraction, 24%) with 225 follow-up visits (mean, 3.8 visits per patient) were evaluated. AT prevalence was 73%. AT frequency (percent of patients visits with at least 1 episode of AT since previous device interrogation) was greater in group 3 versus group 1 ( P =0.0342). Finally, in terms of temporal sequence, AT episodes preceded OI threshold-crossing event in 43% of incidences, followed threshold-crossing event in 29%, and was simultaneous or indeterminate in the remainder. Conclusions— These findings not only support the view that worsening pulmonary congestion is associated with increased AT frequency in patients with left ventricular dysfunction but also suggest that AT events may be responsible for triggering episodic pulmonary congestion more often than previously suspected.