From side player to centre stage: The role of co-morbidities in heart failure

Heart Failure 2016 Congress News

Comorbidities have moved from a secondary consideration to one of the most important factors when planning heart failure management, delegates will hear this morning in a session focusing on this key aspect of the disease.

This is the message from the comorbidities section of the new ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, which comes under the spotlight in a dedicated symposium today chaired by Petar Seferovic (Belgrade University School of Medicine, Serbia) and Frans Rutten (University Medical Center Utrecht, the Netherlands).

Speaking to Heart Failure Congress News, Prof. Seferovic said that “no patient with heart failure is a simple patient” and, as a consequence, comorbidities “are probably one of the most important aspects of the diagnosis and treatment of heart failure”.

He explained that “one of the major tasks” facing clinicians first of all is to adequately diagnose heart failure, followed by appropriate treatment, both of which may be complicated by a patient’s comorbidities. Once identified, there are several factors to take into account.

The first is that comorbidities may affect where a patient is referred to, which may be the wrong specialist. For instance, patients with chronic obstructive pulmonary disease (COPD) may be referred to a pulmonolgist, although the cause of their ‘exacerbation’ is heart failure.

The second important issue is the effect of treatments for heart failure. One example would be the use of renin—angiotensin system inhibitors alongside diuretics in patients with both heart failure and renal dysfunction, which requires careful dose balancing and regular monitoring.

The third aspect is that some treatment for comorbidities may exacerbate the patient’s heart failure. “The best example, and the most frequent in clinical practice, is the use of non-steroidal anti-inflammatory drugs for arthritis,” Prof. Seferovic said. “If they are used concomitantly with heart failure treatment, they may worsen the heart failure.”

Also, drugs used for comorbidities and heart failure may interact with each other. A common example is the use of beta antagonists for the treatment of COPD and asthma alongside beta blockers. “If you use both drugs, you are practically playing with neurohormonal activation, giving drugs that can be inhibiting and activating the sympathetic nervous system,” he said.

Another aspect is that comorbidities may be associated with worse clinical status, and may predict heart failure prognosis. Prof. Seferovic said: “Therefore, it is very important for us to identify them when we admit a patient with any form of heart failure for the first time.”

Prof. Seferovic emphasised that the most important co-morbidities include diabetes, hypertension and angina pectoris/ischaemic heart disease. “These three are very important to recognise early,” he said, as the basic therapeutic strategy of heart failure is that of etiological treatment. “So if we can treat heart failure etiologically, our long-term outcomes will be better,” he added.

Other notable heart failure comorbidities that will be reflected in the new guidelines include iron deficiency, alongside COPD, gout, hyperlipidaemia, cancer, cachexia and depression. “Sometimes we put erectile dysfunction within the same frame, and sometimes so-called ‘cardiorenal syndrome’,” Prof. Seferovic said.

He summarised the importance of comorbidities by stressing that, with improvements in our understanding of the pathogenesis of heart failure, comorbidities have gone from being “looked on as a side player to something which was found to be the most important etiological factor in the development of heart failure”.

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