Management of Comorbid Conditions in Heart Failure: A Review
Introduction
Heart failure is a chronic and progressive condition, and is a major cause of morbidity and mortality worldwide. More than 5.8 million people in United States have a diagnosis of heart failure, and the estimated annual cost of heart failure is around US$37.2 billion.2 Recent insights have emerged to show that heart failure is a complex clinical condition, particularly in the elderly, that usually interacts with other chronic medical conditions via known and possibly yet unknown mechanisms. This review discusses the common comorbid conditions, their interactions with heart failure, and treatment options. Several major comorbidities that are important in management of heart failure, such as cardiorenal syndrome, atrial fibrillation, and malignancy, are discussed in reviews elsewhere in this issue and are therefore not discussed here.
Section snippets
Epidemiology of comorbid conditions in heart failure
The prevalence of comorbid conditions in heart failure varies depending on study population and severity of heart failure. It may also vary secondary to different definitions used in different studies. In a large cross-sectional study involving 122,630 US Medicare beneficiaries who have heart failure and are 65 years or older, Braunstein and colleagues3 examined the relationship of 20 most common noncardiac comorbidities to potentially preventable hospitalizations and total mortality at 1 year.
Diabetes mellitus
Diabetes mellitus is an independent risk factor for the development of heart failure, which was clearly demonstrated in the Framingham Heart Study involving 5209 subjects.6 Study investigators noted a 2-fold increase in incidence of heart failure in men and a greater than 5-fold increase in women during a 20-year surveillance. A large, prospective, observational trial from the United Kingdom (UK Prospective Diabetes Study) involving 3642 patients showed that the risk of heart failure decreased
Hypertension
Hypertension is one of the two major causes of heart failure.17 The other cause, coronary artery disease, most often coexists with or is secondary to hypertension, making hypertension the most common risk factor for heart failure. Data suggest that up to 75% of patients with heart failure may have antecedent hypertension.2 Hypertension as a risk factor for heart failure was demonstrated in a large study that included 5143 subjects aged 40 to 89 years and a mean follow-up of longer than 14 years.
Hyperlipidemia
Advanced heart failure is commonly perceived as a cachectic disease. However, a history of hyperlipidemia is among the top 5 comorbid conditions in patients with heart failure. Hyperlipidemia is not a predictor of poor prognosis in patients with heart failure, and elevated cholesterol levels were paradoxically associated with a better survival rate. This phenomenon is called reverse epidemiology.24 Meanwhile, the use of statin therapy in patients with heart failure has been explored. The
Chronic obstructive pulmonary disease
COPD is a frequent comorbidity in patients with heart failure, with prevalence ranging from 20% to 30%. COPD and heart failure share common risk factors such as smoking and age. Smoking causes local airway inflammation leading to airway obstruction, but at same time can cause systemic inflammation and endothelial dysfunction. Another hypothesis is that COPD itself causes low-grade systemic inflammation29 and hence may play an important role in the progression of cardiovascular disease. Because
Sleep-disordered breathing
Sleep-disordered breathing (SDB) is recently gaining recognition in the heart failure literature. The 2 forms of SDB are obstructive sleep apnea (OSA) and central sleep apnea (CSA). The incidence of sleep apnea is likely to increase because of increasing obesity and aging of the general population, while there has been a long-standing association between advanced heart failure and CSA (“Cheyne-Stokes breathing”). There are multiple mechanisms through which OSA may affect the cardiovascular
Anemia
The prognostic significance of anemia in multiple other disease states is well established. Prevalence varies widely among studies depending on the definition of anemia and the severity of underlying heart failure. Groenveld and colleagues44 examined the role of anemia in a large meta-analysis involving 153,180 patients with heart failure; 37.2% of the patients were anemic and crude mortality was significantly higher in anemic patients (odds ratio, 1.96; 95% CI, 1.72–2.21). This difference was
Obesity
Increasing body mass index (BMI) increases the risk of developing heart failure, which could be due to coexisting cardiovascular risk factors in obese subjects. However, BMI is also known to be an independent risk factor for heart failure. This was demonstrated in 5881 patients from the Framingham Heart Study, in whom there was a 5% to 7% increase in risk of heart failure for every unit increase in BMI.50 In fact, obesity-related cardiomyopathy (adipositas cordis) was described as early as 1818
Dementia and depression
Both dementia and heart failure are diseases of old age. There is mounting evidence that heart failure could lead to cognitive impairment in the elderly. This was described even decades ago as “cardiogenic dementia.”55 The possible mechanisms are chronic cerebral hypoperfusion and possible microembolism from the heart. Also, vascular risk factors associated with heart failure are known to cause vascular dementia, which is the second most common form of dementia after Alzheimer dementia. The
Summary
Multiple comorbidities are common in patients in heart failure. Some of them could contribute to the underlying development of heart failure, whereas others may lead to disease progression and may be associated with poor prognosis. It is not only important to diagnose these comorbid conditions early, but also vital to treat such conditions appropriately, which may have a huge impact on the primary disease itself. This review has covered the common conditions, but there are multiple other
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