Comorbidities in Patients With Heart Failure: Treating the Whole Patient

Patients with heart failure tend to have other health issues, requiring cardiologists to understand how to care for heart failure while keeping in mind treatment for these other comorbidities, said panelists at the European Society of Cardiology Congress 2017, held August 26-30 in Barcelona, Spain.

Comorbidities are important to remember, emphasized Petar M. Seferović, MD, PhD, FACC, FESC, of the University of Belgrade, who outlined treatments for patients who also have diabetes. Cardiovascular disease is a major burden on patients with diabetes and heart failure is among the most frequent of cardiovascular issues.

“It’s important for us to understand that we need to teach … diabetes and heart failure should be looked at as 2 sides of 1 coin and that the patient should be more carefully taken care of regarding diagnosis and treatment,” Seferović said.

Luckily, this is an exciting time for new diabetes treatments, particularly those that aim to improve cardiovascular outcomes. While lifestyle modification, smoking cessation, and blood pressure and cholesterol control are all important, so is glucose control, and Seferović outlined diabetes treatments to lower A1C and what has been shown about their impact on cardiovascular risks.

Insulin has been associated with an increased incidence of heart failure and a higher mortality, and thiazolidinediones have shown to worsen heart failure risk, and should not be used, Seferović explained. However, metformin, which is frequently used and cheap, is linked with favorable cardiovascular outcomes.

Of the newer medications, dipeptidyl peptidase 4 inhibitors, such as sitagliptin, are not recommended in patients with heart failure, while liraglutide, a glucagon-like peptide-1 receptor agonist, has shown reduced death from cardiovascular causes and all causes, as well a reduction in hospitalizations from heart failure, Seferović said.

The really interesting area, though, is the sodium-glucose co-transporter-2 inhibitors, namely empagliflozin. The EMPA-REG trial “was important and caused a lot of excitement,” he said, because it was the first trial that showed improved cardiovascular outcomes in patients with diabetes.

“Cardiologists are happy to see the hospitalization for heart failure be less in patients,” Seferović said.

Another comorbidity that is important to consider is sleep apnea. Martin R. Cowie, MD, MSc, FRCP, FESC, of Imperial College London, explained that patients with sleep apnea have a decreased quality of life stemming from fatigue and sleepiness during the day, which can impact their work hours. The leading treatment is continuous positive airway pressure (CPAP), but the jury is still out on how it affects patients with cardiovascular disease.

A small randomized trial in patients with obstructive sleep apnea had found there was no difference in cardiovascular disease outcomes, but patients were less sleepy, had improved mental health, fewer work days lost, and better quality of life.

However, in patients with central sleep apnea (CSA), which is slightly different and not marked by sleepiness during the day, there isn’t a physical obstruction that prevents someone from breathing normally—instead, the brain doesn’t send the right signals to the muscles controlling breathing.

In a large study using CPAP in patients with CSA, the researchers found that there were more cardiovascular events, as well as some evidence of an increased cardiovascular death rate. According to Cowie, current therapies for CSA haven’t been able to reduce risks of heart failure, but more importantly, it isn’t worth the risk to try treating CSA for patients with heart failure.

The take away, Cowie said, is to “treat the heart failure as best as you can; don’t try to treat the sleep apnea.”

Ewa A. Jankowska, MD, PhD, FESC, FHFA, of Wrocław Medical University, outlined the complication of addressing iron deficiency in patients with heart failure. Iron deficiency is prevalent in chronic heart failure and it leads to anemia, which is a predictor of a poor outcome for these patients. However, iron deficiency on its own actually has a greater impact.

“When we judge independently, the impact of anemia itself and iron deficiency on symptoms on survival … you may be surprised that the impact of iron deficiency itself, without anemia, is much more important than anemia itself,” she explained.

Iron is needed for proper energy metabolism and is present in all tissues and cells. Patients with iron deficiency have lower peak oxygen consumption levels, which reduces their exercise capacity. A study of failing hearts has found that they do not have enough iron.

Physicians can detect iron deficiency by testing for ferritin, which indicates how much iron is in a body. Ferritin is involved with iron metabolism and is related to the storage of intracellular iron.

One treatment is intravenous iron, which was studied in the FAIR-HF trial that included patients with iron deficiency who had been anemic as well as those who had not been anemic. The trial found clinical improvement in all patients.

There are 4 currently ongoing morbidity and mortality trials—AFFIRM-AHF, FAIR-HF-2, HEAD-FID, IRONMAN—using intravenous iron in patients with heart failure.

Finally, Mark Pfeffer, MD, PhD, of Harvard Medical School and Brigham & Women’s Hospital, discussed kidney dysfunction in patients with heart failure. He explained that a young person on dialysis has the mortality rate of an 80-year-old who is not on dialysis. In general, someone with kidney disease, who has not progressed as far as dialysis, has a cardiovascular risk of death that is equivalent to that of a 60- to 70-year-old person.

“If you have chronic kidney disease … no one Is surprised that you’re more likely to develop heart failure, have coronary heart disease, and have stroke,” Pfeffer said.

The problem is that there are factors that make medications not work as they’re supposed to. For instance, as kidneys fail, they no longer remove potassium or creatinine. Rising levels of both of these prevents physicians from giving more of a therapy or increasing doses for patients with heart failure.

There are therapies on the horizon that would combat the high levels of potassium, but it is still unclear at this point if they would allow physicians to prescribe more of a medication.

Pfeffer concluded by reminding the audience that the diseases all go together and impact treatment—cardiologists aren’t just treating a patient’s heart failure, they are also treating the patient’s other diseases.

“We should understand that it’s 1 patient, and look at the whole patient,” he said.