Managing Comorbidity in Heart Failure

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Managing Co-morbidity in Heart Failure? Dr Brian
ORourke Hairmyres Hospital
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Co-morbidity in CHF

• Little interest!
• Many excluded from RCTs
• Publication bias
• 40 gt5 non-cardiac co-morbidities
• Often leads to under-treatment

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Top ten

• Chronic obstructive pulmonary disease 26
• Osteoarthritis 16
• Diabetes mellitus 14
• Thyroid disease 14
• Dementia 9
• Depression 8
• Renal impairment 8
• Asthma 5
• Osteoporosis 5
• Anxiety neurosis 3

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Respiratory Disease

• Common mis-diagnosis
• Investigate as suspected, Chest X-ray, PFTs
• ß-blockers usually well tolerated
• High prevalence of sleep disordered
  breathing -do you snore? -do fall asleep
  during the day?

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Nocturnal CPAP
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Renal impairment

• 8.3 acute or chronic
• Serum creatinine gt133µmol/l or
  Creatinine clearance lt60mls/min
• Multi-factorial aetiology -renovascular
  disease -hypertension -diabetes -dr
  ug induced -obstructive
• Poorer response to drugs
• More side effects

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Some nephrotoxic drugs.

• ACE inhibitors
• Angiotensin receptor antagonists
• Diuretics
• Spironolactone
• NSAIDs

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ACE inhibitor use.

• Caution if creatinine raised
• Avoid if Creatinine gt200µmol/l
• Start low, go slow
• Stop other nephrotoxic drugs if possible

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Anaemia

• Prevalence 4-55
• WHO definition men lt13g/dl females lt12g/dl
• Incidence increases with NYHA class
• Aetiology varied -renal impairment -marrow
  hypoperfusion -blood loss -malnutrition
  -haemodilution
• Haematinics/red cell indices
• STAMINA-HeFT

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Diabetes mellitus

• Increasing prevalence
• Common in CHF population
• Drugs may impair glucose tolerance
• High incidence of vascular disease
• Caution with metformin/pioglitazone

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Polypharmacy

• Average 6.8 drugs (10.1 daily doses)
• Caution with interactions
• Aware of large range of side effects
• Collaborative approach useful
• Minimise less necessary prescriptions

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In summary..

• Co-morbidity common
• More frequent monitoring
• Involve appropriate specialists
• Keep open mind
• Try to be realistic!