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The Comorbidity Conundrum: A Focus on the Role of Noncardiovascular Chronic Conditions in the Heart Failure Patient

  • Congestive Heart Failure (J Lindenfeld, Section Editor)
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Abstract

The rapid aging of the US population combined with improvements in modern medicine has created a new public health concern of comorbidity, a chronic condition that co-exists with a primary illness. Over 141 million Americans suffer from one or more comorbid conditions. In the heart failure (HF) patient, this comorbidity burden is particularly high, with over 40% of patients having five or more chronic conditions. These comorbidities can vary from being a risk factor to a cause of HF progression or even a precipitating factor for decompensation. Comorbidities, particularly the noncardiovascular conditions, have been associated with greater health resource utilization, poor health outcomes, and increased mortality. To minimize the negative impact that these comorbidities have on patient outcomes, appropriate attention should be paid to identifying, prioritizing, and managing each condition; minimizing medication complexity and polypharmacy; and improving overall coordination of care between providers and patients.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Johns Hopkins School of Public Health. Chronic Conditions: Making the Case for Ongoing Care 2010. Available at http://www.rwjf.org/files/research/50968chronic.care.chartbook.pdf. Accessed December 2011. This is an excellent resource from Johns Hopkins that addresses all comorbidity within the United States utilizing multiple large data sources.

  2. Anderson G, Horvath J. The growing burden of chronic disease in America. Public Health Rep. 2004;119:263–70.

    Article  PubMed  Google Scholar 

  3. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269–76.

    Article  PubMed  Google Scholar 

  4. Marengoni A, Rizzuto D, Wang HX, et al. Patterns of chronic multimorbidity in the elderly population. J Am Geriatr Soc. 2009;57:225–30.

    Article  PubMed  Google Scholar 

  5. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics–2011 update: a report from the American Heart Association. Circulation. 2011;123:e18–e209.

    Article  PubMed  Google Scholar 

  6. •• Metra M, Zaca V, Parati G, et al. Cardiovascular and noncardiovascular comorbidities in patients with chronic heart failure. J Cardiovasc Med (Hagerstown). 2011;12:76–84. Published on behalf of the Heart Failure Study Group of the Italian Society of Cardiology, this is the most comprehensive review of the epidemiological, pathophysiological, and clinical characteristics of comorbidities as they impact HF treatment..

    Article  Google Scholar 

  7. Masoudi FA, Krumholz HM. Polypharmacy and comorbidity in heart failure. BMJ. 2003;327:513–4.

    Article  PubMed  Google Scholar 

  8. Brunner-La Rocca HP, Buser PT, Schindler R, et al. Management of elderly patients with congestive heart failure--design of the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF). Am Heart J. 2006;151:949–55.

    Article  PubMed  Google Scholar 

  9. Lang CC, Mancini DM. Non-cardiac comorbidities in chronic heart failure. Heart. 2007;93:665–71.

    Article  PubMed  Google Scholar 

  10. •• Ahluwalia SC, Gross CP, Chaudhry SI, et al. Change in comorbidity prevalence with advancing age among persons with heart failure. J Gen Intern Med. 2011;26:1145–51. Using Medicare beneficiaries, this is the first study to evaluate the impact of age on comorbidity burden..

    Article  PubMed  Google Scholar 

  11. •• Ahluwalia SC, Gross CP, Chaudhry SI, et al. Impact of comorbidity on mortality among older persons with advanced heart failure. J Gen Intern Med. 2011. Available at: http://www.springerlink.com/content/u838377v8wg07031/fulltext.pdf. Accessed December 2011. Using Medicare beneficiaries, these data provide the impact that comorbidities have on mortality in both hospitalized and nonhospitalized patients with HF.

  12. Braunstein JB, Anderson GF, Gerstenblith G, et al. Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure. J Am Coll Cardiol. 2003;42:1226–33.

    Article  PubMed  Google Scholar 

  13. • Wong CY, Chaudhry SI, Desai MM, Krumholz HM. Trends in comorbidity, disability, and polypharmacy in heart failure. Am J Med. 2011;124:136–43. Using NHANES data, these data describe the increase in comorbidity and medication burden over the past two decades in patients with HF..

    Article  PubMed  Google Scholar 

  14. Druss BG, Marcus SC, Olfson M, et al. Comparing the national economic burden of five chronic conditions. Health Aff (Millwood). 2001;20:233–41.

    Article  CAS  Google Scholar 

  15. Lee DS, Donovan L, Austin PC, et al. Comparison of coding of heart failure and comorbidities in administrative and clinical data for use in outcomes research. Med Care. 2005;43:182–8.

    Article  PubMed  Google Scholar 

  16. Schneider KM, O'Donnell BE, Dean D. Prevalence of multiple chronic conditions in the United States' Medicare population. Health Qual Life Outcomes. 2009;7:82.

    Article  PubMed  Google Scholar 

  17. Page 2nd RL, Strongin K, Millis R, Hogan C, Lindenfeld J. Medicare beneficiaries with mild to severe heart failure See 15–23 different providers annually. Circulation. 2008;118:S_1030.

    Google Scholar 

  18. Masoudi FA, Baillie CA, Wang Y, et al. The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998–2001. Arch Intern Med. 2005;165:2069–76.

    Article  PubMed  Google Scholar 

  19. Goldberg RM, Mabee J, Chan L, Wong S. Drug-drug and drug-disease interactions in the ED: analysis of a high-risk population. Am J Emerg Med. 1996;14:447–50.

    Article  PubMed  CAS  Google Scholar 

  20. Redelmeier DA, Tan SH, Booth GL. The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med. 1998;338:1516–20.

    Article  PubMed  CAS  Google Scholar 

  21. Page RL 2nd, Strongin K, Millis R, Hogan C, Lindenfeld J. The magnitude of health care resource utilization by Medicare beneficiaries with heart failure. Circulation. 2007;116:II-600.

    Google Scholar 

  22. Zhang JX, Rathouz PJ, Chin MH. Comorbidity and the concentration of healthcare expenditures in older patients with heart failure. J Am Geriatr Soc. 2003;51(4):476–82.

    Article  PubMed  Google Scholar 

  23. Oudejans I, Mosterd A, Zuithoff NP, Hoes AW. Comorbidity drives mortality in newly diagnosed heart failure: a study among geriatric outpatients. J Card Fail. 2012;18:47–52.

    Article  PubMed  Google Scholar 

  24. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    Article  PubMed  CAS  Google Scholar 

  25. Clarke B, Howlett J, Sapp J, et al. The effect of comorbidity on the competing risk of sudden and nonsudden death in an ambulatory heart failure population. Can J Cardiol. 2011;27:254–61.

    Article  PubMed  Google Scholar 

  26. Chaudhry SI, Wang Y, Gill TM, Krumholz HM. Geriatric conditions and subsequent mortality in older patients with heart failure. J Am Coll Cardiol. 2010;55:309–16.

    Article  PubMed  Google Scholar 

  27. Witteles RM, Fowler MB. Insulin-resistant cardiomyopathy clinical evidence, mechanisms, and treatment options. J Am Coll Cardiol. 2008;51:93–102.

    Article  PubMed  CAS  Google Scholar 

  28. Page 2nd RL, Gozansky WS, Ruscin JM. Possible heart failure exacerbation associated with rosiglitazone: case report and literature review. Pharmacotherapy. 2003;23:945–54.

    Article  PubMed  Google Scholar 

  29. • Szczepanska-Sadowska E, Cudnoch-Jedrzejewska A, Ufnal M, Zera T. Brain and cardiovascular diseases: common neurogenic background of cardiovascular, metabolic and inflammatory diseases. J Physiol Pharmacol. 2010;61:509–21. This review describes in detail the relationship between the similarities in HF pathophysiology and development of central nervous system disorders..

    PubMed  CAS  Google Scholar 

  30. Dec GW. Anemia in heart failure time to rethink its etiology and treatment? J Am Coll Cardiol. 2006;48:2490–2.

    Article  PubMed  Google Scholar 

  31. Dimopoulou I, Daganou M, Tsintzas OK, Tzelepis GE. Effects of severity of long-standing congestive heart failure on pulmonary function. Respir Med. 1998;92:1321–5.

    Article  PubMed  CAS  Google Scholar 

  32. Agostoni P, Cattadori G, Guazzi M, Palermo P, Bussotti M, Marenzi G. Cardiomegaly as a possible cause of lung dysfunction in patients with heart failure. Am Heart J. 2000;140:e24.

    Article  PubMed  CAS  Google Scholar 

  33. Jefferson AL. Cardiac output as a potential risk factor for abnormal brain aging. J Alzheimers Dis. 2010;20:813–21.

    PubMed  Google Scholar 

  34. Qiu C, Winblad B, Marengoni A, et al. Heart failure and risk of dementia and Alzheimer disease: a population-based cohort study. Arch Intern Med. 2006;166:1003–8.

    Article  PubMed  Google Scholar 

  35. Thanassoulis G, Brophy JM, Richard H, Pilote L. Gout, allopurinol use, and heart failure outcomes. Arch Intern Med. 2010;170:1358–64.

    Article  PubMed  CAS  Google Scholar 

  36. Jagasia D, McNulty PH. Diabetes mellitus and heart failure. Congest Heart Fail. 2003;9:133–9.

    Article  PubMed  CAS  Google Scholar 

  37. Silverberg DS, Wexler D, Iaina A, Schwartz D. The interaction between heart failure and other heart diseases, renal failure, and anemia. Semin Nephrol. 2006;26:296–306.

    Article  PubMed  Google Scholar 

  38. Wolfe F, Michaud K. Heart failure in rheumatoid arthritis: rates, predictors, and the effect of anti-tumor necrosis factor therapy. Am J Med. 2004;116:305–11.

    Article  PubMed  Google Scholar 

  39. Ukena C, Mahfoud F, Kindermann M, et al. The cardiopulmonary continuum systemic inflammation as ‘common soil’ of heart and lung disease. Int J Cardiol. 2010;145:172–6.

    Article  PubMed  Google Scholar 

  40. Gnanasekaran G. Epidemiology of depression in heart failure. Heart Fail Clin. 2011;7:1–10.

    Article  PubMed  Google Scholar 

  41. Klein I, Danzi S. Thyroid disease and the heart. Circulation. 2007;116:1725–35.

    Article  PubMed  Google Scholar 

  42. Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. N Engl J Med. 2002;347:305–13.

    Article  PubMed  Google Scholar 

  43. Faulx MD, Francis GS. Adverse drug reactions in patients with cardiovascular disease. Curr Probl Cardiol. 2008;33:703–68.

    Article  PubMed  Google Scholar 

  44. Maxwell CB, Jenkins AT. Drug-induced heart failure. Am J Health Syst Pharm. 2011;68:1791–804.

    Article  PubMed  Google Scholar 

  45. Brater DC. Diuretic therapy. N Engl J Med. 1998;339:387–95.

    Article  PubMed  CAS  Google Scholar 

  46. van Diepen S, Majumdar SR, Bakal JA, et al. Heart failure is a risk factor for orthopedic fracture: a population-based analysis of 16,294 patients. Circulation. 2008;118:1946–52.

    Article  PubMed  Google Scholar 

  47. Rich MW. Heart failure in the oldest patients: the impact of comorbid conditions. Am J Geriatr Cardiol. 2005;14:134–41.

    Article  PubMed  Google Scholar 

  48. Jugdutt BI. Aging and heart failure: changing demographics and implications for therapy in the elderly. Heart Fail Rev. 2010;15:401–5.

    Article  PubMed  Google Scholar 

  49. Mascarenhas J, Azevedo A, Bettencourt P. Coexisting chronic obstructive pulmonary disease and heart failure: implications for treatment, course and mortality. Curr Opin Pulm Med. 2010;16:106–11.

    Article  PubMed  Google Scholar 

  50. Mascarenhas J, Lourenco P, Lopes R, et al. Chronic obstructive pulmonary disease in heart failure. Prevalence, therapeutic and prognostic implications. Am Heart J. 2008;155:521–5.

    Article  PubMed  Google Scholar 

  51. Hannink JD, van Helvoort HA, Dekhuijzen PN, Heijdra YF. Heart failure and COPD: partners in crime? Respirology. 2010;15:895–901.

    Article  PubMed  Google Scholar 

  52. Curkendall SM, DeLuise C, Jones JK, et al. Cardiovascular disease in patients with chronic obstructive pulmonary disease, Saskatchewan Canada cardiovascular disease in COPD patients. Ann Epidemiol. 2006;16:63–70.

    Article  PubMed  Google Scholar 

  53. Hawkins NM, Petrie MC, Jhund PS, et al. Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology. Eur J Heart Fail. 2009;11:130–9.

    Article  PubMed  Google Scholar 

  54. Staszewsky L, Wong M, Masson S, et al. Clinical, neurohormonal, and inflammatory markers and overall prognostic role of chronic obstructive pulmonary disease in patients with heart failure: data from the Val-HeFT heart failure trial. J Card Fail. 2007;13:797–804.

    Article  PubMed  CAS  Google Scholar 

  55. De Blois J, Simard S, Atar D, Agewall S. COPD predicts mortality in HF: the Norwegian Heart Failure Registry. J Card Fail. 2010;16:225–9.

    Article  PubMed  Google Scholar 

  56. Boudestein LC, Rutten FH, Cramer MJ, et al. The impact of concurrent heart failure on prognosis in patients with chronic obstructive pulmonary disease. Eur J Heart Fail. 2009;11:1182–8.

    Article  PubMed  Google Scholar 

  57. Le Jemtel TH, Padeletti M, Jelic S. Diagnostic and therapeutic challenges in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure. J Am Coll Cardiol. 2007;49:171–80.

    Article  PubMed  Google Scholar 

  58. Abroug F, Ouanes-Besbes L. Detection of acute heart failure in chronic obstructive pulmonary disease patients: role of B-type natriuretic peptide. Curr Opin Crit Care. 2008;14:340–7.

    Article  PubMed  Google Scholar 

  59. Tung RH, Camargo Jr CA, Krauser D, et al. Amino-terminal pro-brain natriuretic peptide for the diagnosis of acute heart failure in patients with previous obstructive airway disease. Ann Emerg Med. 2006;48:66–74.

    Article  PubMed  Google Scholar 

  60. de Groote P, Isnard R, Clerson P, et al. Improvement in the management of chronic heart failure since the publication of the updated guidelines of the European Society of Cardiology. The Impact-Reco Programme. Eur J Heart Fail. 2009;11:85–91.

    Article  PubMed  Google Scholar 

  61. Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119:1977–2016.

    Article  PubMed  Google Scholar 

  62. Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010;16:e1–e194.

    Article  PubMed  Google Scholar 

  63. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J. 2008;29:2388–442.

    Article  PubMed  CAS  Google Scholar 

  64. van der Woude HJ, Zaagsma J, Postma DS, et al. Detrimental effects of beta-blockers in COPD: a concern for nonselective beta-blockers. Chest. 2005;127:818–24.

    Article  PubMed  Google Scholar 

  65. • Hawkins NM, MacDonald MR, Petrie MC, et al. Bisoprolol in patients with heart failure and moderate to severe chronic obstructive pulmonary disease: a randomized controlled trial. Eur J Heart Fail. 2009;11:684–90. This is one of the more robust studies evaluating bisoprolol in patients with underlying COPD..

    Article  PubMed  CAS  Google Scholar 

  66. •• Hawkins NM, Petrie MC, Macdonald MR, et al. Heart failure and chronic obstructive pulmonary disease the quandary of β-blockers and β-agonists. J Am Coll Cardiol. 2011;57:2127–38. This systematic review of the literature and guidelines specifically address the use the β blockers and β agonists, providing specific recommendations for HF patients..

    Article  PubMed  CAS  Google Scholar 

  67. • Jabbour A, Macdonald PS, Keogh AM, et al. Differences between beta-blockers in patients with chronic heart failure and chronic obstructive pulmonary disease: a randomized crossover trial. J Am Coll Cardiol. 2010;55:1780–7. This is the a randomized, open-label triple crossover trial that demonstrates switching between β 1 -selective β blockers and the nonselective β-blocker carvedilol is well tolerated but results in demonstrable changes in airway function in patients with COPD and HF..

    Article  PubMed  Google Scholar 

  68. Rutledge T, Reis VA, Linke SE, et al. Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48:1527–37.

    Article  PubMed  Google Scholar 

  69. Abramson J, Berger A, Krumholz HM, Vaccarino V. Depression and risk of heart failure among older persons with isolated systolic hypertension. Arch Intern Med. 2001;161:1725–30.

    Article  PubMed  CAS  Google Scholar 

  70. Jaarsma T, Johansson P, Agren S, Stromberg A. Quality of life and symptoms of depression in advanced heart failure patients and their partners. Curr Opin Support Palliat Care. 2011;4:233–7.

    Article  Google Scholar 

  71. Johansson P, Nieuwenhuis M, Lesman-Leegte I, et al. Depression and the delay between symptom onset and hospitalization in heart failure patients. Eur J Heart Fail. 2011;13:214–9.

    Article  PubMed  Google Scholar 

  72. Jiang W, Alexander J, Christopher E, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161:1849–56.

    Article  PubMed  CAS  Google Scholar 

  73. Murberg TA, Furze G. Depressive symptoms and mortality in patients with congestive heart failure: a six-year follow-up study. Med Sci Monit. 2004;10:CR643–8.

    PubMed  Google Scholar 

  74. O’Connor CM, Jiang W, Kuchibhatla M, et al. Antidepressant use, depression, and survival in patients with heart failure. Arch Intern Med. 2008;168:2232–7.

    Article  PubMed  Google Scholar 

  75. Sherwood A, Blumenthal JA, Trivedi R, et al. Relationship of depression to death or hospitalization in patients with heart failure. Arch Intern Med. 2007;167:367–73.

    Article  PubMed  Google Scholar 

  76. Wu JR, Moser DK, De Jong MJ, et al. Defining an evidence-based cutpoint for medication adherence in heart failure. Am Heart J. 2009;157:285–91.

    Article  PubMed  Google Scholar 

  77. Granger BB, Swedberg K, Ekman I, et al. Adherence to candesartan and placebo and outcomes in chronic heart failure in the CHARM programme: double-blind, randomised, controlled clinical trial. Lancet. 2005;366:2005–11.

    Article  PubMed  CAS  Google Scholar 

  78. Freedland KE, Carney RM, Rich MW. Effect of depression on prognosis in heart failure. Heart Fail Clin. 2011;7:11–21.

    Article  PubMed  Google Scholar 

  79. Sherwood A, Blumenthal JA, Hinderliter AL, et al. Worsening depressive symptoms are associated with adverse clinical outcomes in patients with heart failure. J Am Coll Cardiol. 2011;57:418–23.

    Article  PubMed  Google Scholar 

  80. Tousoulis D, Antonopoulos AS, Antoniades C, et al. Role of depression in heart failure–choosing the right antidepressive treatment. Int J Cardiol. 2010;140:12–8.

    Article  PubMed  Google Scholar 

  81. •• O’Connor CM, Jiang W, Kuchibhatla M, et al. Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial. J Am Coll Cardiol. 2010;56:692–9. This is the first large, randomized placebo-controlled trial evaluating the impact of sertraline on both depression scores and cardiovascular events in patients with depression and HF..

    Article  PubMed  Google Scholar 

  82. • Jiang W, Krishnan R, Kuchibhatla M, et al. Characteristics of depression remission and its relation with cardiovascular outcome among patients with chronic heart failure (from the SADHART-CHF Study). Am J Cardiol. 2011;107:545–51. This is a subanalysis of the SADHART-CHF study showing that remission from depression may improve the cardiovascular outcomes in patients with HF..

    Article  PubMed  Google Scholar 

  83. Angermann CE, Gelbrich G, Stork S, et al. Rationale and design of a randomised, controlled, multicenter trial investigating the effects of selective serotonin re-uptake inhibition on morbidity, mortality and mood in depressed heart failure patients (MOOD-HF). Eur J Heart Fail. 2007;9:1212–22.

    Article  PubMed  CAS  Google Scholar 

  84. Edelmann F, Stahrenberg R, Gelbrich G, et al. Contribution of comorbidities to functional impairment is higher in heart failure with preserved than with reduced ejection fraction. Clin Res Cardiol. 2011;100:755–64.

    Article  PubMed  Google Scholar 

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Page, R.L., Lindenfeld, J. The Comorbidity Conundrum: A Focus on the Role of Noncardiovascular Chronic Conditions in the Heart Failure Patient. Curr Cardiol Rep 14, 276–284 (2012). https://doi.org/10.1007/s11886-012-0259-9

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