CO-MORBIDITIES IN HEART FAILURE

Rarsari S. PratiktoPekanbaru, March 3rd 2018

COMORBIDITIES in HF

1. Anaemia

2. Stroke

3. Angina

4. Asthma & COPD

5. Cachexia

6. Cancer

7. Diabetes

8. Depression

9. GI problems

10. Electrolyte imbalance

11. Liver dysfunction

12. Gout

13. Hyperlipidemia

14. Hypertension

15. Kidney dysfunction

16. Obesity

17. Sleep disordered breathing

18. Thyroid dysfunction

19. Erectile dysfunction

20. Arrhythmias

WHY IMPORTANT ?

1. Confusing diagnostics

2. May affect the use of treatments for HF

3. May cause worsening HF (incl drugs)

4. Predictors of poor prognosis

5. Drugs interactions

6. Reduce patients adherence

7. Worsen clinical status

8. Limited evidences

European Journal of Heart Failure (2014) 16, 103–111

Comorbidities and All-cause mortality

Comorbidities and HF hospitalization

European Journal of Heart Failure (2014) 16, 103–111

The American Journal of Medicine (2011) 124, 136-143

European Journal of Heart Failure (2014) 16, 103–111

COMORBIDITIES in HF

1. Anaemia

2. Stroke

3. Angina

4. Asthma & COPD

5. Cachexia

6. Cancer

7. Diabetes

8. Depression

9. GI problems

10. Electrolyte imbalance

11. Liver dysfunction

12. Gout

13. Hyperlipidemia

14. Hypertension

15. Kidney dysfunction

16. Obesity

17. Sleep disordered breathing

18. Thyroid dysfunction

19. Erectile dysfunction

20. Arrhythmias

• Diabetes

• Thyroid

• Electrolyte imbalance

ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases. 2013

Cardiovascular disease (CVD) and DM

HF causes Insulin Resistance

DM and Myocardial Fibrosis

The Association between Diffuse Myocardial Fibrosis on Cardiac Magnetic Resonance T1 Mapping and Myocardial Dysfunction in Diabetic Rabbits. Sci Rep [Internet]. 2017 Mar 24;7:44937.

METFORMIN SULFONYLUREA THIAZOLINEDION

DPP 4 INHIBITOR GLP-1 AGONIST INSULIN

SITAGLIPTIN ONLY

American Association of Clinical Endocrinology (AACE):HbA1c >7.5% ~ dual therapyHbA1c >9% ~ triple therapy / insulin

• Diabetes

• Thyroid

• Electrolyte imbalance

Thyroid and Cardiovascular function- The clinical significance -

• Intimately linked

• Known thyroid dysfunction assess cardiovascular disease/ risk

• Known cardiovascular disease (especially arrhythmia) assess thyroid function

• Cardiac and peripheral vascular function, partly dependent on thyroid hormone signaling

• Subclinical thyroid dysfunction can also be associated with cardiac disorders

SHOULD BE SCREENED !

THYROID and HF

Hyperthyroid – Cardiac dysfunction

Martinez F et al. Thyroid hormones and heart failure. Heart Fail Rev. 2016:1-4.

β-blocker ACEI atau ARB

Klein I, Danzi S et al. Thyroid disease and the heart. Circulation. 2007;116(15):1725-35.

Cardiovascular effects on thyroid dysfunction

Variables Hyperthyroidism hypothyroidism

Thyroid hormones > <

Oxidative metabolism > <

Natriuretic peptide > <

Lipids an lipoproteins < >

Heart rate > <

Systemic vascular resistance < >

Cardiac output > <

Cardiac contractility > <

Stanciu, E. et al. Impact of thyroid siease on heart faiure. In : The Role of Clinical Cardiac Electrophysiology in The Management of Congestive Heart Failure, 2017

Thyroid function and HF progression: the vicious pathophysiological circle

Anthony Martin Gerdes, and Giorgio Iervasi Circulation. 2010;122:385-393

Thyroid dysfunction in HF

• Screening:

– FT4 and TSH

CLASSICSUBCLINICAL?

RECOMMENDATION1. Treat subclinical thyroid dysfunction2. Don’t treat abnormal dysfunction

because amiodarone

• Diabetes

• Thyroid

• Electrolyte imbalance

Focus on Hyponatremia

Hiponatremia - Gagal Jantung

• Hiponatremia didefinisikan sebagai konsentrasi serum sodium < 135 mEq/L

• Data menunjukkan bahwa prevalensi hiponatremia berkisar antara 19-25% pada pasien dengan gagal jantung

• Pada gagal jantung, derajat hiponatremia dihubungkan dengan faktorprognosis yang kurang baik.

• Hiponatremia pada gagal jantung memiliki tantangan tersendiri dimanaharus dibedakan antara hiponatremia deplesional atau dilusional. Hal ini yang akan menjadi dasar pendekatan tatalaksana hiponatremia.

1. Verbrugge FH, Steels P, Grieten L, Nijst P, Tang WHW, Mullens W. Hyponatremia in acute decompensated heart failure: depletion versus dilution. J Am Coll Cardiol [Internet]. Journal of the American College of Cardiology; 2015 Feb 10 [cited 2016 Feb 8];65(5):480–92. Available from: http://content.onlinejacc.org/article.aspx?articleid=2108922

2. Romanovsky A, Bagshaw S, Rosner MH. Hyponatremia and congestive heart failure: a marker of increased mortality and a target for therapy. Int J Nephrol [Internet]. 2011;2011:732746.

Lama Rawat Pasien Gagal Jantung PJNHK

Lama Rawat Tahun 2014 (hari) Lama Rawat Tahun 2015 (hari)

Gagal Jantung Gagal Jantungdengan hiponatremia

Gagal Jantungtanpa

hiponatremia

Gagal Jantung Gagal Jantungdengan hiponatremia

Gagal Jantungtanpa

hiponatremia

Hyponatremia in HF

Pathophysiology of HypoNa in ADHF

Verbrugge et.al, Hyponatremia in ADHF, JACC 2015

HypoNa – HF Mortality

Rusinaru D, Tribouilloy C, Berry C, Richards AM, Whalley GA, Earle N, et al. .Eur J Heart Fail. 2012;14(10):1139–46

CONCLUSION

• Management of co-morbidities is a key component of the holistic care of patients with HF

• IDENTIFY THEM....TREAT THEM..