The effect of three major co‐morbidities on quality of life and outcome of patients with heart failure with reduced ejection fraction

Abstract

Aims Diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease are prevalent in patients with heart failure with reduced ejection fraction (HFrEF). We have analysed the impact of co-morbidities on quality of life (QoL) and outcome. Methods and results A total of 397 patients (58.8 ± 11.0 years, 73.6% with New York Heart Association functional class ≥3) with stable advanced HFrEF were followed for a median of 1106 (inter-quartile range 379-2606) days, and 68% of patients (270 patients) experienced an adverse outcome (death, urgent heart transplantation, and implantation of mechanical circulatory support). Chronic obstructive pulmonary disease was present in 16.4%, diabetes mellitus in 44.3%, and chronic kidney disease in 34.5% of patients; 33.5% of patients had none, 40.0% had one, 21.9% had two, and 3.8% of patient had three co-morbidities. Patients with more co-morbidities reported similar QoL (assessed by Minnesota Living with Heart Failure Questionnaire, 45.46 ± 22.21/49.07 ± 21.69/47.52 ± 23.54/46.77 ± 23.60 in patients with zero to three co-morbidities, P for trend = 0.51). Multivariable regression analysis revealed that furosemide daily dose, systolic blood pressure, New York Heart Association functional class, and body mass index, but not the number of co-morbidities, were significantly (P < 0.05) associated with QoL. Increasing co-morbidity burden was associated with worse survival (P < 0.0001), lower degree of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker treatment (P = 0.001), and increasing levels of BNP (mean of 685, 912, 1053, and 985 ng/L for patients with zero to three co-morbidities, P for trend = 0.008) and cardiac troponin (sm-cTnI, P for trend = 0.0496), which remained significant (P < 0.05) after the adjustment for left ventricular ejection fraction, left ventricular end-diastolic diameter, right ventricular dysfunction grade, body mass index, and estimated glomerular filtration rate. Conclusions In stable advanced HFrEF patients, co-morbidities are not associated with impaired QoL, but negatively affect the prognosis both directly and indirectly through lower level of HF pharmacotherapy and increased myocardial stress and injury.

Metformin treatment is associated with improved outcome in patients with diabetes and advanced heart failure (HFrEF)

“…To our best knowledge, this is the first study that analyzed the QoL with respect to MET treatment using a validated tool 45 . It has been recently demonstrated that QoL in HF patients is driven by HF itself, not by associated comorbidities 46 . MET-induced improvement in myocardial efficiency 29 suggests that the effect of MET on QoL in HF is rather due to an improvement in HF, not due to improvement in blood glucose control.…”

Influence of diabetes on sacubitril/valsartan titration and clinical outcomes in patients hospitalized for heart failure

“…It is associated with worse renal function, worse side effect profile, greater symptoms for a given degree of cardiac impairment, and higher hospitalization and mortality rates. 18 , 19 , 20 Partly as a result of this higher underlying risk, the benefits of optimal medical therapy are greater in patients with Type 2 diabetes mellitus, 21 and the drive to achieve optimization is more pressing. Despite this, the gap in HFrEF treatment optimization is similar in patients with and without diabetes.…”

“…Diabetes mellitus is a co‐morbidity in 30–40% of all patients with HFrEF and considerably worsens the prognosis. It is associated with worse renal function, worse side effect profile, greater symptoms for a given degree of cardiac impairment, and higher hospitalization and mortality rates 18–20 . Partly as a result of this higher underlying risk, the benefits of optimal medical therapy are greater in patients with Type 2 diabetes mellitus, 21 and the drive to achieve optimization is more pressing.…”

Influence of chronic obstructive pulmonary disease on long-term hospitalization and mortality in patients with heart failure with reduced ejection fraction

“…The shared risk factors in patients with concomitant HF and COPD include aging, smoking, and systemic inflammation [10] and may partly explain their frequent association. However, other comorbidities share the common mechanisms of HF and COPD and possibly impact the standard maintenance medication regimen, thereby contributing to the overall prognosis [11]. Furthermore, as they manifest the same symptoms, COPD is often underdiagnosed in patients with HF.…”