|Year : 2019 | Volume
| Issue : 1 | Page : 72-76
Noncardiac co – morbidities in elderly patients with heart failure
Ehi Judith Ogbemudia, Linda Iruobe Iyawe
Department of Medicine, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Submission||19-Apr-2019|
|Date of Decision||12-Jun-2019|
|Date of Acceptance||08-Jul-2019|
|Date of Web Publication||22-Oct-2019|
Dr. Ehi Judith Ogbemudia
Department of Medicine, University of Benin Teaching Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Background: The population of elderly persons with heart failure (HF) is on the increase, and HF is associated with multiple morbidities, but the common noncard'iac comorbidities have not been established.
Objective: The objective of the study is to determine the common noncard'iac comorbidities in elderly patients with HF.
Materials and Methods: The following data were retrieved from the HF register demographics: cause of HF, type of HF (reduced or preserved ejection fraction), and comorbidities. The comorbidities were: chronic obstructive pulmonary disease (COPD), renal dysfunction, osteoarthritis, and cerebrovascular accident (CVA). The others were: diabetes mellitus (DM), anemia, obesity, and cancer. The frequencies of these comorbidities were determined. Student's t-test and Chi-square tests were applied as appropriate.
Results: There were 204 cases; the mean age was 74.73 ± 7.34 years. The frequencies of comorbidities were: DM 68 (33.3%), renal dysfunction 53 (26%), osteoarthritis 44 (21.6%), and COPD 29 (14.2%). The others were: anemia 26 (12.7%), CVA 18 (8.8%), obesity 8 (3.9%), and cancer 3 (1.5%). The prevalence of HF with reduced and preserved ejection fraction was 88 (43.1%) and 116 (56.9%), respectively. The association between the number of comorbidities and the type of HF (HF with reduced ejection fraction or HF with preserved ejection fraction) yielded a P = 0.068.
Conclusion: The common noncardiac comorbidities in elderly HF patients are DM, renal dysfunction, and osteoarthritis. These conditions should be actively sought for in every elderly patient with HF for more holistic management and better prognosis.
Keywords: Elderly, heart failure, noncardiac comorbidities
|How to cite this article:|
Ogbemudia EJ, Iyawe LI. Noncardiac co – morbidities in elderly patients with heart failure. Nig J Cardiol 2019;16:72-6
| Introduction|| |
The population of elderly persons with heart failure (HF) is on the increase, and they have worse morbidity and mortality compared with the other age groups. Noncardiac comorbidities are chronic diseases of other systems besides the heart which occur concomitantly with HF and contribute to its progression., These associations could be through shared risk factors or direct pathophysiologic links. Comorbidities influence management decisions, lower quality of life, and worsen outcomes in HF patients., Only 37% of hospitalizations in elderly patients with HF are related to HF. Comorbidities are, therefore, a key component in the holistic management of HF and are listed in major HF guidelines.,
In general, the prevalence and pattern of comorbidities in HF have not been extensively investigated in our locale. The etiology and precipitants of HF have been well-studied and documented., The comorbidities in other chronic diseases such as hypertension, chronic kidney disease (CKD), and diabetes have also been reported by Karaye et al., Fasipe et al., and Kayode et al. However, the comorbidities in HF remain understudied. Van Deursen et al. and Streng et al. documented the burden and pattern of comorbidities in HF patients, but these studies were not in the elderly, and they were conducted in Europe. There may be racial differences.
Therefore, the common comorbidities in elderly HF patients have not been established in our locale; hence, the reason for this study. This study will facilitate early detection of common comorbidities in elderly HF patients for a more comprehensive management and better clinical outcomes. The hypothesis from preliminary clinical observations is that diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD) are the most common comorbidities in elderly patients with HF.
Therefore, the purpose of this study is to determine the most common noncardiac comorbidities in elderly patients with HF.
| Materials and Methods|| |
This was a retrospective study conducted in the department of medicine of a tertiary health-care center. The protocol was approved by the Hospital's Research and Ethics Committee, and the study was according to the Helsinki Declaration. Data of the elderly (65 years and above) patients with HF admitted from June 2016 to May 2018 were retrieved from the HF register.
Cases with complete data were included.
Cases without complete data were excluded.
Definition of terms
These are chronic diseases or disorders of other systems besides the heart that occur concomitantly with HF and contribute to its progression. Cardiac morbidities are primarily diseases of the heart and are the principal causes of HF. This study focused on noncardiac comorbidities because they have been shown to have a negative impact on outcomes in HF.
DM was defined as a fasting or random blood glucose ≥126 mg/dl and ≥200 mg/dl, respectively, or active treatment with oral hypoglycemic medications or insulin.
Renal dysfunction/chronic kidney disease
This was defined as an estimated glomerular filtration rate (GFR) <60 ml/min/1.73 m2 based on the modification of diet in renal disease study equation.
Anemia was defined as hemoglobin level <12 mg/dl for females and 13 mg/dl for males.
The presence of pain in the joints worsened by movement in addition to joint space narrowing with osteophytes formation on X-ray defined osteoarthritis. It included osteoarthritis of the knee, cervical, and lumbar spine.
Cerebrovascular accident (CVA) was defined as the rapid development of focal or global disturbance of cerebral function, with symptoms lasting 24 h or longer or leading to death, with no apparent cause other than vascular. This was confirmed on cranial computed tomography.
A body mass index (BMI) of ≥30 kg/m2 defined obesity.
Cancer of the breast
The presence of breast lesion with features of malignancy confirmed on histology.
Chronic obstructive pulmonary disease
COPD was defined as chronic cough with sputum production. In addition, the ratio of forced expiratory volume in 1 s to forced vital capacity of <0.8 on spirometry confirmed the diagnosis.
The age, gender, weight, and height were recorded from the HF register. The other variables were the blood pressure, etiology of HF, and comorbidity. Type of HF (preserved or reduced ejection fraction) the comorbidities included anemia, CKD, COPD, DM, osteoarthritis, cerebrovascular disease, obesity, and cancer. The BMI was derived from the weight and height Wt/Ht2.
Data were analyzed with a statistical package for social sciences version 20 (SPSS Inc., Chicago, IL, USA). The means and ranges of continuous variables were derived. The frequencies of cases with and without comorbidities were also derived, and the prevalence of comorbidities was determined as a percentage of the total number of cases studied. The frequencies of the different comorbidities were also determined. Student's t-test was used to compare continuous variables in two independent groups, and Chi-square test was used to determine an association between categorical variables.
| Results|| |
There were a total of 204 cases 106 (52%) were female while 98 (48%) were male. One hundred and forty-eight (72.5%) had comorbidities while 56 (27.5%) did not have comorbidities. Among those with comorbidities, 52 (35.1%), 72 (49.3%), and 23 (15.5%) had 1, 2, and 3 comorbidities, respectively. The etiologies of HF were hypertensive heart disease (HHD), 130 (63.7%), 55 (27%) had valvular heart disease and cardiomyopathies 19 (9.3%). The prevalence of the three age groups were as follows: 65–73 years (96, 47%), 74–82 years (64, 31.4%), 83 and above (44, 1.6%). One hundred and sixteen (56.9%) had HF with preserved ejection fraction (HFpEF) whereas 88 (43.1%) had HF with reduced ejection fraction (HFrEF). [Figure 1] shows the prevalence of the various noncardiac comorbidities.
|Figure 1: Frequencies of noncardiac comorbidities in elderly patients with heart failure DM: Diabetes Mellitus; RDFN – Renal Dysfunction; OSTEO – Osteoarthritis; COAD – Chronic Obstructive Airway Disease; ANAE – Anemia; CVA – Cerebrovascular Accident; OBESE – Obesity; CAN – Cancer|
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| Discussion|| |
The results show that majority 148 (72.5%) of the cases studied had comorbidities. This means there is a high prevalence of comorbidities in elderly patients with HF. This is not surprising because aging is associated with multiple morbidities, and HF is also associated with comorbidities. Murad et al. and Saczynski et al. reported higher prevalence of comorbidities because they examined both cardiac and noncardiac comorbidities in their studies. Variation in population characteristics may also have contributed to the difference in result. The high prevalence of comorbidities in elderly HF patients is associated with a low quality of life; worse outcomes and increased health-care expenditure due to repeated hospitalizations and polypharmacy.
[Figure 1] shows that DM was the most common comorbidity with a prevalence of 68 (33.3%). DM is associated with the older adult, and it is an established cardiovascular risk factor for atherosclerotic coronary artery disease and diabetic cardiomyopathy (CMP). Bos et al. and Booman-De Winter et al. reported a high prevalence of cardiac dysfunction in DM patients. In a similar study, Ruiz-Laiglesia et al. reported CKD as the most common comorbidity in HF. This is most probably due to differences in the population studied.The coexistence of HF and DM has both prognostic and therapeutic implications. HF patients with DM have a worse prognosis compared to HF without diabetes. Insulin and thiazolidinediones have been associated with worse outcomes in HF patients. Dipeptidyl peptidase 4 inhibitors are also not recommended in HF.
Furthermore, [Figure 1] shows that renal dysfunction was the next most common comorbidity 53 (26%). After DM, renal dysfunction specifically CKD usually coexists with HF and vice versa because of the cross talk between the heart and the kidneys (cardiorenal syndrome). HF reduces renal perfusion and GFR, which activates neurohormonal systems with consequent sodium and water retention. The age-associated decline in GFR may also have contributed to this result. CKD is the single strongest predictor of outcome even beyond left ventricular ejection fraction in HF patients.
Osteoarthritis of the knees, lumbar, and cervical spine constituted 44 (21.6%) of the comorbidities. The use of nonsteroidal anti-inflammatory drugs for pain in these degenerative conditions worsens HF from sodium and water retention. Other less common comorbidities were COAD 28 (13.7%), anemia 26 (12.7%), and CVA 18, (8.8%). The least prevalent morbidity was obesity 8 (3.9%) and cancers 3 (1.5%).
The results show that the causes of HF were HHD, rheumatic heart disease, and CMP, but the different cardiomyopathies (restrictive, hypertrophic, and idiopathic dilated) were grouped together because they were few. [Table 1] shows a wide range in the blood pressures, this is not surprising because the cases studied were made up of different cardiac diseases.
The results show that the oldest age group (83 years and above) was the least prevalent 44 (21.6%), while the majority 96 (47%) were in the age group of 65–73 years. Survival bias may explain why there were fewer cases of the older elderly. The results also show that HFrEF (116 (56.9%) was more common compared to HFpEF 88 (43.1). This is not surprising because HFpEF has been shown to be more common in the elderly. Late presentation to the hospital may explain why some had HFrEF because systolic function declines as HF progresses.
[Table 2] shows that patients with comorbidities had a significantly higher BMI compared to those without comorbidities P = 0.004. Excessive weight is a well-known cardiovascular risk factor. [Table 3] shows there is a significant association between age group and the number of comorbidities P = 0.005. This is only apparent because the sizes of the age groups were not similar. That is the younger elderly were more than, the older elderly as mentioned earlier.
|Table 2: Comparison of demographic variables of cases with and without comorbidities|
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|Table 3: Prevalence of age groups, gender, cause, and type of heart failure in relation to the number of comorbidities|
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The limitations in this study include the fact it was retrospective and of small sample size (pilot study). Nevertheless, it has achieved its main objective which was to determine the common noncardiac comorbidities in elderly patients with HF. There is, however, a need for a main prospective study. Implications for future research includes studies of each comorbidity subgroup for characterization of the clinical profile and cardiac function. Longitudinal studies will help determine which of these comorbidities impacts most negatively on outcomes such as hospitalizations and mortality. A similar study in the middle-aged and young would help determine whether comorbidities in the elderly differ with age group.
| Conclusion|| |
DM, renal dysfunction, and osteoarthritis are the most common noncardiac comorbidities in elderly patients with HF. These conditions should be actively sought for in every elderly HF patient for a more holistic management and better prognosis. DM patients should be given cardioprotective drugs beyond blood glucose lowering.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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