Challenges in treating heart failure with comorbidities

MULTI-DISEASE

As Prof. Piotr Jankowski, chairman of the Health Promotion Committee of the Polish Cardiac Society, points out, the problem of heart failure in the elderly is a growing one.

- It used to be thought that most people with heart failure were patients with reduced left ventricular ejection fraction. Now it is recognized that roughly half of patients have a preserved ejection fraction. However, the elderly population is by far the predominant group of heart failure patients with preserved ejection fraction. This has both diagnostic and therapeutic implications, the professor says.

It turns out that the causes of heart failure in the elderly are somewhat different than in younger people. Among the elderly, the most common causes are hypertension, diabetes or valvular defects. Many people also have coronary artery disease. As a result of these diseases, in addition to myocardial hypertrophy, myocardial fibrosis is accelerated. This is the primary mechanism for the development of heart failure with preserved ejection fraction in the elderly.

- We do not have many therapeutic options for which they have been shown to improve prognosis, slow disease progression or reduce symptoms. The primary recommendations are dehydration treatment for those who have symptoms of conductance, which is the case for the vast majority of patients with heart failure. The second recommendation is the detection and effective treatment of concomitant diseases that may cause heart failure or exacerbate its symptoms," Professor Piotr Jankowski lists.

Increasingly, in the context of the treatment of heart failure patients affected by multimorbidity, there is also talk about the drugs in the flosins group. These are drugs, once considered only antidiabetic drugs, which also have a proven effect of reducing the risk of cardiovascular incidents, reducing the rate of progression of heart failure, as well as a nephroprotective effect. This is especially important, especially in the senior group.

- Both diabetes and chronic kidney disease are very common in this population. So it turns out that by using one drug, we can treat three important diseases that limit a patient's prognosis and reduce their quality of life," says the professor.

RENAL FAILURE

A very common comorbidity in patients with heart failure is chronic kidney disease. As Prof. Jaroslaw Kasprzak, head of the cardiology department at the Dr. W. Bieganski Regional Specialized Hospital in Lodz, points out, a patient with diseased kidneys and heart failure shows a much worse prognosis, both short and long-term. It is also more difficult to treat him, due to the fact that the kidneys are one of the important effectors of drugs used in modifying the course of the disease or correcting its exacerbation.

- The simplest example is diuretics, in which the response in poor renal function may be inadequate. Such a situation requires a very good understanding of what the pathomechanism of this renal dysfunction is, because we will act quite differently if the patient is dehydrated, which also happens in exacerbations of failure, and differently if he has fluid retention. In turn, the estimated renal filtration rate will be important for the choice of drugs," explains Prof. Jaroslaw Kasprzak.

In most situations, priority will be given to carbon diuretics. From the point of view of the chronic use of prognosis-altering drugs in heart failure, the limitations of dosage changes and contraindications for particular groups or combining their use in patients with inadequate renal function will be of great importance.

- Drugs that block the RAA system and mineralocorticoid receptor antagonists compete for renal function, in the sense that both groups share the adverse effect of potassium retention and the possibility of transiently reducing renal filtration. This imposes great caution and the need to monitor adverse effects. Below certain thresholds, these drugs are not recommended at all," the professor says.

Beta-blockers, on the other hand, should pose the least problems in terms of their effect on renal function. This is because their effect can be easily monitored by the chronotropic effect. However, it is necessary to choose such drugs that are not eliminated renally.