Effect of multimorbidity on survival of patients diagnosed with heart failure: a retrospective cohort study in Singapore

Heart failure: the grim reaper of the cardio-renal-metabolic triad

AIMS

Current understanding of the prognosis for patients with chronic kidney disease (CKD) and overlapping cardio-renal-metabolic components, specifically heart failure (HF) and diabetes mellitus (DM), remains limited. While previous studies have explored the interactions between CKD, HF, and DM, they have predominantly focused on cohorts of HF or DM patients. This study aims to fill this gap by investigating the long-term outcomes and treatment patterns in a cohort of CKD patients, particularly those with coexisting HF and DM.

METHODS AND RESULTS

We analysed data from the Swedish national CKD patient cohort, the Swedish Renal Registry, with a follow-up period extending up to 10 years. The study examined the risks of all-cause mortality, major adverse cardiovascular events (MACE)-defined as a composite of non-fatal myocardial infarction, hospitalization for congestive HF, non-fatal stroke, or cardiovascular death-and the initiation of kidney replacement therapy (KRT). Analyses were conducted using Cox proportional hazards and competing risk models. Among the 27 647 patients, 48% had CKD alone, 12% had CKD with HF, 27% had CKD with DM, and 13% had CKD with both HF and DM. After 5 years, mortality rates were 23% for patients with CKD, 30% for those with CKD/DM, 54% for CKD/HF, and 55% for CKD/HF/DM. The 10 year absolute risk of MACE was 28% for CKD alone, 35% for CKD/DM, 67% for CKD/HF, and 73% for CKD/HF/DM. The adjusted hazard ratio (HR) for mortality was approximately three times higher in patients with any HF combination, with HRs of 2.57 [95% confidence interval (CI) 2.43-2.71] for CKD/HF and 3.22 (95% CI 3.05-3.39) for CKD/HF/DM, compared with CKD alone. The impact of HF on MACE prognosis was even more pronounced, with adjusted sub-hazard ratios (SHRs) of 3.33 (95% CI 3.14-3.53) for CKD/HF and 4.26 (95% CI 4.04-4.50) for CKD/HF/DM. Additionally, CKD patients diagnosed with HF were less likely to commence KRT, and the risk of death prior to KRT initiation was roughly twice as high for these groups, with SHRs of 2.05 (95% CI 1.93-2.18) for CKD + HF and 2.43 (95% CI 2.29-2.58) for CKD + HF + DM.

CONCLUSIONS

In a cohort of CKD patients, having HF contributes substantially to increased mortality and the risk of MACE, and these patients are less likely to start KRT. These findings highlight the urgent need for targeted therapeutic strategies and management plans for CKD patients, particularly those with concurrent HF, to enhance patient prognosis.

Factors Associated With Depression and Anxiety for Community-Dwelling Patients With Heart Failure

BACKGROUND

Depression and anxiety are common comorbidities in heart failure (HF) and are associated with adverse outcomes including unplanned hospitalization. However, there is insufficient evidence on the factors associated with depression and anxiety for community patients with HF to inform optimal assessment and treatment in this population.

AIM

The aim of this study was to examine the prevalence of and factors associated with depression and anxiety in community-dwelling patients with HF.

METHODS

A retrospective cohort study of 302 adult patients given a diagnosis of HF referred to United Kingdom's largest specialist cardiac rehabilitation center, from June 2013 to November 2020. Main study outcomes were symptoms of depression using Patient Health Questionnaire-9 and anxiety using the General Anxiety Disorder 7-item scale. Explanatory variables included demographic and clinical characteristics and functional status from the Dartmouth COOP questionnaire: quality of life, pain, level of social activity and daily activities, and being bothered by emotional problems (feelings). Logistic regressions were performed to evaluate the association between demographic and clinical characteristics and depression and anxiety.

RESULTS

Of the sample, 26.2% reported depression and 20.2% had anxiety. Higher depression and anxiety were associated with difficulty in performing daily activities (95% confidence interval, 1.11-6.46 and 1.13-8.09, respectively) and being bothered by feelings (95% confidence interval, 4.06-21.77 and 4.25-22.46, respectively). Depression was associated with limitations in social activity (95% confidence interval, 1.06-6.34) and anxiety with distressing pain (95% confidence interval, 1.38-7.23).

CONCLUSION

Findings indicate the importance of psychosocial interventions for patients with HF to minimize and manage depression and anxiety. Patients with HF may benefit from interventions targeted to maintain independence, promote participation in social activities, and optimally manage pain.

Elements of Integrated Palliative Care in Chronic Heart Failure Across the Care Continuum: A Scoping Review

BACKGROUND

Individuals with chronic heart failure experience high symptom burden, reduced quality of life and high health care utilisation. Although there is growing evidence that a palliative approach, provided concurrently with usual treatment improves outcomes, the method of integrating palliative care for individuals living with chronic heart failure across the care continuum remains elusive.

AIM

To examine the key elements of integrated palliative care recommended for individuals living with chronic heart failure across the care continuum.

DESIGN

Scoping review.

DATA SOURCES

Databases searched were CINAHL, Ovid MEDLINE, Scopus and OpenGrey. Studies written in English and containing key strategic elements specific to chronic heart failure were included. Search terms relating to palliative care and chronic heart failure and the Joanna Briggs Institute methodology for scoping reviews was used.

RESULTS

Seventy-nine (79) articles were selected that described key elements to integrate palliative care for individuals with chronic heart failure. This review identifies four levels of key strategic elements: 1) clinical; 2) professional; 3) organisational and 4) system-level integration. Implementing strategies across these elements facilitates integrated palliative care for individuals with chronic heart failure.

CONCLUSIONS

Inter-sectorial collaborations across systems and the intersection of health and social services are essential to delivering integrated, person-centred palliative care. Further research focussing on patient and family needs at a system-level is needed. Research with strong theoretical underpinnings utilising implementation science methods are required to achieve and sustain complex behaviour change to translate key elements.

Cardiovascular events and mortality in people with type 2 diabetes and multimorbidity: A real-world study of patients followed for up to 19 years

AIM

To quantify the risk of cardiovascular disease (CVD) events, all-cause mortality and cardiovascular mortality in patients diagnosed with type 2 diabetes (T2D) and multimorbidity.

METHODS

This retrospective study used English primary and secondary care data to identify 120 409 adults newly diagnosed with T2D during 2000-2018 with follow-up until death or 31 December 2018. Patients were classified according to the level and type of multimorbidity at T2D diagnosis, and adjusted hazard ratios (aHRs) were calculated for each outcome.

RESULTS

In total, 66 977 (55.6%) patients had T2D only, 37 894 (31.5%) had one co-morbidity, 11 357 (9.4%) had two co-morbidities, 3186 (2.6%) patients had three co-morbidities and 995 (0.8%) patients had four or more co-morbidities. Co-morbidities were associated with increased aHRs for all outcomes. Compared with patients with T2D only, at 19 years after diagnosis of T2D the aHR for four or more co-morbidities was 2.57 (95% CI 2.45-2.69) for a CVD event, 1.73 (1.68-1.78) for all-cause mortality and 2.68 (2.52-2.85) for cardiovascular mortality. Also, 100 183 (83.2%) patients had no CVD co-morbidities, 16 874 (14.0%) patients had one CVD co-morbidity and 3352 (2.8%) patients had two or more co-morbidities. Compared with patients with no CVD co-morbidities, at 19 years after diagnosis of T2D the aHR for two or more CVD co-morbidities was 2.42 (2.35-2.49) for a CVD event, 1.44 (1.42-1.47) for all-cause mortality and 2.44 (2.35-2.54) for cardiovascular mortality.

CONCLUSION

In people with T2D, level of multimorbidity and, in particular, CVD multimorbidity increased the risk of subsequent CVD events, mortality and cardiovascular mortality.

Vindoline-A Natural Product from Catharanthus Roseus Reduces Hyperlipidemia and Renal Pathophysiology in Experimental Type 2 Diabetes

Cardiovascular diseases (CVDs) and kidney diseases in diabetes are linked to increased mortality and morbidity. The aim of this study was to evaluate the effect of vindoline derived from Catharanthus roseus in diabetes-induced CVDs and kidney disease through assessing inflammation, oxidative stress, hyperlipidaemia and kidney function parameters. Type 2 diabetes was induced in male Wistar rats by 10% fructose water intake for two weeks, followed by a single intraperitoneal injection of 40mg/kg body weight of streptozotocin (STZ). Six groups (n = 8) of randomly divided rats received vindoline (20mg/kg) or glibenclamide (5mg/kg) daily for 6 weeks via oral gavage. Lipid profile markers and markers of atherogenic index were decreased in diabetic rats after treatment with vindoline and glibenclamide. The levels of urea were significantly increased in the diabetic control group (13.66 ± 0.9) compared to the diabetic groups treated with vindoline and glibenclamide (10.62 ± 0.6 and 10.82 ± 0.8), respectively. Vindoline did not significantly alter the levels of inflammatory cytokines; however glibenclamide lowered the levels of TNF-α in kidney and heart tissues. Vindoline improved the ferric reducing antioxidant power in diabetic hearts, while superoxide dismutase (SOD) oxygen radical absorbance capacity was increased in the kidneys. Lipid peroxidation was reduced when compared to the diabetic controls. Vindoline restored the structure of the renal parenchyma and was accompanied by significant decrease in the expression of caspase 9 in diabetic rats when compared to the diabetic controls.