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Comorbidities in Patients With Heart Failure: Treating the Whole Patient

Laura Joszt
Patients with heart failure tend to have other health issues, requiring cardiologists to understand how to care for heart failure while keeping in mind treatment for these other comorbidities, said panelists at the European Society of Cardiology Congress 2017, held August 26-30 in Barcelona, Spain.
Ewa A. Jankowska, MD, PhD, FESC, FHFA, of Wrocław Medical University, outlined the complication of addressing iron deficiency in patients with heart failure. Iron deficiency is prevalent in chronic heart failure and it leads to anemia, which is a predictor of a poor outcome for these patients. However, iron deficiency on its own actually has a greater impact.
“When we judge independently, the impact of anemia itself and iron deficiency on symptoms on survival … you may be surprised that the impact of iron deficiency itself, without anemia, is much more important than anemia itself,” she explained.
Iron is needed for proper energy metabolism and is present in all tissues and cells. Patients with iron deficiency have lower peak oxygen consumption levels, which reduces their exercise capacity. A study of failing hearts has found that they do not have enough iron.
Physicians can detect iron deficiency by testing for ferritin, which indicates how much iron is in a body. Ferritin is involved with iron metabolism and is related to the storage of intracellular iron.
One treatment is intravenous iron, which was studied in the FAIR-HF trial that included patients with iron deficiency who had been anemic as well as those who had not been anemic. The trial found clinical improvement in all patients.
There are 4 currently ongoing morbidity and mortality trials—AFFIRM-AHF, FAIR-HF-2, HEAD-FID, IRONMAN—using intravenous iron in patients with heart failure.
Finally, Mark Pfeffer, MD, PhD, of Harvard Medical School and Brigham & Women’s Hospital, discussed kidney dysfunction in patients with heart failure. He explained that a young person on dialysis has the mortality rate of an 80-year-old who is not on dialysis. In general, someone with kidney disease, who has not progressed as far as dialysis, has a cardiovascular risk of death that is equivalent to that of a 60- to 70-year-old person.
“If you have chronic kidney disease … no one Is surprised that you’re more likely to develop heart failure, have coronary heart disease, and have stroke,” Pfeffer said.
The problem is that there are factors that make medications not work as they’re supposed to. For instance, as kidneys fail, they no longer remove potassium or creatinine. Rising levels of both of these prevents physicians from giving more of a therapy or increasing doses for patients with heart failure.
There are therapies on the horizon that would combat the high levels of potassium, but it is still unclear at this point if they would allow physicians to prescribe more of a medication.
Pfeffer concluded by reminding the audience that the diseases all go together and impact treatment—cardiologists aren’t just treating a patient’s heart failure, they are also treating the patient’s other diseases.
“We should understand that it’s 1 patient, and look at the whole patient,” he said.

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