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CO-MORBIDITIES IN HEART FAILURE
Rarsari S. PratiktoPekanbaru, March 3rd 2018
COMORBIDITIES in HF
1. Anaemia
2. Stroke
3. Angina
4. Asthma & COPD
5. Cachexia
6. Cancer
7. Diabetes
8. Depression
9. GI problems
10. Electrolyte imbalance
11. Liver dysfunction
12. Gout
13. Hyperlipidemia
14. Hypertension
15. Kidney dysfunction
16. Obesity
17. Sleep disordered breathing
18. Thyroid dysfunction
19. Erectile dysfunction
20. Arrhythmias
WHY IMPORTANT ?
1. Confusing diagnostics
2. May affect the use of treatments for HF
3. May cause worsening HF (incl drugs)
4. Predictors of poor prognosis
5. Drugs interactions
6. Reduce patients adherence
7. Worsen clinical status
8. Limited evidences
European Journal of Heart Failure (2014) 16, 103–111
Comorbidities and All-cause mortality
Comorbidities and HF hospitalization
European Journal of Heart Failure (2014) 16, 103–111
The American Journal of Medicine (2011) 124, 136-143
European Journal of Heart Failure (2014) 16, 103–111
COMORBIDITIES in HF
1. Anaemia
2. Stroke
3. Angina
4. Asthma & COPD
5. Cachexia
6. Cancer
7. Diabetes
8. Depression
9. GI problems
10. Electrolyte imbalance
11. Liver dysfunction
12. Gout
13. Hyperlipidemia
14. Hypertension
15. Kidney dysfunction
16. Obesity
17. Sleep disordered breathing
18. Thyroid dysfunction
19. Erectile dysfunction
20. Arrhythmias
• Diabetes
• Thyroid
• Electrolyte imbalance
ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases. 2013
Cardiovascular disease (CVD) and DM
HF causes Insulin Resistance
DM and Myocardial Fibrosis
The Association between Diffuse Myocardial Fibrosis on Cardiac Magnetic Resonance T1 Mapping and Myocardial Dysfunction in Diabetic Rabbits. Sci Rep [Internet]. 2017 Mar 24;7:44937.
METFORMIN SULFONYLUREA THIAZOLINEDION
DPP 4 INHIBITOR GLP-1 AGONIST INSULIN
SITAGLIPTIN ONLY
American Association of Clinical Endocrinology (AACE):HbA1c >7.5% ~ dual therapyHbA1c >9% ~ triple therapy / insulin
• Diabetes
• Thyroid
• Electrolyte imbalance
Thyroid and Cardiovascular function- The clinical significance -
• Intimately linked
• Known thyroid dysfunction assess cardiovascular disease/ risk
• Known cardiovascular disease (especially arrhythmia) assess thyroid function
• Cardiac and peripheral vascular function, partly dependent on thyroid hormone signaling
• Subclinical thyroid dysfunction can also be associated with cardiac disorders
SHOULD BE SCREENED !
THYROID and HF
Hyperthyroid – Cardiac dysfunction
Martinez F et al. Thyroid hormones and heart failure. Heart Fail Rev. 2016:1-4.
β-blocker ACEI atau ARB
Klein I, Danzi S et al. Thyroid disease and the heart. Circulation. 2007;116(15):1725-35.
Cardiovascular effects on thyroid dysfunction
Variables Hyperthyroidism hypothyroidism
Thyroid hormones > <
Oxidative metabolism > <
Natriuretic peptide > <
Lipids an lipoproteins < >
Heart rate > <
Systemic vascular resistance < >
Cardiac output > <
Cardiac contractility > <
Stanciu, E. et al. Impact of thyroid siease on heart faiure. In : The Role of Clinical Cardiac Electrophysiology in The Management of Congestive Heart Failure, 2017
Thyroid function and HF progression: the vicious pathophysiological circle
Anthony Martin Gerdes, and Giorgio Iervasi Circulation. 2010;122:385-393
Thyroid dysfunction in HF
• Screening:
– FT4 and TSH
CLASSICSUBCLINICAL?
RECOMMENDATION1. Treat subclinical thyroid dysfunction2. Don’t treat abnormal dysfunction
because amiodarone
• Diabetes
• Thyroid
• Electrolyte imbalance
Focus on Hyponatremia
Hiponatremia - Gagal Jantung
• Hiponatremia didefinisikan sebagai konsentrasi serum sodium < 135 mEq/L
• Data menunjukkan bahwa prevalensi hiponatremia berkisar antara 19-25% pada pasien dengan gagal jantung
• Pada gagal jantung, derajat hiponatremia dihubungkan dengan faktorprognosis yang kurang baik.
• Hiponatremia pada gagal jantung memiliki tantangan tersendiri dimanaharus dibedakan antara hiponatremia deplesional atau dilusional. Hal ini yang akan menjadi dasar pendekatan tatalaksana hiponatremia.
1. Verbrugge FH, Steels P, Grieten L, Nijst P, Tang WHW, Mullens W. Hyponatremia in acute decompensated heart failure: depletion versus dilution. J Am Coll Cardiol [Internet]. Journal of the American College of Cardiology; 2015 Feb 10 [cited 2016 Feb 8];65(5):480–92. Available from: http://content.onlinejacc.org/article.aspx?articleid=2108922
2. Romanovsky A, Bagshaw S, Rosner MH. Hyponatremia and congestive heart failure: a marker of increased mortality and a target for therapy. Int J Nephrol [Internet]. 2011;2011:732746.
Lama Rawat Pasien Gagal Jantung PJNHK
Lama Rawat Tahun 2014 (hari) Lama Rawat Tahun 2015 (hari)
Gagal Jantung Gagal Jantungdengan hiponatremia
Gagal Jantungtanpa
hiponatremia
Gagal Jantung Gagal Jantungdengan hiponatremia
Gagal Jantungtanpa
hiponatremia
Hyponatremia in HF
Pathophysiology of HypoNa in ADHF
Verbrugge et.al, Hyponatremia in ADHF, JACC 2015
HypoNa – HF Mortality
Rusinaru D, Tribouilloy C, Berry C, Richards AM, Whalley GA, Earle N, et al. .Eur J Heart Fail. 2012;14(10):1139–46
CONCLUSION
• Management of co-morbidities is a key component of the holistic care of patients with HF
• IDENTIFY THEM....TREAT THEM..