Polymorbidity and its association with the unfavorable course of chronic heart failure in outpatients aged 60 years and older

Aim. This study was carried out to evaluate polymorbidity taking into account geriatric syndromes and their relationship with the course of chronic heart failure (CHF) in outpatients aged 60 years and older. Methods. We conducted an open, prospective, non-randomized study. The main group included 80 patients with CHF, the comparison group – 40 patients without CHF. Conducted clinical examination, ECG, echocardiography, two-photon X-ray absorptiometry. The scale of assessment of clinical status in CHF,Charlson comorbidity index were used. The criteria for frailty were the presence of at least 3 signs due FRAIL scale. Mean follow-up was 24.1±13.0 months. Results. All patients with CHF (100%) and 92.5% of the comparison group had a concomitant pathology. A combination of 3 or more of any diseases was more common in CHF compared to control group (p=0.008), CKD (66%) and obesity (35%) were the most common pathology. Combinations of osteoporosis and CKD (28%), obesity and CKD (23%) were the most frequent in the CHF patients, a combination of obesity and CKD (28%), obesity and diabetes (18%) – without CHF patients. The same incidence of osteoporosis (p=0.768), falls (p=0.980), fractures (p=0.549) and frailty (p=0.828) was observed in CHF patients and different EFLV, but prevalence of frailty was observed at the age of 75 years and older. During the observation period, 24% CHF patients and 5% patients without CHF (p=0.022) died. The worst survival of patients with ischemic genesis of CHF and osteoporosis was noted. The factors associated with an increased risk of death in CHF patients were the ischemic etiology of CHF (OR 8.33; 95% CI 1.11–62.4; p=0.039), male gender (OR 7.91; 95% CI 2.3–27.2; p=0.001), LV EF <45% (OR 2.52; 95% CI 1.01–6,27; p=0.047), low bone mineral density in femoral neck region (р=0.016, ОR 4.3, 95% CI 1.3–17.2), comorbidity score (OR 1.19; 95% CI 1.04–1.37; p=0.012), a total score on the scale of assessment of clinical status in CHF (OR 1.13; 95% CI 1.03–1.24; p=0.008). Conclusion. All СHF patients had concomitant diseases, CKD and obesity were the most common pathologies. The ischemic etiology of CHF, along with the male gender, LV EF less than 45%, severe clinical statusand high score on the Charlson comorbidity index turned out to be risk factors for death in outpatients aged 60 years and older with CHF.

1. Vasan RS, Xanthakis V, Lyass A, Andersson C, Tsao C, Cheng S et al. Epidemiology of Left Ventricular Systolic Dysfunction and Heart Failure in the Framingham Study. JACC: Cardiovascular Imaging. 2018;11(1):1–11. DOI:10.1016/j.jcmg.2017.08.007

2. Mareev V.Yu., Ageev F.T., Arutyunov G.P., Koroteev A.V., Mareev Yu.V., Ovchinnikov A.G. et al. SEHF, RSC and RSMSIM national guidelines on CHF diagnostics and treatment (fourth revision) Approved at the SEHF Congress on December 7, 2012, at the SEHF Board of Directors meeting on March 31, 2013, and at the RSC Congress on September 25, 2013. Russian Heart Failure Journal. 2013;14 (7):379–472. [Russian]

3. Mareev V.Yu., Fomin I.V., Ageev F.T., Begrambekova Yu.L., Vasyuk Yu.A., Garganeeva A.A. et al. Russian Heart Failure Society, Russian Society of Cardiology. Russian Scientific Medical Society of Internal Medicine Guidelines for Heart failure: chronic (CHF) and acute decompensated (ADHF). Diagnosis, prevention and treatment. Kardiologiia. 2018;58 (6S): 8–164. [Russian]. DOI:10.18087/cardio.2475

4. Mamas MA, Sperrin M, Watson MC, Coutts A, Wilde K, Burton C et al. Do patients have worse outcomes in heart failure than in cancer? A primary care-based cohort study with 10-year follow-up in Scotland: Outcomes in heart failure and cancer. European Journal of Heart Failure. 2017;19(9):1095–104. DOI:10.1002/ejhf.822

5. Orlova Ya.A., Tkacheva O.N., Arutyunov G.P., Kotovskaya Yu.V., Lopatin Yu.M., Mareev V.Yu. et al. Features of diagnostics and treatment of chronic heart failure in elderly and senile patients. Expert opinion of the Society of Experts in Heart Failure, Russian Association of Gerontologists, and Euroasian Association of Therapists. Kardiologiia. 2018;58 (12S): 42–72. [Russian]. DOI:10.18087/cardio.2560

6. Boriani G, Malavasi VL. Patient outcome after implant of a cardioverter defibrillator in the ‘real world’: the key role of co-morbidities. European Journal of Heart Failure. 2017;19(3):387–90. DOI:10.1002/ejhf.743

7. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European Heart Journal. 2016;37(27):2129–200. DOI:10.1093/eurheartj/ehw128

8. Nedogoda S.V., Barykina I.N., Salasyuk A.S. National clinical guidelines for obesity: concept and perspectives. Journal of Volgograd State Medical University. 2017;1(61):134–40. [Russian]

9. Belenkov Yu.N., Mareev V.Yu. Principles of rational treatment of chronic heart failure. -M.: Media Medika;2000. – 266 p. [Russian]

10. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases. 1987;40(5):373–83. DOI:10.1016/0021-9681(87)90171-8

11. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. The journal of nutrition, health & aging. 2012;16(7):601–8. DOI:10.1007/s12603-012-0084-2

12. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. [Internet] Available at: http://www.who.int/vmnis/indicators/haemoglobin/en/

13. KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of Chronic Kidney Disease. Kidney International supplements. 2013;3(1):1–150. [Available at: https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf ]

14. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography. 2015;28(1):1-39.e14. DOI:10.1016/j.echo.2014.10.003

15. Schiller N., Osipov M.A. Clinical echocardiography. 2nd edition. – M.: Praktika;2005. – 344 p. [Russian]. ISBN 5-89816-049-3

16. Mel’nichenko G.A., Belaya J.E., Rozhinskaya L.Ya., Toroptsova N.V., Alekseeva L.I., Biryukova E.V. et al. Russian federal clinical guidelines on the diagnostics, treatment, and prevention of osteoporosis. Problems of Endocrinology. 2018;63 (6):392–426. [Russian]. DOI:10.14341/probl2017636392-426

17. Liu X. Classification accuracy and cut point selection. Statistics in Medicine. 2012;31(23):2676–86. DOI:10.1002/sim.4509

18. Ni H, Xu J. Recent Trends in Heart Failure-related Mortality: United States, 2000-2014. NCHS data brief. 2015;231:1–8. PMID: 26727546

19. Steinmann E, Brunner-La Rocca H-P, Maeder MT, Kaufmann BA, Pfisterer M, Rickenbacher P. Is the clinical presentation of chronic heart failure different in elderly versus younger patients and those with preserved versus reduced ejection fraction? European Journal of Internal Medicine. 2018;57:61–9. DOI:10.1016/j.ejim.2018.06.005

20. Laux G, Kuehlein T, Rosemann T, Szecsenyi J. Coand multimorbidity patterns in primary care based on episodes of care: results from the German CONTENT project. BMC Health Services Research. 2008;8(1):14. DOI:10.1186/1472-6963-8-14

21. van Deursen VM, Urso R, Laroche C, Damman K, Dahlström U, Tavazzi L et al. Co-morbidities in patients with heart failure: an analysis of the European Heart Failure Pilot Survey: Co-morbidities in heart failure. European Journal of Heart Failure. 2014;16(1):103– 11. DOI:10.1002/ejhf.30

22. Streng KW, Nauta JF, Hillege HL, Anker SD, Cleland JG, Dickstein K et al. Non-cardiac comorbidities in heart failure with reduced, mid-range and preserved ejection fraction. International Journal of Cardiology. 2018;271:132–9. DOI:10.1016/j.ijcard.2018.04.001

23. Sitnikova M.Yu., Lyasnikova E.A., Yurchenko A.V., Trukshina M.A., Kuular A.A., Galenko V.L. et al. Results of 3 years work of the Russian hospital register of chronic heart failure (RUssian hoSpital Heart Failure Registry – RUS-HFR): relationship between management and outcomes in patients with chronic heart failure. Kardiologiia. 2018;58 (10S): 9–19. [Russian]. DOI:10.18087/cardio.2483

24. Tuegel C, Bansal N. Heart failure in patients with kidney disease. Heart. 2017;103(23):1848–53. DOI:10.1136/heartjnl-2016-310794

25. Xing W, Lv X, Gao W, Wang J, Yang Z, Wang S et al. Bone mineral density in patients with chronic heart failure: a meta-analysis. Clinical Interventions in Aging. 2018;13:343–53. DOI:10.2147/CIA.S154356

26. Chiu C-Z, Yeh J-H, Shyu K-G, Hou S-M, Lin C-L, Liang J-A. Can osteoporosis increase the incidence of heart failure in adults? Current Medical Research and Opinion. 2017;33(6):1119–25. DOI:10.1080/03007995.2017.1308343

27. Gerber Y, Melton LJ, Weston SA, Roger VL. Osteoporotic Fractures and Heart Failure in the Community. The American Journal of Medicine. 2011;124(5):418–25. DOI:10.1016/j.amjmed.2010.11.029

28. Veronese N, Stubbs B, Crepaldi G, Solmi M, Cooper C, Harvey NC et al. Relationship Between Low Bone Mineral Density and Fractures With Incident Cardiovascular Disease: A Systematic Review and Meta-Analysis. Journal of Bone and Mineral Research. 2017;32(5):1126–35. DOI:10.1002/jbmr.3089

29. Morley JE. Frailty and Sarcopenia: The New Geriatric Giants. Revista De Investigacion Clinica. 2016;68(2):59–67. PMID: 27103041

30. Tkacheva O. N., Runikhina N.K., Ostapenko V.S., Sharashkina N. V. Seven questions for elderly in the practice of primary care physicians. Advances in gerontology. 2017;30 (2):231–5. [Russian]

31. Tkacheva O.N., Runikhina N.K., Ostapenko V.S., Sharashkina N.V., Mkhitaryan E.A., Onuchina Yu.S. et al. Validation of the questionnaire for screening frailty. Advances in gerontology. 2017;30(2):236–42. [Russian]

32. Leng S, Chen X, Mao G. Frailty syndrome: an overview. Clinical Interventions in Aging. 2014;9:433–41. DOI:10.2147/CIA.S45300

33. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2004;59(3):M255–63. DOI:10.1093/gerona/59.3.M255

34. Kotovskaya Yu.V., Rozanov A.V., Kurashev D.Kh., Runikhina N.K., Schedrina A.Yu., Tkacheva O.N. et al. Problems of management of heart failure patients of older age groups. RMJ. Medical review. 2018;2 (8–1):24–6. [Russian]

35. Lee K, Pressler SJ, Titler M. Falls in Patients With Heart Failure: A Systematic Review. The Journal of Cardiovascular Nursing. 2016;31(6):555–61. DOI:10.1097/JCN.0000000000000292

36. Topolyanskaya S.V., Osipovskaya I.A., Lifanova L.S., Eliseeva T.A., Vakulenko O.N. Mineral density and metabolism of bone tissue in patients with chronic heart failure insufficiency of senior age. Archive of internal medicine. 2017;7 (3):205–11. [Russian]. DOI:10.20514/2226-6704-20177-3-205-211

37. Ponikowski P, Anker SD, AlHabib KF, Cowie MR, Force TL, Hu S et al. Heart failure: preventing disease and death worldwide: Addressing heart failure. ESC Heart Failure. 2014;1(1):4–25. DOI:10.1002/ehf2.12005

38. Polyakov D.S., Fomin I.V., Valikulova F.Yu., Vaisberg A.R., Kraiem N., Badin Yu.V. et al. The EPOCH-CHF epidemiological program: decompensated chronic heart failure in real-life clinical practice (EPOCH-D–CHF). Russian Heart Failure Journal. 2016;17 (5):299– 305. [Russian]. DOI:10.18087/rhfj.2016.5.2239

39. Koudstaal S, Pujades-Rodriguez M, Denaxas S, Gho JMIH, Shah AD, Yu N et al. Prognostic burden of heart failure recorded in primary care, acute hospital admissions, or both: a population-based linked electronic health record cohort study in 2.1 million people: Prognosis of HF recorded in primary care, acute HF admissions, or both. European Journal of Heart Failure. 2017;19(9):1119–27. DOI:10.1002/ejhf.709

40. Frolova E.V. The clinical features of heart failure in elderly and old age. Kardiologiia. 2018;58(8S):4–11. [Russian]. DOI:10.18087/cardio.2487

41. Boriani G, Berti E, Belotti LMB, Biffi M, De Palma R, Malavasi VL et al. Cardiac device therapy in patients with left ventricular dysfunction and heart failure: ‘real-world’ data on long-term outcomes (mortality, hospitalizations, days alive and out of hospital). European Journal of Heart Failure. 2016;18(6):693–702. DOI:10.1002/ejhf.509