Heart Failure: Multiple Chronic Conditions

A study on heart failure patients in Asia has identified patterns of chronic conditions like hypertension and coronary artery disease.

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Heart failure is a condition in which the heart loses the ability to pump enough blood to the body’s tissues. Multimorbidity, also known as multiple comorbidity (more than one illness or disease occurring in one person at the same time) or multiple chronic conditions, is common in patients with heart failure especially in Asia, where almost two-thirds of patients with heart failure were found to have multimorbidity. 

Multimorbidity can impede survival and complicate the diagnosis, treatment and outcomes of patients with heart failure and yet, previous studies have only investigated single comorbidity in isolation. 

A study, led by Dr Jasper Tromp, Research Fellow from the National Heart Research Institution Singapore (NHRIS), analysed data on 6,480 patients with chronic heart failure from across 11 Asian regions (Hong Kong, Taiwan, China, Japan, Korea, India, Malaysia, Thailand, Singapore, Indonesia and the Philippines), and identified patterns of multimorbidity among the patients and their association with the patients’ quality of life and health outcomes. Five multimorbidity groups were identified with distinct geographic distributions across Asia: 

Elderly/Atrial fibrillation (Hong Kong, Japan and Korea)

Characteristics include:
• Oldest with highest prevalence of AF and stroke
• More often with heart failure with preserved ejection fraction
• Concentric remodelling

Metabolic (Malaysia, the Philippines, Singapore and Taiwan)

Characteristics include:
• High prevalence of obesity, hypertension and diabetes
• More often with heart failure with preserved ejection fraction
• Concentric remodelling

Young (China, India, Japan, Korea and Thailand)

Characteristics include:
• Few comorbidities
• More often with heart failure with reduced ejection fraction
• Eccentric hypertrophy
• Best outcomes
• Best effect of medication

Ischaemic (India, Indonesia and Malaysia)

Characteristics include:
• Male patients with coronary artery disease and ischaemic aetiology of heart failure
• More often with heart failure with reduced ejection fraction
• Eccentric hypertrophy
• Second-worst outcomes

Lean Diabetic (Hong Kong, Malaysia and Singapore)

Characteristics include:
• Most often diabetic with low BMI
• More often with heart failure with preserved ejection fraction
• Concentric hypertrophy
• Worst outcomes and quality of life

From the data, the median number of comorbidities was three, and 81 percent of the patients had two or more comorbidities in addition to heart failure. Among all comorbidities, hypertension was the most common, followed by coronary artery disease and chronic kidney disease

Most noteworthy in the study was the prominence of the lean diabetic group in Southeast Asia, particularly Singapore and Malaysia. The lean diabetic group consisted of patients of intermediate age (mean age 66.1 years) with a strikingly high prevalence of diabetes despite a low prevalence of obesity. They also had high prevalence of hypertension, chronic kidney disease, anaemia, and coronary artery disease.

These patients were commonly of Malay ethnicity and from high-income regions. These also appeared to be the sickest patients, had the worst quality of life with the worst signs and symptoms of heart failure and frequent history of hospitalisation for heart failure.

The data on the lean diabetic group in Southeast Asia came as a surprise, given the rise in obesity from the region with rapidly growing population. Previous studies have shown that the prevalence of diabetes is increasing among Asian individuals and that diabetes occurs on average at a far lower BMI. The high proportion of chronic kidney disease in these patients potentially attributed to their worst outcomes, with more than twice as many deaths or hospitalisations for heart failure compared to the young group. 

“The study’s findings underscore the importance of multimorbidity in patients with heart failure and the need for more comprehensive approaches in phenotyping patients with heart failure and multimorbidity,” said Dr Tromp.

Read these next:
Screening for Heart Disease
Heart Failure - Signs, Symptoms and Diagnosis
Heart Failure - Understanding It



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