CLINICAL
NEWS
American College of Cardiology Extended Learning
ACCEL interviews and topical summaries of cardiology’s
most interesting research areas
Diastolic HF: Target Comorbidities
It’s one of the few things that seems to work
G
iven the striking lack of effective therapies for managing patients with HFpEF
(or ‘diastolic’ HF), two recent papers
in JACC—both co-authored by Christopher M.
O’Connor, MD, Editor-in-Chief of JACC Heart
Failure—offer insights that may provide new directions for therapy and disease management.
One paper focuses on noncardiac comorbidities.1 The fact that patients with HF typically have
multiple comorbidities is not news, but the extent
of the problem was highlighted in data from the
Centers for Medicare & Medicaid Services, demonstrating that 55% of Medicare patients coded as
having HF have >5 chronic comorbidities.2 Looking at the prevalence of specific comorbidities,
O’Connor and colleagues focused on several of the
most common: chronic obstructive pulmonary
disease (COPD), anemia, diabetes mellitus (DM),
renal disease, sleep-disordered breathing (SDB),
and obesity.
cate matters for patients with HF. Conversely,
looking at HF specifics, elevated end-diastolic
pressure and beta-blocker use may compromise
lung function.
WHY FOCUS ON COMORBIDITIES?
Yes, comorbidities are almost universal in patients
with HF, but guidelines provide little discussion of
these comorbidities. This is not surprising given
that so many are noncardiac in nature and the
evidence base is sparse and mostly observational.
Compared to patients with HFrEF, patients with
preserved ejection fraction tend to have an increased burden of COPD, DM, and anemia, which
are all associated with increased morbidity and
mortality.
Because the development of novel HF therapies
has slowed in recent years, and most contemporary HF trials have failed to improve outcomes
above standard medical therapy, O’Connor et al.
suggest the need for a critical reappraisal of treatment strategies in HF in which clinicians target
comorbidities, in addition to targeting the underlying cardiac dysfunction. This approach may be
particularly relevant for HFpEF patients for whom
no therapies are available to reduce the substantial
morbidity and mortality.
Another big factor: there is a bidirectional
impact for many comorbidities. Here are some
examples:
Renal dysfunction: It produces sodium and fluid retention, anemia, inflammation, RAAS and
sympathetic activation that are met in return by
HF that promotes cardiorenal synd