Comorbidities - Professor Richard Kirk 2023

Professor Richard Kirk
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Comorbidities are common in heart failure and may co-exist at the initial presentation or may precipitate an exacerbation of heart failure in those who are otherwise stable.

Factors that contribute to anaemia include iron and vitamin deficiency, chronic inflammation, blood loss (phlebotomy) and medications (e.g. ACEi and ARBs).
  • Transfuse in the acute setting
  • Correct iron levels with FerInJect (oral iron poorly absorbed in heart failure)
  • If anaemia fails to improve despite adequate iron and vitamins considered Erythropoietin
Heart failure predisposes to infectious complications - frequent respiratory and gastrointestinal infections. Many of these are viral and vaccinations against them (influenza, rotavirus), passive RSV with palivizumab injections are appropriate. Similarly vaccination against haemophilus influenza and streptococcus pneumonia should be up to date. It may be hard to differentiate infection from an exacerbation of heart failure, especially if heart failure has been exacerbated by an infection. If both the procalcitonin (PCT) and NT-proBNP are elevated, it is likely that there is an infection with exacerbation of HF and in addition to appropriate antibiotic therapy, HF treatment may need to be escalated. If the NT proBNP has not increased then no change in HF therapy is required.
This is common in heart failure due to decreased intake and increased expenditure from the metabolic excess. Increasing calory intake - either through high energy supplements, early recourse to NG or PEG/PEJ feeding help preserve GI function and resistance to infections and are preferable to intravenous feeding when possible.
Metabolic disease
Heart failure occurs in some metabolic diseases e.g. Propionic acidaemia. In addition to treatment of the primary disorder HF treatment is often necessary, but if definitive treatment is possible e.g. liver transplantation, the heart failure may improve.
Unsurprisingly chronic fatigue, medications and restrictions in lifestyle may lead to depression and psychological difficulties. Cognitive and poor psychological performance is also recognised, especially in those who have undergone neonatal surgery. These issues should be actively sought for and appropriate referrals made.
Pulmonary Hypertension (PH)
Pulmonary hypertension may occur due to elevation of left atrial pressure. This may be reversible with heart failure treatment but if this is not effective chronic elevation may lead to permanent damage to the pulmonary vasculature and the development of fixed pulmonary vascular resistance. When PH is suspected cardiac catheterization to assess the pulmonary vascular resistance and its ability to reverse should be undertaken. In patients with dilated cardiomyopathy increasing HF therapy may reduce the left atrial pressure, if this is ineffective VAD may be required. In the case of restrictive physiology when the increase in pulmonary artery pressure may be severe listing for cardiac transplant may be considered as once the pulmonary vasculature becomes non- reactive, cardiac transplant is not possible and heart lung transplant becomes the only option with a significantly worse prognosis than cardiac transplant alone.  
Renal Dysfunction
Renal insufficiency is common in heart failure and is often underestimated as creatinine levels are directly related to muscle mass - often reduced in heart failure. Poor renal function may be due to a low trans-renal perfusion pressure (lower arterial pressure and raised systemic venous pressure), nephrotoxic medications for HF treatment (ACEi. ARBs etc.), antibiotics for infectious complications and frequently a combination of factors. The GFR should be assessed and a renal consult sought if low.
Cardiac failure frequently leads to respiratory issues, which further compound the heart failure. A high left atrial pressure leads to pulmonary venous congestion and pulmonary oedema which in turn decreases lung compliance leading to restrictive lung function, impaired pulmonary lymphatic drainage and fluid retention, often with pleural effusions. Cardiomegaly is also a frequent cause of bronchial compression and lobar collapse. When there are significant pulmonary issues a bronchopulmonology consult should be arranged.
Last Updated: April 2023
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