Comprehensive therapeutic approach for patients with heart failure and comorbidity

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Abbreviations: ANP, A or atrial natriuretic peptide; BNP, B or brain natriuretic peptide; CNP, C natriuretic peptide; GMP, guanosine monophosphate; GTP: guanosine triphosphate; NPR, natriuretic peptide receptor." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D.A. Pascual-Figal, J. Casademont, J.M. Lobos, P. Piñera, A. Bayés-Genis, J. Ordóñez-Llanos, J.R. González-Juanatey" "autores" => array:7 [ 0 => array:2 [ "nombre" => "D.A." "apellidos" => "Pascual-Figal" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Casademont" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Lobos" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Piñera" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Bayés-Genis" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Ordóñez-Llanos" ] 6 => array:2 [ "nombre" => "J.R." 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Heart Failure" "titulo" => "Comprehensive therapeutic approach for patients with heart failure and comorbidity" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "323" "paginaFinal" => "330" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F.J. Ruiz-Laiglesia, V. Garcés-Horna, F. Formiga" "autores" => array:3 [ 0 => array:4 [ "nombre" => "F.J." "apellidos" => "Ruiz-Laiglesia" "email" => array:1 [ 0 => "fruizl@unizar.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "V." "apellidos" => "Garcés-Horna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Formiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina Interna, Hospital Universitario de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Abordaje terapéutico integral del paciente con insuficiencia cardiaca y comorbilidad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1658 "Ancho" => 1658 "Tamanyo" => 184918 ] ] "descripcion" => array:1 [ "en" => "Differential aspects to consider for patients with heart failure and comorbidity." ] ] ] "textoCompleto" => "The current contextThe prevalence of HF increases with age but can also affect younger individuals in non-negligible proportions. Although prevalence data for HF in Spain are partial, a study published in 2011 that included 306,299 individuals older than 14 years belonging to 21 health areas of Lerida, Spain, and using the International Classification of Diseases ICD-10 measured a prevalence rate in the adult population of 0.9%. Of the patients diagnosed with HF, 7.8% were younger than 65 years.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> According to the hospital morbidity survey of the Spanish National Institute of Statistics<a class="elsevierStyleCrossRef" href="#bib0015">3</a> and based on the 2013 Minimum Basic Data Set, 23% of the 116,369 discharges with a primary diagnosis of HF were for patients younger than 65 years. Considering that these data only calculate episodes and that the annual readmission rate for HF (38%)<a class="elsevierStyleCrossRef" href="#bib0020">4</a> is mostly due to elderly patients, the incidence rate for HF in those younger than 65 years would probably be greater.Patients with HF undergo a chronic process, usually have multiple diseases, and their care is typically complex. These individuals are therefore frail patients who frequently have disability (physical and/or cognitive), which can result in a certain degree of dependence beyond that generated by the patient's age or psychosocial conditions.Data from the Spanish National Registry for Heart Failure (RICA), coordinated by the Heart Failure and Atrial Fibrillation Workgroup of the Spanish Society of Internal Medicine, confirms the high rate of comorbidity (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The set of comorbidities determine the high levels of dependence observed among patients in the RICA who are older than 75 years. It is noteworthy that 19.1% of this cohort, especially women, have significant or full dependence for daily life activities, according to the Barthel index, which has important prognostic implications.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> Between 30% and 50% of patients with HF have some degree of cognitive impairment,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> 15% have no formal education and 10% live alone.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> The combination of these physical, societal and intellectual deficiencies makes individuals with HF into frail patients who are more vulnerable to conditions of stress, which are associated with greater morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Therefore, the approach for patients with HF should integrate not only biomedical measures such as the ejection fraction and biomarkers but also an assessment (with validated scales) of the functional spheres: physical (Barthel, Lawton-Brody), cognitive (Pfeiffer, Mini Mental State Examination), emotional (Yesavage) and family/social (Gijon scale).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Heterogeneity of heart failureClassically, large clinical trials and clinical practice guidelines have only differentiated 2 populations of patients with HF when assessing response to treatment: those with preserved left ventricular ejection fraction (HFPEF) and those with reduced fraction. However, the reality is much more complex. A nonrandom grouping of cardiometabolic multimorbidities (diabetes mellitus [DM], arterial hypertension [AHT], heart disease, hyperlipidemia and obesity) has been identified in the general population.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Similarly, attempts have been made to identify different phenotypes based on clinical, pathophysiological and prognostic aspects in patients with HF.<a class="elsevierStyleCrossRefs" href="#bib0010">2,11–13</a> The results are difficult to superimpose because the designs were diverse; however, it is worth noting the study by Kajimoto et al.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> The authors analyzed 4720 patients, 42% of whom had HFPEF, and showed that the survival curve was similar regardless of whether the left ventricular ejection fraction was preserved or not. However, when aspects such as the presence of coronary ischemia, AHT, DM, previous hospitalizations, anemia, systolic blood pressure and valvular heart disease were included in the analysis in these 2 apparently homogeneous groups, subgroups with different prognoses and readmissions rates were identified. Shah et al.,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> by applying the computed clusters statistics on patients with HFPEF, found a reclassification into 3 exclusive phenotypes: phenotype 1, composed of younger patients with moderate diastolic dysfunction, slightly increased natriuretic peptide levels and better prognoses; phenotype 2, composed of patients with obesity, diabetes, increased prevalence of sleep apnea and greater diastolic dysfunction; and phenotype 3, composed of older patients with chronic renal failure (CRF), greater electrical and structural remodeling, pulmonary hypertension, right ventricular dysfunction, increased mortality and higher readmissions. The importance of these studies lies in the demonstration of the heterogeneity of patients with HF, an issue that future treatment guidelines and clinical trials will have to include to adapt their recommendations to each individual patient, in place of recommendations that are probably less realistic from the practical point of view.Polypharmacy, adherence and treatment optimizationPolypharmacyTreating patients with HF is complex. As new scientific evidence has become available, the therapeutic arsenal has grown in a typical “additive phenomenon”. To this HF arsenal, we can add the drugs for each of the various comorbidities. According to the National Health and Nutrition Examination Survey, patients with HF went from taking 4.1 drugs in the period 1988–1994 to 6.4 in 2003–2008.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> In the study by Galindo Ortego et al.,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> performed in the Healthcare Region of Lerida during 2007, the mean number of drugs consumed (according to therapeutic group) by patients with HF in primary care was 8.69 per patient. It is logical to assume that polypharmacy (defined as the consumption of 5 or more drugs<a class="elsevierStyleCrossRef" href="#bib0075">15</a>) is an added problem and a possible source of complications. The prevalence of polypharmacy increases with age and is associated with the risk of inappropriate prescription, underutilization of drugs that have been shown effective, medical errors, low adherence, drug interactions and adverse effects.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Gastelurrutia et al. followed 99 patients with HF and a mean consumption of 10 drugs for 6 months. Thirty-one percent of these patients had undertreated comorbidities, 22% had dosage or prescription errors, 16% had drug interactions that could have caused adverse effects, and 14% lacked treatment adherence.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Treatment adherenceBy consensus, a patient is considered to adhere to a prescribed drug when the dose consumed over a period of time exceeds 80% of the required amount.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> The rates of treatment adherence for HF vary depending on the methods and populations assessed; however, it has been shown that noncompliant patients have a greater risk of mortality and readmission.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>Treatment optimizationFor these reasons, it is important to simplify the treatment of patients with HF by not prescribing, or withdrawing if possible, certain drugs. There are tools that help optimize treatments, by detecting inappropriate prescriptions and preventing adverse effects (screening tool of older persons’ potentially inappropriate prescriptions [STOPP]) and by detecting errors of omission (screening tool to alert doctors to right treatment [START]). The STOPP-START criteria, validated in the over 65-year-old population, have been recently updated. There is a Spanish version of these criteria,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> which can be applied to both IC and its various comorbidities.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>Drug treatment for heart failure and its comorbiditiesHeart failure and chronic obstructive pulmonary diseaseFor patients with HF, chronic obstructive pulmonary disease (COPD) should be treated according to the current clinical guidelines.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> However, it is important to note that β2-adrenergic agonists, the cornerstone of drug treatment for COPD, are not selective drugs. Their action on β1-adrenergic myocardial receptors can therefore cause tachycardia and increased oxygen consumption, creating negative effects on the clinical progression of patients with HF. The meta-analysis by Salpeter et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> and the observational study by Au et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> showed an increase in mortality and readmissions for HF in patients with COPD and left ventricular dysfunction treated with short-acting agonists. Therefore, the use of long-acting agonists is advocated. These agonists have less of an effect on these receptors.For patients with COPD, short-acting anticholinergic agents, such as ipratropium bromide, are associated with an increased rate of cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> For the long-acting agents, conversely, short-term cardiac adverse effects have not been observed. Thus, tiotropium has been shown to reduce cardiovascular mortality (when compared with placebo) in patients with COPD and has been shown to be safe for patients with HF who require prolonged bronchodilator action.<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a>Corticosteroids are a pharmacological group with a risk of sodium and fluid retention. Their use at high doses can therefore increase the number of HF decompensations. In the event corticosteroids are used, it is preferable that they be inhaled, which can be an effective alternative with fewer adverse effects.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>Theophyllines, which are steadily decreasing in use, are not recommended for patients with COPD and HF due to the high risk of arrhythmias that their use entails.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>From the point of view of HF, β-blocker therapy increases survival in patients with chronic HF. However, this use of this therapy often decreases in patients with concomitant COPD due to the possible reduction in the bronchodilator effect of the β2-agonist and the potential worsening of bronchospasms.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> It is important to remember that a Cochrane review concluded that cardioselective β-blockage is safe for patients with HF and COPD.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> Thus, the recent guidelines of the National Institute for Health and Clinical Excellence and the European Society of Cardiology (ESC) explicitly indicate that COPD is not a contraindication for the use of cardioselective β-blockers, such as metoprolol, bisoprolol and nebivolol.<a class="elsevierStyleCrossRefs" href="#bib0160">32,33</a> It is recommended that treatment always start with low doses that are gradually increased.Finally, we must consider that high-dose loop diuretics can cause metabolic alkalosis and compensatory hypoventilation, aggravating a possible hypercapnia.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Heart failure and diabetes mellitusDM is considered an independent risk factor for the onset of atherosclerotic cardiovascular disease and HF.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> Additionally, the presence of DM in patients with established HF is associated with greater morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>The selection of hypoglycemic drugs in the context of HF can be controversial. Although metformin has been associated with lactic acidosis in cases of concomitant renal failure,<a class="elsevierStyleCrossRef" href="#bib0185">37</a> it is the only drug that has shown to reduce all-cause mortality in patients with HF<a class="elsevierStyleCrossRef" href="#bib0190">38</a> and is considered a first choice. As with other oral diabetes drugs, a useful recommendation is to withdraw metformin during hospitalization for HF decompensation and substitute it with temporary insulinization.In terms of sulfonylureas, the University Group Diabetes Program study<a class="elsevierStyleCrossRef" href="#bib0195">39</a> concluded that their use is associated with a higher rate of cardiovascular events. Subsequent studies such as the UK Prospective Diabetes Study (UKPDS-33) could not confirm this finding.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> Thus, there is still controversy over the safety of sulfonylureas. Thiazolidinediones and glitazones have been related to a greater risk of fluid retention and are therefore contraindicated for all patients with HF, regardless of functional class.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> There are limited data available on the use of acarbose in patients with HF, and therefore recommendations on its use cannot be made.The cardiovascular safety of incretin mimetic agents (dipeptidyl-peptidase-4 inhibitors) and glucagon-like peptide-1 receptor agonists continues to be debated. For the former, a meta-analysis was published in 2014 whose data demonstrated that these agents could be associated with a greater risk of HF, with no differences between the different dipeptidyl-peptidase-4 inhibitors.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> Recently, however, the Trial to Evaluate Cardiovascular Outcomes after Treatment with Sitagliptin that included patients with type 2 DM and prior cardiovascular disease concluded that, compared with placebo, sitagliptin did not increase the risk of hospitalization for HF.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> With regard to glucagon-like peptide-1 receptor agonists, there is still insufficient experience with patients with type 2 DM and HF, although a first study is underway on the cardiovascular safety: the Evaluation of Lixisenatide in Acute Coronary Syndrome study.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> Lastly, the observational study by Yu et al. on 57,737 patients with type 2 DM jointly analyzed dipeptidyl-peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists. The study found no relationship between their use and the incidence rate of HF.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>With regard to the new glycosuric drugs, sodium-glucose cotransporter 2 inhibitors, the experience in the New York Heart Association (NYHA) class I–II is very limited and is nonexistent for dapagliflozin in class III–IV. In general, it is considered that these drugs should not be used concomitantly with loop diuretics or in patients with impaired renal function.Insulin has positive inotropic effects on myocardial tissue and can therefore improve the hemodynamics of patients with systolic HF. In the Outcome Reduction With Initial Glargine Intervention clinical trial, there seemed to be a nonsignificant tendency toward a reduction in hospitalizations for HF among the patients with strict glycemic control with insulin glargine.<a class="elsevierStyleCrossRef" href="#bib0230">46</a>The administration of β-blockers to patients with DM has been questioned, given the possibility that the blockers can reduce sensitivity to insulin and minimize the symptoms of hypoglycemia. However, there is sufficient evidence to support the use of β-blockers for patients with DM and HF, unless there is a contraindication for some other reason.<a class="elsevierStyleCrossRef" href="#bib0235">47</a>The guidelines recommend that treatment with angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB-II) in patients with DM should start at low doses, with a gradual adjustment to the maximum tolerated dosage and frequent renal function and electrolyte monitoring.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> Patients with DM and HF can also benefit from the addition of mineralocorticoid receptor antagonists. However, if the antagonists are administered in combination with ACEIs or ARB-II, the renal function should be monitored for the possibility of worsening creatinine clearance and hyperkalemia.<a class="elsevierStyleCrossRef" href="#bib0245">49</a>Diuretics can worsen glucose metabolism, specifically thiazides and loop diuretics. Nevertheless, treatment with diuretics is usually inevitable for patients with HF to improve congestion in acute phases and to maintain stability in chronic HF.Heart failure and arterial hypertensionAHT remains the most significant risk factor for the development and progression of HF. Most drugs used for treating HF also help control blood pressure. The latest guidelines recommend ACEIs (or ARB II) as the first-line treatment for AHT in patients with HF.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> β-Blockers may also be used safely, as well as mineralocorticoid receptor antagonists, amlodipine and diuretics. However, nondihydropyridine calcium antagonists (diltiazem and verapamil) are contraindicated for treating AHT in patients with HF and reduced left ventricular ejection fraction due to its negative inotropic effect.<a class="elsevierStyleCrossRef" href="#bib0255">51</a>Heart failure and anemiaIn recent years, anemia in patients with HF has been the subject of attention due to its frequency and for causing a poorer functional and vital prognosis.<a class="elsevierStyleCrossRefs" href="#bib0260">52,53</a> Although the etiology of anemia in HF is usually multifactorial, an etiological study should be conducted to specifically treat the correctable causes. Currently, treatment is particularly focused on the use of erythropoiesis-stimulating agents and iron.Although the experimental data on the treatment with erythropoietin analogs for patients with anemia and HF appear promising,<a class="elsevierStyleCrossRef" href="#bib0270">54</a> large randomized clinical trials have shown that the analogs do not improve the clinical situation (Study of Anemia in Heart Failure Trial<a class="elsevierStyleCrossRef" href="#bib0275">55</a>) and have neutral or even negative effects on the prognosis (Cross-tumoral Phase 2 With Crizotinib,<a class="elsevierStyleCrossRef" href="#bib0280">56</a> Correction of Hemoglobin and Outcomes in Renal Insufficiency,<a class="elsevierStyleCrossRef" href="#bib0285">57</a> Trial to Reduce Cardiovascular Events With Aranesp Therapy<a class="elsevierStyleCrossRef" href="#bib0290">58</a> and Reduction of Events With Darbepoetin Alfa in Heart Failure<a class="elsevierStyleCrossRef" href="#bib0295">59</a>), despite the increase in hemoglobin concentrations. Therefore, with the currently available data, erythropoietin or its analogs are recommended only for patients with anemia and HF when there is coexisting chronic kidney disease, with the objective of achieving hemoglobin concentrations between 11 and 12g/dL.<a class="elsevierStyleCrossRef" href="#bib0300">60</a>In terms of iron, 2 clinical trials have assessed treatment with intravenous ferric carboxymaltose in HF with systolic dysfunction and iron deficiency (ferritin <100ng/mL or 100–300ng/mL if the transferrin saturation <20%), with or without anemia. The 2 studies are the Ferric Carboxymaltose Assessment in Patients with Iron Deficiency and Chronic Heart Failure study,<a class="elsevierStyleCrossRef" href="#bib0305">61</a> which showed an improvement in quality of life and functional capacity, and the CONFIRM-HF (Ferric Carboxymaltose Evaluation on Performance in Patients with Iron Deficiency in Combination with Chronic Heart Failure) study,<a class="elsevierStyleCrossRef" href="#bib0310">62</a> which in addition to these objectives, showed a reduction in the number of hospitalizations but no reduction in mortality. As to the optimal administration route, the IRON-HF study<a class="elsevierStyleCrossRef" href="#bib0315">63</a> showed that intravenous administration was superior in the functional improvement of patients with HF compared with oral supplements. Thus, the clinical practice guidelines for HF indicate iron replenishment for symptomatic patients with systolic dysfunction and iron deficiency. However, the effect of this treatment in HFPEF and the long-term safety of iron treatment in HF are unknown.<a class="elsevierStyleCrossRef" href="#bib0255">51</a>Heart failure and chronic renal failureCRF is a highly prevalent comorbidity in HF. It has been shown that CRF is associated with a poorer prognosis in patients with HF,<a class="elsevierStyleCrossRef" href="#bib0320">64</a> and, in the practice, CRF hinders the treatment, as shown by the Acute Decompensated Heart Failure National Registry study.<a class="elsevierStyleCrossRef" href="#bib0325">65</a> ACEIs (or ARB-II) and mineralocorticoid receptor antagonists are contraindicated for serum creatinine concentrations >2.5mg/dL, glomerular filtration rates <30mL/min and potassium levels >5mEq/L.<a class="elsevierStyleCrossRef" href="#bib0330">66</a>Other comorbiditiesThere are other comorbidities that should also be detected and treated, including sleep apnea–hypopnea syndrome, depression, cognitive impairment and peptic ulcers.Adequacy of heart failure treatment according to the progression stageTo correctly assess therapeutic appropriateness in HF, we should consider various aspects: the patient's life expectancy, the time that has to elapse between the start of a treatment and its benefits (delay time or payoff time), the therapeutic objectives (curative or palliative) and the results that are sought (life extension, morbidity and mortality prevention, maintenance of the functional condition or treatment of the exacerbations).<a class="elsevierStyleCrossRef" href="#bib0335">67</a> If these pillars are not balanced, the “therapeutic building” can fall down.These aspects need to be distributed appropriately in each of the 3 phases in which the evolution of a chronic disease such as HF can be divided: stable (NYHA I–III), advanced (NYHA III–IV) and palliative (NYHA IV). It is sometimes difficult to establish the borders between these stages. Unlike cancer, for example, HF does not have a slow progressive decline but rather an evolution subject to exacerbations, followed by recovery almost to the previous functional condition, with the added possibility of unexpected death.<a class="elsevierStyleCrossRef" href="#bib0340">68</a> To establish an appropriate therapeutic plan, we need to make an estimate of the vital prognosis. Although there are various prognostic scales with numerous variables aimed at patients with HF, indices as simple as the Barthel index help estimate mortality at 3 months. In RICA, 28% of the patients with a Barthel index ≤60 died during the 3 months following admission. The remaining patients, who had a Barthel index of >60, had a mortality almost 3 times lower (11%).<a class="elsevierStyleCrossRef" href="#bib0345">69</a> In a meta-analysis of 70 studies, Salpeter et al. identified a set of clinical and laboratory data from patients with HF that, combined, was associated with a life expectancy shorter than 6 months.<a class="elsevierStyleCrossRef" href="#bib0350">70</a> The Elderly Patients with Multiple Diseases workgroup of the Spanish Society of Internal Medicine validated the “Palliate index”, which estimates the probability of dying within the next 6 months for patients with advanced chronic diseases, including HF in functional condition NYHAIII–IV.<a class="elsevierStyleCrossRef" href="#bib0355">71</a> The Palliate index has a high negative predictive value.<a class="elsevierStyleCrossRef" href="#bib0360">72</a> This workgroup has developed an additional index for patients with multiple diseases, the PROFUND index, which estimates the probability of dying after hospitalization for any cause.<a class="elsevierStyleCrossRef" href="#bib0365">73</a>In the final evolutionary phase of HF, treatment needs to prioritize symptom control and the preservation of the quality of life, preventing suffering and needless prolongation of life. Dyspnea, depression, asthenia, pain and edema are the main sources of physical suffering during this period and the ones upon which we should act. It is worth considering deprescription as an option for the proper approach for patients in this phase; i.e., discontinuing the use of drugs such as statins, anticoagulants, antiplatelets and, in case of hypotension or renal failure, β-blockers and ACEIs,<a class="elsevierStyleCrossRef" href="#bib0370">74</a> maintaining the strictly essential treatment for better symptom control. It is essential to inform the patient beforehand about the likely progression of the disease and understand their preferences as to where they want their symptoms to be alleviated or where to pass their final moments (at home or in the hospital) and their wishes concerning cardiopulmonary resuscitation maneuvers.<a class="elsevierStyleCrossRefs" href="#bib0375">75,76</a>Healthcare coordinationThe care of patients with HF requires comprehensive action by the various health suppliers. Eighty-five percent of patients with HF have at least one other comorbidity of those included in the Charlson index.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Therefore, these patients are complex and frequently have multiple diseases.<a class="elsevierStyleCrossRef" href="#bib0385">77</a> To care for these patients, the Spanish Societies of Family and Community Medicine, Internal Medicine and Community Nursing have published 2 consensus documents,<a class="elsevierStyleCrossRefs" href="#bib0390">78,79</a> which make the family doctor and internist the reference healthcare professionals in caring for patients with chronic diseases, including HF. The documents also make nursing responsible for the delivery and coordination of care and case management, within and outside the hospital. The hospital pharmacy and primary care play a significant role in caring for polymedicated patients, promoting adherence and therapeutic reconciliation in the transition between healthcare levels. Social work professionals should detect the patients’ social problems and needs. The family and caregivers need to be aware of the healthcare resources, collaborate in the patient's self-care and in monitoring their symptoms. All of these elements should be coordinated in a healthcare model directed not toward treating exacerbations but rather avoiding them.ConclusionsHF is, in short, a very common disease in the day-to-day practice of medical internists. A deep understanding not only of its treatment options but also of the associated common comorbidities is necessary. It is essential that we study the whole patient and understand the disease as a dynamic process in which the needs and intensity of treatment vary over time. In addition to the most common medical comorbidities such as DM, COPD, anemia and CRF, it is important to assess the overall physical and cognitive function, as well as the patient's mood and social and family environment. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the differential aspects for a correct approach to patients with HF and comorbidity in a summarized manner.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Conflict of interestsThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres707937" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec717567" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres707936" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec717566" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "The current context" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Heterogeneity of heart failure" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Polypharmacy, adherence and treatment optimization" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Polypharmacy" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Treatment adherence" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Treatment optimization" ] ] ] 7 => array:3 [ "identificador" => "sec0035" "titulo" => "Drug treatment for heart failure and its comorbidities" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Heart failure and chronic obstructive pulmonary disease" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Heart failure and diabetes mellitus" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Heart failure and arterial hypertension" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Heart failure and anemia" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Heart failure and chronic renal failure" ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Other comorbidities" ] ] ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Adequacy of heart failure treatment according to the progression stage" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Healthcare coordination" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusions" ] 11 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec717567" "palabras" => array:3 [ 0 => "Heart failure" 1 => "Comorbidity" 2 => "Treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec717566" "palabras" => array:3 [ 0 => "Insuficiencia cardíaca" 1 => "Comorbilidad" 2 => "Tratamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a «cardiometabolic phenotype». Their interrelation changes the evolution and treatment that each disease would have in isolation. Patients with heart failure and comorbidity are frail and complex. They require a comprehensive assessment (not just biomedical), which includes functional, cognitive, affective and psychosocial aspects. The overall treatment, which is not covered in the clinical practice guidelines, should adapt to each and every one of the comorbidities. Polypharmacy should be avoided as much as possible, due to its interactions and reduced adherence. Treatment needs to be optimized and adapted to the evolutionary phase of the disease and the specific needs of each patient. The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient's care." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La prevalencia de insuficiencia cardiaca aumenta con la edad y se acompaña de otras enfermedades, englobadas en un «fenotipo cardiometabólico». Su interrelación modifica la evolución y tratamiento que cada una tendría aisladamente. El paciente con insuficiencia cardiaca y comorbilidad es un enfermo frágil y complejo. Precisa una valoración integral, no solo biomédica, que incluya aspectos funcionales, cognitivos, afectivos y psicosociales. El tratamiento global, no recogido en las guías de práctica clínica, ha de adaptarse a todas y cada unas de las comorbilidades. Debe evitarse, en lo posible, la polifarmacia, por sus interacciones y la disminución de adherencia. Es necesario optimizar y adaptar el tratamiento a la fase evolutiva de la enfermedad y las necesidades específicas de cada paciente. La complejidad del proceso asistencial del paciente con insuficiencia cardiaca y comorbilidades exige la coordinación de los proveedores de salud, el apoyo familiar y del entorno." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ruiz-Laiglesia FJ, Garcés-Horna V, Formiga F. Abordaje terapéutico integral del paciente con insuficiencia cardiaca y comorbilidad. Rev Clin Esp. 2016;216:323–330." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1658 "Ancho" => 1658 "Tamanyo" => 184918 ] ] "descripcion" => array:1 [ "en" => "Differential aspects to consider for patients with heart failure and comorbidity." ] ] 1 => array:9 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Ruiz Laiglesia et al.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comorbidity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High blood pressure. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic obstructive pulmonary disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Myocardial infarction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cerebrovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peripheral arterial disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1167744.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comorbidity in patients with heart failure according to data from the Spanish National Heart Failure Registry (RICA)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:79 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comorbidity in heart failure. 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Symposium. Heart Failure

Comprehensive therapeutic approach for patients with heart failure and comorbidity

Abordaje terapéutico integral del paciente con insuficiencia cardiaca y comorbilidad

F.J. Ruiz-Laiglesiaa,

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fruizl@unizar.es

Corresponding author.

, V. Garcés-Hornaa, F. Formigab

a Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain

b Departamento de Medicina Interna, Hospital Universitario de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">The current context</span><p id="par0005" class="elsevierStylePara elsevierViewall">The prevalence of HF increases with age but can also affect younger individuals in non-negligible proportions&#46; Although prevalence data for HF in Spain are partial&#44; a study published in 2011 that included 306&#44;299 individuals older than 14 years belonging to 21 health areas of Lerida&#44; Spain&#44; and using the International Classification of Diseases ICD-10 measured a prevalence rate in the adult population of 0&#46;9&#37;&#46; Of the patients diagnosed with HF&#44; 7&#46;8&#37; were younger than 65 years&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> According to the hospital morbidity survey of the Spanish National Institute of Statistics<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and based on the 2013 Minimum Basic Data Set&#44; 23&#37; of the 116&#44;369 discharges with a primary diagnosis of HF were for patients younger than 65 years&#46; Considering that these data only calculate episodes and that the annual readmission rate for HF &#40;38&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> is mostly due to elderly patients&#44; the incidence rate for HF in those younger than 65 years would probably be greater&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with HF undergo a chronic process&#44; usually have multiple diseases&#44; and their care is typically complex&#46; These individuals are therefore frail patients who frequently have disability &#40;physical and&#47;or cognitive&#41;&#44; which can result in a certain degree of dependence beyond that generated by the patient&#39;s age or psychosocial conditions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Data from the Spanish National Registry for Heart Failure &#40;RICA&#41;&#44; coordinated by the Heart Failure and Atrial Fibrillation Workgroup of the Spanish Society of Internal Medicine&#44; confirms the high rate of comorbidity &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The set of comorbidities determine the high levels of dependence observed among patients in the RICA who are older than 75 years&#46; It is noteworthy that 19&#46;1&#37; of this cohort&#44; especially women&#44; have significant or full dependence for daily life activities&#44; according to the Barthel index&#44; which has important prognostic implications&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Between 30&#37; and 50&#37; of patients with HF have some degree of cognitive impairment&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> 15&#37; have no formal education and 10&#37; live alone&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The combination of these physical&#44; societal and intellectual deficiencies makes individuals with HF into frail patients who are more vulnerable to conditions of stress&#44; which are associated with greater morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Therefore&#44; the approach for patients with HF should integrate not only biomedical measures such as the ejection fraction and biomarkers but also an assessment &#40;with validated scales&#41; of the functional spheres&#58; physical &#40;Barthel&#44; Lawton-Brody&#41;&#44; cognitive &#40;Pfeiffer&#44; Mini Mental State Examination&#41;&#44; emotional &#40;Yesavage&#41; and family&#47;social &#40;Gijon scale&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Heterogeneity of heart failure</span><p id="par0020" class="elsevierStylePara elsevierViewall">Classically&#44; large clinical trials and clinical practice guidelines have only differentiated 2 populations of patients with HF when assessing response to treatment&#58; those with preserved left ventricular ejection fraction &#40;HFPEF&#41; and those with reduced fraction&#46; However&#44; the reality is much more complex&#46; A nonrandom grouping of cardiometabolic multimorbidities &#40;diabetes mellitus &#91;DM&#93;&#44; arterial hypertension &#91;AHT&#93;&#44; heart disease&#44; hyperlipidemia and obesity&#41; has been identified in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Similarly&#44; attempts have been made to identify different phenotypes based on clinical&#44; pathophysiological and prognostic aspects in patients with HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;11&#8211;13</span></a> The results are difficult to superimpose because the designs were diverse&#59; however&#44; it is worth noting the study by Kajimoto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The authors analyzed 4720 patients&#44; 42&#37; of whom had HFPEF&#44; and showed that the survival curve was similar regardless of whether the left ventricular ejection fraction was preserved or not&#46; However&#44; when aspects such as the presence of coronary ischemia&#44; AHT&#44; DM&#44; previous hospitalizations&#44; anemia&#44; systolic blood pressure and valvular heart disease were included in the analysis in these 2 apparently homogeneous groups&#44; subgroups with different prognoses and readmissions rates were identified&#46; Shah et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> by applying the computed clusters statistics on patients with HFPEF&#44; found a reclassification into 3 exclusive phenotypes&#58; phenotype 1&#44; composed of younger patients with moderate diastolic dysfunction&#44; slightly increased natriuretic peptide levels and better prognoses&#59; phenotype 2&#44; composed of patients with obesity&#44; diabetes&#44; increased prevalence of sleep apnea and greater diastolic dysfunction&#59; and phenotype 3&#44; composed of older patients with chronic renal failure &#40;CRF&#41;&#44; greater electrical and structural remodeling&#44; pulmonary hypertension&#44; right ventricular dysfunction&#44; increased mortality and higher readmissions&#46; The importance of these studies lies in the demonstration of the heterogeneity of patients with HF&#44; an issue that future treatment guidelines and clinical trials will have to include to adapt their recommendations to each individual patient&#44; in place of recommendations that are probably less realistic from the practical point of view&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Polypharmacy&#44; adherence and treatment optimization</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Polypharmacy</span><p id="par0025" class="elsevierStylePara elsevierViewall">Treating patients with HF is complex&#46; As new scientific evidence has become available&#44; the therapeutic arsenal has grown in a typical &#8220;additive phenomenon&#8221;&#46; To this HF arsenal&#44; we can add the drugs for each of the various comorbidities&#46; According to the National Health and Nutrition Examination Survey&#44; patients with HF went from taking 4&#46;1 drugs in the period 1988&#8211;1994 to 6&#46;4 in 2003&#8211;2008&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In the study by Galindo Ortego et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> performed in the Healthcare Region of Lerida during 2007&#44; the mean number of drugs consumed &#40;according to therapeutic group&#41; by patients with HF in primary care was 8&#46;69 per patient&#46; It is logical to assume that polypharmacy &#40;defined as the consumption of 5 or more drugs<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#41; is an added problem and a possible source of complications&#46; The prevalence of polypharmacy increases with age and is associated with the risk of inappropriate prescription&#44; underutilization of drugs that have been shown effective&#44; medical errors&#44; low adherence&#44; drug interactions and adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Gastelurrutia et al&#46; followed 99 patients with HF and a mean consumption of 10 drugs for 6 months&#46; Thirty-one percent of these patients had undertreated comorbidities&#44; 22&#37; had dosage or prescription errors&#44; 16&#37; had drug interactions that could have caused adverse effects&#44; and 14&#37; lacked treatment adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Treatment adherence</span><p id="par0030" class="elsevierStylePara elsevierViewall">By consensus&#44; a patient is considered to adhere to a prescribed drug when the dose consumed over a period of time exceeds 80&#37; of the required amount&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The rates of treatment adherence for HF vary depending on the methods and populations assessed&#59; however&#44; it has been shown that noncompliant patients have a greater risk of mortality and readmission&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Treatment optimization</span><p id="par0035" class="elsevierStylePara elsevierViewall">For these reasons&#44; it is important to simplify the treatment of patients with HF by not prescribing&#44; or withdrawing if possible&#44; certain drugs&#46; There are tools that help optimize treatments&#44; by detecting inappropriate prescriptions and preventing adverse effects &#40;screening tool of older persons&#8217; potentially inappropriate prescriptions &#91;STOPP&#93;&#41; and by detecting errors of omission &#40;screening tool to alert doctors to right treatment &#91;START&#93;&#41;&#46; The STOPP-START criteria&#44; validated in the over 65-year-old population&#44; have been recently updated&#46; There is a Spanish version of these criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> which can be applied to both IC and its various comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Drug treatment for heart failure and its comorbidities</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Heart failure and chronic obstructive pulmonary disease</span><p id="par0040" class="elsevierStylePara elsevierViewall">For patients with HF&#44; chronic obstructive pulmonary disease &#40;COPD&#41; should be treated according to the current clinical guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> However&#44; it is important to note that &#946;2-adrenergic agonists&#44; the cornerstone of drug treatment for COPD&#44; are not selective drugs&#46; Their action on &#946;1-adrenergic myocardial receptors can therefore cause tachycardia and increased oxygen consumption&#44; creating negative effects on the clinical progression of patients with HF&#46; The meta-analysis by Salpeter et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and the observational study by Au et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> showed an increase in mortality and readmissions for HF in patients with COPD and left ventricular dysfunction treated with short-acting agonists&#46; Therefore&#44; the use of long-acting agonists is advocated&#46; These agonists have less of an effect on these receptors&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For patients with COPD&#44; short-acting anticholinergic agents&#44; such as ipratropium bromide&#44; are associated with an increased rate of cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> For the long-acting agents&#44; conversely&#44; short-term cardiac adverse effects have not been observed&#46; Thus&#44; tiotropium has been shown to reduce cardiovascular mortality &#40;when compared with placebo&#41; in patients with COPD and has been shown to be safe for patients with HF who require prolonged bronchodilator action&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Corticosteroids are a pharmacological group with a risk of sodium and fluid retention&#46; Their use at high doses can therefore increase the number of HF decompensations&#46; In the event corticosteroids are used&#44; it is preferable that they be inhaled&#44; which can be an effective alternative with fewer adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Theophyllines&#44; which are steadily decreasing in use&#44; are not recommended for patients with COPD and HF due to the high risk of arrhythmias that their use entails&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">From the point of view of HF&#44; &#946;-blocker therapy increases survival in patients with chronic HF&#46; However&#44; this use of this therapy often decreases in patients with concomitant COPD due to the possible reduction in the bronchodilator effect of the &#946;2-agonist and the potential worsening of bronchospasms&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> It is important to remember that a Cochrane review concluded that cardioselective &#946;-blockage is safe for patients with HF and COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Thus&#44; the recent guidelines of the National Institute for Health and Clinical Excellence and the European Society of Cardiology &#40;ESC&#41; explicitly indicate that COPD is not a contraindication for the use of cardioselective &#946;-blockers&#44; such as metoprolol&#44; bisoprolol and nebivolol&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a> It is recommended that treatment always start with low doses that are gradually increased&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally&#44; we must consider that high-dose loop diuretics can cause metabolic alkalosis and compensatory hypoventilation&#44; aggravating a possible hypercapnia&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Heart failure and diabetes mellitus</span><p id="par0070" class="elsevierStylePara elsevierViewall">DM is considered an independent risk factor for the onset of atherosclerotic cardiovascular disease and HF&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Additionally&#44; the presence of DM in patients with established HF is associated with greater morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The selection of hypoglycemic drugs in the context of HF can be controversial&#46; Although metformin has been associated with lactic acidosis in cases of concomitant renal failure&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> it is the only drug that has shown to reduce all-cause mortality in patients with HF<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> and is considered a first choice&#46; As with other oral diabetes drugs&#44; a useful recommendation is to withdraw metformin during hospitalization for HF decompensation and substitute it with temporary insulinization&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In terms of sulfonylureas&#44; the University Group Diabetes Program study<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> concluded that their use is associated with a higher rate of cardiovascular events&#46; Subsequent studies such as the UK Prospective Diabetes Study &#40;UKPDS-33&#41; could not confirm this finding&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> Thus&#44; there is still controversy over the safety of sulfonylureas&#46; Thiazolidinediones and glitazones have been related to a greater risk of fluid retention and are therefore contraindicated for all patients with HF&#44; regardless of functional class&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> There are limited data available on the use of acarbose in patients with HF&#44; and therefore recommendations on its use cannot be made&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The cardiovascular safety of incretin mimetic agents &#40;dipeptidyl-peptidase-4 inhibitors&#41; and glucagon-like peptide-1 receptor agonists continues to be debated&#46; For the former&#44; a meta-analysis was published in 2014 whose data demonstrated that these agents could be associated with a greater risk of HF&#44; with no differences between the different dipeptidyl-peptidase-4 inhibitors&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Recently&#44; however&#44; the Trial to Evaluate Cardiovascular Outcomes after Treatment with Sitagliptin that included patients with type 2 DM and prior cardiovascular disease concluded that&#44; compared with placebo&#44; sitagliptin did not increase the risk of hospitalization for HF&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> With regard to glucagon-like peptide-1 receptor agonists&#44; there is still insufficient experience with patients with type 2 DM and HF&#44; although a first study is underway on the cardiovascular safety&#58; the Evaluation of Lixisenatide in Acute Coronary Syndrome study&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> Lastly&#44; the observational study by Yu et al&#46; on 57&#44;737 patients with type 2 DM jointly analyzed dipeptidyl-peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists&#46; The study found no relationship between their use and the incidence rate of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">With regard to the new glycosuric drugs&#44; sodium-glucose cotransporter 2 inhibitors&#44; the experience in the New York Heart Association &#40;NYHA&#41; class <span class="elsevierStyleSmallCaps">I</span>&#8211;<span class="elsevierStyleSmallCaps">II</span> is very limited and is nonexistent for dapagliflozin in class <span class="elsevierStyleSmallCaps">III</span>&#8211;<span class="elsevierStyleSmallCaps">IV</span>&#46; In general&#44; it is considered that these drugs should not be used concomitantly with loop diuretics or in patients with impaired renal function&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Insulin has positive inotropic effects on myocardial tissue and can therefore improve the hemodynamics of patients with systolic HF&#46; In the Outcome Reduction With Initial Glargine Intervention clinical trial&#44; there seemed to be a nonsignificant tendency toward a reduction in hospitalizations for HF among the patients with strict glycemic control with insulin glargine&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The administration of &#946;-blockers to patients with DM has been questioned&#44; given the possibility that the blockers can reduce sensitivity to insulin and minimize the symptoms of hypoglycemia&#46; However&#44; there is sufficient evidence to support the use of &#946;-blockers for patients with DM and HF&#44; unless there is a contraindication for some other reason&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The guidelines recommend that treatment with angiotensin-converting enzyme inhibitors &#40;ACEI&#41; and angiotensin <span class="elsevierStyleSmallCaps">II</span> receptor blockers &#40;ARB-II&#41; in patients with DM should start at low doses&#44; with a gradual adjustment to the maximum tolerated dosage and frequent renal function and electrolyte monitoring&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> Patients with DM and HF can also benefit from the addition of mineralocorticoid receptor antagonists&#46; However&#44; if the antagonists are administered in combination with ACEIs or ARB-II&#44; the renal function should be monitored for the possibility of worsening creatinine clearance and hyperkalemia&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Diuretics can worsen glucose metabolism&#44; specifically thiazides and loop diuretics&#46; Nevertheless&#44; treatment with diuretics is usually inevitable for patients with HF to improve congestion in acute phases and to maintain stability in chronic HF&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Heart failure and arterial hypertension</span><p id="par0115" class="elsevierStylePara elsevierViewall">AHT remains the most significant risk factor for the development and progression of HF&#46; Most drugs used for treating HF also help control blood pressure&#46; The latest guidelines recommend ACEIs &#40;or ARB II&#41; as the first-line treatment for AHT in patients with HF&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> &#946;-Blockers may also be used safely&#44; as well as mineralocorticoid receptor antagonists&#44; amlodipine and diuretics&#46; However&#44; nondihydropyridine calcium antagonists &#40;diltiazem and verapamil&#41; are contraindicated for treating AHT in patients with HF and reduced left ventricular ejection fraction due to its negative inotropic effect&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Heart failure and anemia</span><p id="par0120" class="elsevierStylePara elsevierViewall">In recent years&#44; anemia in patients with HF has been the subject of attention due to its frequency and for causing a poorer functional and vital prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#44;53</span></a> Although the etiology of anemia in HF is usually multifactorial&#44; an etiological study should be conducted to specifically treat the correctable causes&#46; Currently&#44; treatment is particularly focused on the use of erythropoiesis-stimulating agents and iron&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although the experimental data on the treatment with erythropoietin analogs for patients with anemia and HF appear promising&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> large randomized clinical trials have shown that the analogs do not improve the clinical situation &#40;Study of Anemia in Heart Failure Trial<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a>&#41; and have neutral or even negative effects on the prognosis &#40;Cross-tumoral Phase 2 With Crizotinib&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Correction of Hemoglobin and Outcomes in Renal Insufficiency&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> Trial to Reduce Cardiovascular Events With Aranesp Therapy<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> and Reduction of Events With Darbepoetin Alfa in Heart Failure<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a>&#41;&#44; despite the increase in hemoglobin concentrations&#46; Therefore&#44; with the currently available data&#44; erythropoietin or its analogs are recommended only for patients with anemia and HF when there is coexisting chronic kidney disease&#44; with the objective of achieving hemoglobin concentrations between 11 and 12<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In terms of iron&#44; 2 clinical trials have assessed treatment with intravenous ferric carboxymaltose in HF with systolic dysfunction and iron deficiency &#40;ferritin &#60;100<span class="elsevierStyleHsp" style=""></span>ng&#47;mL or 100&#8211;300<span class="elsevierStyleHsp" style=""></span>ng&#47;mL if the transferrin saturation &#60;20&#37;&#41;&#44; with or without anemia&#46; The 2 studies are the Ferric Carboxymaltose Assessment in Patients with Iron Deficiency and Chronic Heart Failure study&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> which showed an improvement in quality of life and functional capacity&#44; and the CONFIRM-HF &#40;Ferric Carboxymaltose Evaluation on Performance in Patients with Iron Deficiency in Combination with Chronic Heart Failure&#41; study&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> which in addition to these objectives&#44; showed a reduction in the number of hospitalizations but no reduction in mortality&#46; As to the optimal administration route&#44; the IRON-HF study<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> showed that intravenous administration was superior in the functional improvement of patients with HF compared with oral supplements&#46; Thus&#44; the clinical practice guidelines for HF indicate iron replenishment for symptomatic patients with systolic dysfunction and iron deficiency&#46; However&#44; the effect of this treatment in HFPEF and the long-term safety of iron treatment in HF are unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Heart failure and chronic renal failure</span><p id="par0135" class="elsevierStylePara elsevierViewall">CRF is a highly prevalent comorbidity in HF&#46; It has been shown that CRF is associated with a poorer prognosis in patients with HF&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> and&#44; in the practice&#44; CRF hinders the treatment&#44; as shown by the Acute Decompensated Heart Failure National Registry study&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> ACEIs &#40;or ARB-II&#41; and mineralocorticoid receptor antagonists are contraindicated for serum creatinine concentrations &#62;2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; glomerular filtration rates &#60;30<span class="elsevierStyleHsp" style=""></span>mL&#47;min and potassium levels &#62;5<span class="elsevierStyleHsp" style=""></span>mEq&#47;L&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Other comorbidities</span><p id="par0140" class="elsevierStylePara elsevierViewall">There are other comorbidities that should also be detected and treated&#44; including sleep apnea&#8211;hypopnea syndrome&#44; depression&#44; cognitive impairment and peptic ulcers&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Adequacy of heart failure treatment according to the progression stage</span><p id="par0145" class="elsevierStylePara elsevierViewall">To correctly assess therapeutic appropriateness in HF&#44; we should consider various aspects&#58; the patient&#39;s life expectancy&#44; the time that has to elapse between the start of a treatment and its benefits &#40;delay time or payoff time&#41;&#44; the therapeutic objectives &#40;curative or palliative&#41; and the results that are sought &#40;life extension&#44; morbidity and mortality prevention&#44; maintenance of the functional condition or treatment of the exacerbations&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> If these pillars are not balanced&#44; the &#8220;therapeutic building&#8221; can fall down&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">These aspects need to be distributed appropriately in each of the 3 phases in which the evolution of a chronic disease such as HF can be divided&#58; stable &#40;NYHA I&#8211;III&#41;&#44; advanced &#40;NYHA III&#8211;IV&#41; and palliative &#40;NYHA IV&#41;&#46; It is sometimes difficult to establish the borders between these stages&#46; Unlike cancer&#44; for example&#44; HF does not have a slow progressive decline but rather an evolution subject to exacerbations&#44; followed by recovery almost to the previous functional condition&#44; with the added possibility of unexpected death&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> To establish an appropriate therapeutic plan&#44; we need to make an estimate of the vital prognosis&#46; Although there are various prognostic scales with numerous variables aimed at patients with HF&#44; indices as simple as the Barthel index help estimate mortality at 3 months&#46; In RICA&#44; 28&#37; of the patients with a Barthel index &#8804;60 died during the 3 months following admission&#46; The remaining patients&#44; who had a Barthel index of &#62;60&#44; had a mortality almost 3 times lower &#40;11&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> In a meta-analysis of 70 studies&#44; Salpeter et al&#46; identified a set of clinical and laboratory data from patients with HF that&#44; combined&#44; was associated with a life expectancy shorter than 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> The Elderly Patients with Multiple Diseases workgroup of the Spanish Society of Internal Medicine validated the &#8220;Palliate index&#8221;&#44; which estimates the probability of dying within the next 6 months for patients with advanced chronic diseases&#44; including HF in functional condition NYHA<span class="elsevierStyleSmallCaps">III</span>&#8211;<span class="elsevierStyleSmallCaps">IV</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> The Palliate index has a high negative predictive value&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> This workgroup has developed an additional index for patients with multiple diseases&#44; the PROFUND index&#44; which estimates the probability of dying after hospitalization for any cause&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In the final evolutionary phase of HF&#44; treatment needs to prioritize symptom control and the preservation of the quality of life&#44; preventing suffering and needless prolongation of life&#46; Dyspnea&#44; depression&#44; asthenia&#44; pain and edema are the main sources of physical suffering during this period and the ones upon which we should act&#46; It is worth considering deprescription as an option for the proper approach for patients in this phase&#59; i&#46;e&#46;&#44; discontinuing the use of drugs such as statins&#44; anticoagulants&#44; antiplatelets and&#44; in case of hypotension or renal failure&#44; &#946;-blockers and ACEIs&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> maintaining the strictly essential treatment for better symptom control&#46; It is essential to inform the patient beforehand about the likely progression of the disease and understand their preferences as to where they want their symptoms to be alleviated or where to pass their final moments &#40;at home or in the hospital&#41; and their wishes concerning cardiopulmonary resuscitation maneuvers&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">75&#44;76</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Healthcare coordination</span><p id="par0160" class="elsevierStylePara elsevierViewall">The care of patients with HF requires comprehensive action by the various health suppliers&#46; Eighty-five percent of patients with HF have at least one other comorbidity of those included in the Charlson index&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Therefore&#44; these patients are complex and frequently have multiple diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> To care for these patients&#44; the Spanish Societies of Family and Community Medicine&#44; Internal Medicine and Community Nursing have published 2 consensus documents&#44;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78&#44;79</span></a> which make the family doctor and internist the reference healthcare professionals in caring for patients with chronic diseases&#44; including HF&#46; The documents also make nursing responsible for the delivery and coordination of care and case management&#44; within and outside the hospital&#46; The hospital pharmacy and primary care play a significant role in caring for polymedicated patients&#44; promoting adherence and therapeutic reconciliation in the transition between healthcare levels&#46; Social work professionals should detect the patients&#8217; social problems and needs&#46; The family and caregivers need to be aware of the healthcare resources&#44; collaborate in the patient&#39;s self-care and in monitoring their symptoms&#46; All of these elements should be coordinated in a healthcare model directed not toward treating exacerbations but rather avoiding them&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0165" class="elsevierStylePara elsevierViewall">HF is&#44; in short&#44; a very common disease in the day-to-day practice of medical internists&#46; A deep understanding not only of its treatment options but also of the associated common comorbidities is necessary&#46; It is essential that we study the whole patient and understand the disease as a dynamic process in which the needs and intensity of treatment vary over time&#46; In addition to the most common medical comorbidities such as DM&#44; COPD&#44; anemia and CRF&#44; it is important to assess the overall physical and cognitive function&#44; as well as the patient&#39;s mood and social and family environment&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the differential aspects for a correct approach to patients with HF and comorbidity in a summarized manner&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interests</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The prevalence of heart failure increases with age and is accompanied by other diseases&#44; which are encompassed within a &#171;cardiometabolic phenotype&#187;&#46; Their interrelation changes the evolution and treatment that each disease would have in isolation&#46; Patients with heart failure and comorbidity are frail and complex&#46; They require a comprehensive assessment &#40;not just biomedical&#41;&#44; which includes functional&#44; cognitive&#44; affective and psychosocial aspects&#46; The overall treatment&#44; which is not covered in the clinical practice guidelines&#44; should adapt to each and every one of the comorbidities&#46; Polypharmacy should be avoided as much as possible&#44; due to its interactions and reduced adherence&#46; Treatment needs to be optimized and adapted to the evolutionary phase of the disease and the specific needs of each patient&#46; The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient&#39;s care&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de insuficiencia cardiaca aumenta con la edad y se acompa&#241;a de otras enfermedades&#44; englobadas en un <span class="elsevierStyleItalic">&#171;fenotipo cardiometab&#243;lico&#187;</span>&#46; Su interrelaci&#243;n modifica la evoluci&#243;n y tratamiento que cada una tendr&#237;a aisladamente&#46; El paciente con insuficiencia cardiaca y comorbilidad es un enfermo fr&#225;gil y complejo&#46; Precisa una valoraci&#243;n integral&#44; no solo biom&#233;dica&#44; que incluya aspectos funcionales&#44; cognitivos&#44; afectivos y psicosociales&#46; El tratamiento global&#44; no recogido en las gu&#237;as de pr&#225;ctica cl&#237;nica&#44; ha de adaptarse a todas y cada unas de las comorbilidades&#46; Debe evitarse&#44; en lo posible&#44; la polifarmacia&#44; por sus interacciones y la disminuci&#243;n de adherencia&#46; Es necesario optimizar y adaptar el tratamiento a la fase evolutiva de la enfermedad y las necesidades espec&#237;ficas de cada paciente&#46; La complejidad del proceso asistencial del paciente con insuficiencia cardiaca y comorbilidades exige la coordinaci&#243;n de los proveedores de salud&#44; el apoyo familiar y del entorno&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ruiz-Laiglesia FJ&#44; Garc&#233;s-Horna V&#44; Formiga F&#46; Abordaje terap&#233;utico integral del paciente con insuficiencia cardiaca y comorbilidad&#46; Rev Clin Esp&#46; 2016&#59;216&#58;323&#8211;330&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cerebrovascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peripheral arterial disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;5&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Comorbidity in patients with heart failure according to data from the Spanish National Heart Failure Registry &#40;RICA&#41;&#46;</p>"
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      "titulo" => "References"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2015.09.008

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