image: Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's demands. view more
Credit: George Hodan, PublicDomainPictures.net
This week, publication of a Special Issue on cardiovascular disease (CVD) and multimorbidity continues in PLOS Medicine, advised by guest editors Carolyn S. P. Lam, National Heart Centre and Duke-NUS Medical School, Singapore, Kazem Rahimi, The George Institute for Global Health, University of Oxford, UK, and Steven Steinhubl, Scripps Translational Science Institute, USA.
Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's demands. Multimorbidity, commonly defined as the presence of two or more chronic medical conditions in an individual, is very common in patients with heart failure. Two research articles this week focus on how multimorbidity patterns in patients with heart failure are linked to health outcomes.
In the first study, Claire Lawson of the University of Leicester, UK, and colleagues use data from 10,575 patients in the Swedish Heart Failure Registry to examine associations between different comorbidities, symptoms, and patient-rated health. They found that non-cardiovascular comorbidities were associated with higher overall symptom burden and more severe symptoms than cardiovascular comorbidities, with anxiety or depression having the strongest association with functional limitations (odds ratio [OR] 10.03, Confidence Interval 5.16 to 19.50) and patient-rated health score (mean difference -18.68, CI -23.22 to -14.14). The predominant symptoms associated with worse health in those with cardiovascular comorbidities were pain and anxiety, whereas the predominant symptoms associated with worse health in those with non-cardiovascular comorbidities were shortness of breath and fatigue. While the study findings are limited by the cross-sectional nature of the study, the findings provide evidence that individualised person-centred care to target specific comorbidities and associated symptoms could be a useful approach in patients with heart failure.
In the second study, Jasper Tromp and Carolyn S. P. Lam of the National Heart Centre, Singapore, and colleagues used data from the ASIAN-HF registry and applied latent class analysis to examine patterns of multimorbidity in 6480 patients with heart failure from 11 Asian regions. They found that comorbidities clustered into 5 distinct patterns: Elderly/atrial fibrillation (N=1048: oldest, more AF), Metabolic (N=1129: Obesity, diabetes, hypertension), Young (N=1759: youngest, low comorbidity rates, non-ischemic etiology), Ischemic (N=1261: Ischemic etiology) and Lean Diabetic (N=1283: diabetic, hypertensive, low prevalence of obesity and high prevalence of chronic kidney disease). Compared with the Young group, they observed poorer clinical outcomes at 1 year in the Lean Diabetic (hazard ratio [HR] 1.79, 95% CI 1.46-2.22), Elderly/AF (HR 1.57, 95% CI 1.26-1.96), Ischemic (HR 1.51, 95% CI 1.22-1.88) and the Metabolic (HR 1.28, 95% CI 1.02-1.60) groups after adjustment for confounders. While the study may be limited by participation bias, the findings underscore the importance of more comprehensive approaches in phenotyping patients with heart failure and multimorbidity.
Frailty is common in elderly individuals with CVD and is associated with elevated mortality. However, no consensus exists on the definition of frailty and many frailty scores have been developed. Gloria Aguayo from the Luxembourg Institute of Health, Luxembourg, and colleagues used data from 5,294 adults age 60 years and over participating in the English Longitudinal Study of Ageing to examine the predictive ability of 35 frailty scores (identified in a literature search) for incident CVD, cancer and all-cause mortality over 7-year follow-up. They observed that all frailty scores were associated with all-cause mortality, some were also associated with incident CVD, and none were associated with incident cancer. In sex- and age-adjusted models, all frailty scores showed significant added predictive performance for all-cause mortality, increasing the C statistic by up to 3%. However, none of the scores significantly improved basic prediction models for CVD or cancer. These results show that certain scores outperform others with regard to all-cause mortality and CVD health outcomes in later life.
In a Guest Editorial, Kazem Rahimi, Carolyn Lam, and Steven Steinhubl discuss the research published in the Special Issue. They argue that understanding multimorbidity in patients with CVD requires dealing with complexity and understanding patients' experiences, and they emphasize the importance of interdisciplinary research.
###
Research Article - Lawson et al.
Funding:
The authors received no specific funding for this work.
Competing Interests:
UD has no disclosures related to the present work but outside the work, he has received research grants to his institution from Astra-Zeneca, served on the speakers' bureau and received consulting fees from Astra Zeneca and Novartis.
Citation:
Lawson CA, Solis-Trapala I, Dahlstrom U, Mamas M, Jaarsma T, Kadam UT, et al. (2018) Comorbidity health pathways in heart failure patients: A sequences-of-regressions analysis using cross-sectional data from 10,575 patients in the Swedish Heart Failure Registry. PLoS Med 15(3): e1002540. https://doi.org/10.1371/journal.pmed.1002540
Author Affiliations:
Diabetes Research Centre, Leicester University, Leicester, United Kingdom
Institute for Applied Clinical Sciences, Keele University, Keele, United Kingdom
Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
Department of Cardiology, Linköping University, Linköping, Sweden
Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, United Kingdom
Department of Social and Welfare Studies, Linköping University, Linköping, Sweden
Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
In your coverage please use this URL to provide access to the freely available paper: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002540
Research Article - Lam et al.
Funding:
The ASIAN-HF registry is supported by research grants from Boston Scientific Investigator Sponsored Research Program, National Medical Research Council of Singapore, A*STAR Biomedical Research Council ATTRaCT program, and Bayer. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests:
CSPL served as a guest editor on PLOS Medicine's Cardiovascular Disease Special Issue. KL is an employee of Bayer AG.
Citation:
Tromp J, Tay WT, Ouwerkerk W, Teng T-HK, Yap J, MacDonald MR, et al. (2018) Multimorbidity in patients with heart failure from 11 Asian regions: A prospective cohort study using the ASIAN-HF registry. PLoS Med 15(3): e1002541. https://doi.org/10.1371/journal.pmed.1002541
Author Affiliations:
National Heart Centre Singapore, Singapore, Singapore
Department of Cardiology, University Medical Center Groningen, Groningen, Netherlands
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, Netherlands
School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
Changi General Hospital, Singapore, Singapore
Bayer, Wuppertal, Germany
Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
Medical University of South Carolina, Charleston, South Carolina, United States of America
Ralph H. Johnson VA Medical Center, Charleston, South Carolina, United States of America
Minneapolis VA Medical Center, Minneapolis, Minnesota, United States of America
National University Heart Centre, Singapore, Singapore
Duke-NUS Medical School, Singapore, Singapore
In your coverage please use this URL to provide access to the freely available paper: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002541
Research Article - Aguayo et al.
Funding:
This study was funded by the Ministry of Higher Education and Research, Luxembourg, through an internal project from the Luxembourg Institute of Health (funding GAA). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests:
The authors have declared that no competing interests exist.
Citation:
Aguayo GA, Vaillant MT, Donneau A-F, Schritz A, Stranges S, Malisoux L, et al. (2018) Comparative analysis of the association between 35 frailty scores and cardiovascular events, cancer, and total mortality in an elderly general population in England: An observational study. PLoS Med 15(3): e1002543. https://doi.org/10.1371/journal.pmed.1002543
Author Affiliations:
Population Health Department, Luxembourg Institute of Health, Strassen, Luxembourg
Competence Center for Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
Department of Public Health, University of Liège, Liège, Belgium
Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Canada
Section of Geriatrics, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
Department of Public Health, Aarhus University, Aarhus, Denmark
Danish Diabetes Academy, Odense, Denmark
In your coverage please use this URL to provide access to the freely available paper: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002543
Editorial
Funding:
The authors received no specific funding for this work.
Competing Interests:
I have read the journal's policy and the authors of this manuscript have the following competing interests: KR receives a stipend as a specialty consulting editor for PLOS Medicine and serves on the journal's editorial board and is an Associate Editor of the BMJ Heart. KR has received funding from the Oxford Martin School and UK national funding agencies including British Heart Foundation, National Institute for Health Research, Medical Research Council, and Wellcome Trust. CSPL is supported by a Clinician Scientist Award from the National Medical Research Council of Singapore and has received research support from Boston Scientific, Bayer, Thermofisher, Medtronic, and Vifor Pharma. CSPL has consulted for Bayer, Novartis, Takeda, Merck, Astra Zeneca, Janssen Research & Development, Menarini, Boehringer Ingelheim, Abbott Diagnostics, Corvia, Stealth BioTherapeutics, Roche, and Amgen. SS's institution has received restricted grants from the Qualcomm Foundation and Janssen Pharmaceuticals in support of Digital Medicine research. SS has served as a medical advisor for Novartis, MyoKardia, DynoSense, LifeWatch, Airstrip, EasyG, Spry Health, and FocusMotion and serves as a Board member for Celes Health. KR, CSPL, and SS served as guest editors to PLOS Medicine for the Cardiovascular Disease special issue.
Citation:
Rahimi K, Lam CSP, Steinhubl S (2018) Cardiovascular disease and multimorbidity: A call for interdisciplinary research and personalized cardiovascular care. PLoS Med 15(3): e1002545. https://doi.org/10.1371/journal.pmed.1002545
Author Affiliations:
University of Oxford, Oxford, United Kingdom
National Heart Centre Singapore, Singapore, Singapore
Scripps Translational Science Institute, La Jolla, California, United States of America
In your coverage please use this URL to provide access to the freely available paper: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002545
Journal
PLoS Medicine