Optimal Treatment Outlined for Patients with Heart Failure and Serious Comorbidities, Including "Diabesity"

NEW ORLEANS, LA—Investigators at the forefront of treating the patient with heart failure (HF) and concomitant diabetes, obesity, depression, sleep apnea, left ventricular (LV) hypertrophy or renal insufficiency presented the latest management findings today at ACC.11, the American College of Cardiology's 60th Annual Scientific Session.

“Diabesity”—the combination of diabetes and obesity, is present in a “truly astounding” percentage of U.S. patients. In fact, in some states, more than 30% of patients have this deadly combination. Treating this population is a challenge. One novel approach is bariatric surgery, said James B. Young, MD, of the Cleveland Clinic, Cleveland, OH.

While data for this procedure in patients HF are scant, one study found a 10-year reduction in relative risk of 40% in patients with coronary heart disease treated with bariatric surgery and a program initiated at the Cleveland Clinic will help determine outcomes in patients considered “too obese” for heart transplantation. Despite slow uptake of bariatric surgery, due in part to a negative bias of physicians and patient fear of surgery, the procedure offers several benefits, Dr. Young noted, including a shorter operative time, eventual—and continual—weight reduction, and reduction in glucose.

Obesity alone is second only to tobacco use as the number one cause of preventable death in the United States; 70% of adults are overweight or obese. A direct relationship exists between body mass index (BMI) and mortality, and, “if the current obesity epidemic continues, we may soon witness an unfortunate end to the steady increase in life expectancy,” said Carl J. Lavie, MD, Ochsner Medical Center, New Orleans. For patients with HF, however, an intriguing “obesity paradox” exists in that studies have shown those who are overweight and obese respond better to treatment and have better outcomes than their normal or underweight peers.

Possible reasons for this include the fact that obese persons may have more metabolic reserve and high blood pressure, and thus may be able to tolerate more medication. Two other possibilities are that adipose tissue produces TNF-alpha receptors that neutralize TNF-alpha and that higher circulating lipoproteins may detoxify lipopolysaccharide that affect inflammatory cytokines.

HIGH COST OF DEPRESSION IN HEART FAILURE PATIENTS

Depressive symptoms and clinical depression are common conditions in patients with heart failure, and symptom severity is associated with higher health care usage, functional decline, higher readmission rates, and mortality. To date, studies have shown that while SSRI antidepressants and exercise can reduce these symptoms, no options exist that can reduce clinical events, noted Ivonne Lesman-Leegte, MSc, of the University Medical Center Groningen, Netherlands.

The CREATE trial of 284 patients found citalopram for 12 weeks) to be safe and effective in reducing depression vs. placebo, Lesman-Leegte noted. Additionally, the SADHART-HF trial of 469 patients taking sertraline for 12 weeks vs. placebo was found to be safe but did not result in a significant greater reduction in depression and netted no significant improvement in cardiovascular status. Results are expected soon from the MOOD-HF study, in which 700 patients are being treated with escitalopram (6 months) or placebo.

THE ROLE OF SLEEP APNEA IN HEART FAILURE

While it is well known that an “ominous triad” of heart failure, sleep apnea and sympathetic excitation exists, clinicians may be underestimating the importance of sleep apnea in the pathogenesis or therapy of heart failure. In fact, those with sleep apnea and heart failure rarely “feel sleepy,” said John S. Floras, MD, University of Toronto, Ontario, Canada.

Dr. Flores noted that large randomized, controlled trials are need to test the hypothesis that effective treatment of sleep apnea will reduce cardiovascular events and improve prognosis. Currently, the ADVENT-HF trial is determining whether, in medically treated patients with heart failure and sleep apnea, suppression of sleep apnea by adaptive servo-ventilation will reduce a composite endpoint of death, LV assist device implantation, heart transplant, and hospitalizations due to cardiovascular disease.

PREVENTING LEFT VENTRICULAR HYPERTROPHY, HYPONATREMIA

The best protection against independent risk of LV hypertrophy is to prevent its development in patients with heart failure the first place, said Hector O. Ventura, MD, Ochsner Clinic Foundation, New Orleans. Once LV hypertrophy has been diagnosed, patients should be protected from hypokalemia, treated for coronary insufficiency (if present), have their hypertension carefully reduced and controlled, and be followed after all cardiac events.

One of the most difficult patients to treat is one with heart failure, borderline hypertension and hyponatremia, said Marrick L. Kukin, M.D., Columbia University College of Physicians and Surgeons, New York City. For this population, he recommends a regimen that includes treating with tolvaptan and a diuretic so that the serum sodium is appropriately managed. He added that the ASCEND-HF trial in more than 7,000 patients found the vasodilator nesiritide to have no major affect against acute dyspnea compared with placebo and standard of care.