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Optimal outcomes require increased vigilance for HF co morbidities 

Topics: Heart Failure (HF)
Date: 19 May 2014
Heart failure (HF), says Mitja Lainscak, should never be viewed in isolation, but considered together with other patient co morbidities. In a session today (11:00, Trianti lecture rooms) Lainscak and colleagues will explore the interplay between HF and co morbidities including COPD, anaemia, diabetes, and kidney disease.

“Co morbidities undoubtedly affect both the clinical manifestations and prognosis of HF. They contribute to disease progression and may alter responses to treatment,” says Lainscak, who believes three quarters of HF patients have relevant co morbidities. “There’s a paradigm shift that for optimal outcomes we shouldn’t treat systems individually, but view patients holistically,” says Lainscak, from the University Clinic Golnik, Slovenia. In HF, he stresses, comorbidities should not be considered as contraindications to life-saving HF therapies.

Growing up in Murska Sobata, a small town in North-East Slovenia, Lainscak followed the career path ordained for the most academically able school leavers. Studying medicine at the University of Ljubljana, at that time the only medical faculty in Slovenia, he enjoyed teaching fellow students, and displayed early leadership qualities as President of the Medical Students’ Society. Initially he was attracted to cardiology due to its strong association with sports medicine (he competed in triathlons, and marathons), but had additional interests including neurology and radiology. Then in 1997 his father died of sudden cardiac death at the age of 53 years. “This crystallized my decision to become a cardiologist,” he says.

Lainscak simultaneously studied for his MSc and PhD at the same time as undertaking his medical residency. For his MSc he looked at outcomes of hospitalized HF patients, while for his PhD he explored implementation of HF clinics in community hospitals. With his supervisor Irena Keber, he contributed to setting up HF clinics across Slovenia, and as a direct result of their efforts nine out of 14 hospitals taking care of cardiac patients in Slovenia now have HF clinics. “Such clinics create huge financial savings since they prevent HF hospitalisations,” he says.

Lainscak’s experiences stimulated an interest in cachexia. “I was puzzled by patients who gained no weight despite considerable oedema,” he says. In 2006 he was awarded an ESC research fellowship to work with Stefan D. Anker in the Division of Applied Cachexia Research, at the Charité in Berlin. Anker, who became something of a role model to Lainscak, got him involved in numerous cachexia and HF studies. “Cachexia is still a bit of a black box. Certain mechanisms are over activated in chronic disease irrespective of whether the heart, kidneys or lungs are involved. These are likely to involve chronic inflammation, and over activation of the renin-angiotensin system and sympathetic nervous system,” he says. While no remedies are available to treat cachexia, Lainscak believes that targeting such systems might eventually prove effective in reversing the cascade of events.

One of the main challenges facing researchers has been that the clinical definition of cachexia only became available in 2008 (Clinical Nutrition, 2008, 27:793- 799), resulting in an underestimation of cachexia prevalence and severity. “People always associate cachexia with thin patients, but we’re coming to realize that people who are obese can also be affected,” says Lainscak, adding that what has turned out to be important is the relative proportion of weight loss. “The result is that we’re still gathering more reliable epidemiological information.”

At the Charité Lainscak contributed to studies exploring the mechanisms that gave rise to the development of cachexia, and perpetuate the disease once present. These involved obtaining muscle and fat biopsies from HF patients at the outset of diagnosis, and then following subjects up to determine who developed cachexia and what factors contributed. Continuing his collaborations with Anker, Lainscak is involved with the ongoing ‘Studies Investigating Comorbidities Aggravating Heart Failure’ (SICA-HF), where he coordinates patients recruited to the Golnik site, one of 11 centres across six countries in the EU and Russia. The aim of the FP7 funded research, which started in October 2009, is to provide detailed characteristics of patients with HF and comorbidities including obesity, cachexia, and type 2 diabetes. “Little is known about the characteristics of these subgroups of CHF patients. We’re hoping to be able to tease out what’s biochemically different about these distinct groups of patients with the hope of gaining hints about potential therapies,” he explains. By becoming involved in trials and registries, he adds, his goal is to raise the standards of HF treatment in Slovenia. In 2007 Lainscak was appointed head of the Division of Cardiology at the University Clinic for Respiratory and Allergic Diseases at University Clinic, Golnik. “In Slovenia we face a shortage of medical doctors due to the fact that until nine years ago we only had one medical school, and have experienced additional shortfalls due to prolongation of our residency programmes from four to six years.,” says Lainscak. Indeed, the latest Eurostat Regional Year Book reveal that Slovenia has 2.43 doctors per 1000 people, compared to 6.13 in Greece, 3.73 in Germany and 3.27 in France.

In Golnik, where Lainscak works as a non invasive cardiologist, he has developed a particular interest in links between HF and respiratory conditions, in particular COPD. Although available epidemiological data suggests that COPD and CHF exist in up to 30% of patients, he says, surprisingly few patients with HF undergo basic diagnostic workups for COPD, and vice versa. Lainscak is currently undertaking studies using NTproBNP and troponin T as biomarkers to diagnose HF in patients admitted to the emergency room for acute COPD exacerbations (Int J Cardiol 2012, 161: 156- 159). “Since there are no available life-saving treatments for COPD, identifying whether patients have additional CV conditions can be valuable for improving symptoms and outcome,” he says. “It’s important to use biomarkers since it’s difficult to obtain good echocardiography images in patients with COPD.”

One concern, however, is that if COPD is identified in HF patients clinicians may be reluctant to provide optimal treatments with beta blockers that cause bronchoconstriction. The EuroHeart Failure Survey in 2007 found that beta-blockers were less often used in HF patients with respiratory disease than those without (Eur J Heart Fail 2007, 9: 292-299). “There’s no rationale for withholding beta blockers in COPD since it’s an irreversible obstructive pulmonary disorder which per definition is non reactive to triggers,” says Lainscak.

Even with asthma patients, he adds, evidence suggests beta blockers up regulate beta 2 receptor antagonists. “This provides more places for beta 2 agonists, the treatment of choice in acute asthma attacks. So by prescribing beta blockers to asthma patients you may actually prepare them in advance for acute attacks,” he explains. In a recent study Lainscak and colleagues showed that CHF patients with moderate to severe COPD experience less pulmonary adverse events taking the beta blocker bisoprolol than the beta blocker carvedilol (Respiratory Medicine 2011, 105 S1: S44-S49). “Our take home message, shared by others in the field, is that patients with concomitant pulmonary issues do better on cardio selective beta blockers,” he says.

As a member of the Heart Failure Association’s Patient Care Committee, Lainscak works to promote the optimal management of patients. “To achieve our goal we need to take a multidisciplinary approach educating cardiologists, nurses, GPs and the patients themselves,” he says. Among other projects, he coordinated the Practical Recommendations on Non- Pharmacological Measures (Eur JHF 2011, 13:115-126) and was a member of the panel who prepared the HF curriculum (EurJHF 2014, 16: 151-62). Lainscak sees this work as directly complimentary to his post as chair of the Heart Failure Working Group at the Slovenian Society of Cardiology, where a major task is to increase awareness of the lay public and health care providers. Other current activities include being on the editorial boards of several journals and serving as Associate Editor for ‘Heart&Lungs’ at ‘International Journal of Cardiology’ and for ‘Metabolism’ at ‘Journal of Cachexia, Sarcopenia, and Muscle’. “Being involved in publications gives you an overview of what’s happening in the field, and undoubtedly improves your writing technique,” says Lainscak, who predicts that his hectic work schedule can only get a whole lot worse. That said, he was off to the seaside for a rare weekend of relaxation with his wife and 11 month old son Filip who has just started walking.