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Table of Contents
RESEARCH ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 2  |  Page : 53-57

Association between echocardiography findings and cardiovascular comorbidities in Indian patients with chronic heart failure


1 Department of Research and Development, Madhavbaug Hospital, Khopoli, Maharashtra, India
2 Department of Clinical Operations, Madhavbaug Hospital, Khopoli, Maharashtra, India
3 Medical Department, Madhavbaug Hospital, Khopoli, Maharashtra, India

Date of Submission31-Mar-2019
Date of Acceptance07-May-2019
Date of Web Publication26-Jun-2019

Correspondence Address:
Rahul Mandole
Department of Research and Development, Madhavbaug Hospital, Khopoli, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cp.cp_11_19

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  Abstract 


Background: Various comorbidities contribute to structural and functional changes in congestive heart failure (CHF). Echocardiography is a first-line diagnostic tool for screening and monitoring CHF patients. Hence, it is important to study the association between echocardiographic findings and comorbidities in CHF. Methodology: A retrospective study was conducted using data from CHF patients evaluated at the Madhavbaug clinics between August 2018 and January 2019. Patients were classified based on normal (>55%) and compromised (<55%) left ventricular ejection fraction (LVEF) and grades of diastolic dysfunction (Grade I – impaired relaxation, Grade II – pseudonormal, and Grade III – reversible restrictive). Chi-square test was used to assess the associations between comorbidities and echocardiographic findings (including ejection fraction and grade of diastolic dysfunction). Results: One hundred and thirty-eight patients' data were evaluated. The majority of patients were male (74.15%), and the mean age was 59.15 ± 10.28 years. Sixty-two patients had compromised LVEF, whereas 76 patients had normal LVEF. Most patients (n = 77) had Grade I diastolic dysfunction, followed by Grade II (n = 53) and Grade III (n = 3). Patients with comorbidities including coronary artery disease (CAD) (odds ratio [OR]: 2.3, 95% confidence interval [CI]: [1.13–4.65],P = 0.02), dilated cardiomyopathy (OR: 30.6, 95% CI: [1.75–534.01],P = 0.002), and myocardial infarction (OR: 6.22, 95% CI: [2.45–15.78],P = 0.001) had higher odds of having compromised ejection fraction (LVEF <55%). Hypertension (HTN) (OR: 2.11, 95% CI: [1.02–4.6],P = 0.049) was associated with higher odds of Grade I diastolic dysfunction. Conclusions: Comorbidities such as CAD, dilated cardiomyopathy, and myocardial infarction are associated with increased odds of compromised ejection fraction, whereas HTN is associated with Grade I diastolic dysfunction.

Keywords: Coronary artery disease, diastolic dysfunction, ejection fraction, heart failure


How to cite this article:
Sane R, Amin G, Dongre S, Mandole R. Association between echocardiography findings and cardiovascular comorbidities in Indian patients with chronic heart failure. Cardiol Plus 2019;4:53-7

How to cite this URL:
Sane R, Amin G, Dongre S, Mandole R. Association between echocardiography findings and cardiovascular comorbidities in Indian patients with chronic heart failure. Cardiol Plus [serial online] 2019 [cited 2019 Jul 16];4:53-7. Available from: http://www.cardiologyplus.org/text.asp?2019/4/2/53/261427




  Introduction Top


Cardiovascular disease is one of the major causes of mortality and morbidity in the world. One of the most common cardiovascular diseases is congestive heart failure (CHF). Literature suggests that more than a crore of Indian population suffer from CHF. Due to its high prevalence, it is of significant concern to the health-care system.[1],[2]

Comorbidities are prevalent in patients of CHF. It is observed that >50% of patients with CHF have five or more chronic comorbidities.[3] These might be cardiac or noncardiac comorbidities such as renal failure, coronary artery disease (CAD), hypertension (HTN), diabetes mellitus (DM), ischemic heart disease, dilated cardiomyopathy, myocardial infarction, anemia, obesity, and hypothyroidism. These comorbidities exacerbate symptoms, worsen prognosis, and complicate treatment.[4]

CAD is the most common etiological factor for the development of heart failure with reduced ejection fraction (HFrEF). The classical risk factors for coronary heart disease include arterial HTN, smoking, DM, and obesity. Dilated cardiomyopathy is the second most common cause for HFrEF, found in almost 25% of chronic heart failure patients.[5] It is known that hypothyroidism can affect cardiac contractility, and low free T3 levels are associated with increased mortality in patients with heart disease.[6]

Echocardiography is an imaging technique which provides information about the structure and function of the heart. Structural abnormalities, systolic dysfunction, diastolic dysfunction, or a combination of these abnormalities are commonly seen in patients with heart disease. According to ACC/AHA as well as ESC guidelines, echocardiography is the single most useful test in the diagnosis of heart failure. It accurately and noninvasively provides objective evidence of structural or functional abnormalities which explain a patient's symptoms of heart failure. Echocardiography is also able to identify the hemodynamic and morphologic changes in HF over time and is therefore considered an indispensable tool in the management of heart failure.[7],[8]

However, there are limited data regarding the association of echocardiographic findings and comorbidities in CHF patients. This information could have clinical benefits for screening as well as for planning preventive therapies to avoid progression of the disease. Hence, the current study was designed to evaluate the association between echocardiographic findings and comorbidities in CHF patients in India.


  Methodology Top


This was a retrospective study conducted by collecting data of CHF patients who had visited one of the Madhavbaug clinics in the state of Maharashtra in India. Patients had to have been seen at the clinic between July 2018 and December 2018 to be considered for inclusion. The case records of CHF patients attending the clinic in the desired time period were screened for the presence of baseline details relevant to the objective of this study and for the presence of two-dimensional echocardiography (2D echo) results with assessment of left ventricular ejection fraction (LVEF). Data of only those patients whose baseline demographic data, details about comorbidities, and LVEF were present in the case records were included. The study conforms to the national medical research ethics and it was approved by the relevant departments.

Data entry was completed in a Microsoft Excel sheet. GraphPad InStat software V3.0 (San Diego, California, GraphPad Software) was used to analyze the noted data. The patients were classified based on normal (>55%) and compromised (<55%) LVEF. The patients were also classified based on grades of diastolic dysfunction: Grade I – impaired relaxation, Grade II – pseudonormal, and Grade III – reversible restrictive.[9] Categorical data were shown in numerical form, whereas continuous data were noted as mean ± standard deviation. To assess the association between comorbidities and findings on echocardiography (ejection fraction and diastolic dysfunction), Chi-square test was used. Data from Chi-square testing were presented as odds ratio (OR) with 95% confidence interval (CI). P < 0.05 was considered statistically significant.


  Results Top


One hundred and thirty-eight patients who consulted the Madhavbaug clinics within the specified study period met the screening inclusion criteria of the study. The data of all included patients were noted accordingly and are presented in [Table 1]. Included patients were predominantly male (n = 109, 74.15%). The mean age of patients enrolled in this study was found to be 59.15 ± 10.28 years.
Table 1: Demographic details of patients (n=138)

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The echocardiographic findings of these 138 CHF patients were noted, and mean values were calculated. It was found that the mean LVEF for the CHF patients was 51.32% ± 12.53%. Of these 138 patients, 45% of patients had compromised LVEF, whereas 55% of patients had LVEF within the normal range [Table 2]. [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d is a representative image of a 2D echo taken at the study center.
Table 2: Distribution of patients by compromised and normal ejection fraction (n=138)

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Figure 1: (a-d) Two-dimensional echocardiography images of congestive heart failure patients conducted at study centers

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The grade-wise distribution of patients with diastolic dysfunction is presented in [Table 3]. About 57.89% of patients were observed to have Grade I diastolic dysfunction, whereas 39.84% of patients had Grade II or worse diastolic dysfunction.
Table 3: Distribution of patients with diastolic dysfunction grading (n=133)

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Subgroup analyses testing the association between echocardiographic ejection fraction groups and comorbidities of CHF are shown in [Table 4]. The data suggest that there is statistically significant association between patients with compromised EF (LVEF <55%) and comorbidities including CAD (OR: 2.3, 95% CI: [1.13–4.65], P = 0.02), dilated cardiomyopathy (OR: 30.6, 95% CI: [1.75–534.01], P = 0.002), and myocardial infarction (OR: 6.22, 95% CI: [2.45–15.78], P = 0.001).
Table 4: Association between common comorbidities with ejection fraction in congestive heart failure patients (n=138)

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Subgroup analyses testing the association between diastolic dysfunction groups and comorbidities of CHF are shown in [Table 5]. The data suggest that there is statistically significant association between patients with Grade I diastolic dysfunction (OR: 2.11, 95% CI: [1.02–4.6], P = 0.049) and HTN.
Table 5: Association between common comorbidities with diastolic dysfunction grading in congestive heart failure patients (n=132)

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  Discussion Top


Most of the symptoms observed in patients with CHF are associated with the presence of comorbidities such as CAD, HTN, DM, ischemic heart disease, obesity, dilated cardiomyopathy, myocardial infarction, and hypothyroidism. These comorbidities have an impact on hospitalizations and are associated with mortality in patients with CHF.[10],[11] CAD is one of the leading comorbidities observed in patients with CHF. The data suggest that ischemic cardiomyopathy is believed to be the primary etiology in 41% of CHF patients.[12] Dilated cardiomyopathy is the second most common cardiac comorbidity seen in patients with CHF. It is attributed to about 25% of chronic heart failure patients.[5] HTN itself has a strong impact on the progression of CHF and is a key factor in the development of left ventricular hypertrophy and diastolic dysfunction seen in patients with CHF.[13] Extracardiac comorbidities such as DM affect ventricular structure and function through various mechanisms. In DM, various factors such as glycosylated end-product formation, impaired endothelial function, sympathetic nervous system activation, and derangements in myocardial metabolism lead to diabetic cardiomyopathy.[14] Thyroid hormones also play an important role in heart failure. In heart failure, the conversion of T4 to T3 decreases. Since T3 is the main regulator of gene expression in myocardial muscle, this decrease has been thought to affect myocardial contractility and remodeling.[15] Looking at this background, it is obvious that comorbidities have a role in the pathology of CHF. They strongly influence outcomes, and hence, a diagnostic tool is needed to help predict the course of the disease.

One such diagnostic intervention is echocardiography which can assess myocardial structure and function, valvular disease, and hemodynamics and is considered an indispensable tool for the diagnosis of CHF. One of the important parameters measured using echocardiography is LVEF. It plays a pivotal role in the management of CHF as it helps to identify patients who are likely to respond to therapy for HF with reduced EF. Another such important entity which can be measured with echocardiography is diastolic function of the heart. Diastolic dysfunction is an important etiological factor in patients of heart failure with preserved ejection fraction and no structural abnormalities. It is categorized into mild or Grade I (delayed relaxation), moderate or Grade II (pseudonormal), and severe or Grade III (restrictive) dysfunction. These parameters help physicians to choose prognostically beneficial therapy for CHF.[16]

The authors felt a need to know whether these echocardiographic findings are associated with comorbidities of CHF, the knowledge of which would help in better predicting prognosis of the disease. A retrospective analysis of the data collected from CHF patients in India suggested that majority of the patients were male in the age group of 59 years. These findings are in sync with the published demographic statistics that CHF is a disease of the elderly.[10] Most of the patients in the current study had preserved/normal ejection fraction, but 45% had compromised ejection fraction, whereas the majority of patients also had Grade I diastolic dysfunction.

Subgroup analyses suggested that patients with CAD, myocardial infarction, and ischemic cardiomyopathy had higher odds of compromised ejection fraction than those with normal ejection fraction. Similarly, HTN was associated with higher odds of Grade I diastolic dysfunction, compared with Grade II and III diastolic dysfunction. A study by Streng et al. showed similar findings with many comorbidities showing associations with compromised ejection fraction.[17] A study by Anand et al. studied similar risk factors but had contradictory findings.[18] The findings of that study suggest that morbid obesity, CAD, DM, and HTN were associated with increased odds of having heart failure of preserved ejection fraction. However, neither of these prior studies studied risk factors for diastolic dysfunction.

Our study had a few limitations. The sample size was small and restricted to the CHF patients of West India. Future prospective studies with larger sample size representative of the whole country will help in creating more robust evidence.


  Conclusions Top


Patients with comorbidities such as CAD, dilated cardiomyopathy, ischemic cardiomyopathy, and myocardial infarction have higher odds of compromised ejection fraction, whereas patients with HTN have higher odds of Grade I diastolic dysfunction. These findings should help physicians in planning preventive therapies to avoid progression of the disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Role of Comorbidities in Chronic Heart Failure (RoC-HF) Study – Study Protocol. Available from: https://clinicaltrials.gov/ProvidedDocs/78/NCT02922478/Prot_SAP_000.pdf. [Last accessed on 2019 Mar 21].  Back to cited text no. 5
    
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WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S. Heart disease and stroke statistics-2010 update: A report from the American Heart Association. Circulation 2010;121:e46-215.  Back to cited text no. 10
    
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Edelmann F, Stahrenberg R, Gelbrich G, Durstewitz K, Angermann CE, Düngen HD, et al. Contribution of comorbidities to functional impairment is higher in heart failure with preserved than with reduced ejection fraction. Clin Res Cardiol 2011;100:755-64.  Back to cited text no. 11
    
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Maggioni AP, Anker SD, Dahlström U, Filippatos G, Ponikowski P, Zannad F, et al. Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology Guidelines? Evidence from 12,440 patients of the ESC heart failure long-term registry. Eur J Heart Fail 2013;15:1173-84.  Back to cited text no. 12
    
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Lam CS, Roger VL, Rodeheffer RJ, Bursi F, Borlaug BA, Ommen SR, et al. Cardiac structure and ventricular-vascular function in persons with heart failure and preserved ejection fraction from Olmsted county, Minnesota. Circulation 2007;115:1982-90.  Back to cited text no. 13
    
14.
Leung AA, Eurich DT, Lamb DA, Majumdar SR, Johnson JA, Blackburn DF, et al. Risk of heart failure in patients with recent-onset type 2 diabetes: Population-based cohort study. J Card Fail 2009;15:152-7.  Back to cited text no. 14
    
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Kahaly GJ, Dillmann WH. Thyroid hormone action in the heart. Endocr Rev 2005;26:704-28.  Back to cited text no. 15
    
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Marwick TH. The role of echocardiography in heart failure. J Nucl Med 2015;56 Suppl 4:31S-38S.  Back to cited text no. 16
    
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Streng KW, Nauta JF, Hillege HL, Anker SD, Cleland JG, Dickstein K, et al. Non-cardiac comorbidities in heart failure with reduced, mid-range and preserved ejection fraction. Int J Cardiol 2018;271:132-9.  Back to cited text no. 17
    
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Anand V, Kealhofer J, Garg SK, Bano S. Comorbidities associated with heart failure with preserved ejection fraction: A nationwide analysis. Circulation 2018;134:A17288.  Back to cited text no. 18
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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