Polypharmacy and comorbidity in heart failure
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7414.513 (Published 04 September 2003) Cite this as: BMJ 2003;327:513All rapid responses
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Dear Sir,
The article “Polypharmacy and co morbidity in heart failure” suggest
that this group of patients in a US context have considerable challenges
for health care providers. As a Primary Health Care Team, our practice and
community nurses have been managing all our patients with stable chronic
heart failure (228 patients, average age 80.2 years in a total practice
population of 14,300) for the last seven years 1.
A recent analysis of our database shows the following levels of co-
morbidity amongst our patients with chronic heart failure:
· Diabetes 14%
· Chronic respiratory disease 24%
· Atrial fibrillation 25%
· Stroke or TIA 13%
· Dementia 4%
Additionally a further analysis shows that 11.8% (27patients) of our
patients are housebound and 4.8%(11 patients) are in residential care in
the community. The average age of these groups of patients is 86 and these
patients need a domiciliary service provided by our community nurses.
These two problems - co morbidity and lack of mobility - make this a
very difficult group of patients to look after. Current emphasis in many
parts of the UK for hospital based heart failure clinics and services are
therefore not appropriate for many of these patients. We have demonstrated
that care for this group of patients based on the Primary Health Care Team
is both feasible and clinically sound and would argue that this where
important investment should be made.
1 Marriot R. Improving the management of CHF: a unique approach.
Cardiology News 2002: 5; 23-25.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
Chronic heart failure is embedded in a network of comorbidity
(diabetes, chronic lung disease, atrial fibrillation, stroke).
But as practitioner I am confronted with one trigger of all these
diseases: Streptococcal infection.
Ever and ever recurrent common cold infections induce
streptococcal-reactive-diseases. They hide behind
these metabolic syndromes, fibrinolytic dysfunctions of cardiovascular
disease.
One example:
Born 1928 a little girl suffered from common cold.
1932 she developed a glomerulonephritis.
1956 polyarthritis of both legs, stiffness, no pain.
Treatment: Tonsillectomy, hard, fibrotic, infected tonsils.
1960 first shot of penicillin, complicated by allergy.
1964 thyreotoxicosis, treated by radiotherapy.
1995 myocarditis, combined mitral- and aortic-valve-disease.
1996 painfull polyarthritis and glomerulonephritis.
1997 non-insulin-dependent diabetes mellitus.
1998 noduli rheumatici.
The diagnostic turning point was 1999:
The tendosynovitis of the hand was operated. Perioperatively amoxycillin
and clavulanic acid induced
VANISHING of ALL POLYARTHITIC PAINS.
Now it became clear:
This patient fought with streptococci since 1932.
All her life was adaptation to these streptococci.
The progressive aortic valve stenosis induced severe cardiopulmonary
problems. Aortic valve implantation 2000.
Now the patient is well.
In times of exacerbation the markers of inflammation and coagulation show
the fibrinolytic dysfunction.
Antibiotic treatment and anticoagulation with LMW-heparin and coumarin
reduce pain and stiffness.
Sincerely Yours
Friedrich Flachsbart
Competing interests:
None declared
Editorial note
The patient whose case is described has given her signed informed consent to publication.
Competing interests: No competing interests
Heart failure and Co-morbidity
Masoudi and Krumholz advise patients with Heart Failure to enroll in
disease management programmes. However people may have difficulty in
deciding which programmme to choose. The nurses in heart failure schemes
may not have the knowledge to deal with diabetes or chronic respiratory
disease (2 common co-morbidities in the rapid response by Marriot).
Similarly diabetic or respiratory nurses may know little about heart
failure. So disease management programmes may end up looking after younger
people with single pathology while older people with multiple pathology
and greater need are excluded from optimal care. This exclusion may
explain why disease management programmes are so successful: they exclude
complex patients. Not all practices will be prepared to do the detailed
and careful work described by Marriot. Practices may prefer more lucrative
activities. Geriatric Day Hospitals have full facilities for such
patients, particularly initiating ACE inhibitors and beta blockers under
close supervision or arranging chest x rays. However there are the usual
disadvantages of transport issues and patients waiting all day when they
are only seen for a short time. Nevertheless, they may be the only way to
manage these patients in inner cities, as we do in our unit.
Competing interests:
None declared
Competing interests: No competing interests