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15CLINICAL DIAGNOSIS OF ANEMIA IN PATIENTS WITH CHRONIC
HEART FAILURE
Umid Sunnatovich Kamol Jumayev Nilufar Fazila Rajabovna
Mamedov Boltayev Sharipovna Tuymurodova
Akhmedova
Bukhara State Medical Institute
ABSTRACT
Cardiovascular diseases, including heart failure, remain one of the leading causes of death worldwide [1-4]. Anemia and chronic kidney disease (CKD) are considered the main risk factors for an unfavorable outcome in patients with chronic heart failure (CHF). Research results suggest that anemia increases overall and cardiovascular mortality in patients with CHF [7-9]. The relevance of the problem of anemia in CHF is due to the aging population and the lack of algorithms for correcting the hemoglobin level in such patients [5]. Besides, CHF is increasingly common in elderly patients with diabetes mellitus (DM) and CKD, which are associated with an increased risk of anemia [6]. In such patients, as well as in patients with CHF of NYHA functional class III-IV, its frequency can reach 55% [9]. Data on the prevalence of anemia in CHF are numerous, but very contradictory, which is explained by the use of different diagnostic criteria and heterogeneity of patient populations. Thus, the frequency of anemia in patients with CHF in different studies ranged from 4 to 61% [5-6]. The aim of the study was to study the frequency, clinical associations of anemia and its impact on the prognosis in patients with CHF.
Keywords. Anemia, chronic heart failure.
Clinical associations of anemia in patients with chronic heart failure syndrome, end-stage chronic renal failure, severe liver function disorders, autoimmune and oncological diseases. Patients with CHF were treated in accordance with national guidelines [1]. According to the WHO definition, the criterion for the diagnosis of anemia in adult women was a decrease in the concentration of hemoglobin <12 g / dl, and in men - Iron deficiency anemia was diagnosed with a decrease in serum iron levels <8.95 mmol / l in women and <11.64 mmol/L in men and ferritin levels <10 mg / dl and <20 mg / dl, respectively, B12-deficient anemia - with a decrease in vitamin B12 levels <160 pg / ml, folate-deficient anemia - with a decrease in folate levels To assess the functional state of the kidneys, the glomerular filtration rate (GFR) was calculated using the CKD-EPI formula. CKD was diagnosed according to the 2012 KDIGO criteria [11]. Levels of urea, electrolytes (potassium, sodium, and chlorine), and blood glucose were also measured. Statistical analysis was performed using package of applied
statistical programs Statistica 8.0 for Windows using standard algorithms of variational statistics. For quantitative indicators, the arithmetic mean and standard deviation (M±SD) were calculated. When comparing the average values, a two-sided Student t-test was used. Qualitative variables are described by absolute (n) and relative ( % ) values. The %2 criterion was used to compare the frequencies of features and qualitative variables. The significance of differences between groups was assessed using the nonparametric Mann-Whitney test. Spearman's rank correlation coefficient was calculated for nonparametric data distribution [1-9]. Differences in mean values and correlations were considered significant at the significance level of p Results The study included 70 patients, including 37 men, aged 18 to 90 years (mean 53.1±12.5 years) with a diagnosis of CHF (Table 1). More than 2/3 of patients were diagnosed with CHF of functional class III-IV. Most patients (86.0%) had sinus rhythm. More than half of the patients suffered from arterial hypertension or type 2 diabetes, and about a quarter had a ST-segment elevation myocardial infarction. Reduction of estimated GFR Anemia was observed in 53 (31.2%) of 170 patients with CHF, including in 44 (32%) of 137 men and 9 (27%) of 33 women. In 46 patients, anemia was mild, in 7 - moderate-severe. All patients with anemia were found to be deficient in iron, 4 (7.5%) in folic acid, and 1 (1.9%) in vitamin B12. The groups of patients with CHF, combined and not combined with anemia, were comparable by gender, but the former were older (p=0.002; Table 2). In addition, patients with anemia were more likely to have arterial hypertension (p=0.04), DM (p=0.008), and CKD stages 3-5 (p=0.00002 Serum creatinine (p=0.0003) and urea (p=0.000001) were higher and lower. GFR (p=0.0003) and left ventricular ejection fraction (p=0.04). At the same time, the distribution of patients according to the severity of CHF between the two groups did not significantly differ (Figure 1). Patients with anemia were significantly more likely to receive therapy with clopidogrel (p<0.003), calcium channel blockers (p<0.0007) and statins (p To determine the borderline values of possible predictors of anemia in patients with CHF, ROC analysis was used. When constructing ROC models that reflect the relationship between significant parameters and the development of anemia in CHF, curves were obtained that did not cross the control diagonal, provided sensitivity and specificity >50%.
Men, n ( % ) Age, years (range) Body weight, kg Body mass index, kg / m2 Smoking, n ( % ) Functional class of CHF, n ( % ) I II III IV Arterial hypertension, n ( % ) A history of myocardial infarction, n ( % ) Diabetes mellitus, n ( % ) A history of stroke, n ( % ) Chronic kidney disease stages 3-5, n ( % ) Dyslipidemia, n ( % ) Sinus rhythm at admission, n ( % ) LV ejection fraction, % (range) Heart rate, per minute Systolic blood pressure, mmHg Diastolic blood pressure, mmHg Laboratory parameters Hemoglobin, g/dl (range) White blood cells, *109 / l Sodium, mmol / l GFR, ml / min / 1.73 m2 Serum creatinine, mg / dl Uric acid, mg / dl area under the curve >0.6 (at least
satisfactory model quality) at the level of statistical significance p> age >1.25 mg / dl, urea level >19.7 mg / dl and who-55.5 years (Table 4). As a result of inpatient treatment, the proportion of patients with functional class III and IV CHF significantly decreased from 39.4% to 4.1% and from 29.4% to 2.9%, respectively. To assess the impact of anemia on the outcomes of CHF, we analyzed in-hospital mortality, 30-day mortality, and the frequency of repeated hospitalizations for cardiovascular diseases during 3 and 12 months. Patients with anemia showed a significant increase in the frequency of repeated hospitalizations within 3 months after hospital discharge (45.0% vs. 14.0% in patients without anemia (p=0.015). There were no significant differences in mortality after one year (1.9% and 2.6%, respectively).In developed countries, the prevalence of CHF among adults is approximately 1-2%, and in those over the age of 70 exceeds 10% [12-15]. At the age of 55, the risk of developing CHF is 33% in men and 28% in women [14]. Among people over 65 years of age with newly detected dyspnea during physical exertion, one in six suffers from unrecognized CHF, mainly with a preserved ejection fraction [16-17]. The proportion of the latter among patients with CHF varies from 22 to 73%, depending on the diagnostic criteria, age, gender, history of myocardial infarction, and year of publication [15-16, 18]. . The most common cause of anemia is iron deficiency. For example, in a study conducted in the state of Rajasthan (India), it was detected in 76% of patients with anemia and CHF and was more common in women than in men (91.6% and 68.6%, respectively) [5].The conducted studies made it possible to identify risk factors for anemia in patients with CHF. These include, first of all, the elderly. Thus, according to T. Horwich et al., anemia in CHF was significantly more common in patients older than 55 years [28]. Similar data were obtained in our study. According to literature data, anemia in CHF is more common in men than in women [29]. However, the data obtained by us did not reveal any gender differences among the studied patient population. Numerous large randomized trials (OPTIME, FAIR-HF, etc.) have shown that The presence of anemia is associated with a higher NYHA functional class in patients with CHF [30-32]. In the present study, anemia did not significantly affect the severity of CHF, which once again indicates that the data obtained are heterogeneous depending on the characteristics of patient populations. There is an indisputable link between diabetes and anemia in CHF. It has been proven that impaired renal function and concomitant diabetes are factors that not only aggravate the course of CHF, but also increase the likelihood of developing anemia [20-29]. In our study, anemia in patients with CHF was associated with an age of >1.25 mg / dl, the level of urea >19.7 mg/dl and who-55.5 years, CKD, diabetes mellitus, arterial hypertension, and renal function indicators (baseline GFR <54.8 ml/min/1,73 m54.8 ml/min/1.73 m ,serum creatinine >1.25 mg/dl, urea level >19.7 mg/dl and who-1.25 mg/dl, urea >1.25 mg/dl, urea level >19.7 mg/dl and who-19.7 mg/dl), which does not contradict the literature data. Anemia in CHF worsens the course of the disease and
significantly worsens the prognosis of patients both in the near and long-term periods [25-29], although the adverse effect of anemia has not been confirmed in all studies. For example, a Botswana hospital in South Africa studied the effects of anemia and CKD on in-hospital outcomes in 193 patients with CHF. Anemia was detected in 32% of cases, renal dysfunction-in 31%. However, despite the prevalence of anemia and impaired renal function in CHF, they were not independent predictors of in-hospital mortality and duration of hospitalization. According to the authors, the results of studies conducted in developed countries and low-and middle-income countries may differ [10-19]. In the present study, anemia was associated with more frequent rehospitalizations within 3 months of hospital discharge, but did not affect patient mortality. Conclusion: Anemia occurs in one-third of patients with CHF, is associated with older age, certain comorbidities (CKD, diabetes mellitus, and arterial hypertension), and laboratory indicators of renal function (decreased GFR and increased serum creatinine and urea levels), as well as an increased risk of repeated hospitalizations due to cardiovascular diseases within 3 months after discharge from the hospital.
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