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Malignant and Benign Phenotypes of Multimorbidity in Heart Failure

Implications for Clinical Practice

Chen, Lei, PhD; Chan, Yih-Kai, PhD; Busija, Lucy, PhD; Norekval, Tone M., PhD; Riegel, Barbara, PhD; Stewart, Simon, PhD

Journal of Cardiovascular Nursing: May/June 2019 - Volume 34 - Issue 3 - p 258–266
doi: 10.1097/JCN.0000000000000557
ARTICLES: Heart Failure

Background: The impact of different patterns of multimorbidity in heart failure (HF) on health outcomes is unknown.

Objectives: The aim of this study was to test the hypothesis that, independent of the extent of comorbidity, there are distinctive phenotypes of multimorbidity that convey an increased risk for premature mortality in patients hospitalized with HF.

Methods: We analyzed the clinical profile and health outcomes of 787 patients hospitalized with HF participating in a multidisciplinary HF management program with a minimum 12-month follow-up. A Classification and Regression Tree model was applied to explore the distinctive combinations of 10 most prevalent concurrent conditions (other than coronary artery disease and hypertension) associated with 12-month all-cause mortality.

Results: Mean (SD) age was 74 (12) years (59% men), and 65% had left ventricular systolic dysfunction. Most patients (88%) had 3 or more comorbid conditions, with a mean of 4.3 concurrent conditions in addition to HF. A total of 248 patients (32%) died (median, 663 [IQR, 492–910] days), including 142 deaths (18%) within 12 months. Patients with concurrent dysrhythmia, anemia, and respiratory disease experienced significantly higher 12-month all-cause mortality than those without these conditions (36.1% vs 3.6%, respectively; hazard ratio, 6.1 [95% confidence interval, 2.0–19.1]). Overall, this “malignant” phenotype of multimorbidity was associated with not only a markedly increased risk of all-cause mortality but also more unplanned readmissions, longer inpatient stays, and highest costs in the short (30-day) and longer terms when compared with more “benign” phenotypes of multimorbidity.

Conclusions: We found a differential pattern of health outcomes according to pattern of comorbidity present in older patients hospitalized with HF and exposed to postdischarge, multidisciplinary management.

Lei Chen, PhD Research Fellow, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne.

Yih-Kai Chan, PhD Research Fellow, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne.

Lucy Busija, PhD Senior Research Fellow, Institute for Health and Ageing, Australian Catholic University, Melbourne.

Tone M. Norekval, PhD Professor, Department of Heart Disease, Haukeland University Hospital; and Department of Clinical Science, University of Bergen, Bergen, Norway.

Barbara Riegel, PhD Professor, Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, Philadelphia.

Simon Stewart, PhD Professor, Cardiology Unit, The Queen Elizabeth Hospital, Adelaide, Australia.

This work was supported by the National Health and Medical Research Council of Australia (1049133 and 1041796 to S.S.).

The authors have no conflicts of interest to disclose.

Correspondence Simon Stewart, PhD, Cardiology Unit, The Queen Elizabeth Hospital, 28 Woodville Rd, South Australia 5011, Australia (

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