Reconceptualising Dignity-Centred Care for Hospitalised Older Adults: A Discursive Theoretical Analysis Using the Levine's Conservation Model.

Heart failure (HF) affects more than 64 million people worldwide and is accompanied by a 1-year mortality rate of 15–30% []. Due to demographic changes and an ageing population, HF patients have become more complex, facing a multifactorial disease worsened by cardiovascular and non-cardiovascular comorbidities [, ]. Multimorbidity, defined as the coexistence of at least two chronic conditions [], is now the norm, especially among elderly patients []. Given the increasing prevalence, multimorbidity has considerably gained prominence in clinical practice []. Consequently, both US and European guidelines for the management of HF emphasize the identification and treatment of concomitant comorbidities to provide best medical care and potentially reduce adverse outcomes [, ]. Beyond worsening prognosis and quality of life, multimorbidity poses a considerable economic and financial burden both individually and globally [, ]. Accordingly, research has shifted from a single-disease framework where most studies excluded individuals with multiple conditions to a more holistic approach including incident and prevalent comorbidities [, ]. HF rarely occurs in isolation, with about 40% of HF patients being accompained by more than five comorbidities and over 80% accompanied by at least two comorbidities [–]. These include both cardiovascular and non-cardiovascular comorbidities, such as obesity, chronic kidney disease, diabetes mellitus, hypertension, and atrial fibrillation [, ]. While the most common comorbidities in HF are cardiovascular related, non-cardiovascular causes may be linked to even higher hospitalization and mortality rates [, ]. Moreover, symptoms in patients with HF are dominated by comorbidities and significantly impact health status, especially when they are persisting and quality of life remains poor even with optimized HF treatment [, ]. Overall, multimorbidity increases event rates in both chronic [, ] and acute [, ] HF, the risk of mortality and hospitalization []. However, a higher comorbidity burden implies an increased complexity of clinical management and suboptimal guideline directed medical treatment (GDMT) []. Despite the adverse outcome of multimorbidity, combined use of HF drugs decreases alongside the comorbidity burden, although GDMT was shown to be beneficial regardless of the number of comorbidities [, ]. The HF population is complex and heterogeneous, with significant differences depending on the phenotype of the left ventricular ejection fraction (LVEF) with regard to sex, age, outcomes and comorbidities []. While the prevalence of both cardiovascular and non-cardiovascular comorbidities is high in all HF subtypes, patients with HF and preserved ejection fraction (HFpEF) were shown to have the highest burden of comorbidities []. Recent studies have researched the prevalence and implications of multimorbidity in HF across LVEF groups, however data concerning the phenotype of HF with mildly reduced EF (HFmrEF) mostly relies on post-hoc analyses from pre-existing trials and registries []. HFmrEF represents a heterogeneous and intermediate entity within the HF spectrum. It shares the higher prevalence of ischemic heart disease and the sex distribution (more males than females) with HFrEF, while overlapping with HFpEF especially in terms of non-cardiac comorbidities such as hypertension, atrial fibrillation and obesity []. These mixed pathophysiological features contribute to varied clinical presentations, underscoring the importance of a more refined characterization to define HFmrEF as a distinct clinical entity.