Heart Failure in the Real World: Epidemiology, Biomarkers and Clinical Studies in Patients with Comorbidities – Krister Lindmark's research group

Heart failure is a serious condition, and patients often have multiple coexisting diseases that complicate both treatment and clinical research. Our research combines epidemiology, biomarker studies and clinical trials to address important evidence gaps in underrepresented patient populations. A particular focus is placed on patients with combined heart and kidney disease.

Our Research

Heart failure is usually a consequence of other cardiovascular diseases. As a result, patients with heart failure are often older and commonly have other medical conditions alongside their heart disease. Although major advances have been made in understanding and treating heart failure, large groups of patients have been excluded from clinical trials. In addition, the oldest and most medically complex patients are often underrepresented in national registries and research studies.

Our goal is to better reflect the realities of everyday clinical practice. We aim to improve our understanding of how patients with heart failure, including those of advanced age and with multiple comorbidities, respond to commonly used treatments, how hospital readmissions can be predicted and prevented, and how cardiovascular disease progresses over time. Particular attention is given to kidney disease, one of the most common and clinically important comorbidities in heart failure, which often complicates treatment decisions and patient management.

Our research includes

  • Epidemiological studies, where large population registries and laboratory databases are linked to investigate the interaction between heart failure and kidney disease, and how impaired kidney function influences heart failure treatment.
  • Biomarker studies, using samples collected both from patients with newly diagnosed heart failure and from population-based biobanks where samples were obtained years before disease onset, allowing us to identify factors associated with the development of heart failure.
  • Clinical trials in patient groups where evidence is lacking, with a special focus on patients with combined heart and kidney disease who have been excluded from many previous studies.
  • Ultrasound studies aimed at predicting clinical deterioration and guiding treatment following hospitalisation for acute heart failure.

Projects

Combined Heart and Kidney Failure in Stockholm

In this project, we study how kidney function and heart failure develop over time in adults living in the Stockholm region. The study includes all residents aged 18 years or older who have undergone at least one blood test assessing electrolyte balance between 2000 and 2025, providing a unique opportunity to follow health trajectories across a large segment of the population. By combining laboratory data with information from national and regional healthcare registries, we can investigate how heart failure, kidney disease and other medical conditions interact over time.

We examine the effects of heart failure medications, changes in kidney function, and major medical events such as hospitalisations, surgical procedures and serious complications. The aim is to improve our understanding of how kidney disease develops in patients with heart failure, identify important risk factors, and evaluate adherence to current treatment guidelines. The results will contribute to better care for patients with heart and kidney disease and provide valuable information for the design of future clinical trials.

Biobank Studies in a Heart Failure Cohort from Umeå

This project, led from Karolinska Institutet in collaboration with Umeå University, uses unique population-based and biobank data from northern Sweden to investigate why some individuals develop heart failure and kidney disease while others remain healthy. The study is based on a carefully validated cohort of more than 5,000 patients with heart failure treated at Umeå University Hospital. More than half of these individuals participated in health surveys and provided blood samples many years, and in some cases decades, before developing heart failure. These patients are compared with matched individuals who have not developed the disease.

By analysing biomarkers related to inflammation, metabolism, kidney function and blood pressure, we aim to identify early indicators of increased cardiovascular and renal risk. We will also investigate how risk factors such as hypertension, blood lipid levels, alcohol consumption and medication use influence disease development over time. By linking biobank samples, primary care data and national healthcare registries, we can study disease processes long before symptoms appear. The goal is to improve prevention strategies for heart and kidney disease and identify individuals who may benefit from early intervention and targeted treatment.

SCARF – Swedish Cardiac And Renal Failure Studies

In this research programme, we investigate whether established heart failure medications that have not been adequately studied in patients with combined heart and kidney failure can improve outcomes in individuals living with both conditions. These patients face a particularly high risk of hospitalisation, worsening kidney function and premature death, yet they have often been underrepresented in previous clinical trials.

The first phase of the programme focuses on the medication eplerenone. It begins with a pilot study in which a small group of patients is monitored closely to assess treatment safety, quality of life, physical function and kidney function. The results will inform a larger national multicentre study comparing eplerenone with standard care. Through regular clinical assessments, laboratory testing and patient-reported outcomes, we aim to evaluate both the benefits and potential risks of treatment. The goal is to improve the management of patients with combined heart and kidney disease and provide scientific evidence to support future treatment recommendations in an area where important knowledge gaps remain.

ULRICA – Using SGLT2 Inhibitors to Limit Symptoms and Reduce NT-proBNP in Cardiac ATTR Amyloidosis

This project investigates whether dapagliflozin can improve symptoms and quality of life in patients with transthyretin amyloidosis (ATTR), an uncommon but serious disease in which misfolded proteins accumulate in different organs, including the heart. Cardiac involvement can lead to severe heart failure with symptoms such as breathlessness, fatigue and recurrent hospitalisations. Despite major advances in diagnosis and disease-specific therapies, effective treatment options remain limited for many patients with advanced cardiac disease.

The project begins with a pilot study and is followed by a larger randomised clinical trial involving participants from several Swedish university hospitals. By monitoring changes in symptoms, physical capacity, heart function and blood-based biomarkers, we aim to determine whether dapagliflozin can reduce disease burden and improve patient outcomes. The ultimate goal is to develop better treatment strategies for a patient group with significant unmet medical needs.

PREFERS – The Preserved and Reduced Ejection Fraction Epidemiological Regional Stockholm Study

This project is led by Associate Professor Mattias Ekström and aims to understand why some individuals with hypertension develop heart failure, particularly heart failure with preserved ejection fraction (HFpEF), while others do not. Through longitudinal clinical studies, we combine echocardiography, blood pressure measurements, biomarkers, and transcriptomic and epigenetic analyses to identify early disease mechanisms and risk markers.

The goal is to enable earlier detection, improved risk stratification and more personalised prevention strategies for heart failure in patients with hypertension.

CLUE – Congestion via LUng and IVC Evaluation

This project, led by Dr Carl Haggård, investigates whether a simple and rapid ultrasound examination of the lungs and major veins can improve care for patients recently hospitalised with heart failure. Although many patients are considered ready for discharge, a substantial proportion still have residual fluid overload, which increases the risk of clinical deterioration and readmission. Using a focused ultrasound examination that takes only a few minutes to perform, we aim to identify signs of hidden congestion before symptoms become apparent.

Participants will undergo ultrasound assessments at hospital discharge and again at their first follow-up visit a few weeks later. The findings will be compared with traditional clinical assessments, blood tests and patient-reported symptoms. The project aims to determine both how common persistent congestion is and whether this approach can improve quality of life, reduce readmissions and support safer treatment decisions. If successful, the method could become a simple and cost-effective tool for improving the follow-up of patients with heart failure in routine clinical practice.

Publications

All publications from group members