Heart Failure and Multimorbidity in Asia

Impact of age and comorbidities on colorectal endoscopic submucosal dissection outcomes: Large multicenter study in a Western cohort

Background and study aims

Endoscopic submucosal dissection (ESD) has emerged as the standard treatment for colorectal lesions. Considering aging of the global population, we aimed to assess effectiveness and safety of colorectal ESD in patients aged ≥ 80 years compared with those aged 65 to 79 years in a large Western cohort.

Patients and methods

We retrospectively enrolled patients aged > 64 years undergoing colorectal ESD, classifying them into a very elderly group (VE-Group, aged > 80 years) and elderly group (E-Group, 65-79 years). Procedure outcomes and safety were compared between the VE-Group and E-Group and between patients with comorbidities and those who were healthy (1-CM-Group and H-Group).

Results

A total of 980 patients were included (269; 27.5% in the VE-Group and 711; 72.5% in the E-Group). En-bloc, R0, and oncological curative resection rates did not differ, nor did intra-procedure or post-procedure adverse events (AEs). Delirium occurrence was registered in VE-group [6 (2.2%) in VE-Group vs 1 (0.1%) in E-Group; P = 0.001; OR = 16.2, (95%CI:1.9-135.2)]. The 1-CM-Group had a higher rate of intra-procedure bleeding ( P = 0.001), delayed perforation ( P = 0.03), fever onset ( P < 0.001), and systemic infections ( P = 0.02) compared with the H-Group. Having one or more comorbidities was associated with increased overall AEs ( P < 0.001; OR 2.3, 95% CI 1.5-3.6).

Conclusions

Colorectal ESD is feasible in elderly patients. Physicians should consider delirium a possible AE in patients older than age 80 years. These findings, which bridge the gap between Asian and Western clinical data, underscore the importance of tailored pre-procedure and post-procedure assessments in a global clinical context.

Validation of ARIC heart failure risk score in an Asian population: Results from the CORE-Thailand registry

BACKGROUND

The Atherosclerotic Risk in Communities (ARIC) heart failure (HF) score was originally developed in the USA to predict new-onset HF. Our goal was to validate the ARIC-HF score and develop a new score to predict HF in an Asian population.

METHODS

The Cohort Of patients with high Risk for cardiovascular Events (CORE-Thailand) was a prospective registry of Thai patients with high atherosclerotic risk. Patients were followed for 5 years for HF events. The ARIC-HF score was applied to predict HF. The new ARIC-CORE score was developed by re-estimating the coefficients of ARIC score variables using ridge regression. The discrimination and calibration of the models were assessed. The net reclassification index (NRI) was used to compare the prediction performance between the models. Clinical utility was assessed with a decision curve analysis.

RESULTS

From a total of 8,919 patients, 185 (2.1 %) developed HF. The ARIC-HF score and ARIC-CORE HF risk score provided good discrimination with C-statistics of 0.710, (95 % confidence interval (CI); 0.673-0.747) and 0.75, (95 % CI; 0.715-0.785), respectively. Both models showed a good calibration. Using the ARIC-CORE HF score was associated with an improved reclassification of HF (NRI 0.369, 95 % CI; 0.286-0.551) compared to the ARIC-HF score. The net clinical benefit of the ARIC-CORE HF score was higher than the ARIC-HF score in the decision curve analysis.

CONCLUSION

The ARIC-HF score performed well in predicting heart failure in the CORE population. The ARIC-CORE HF score showed superior predictive ability and clinical benefit. Further research is needed to validate these models in diverse Asian populations.

Self-Care Behaviors of Patients With Heart Failure in Thailand: A qualitative descriptive study

INTRODUCTION

This study explored people's experiences of living with heart failure and their understanding of self-management and difficulties faced when making lifestyle changes in the context of high-salt food preferences and a subtropical climate.

METHODS

This qualitative descriptive study was conducted with 20 Thai individuals with heart failure. Data were analyzed using thematic content analysis.

RESULTS

Two overarching themes were: (a) adapting long-established dietary and lifestyle behaviors is challenging in the context of limited knowledge of heart failure, cultural food preparation practices and a subtropical climate and (b) personal values, attitudes, and preferences have primacy over dietary and fluid restrictions.

DISCUSSION

In Thailand, strong cultural preferences for high salt, preprepared street foods contribute to repeated admissions for decompensated heart failure. Community-based models of care are urgently needed that support effective chronic heart failure management, with solutions that consider local needs, climate and cultural factors.

Prevalence and predictors of poor heart failure treatment outcomes in Ethiopia: a systematic review and meta-analysis

Background

Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Various factors can exacerbate disease progression in patients with HF and negatively impact treatment outcomes. This study aims to evaluate the pooled prevalence and contributing factors associated with poor heart failure treatment outcomes in Ethiopia.

Methods

A systematic review and meta-analysis were conducted using five databases: Google Scholar, ScienceDirect, Hinari, PubMed, and Scopus. In total, 12 studies met the eligibility criteria for inclusion in this analysis. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Data extraction was performed using a Microsoft Excel spreadsheet, and statistical analysis was conducted with STATA 14. The Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument was utilized for quality assessment. Heterogeneity among the studies was evaluated using the I 2 statistic and the Cochrane Q test. Publication bias was assessed using Begg's test, Egger's weighted regression, and funnel plots.

Results

The pooled prevalence of poor HF treatment outcomes was found to be 16.67% [95% confidence interval (CI): 10.67-22.67]. No significant heterogeneity was observed across the included studies (I 2 = 0.0%, p = 0.962). Significant predictors of a poor treatment outcome were smoking cigarettes [adjusted odds ratio (AOR) = 10.74; 95% CI: 3.24-35.63] and medication-related problems (AOR = 3.99; 95% CI: 1.90-8.37).

Conclusion

The prevalence of poor HF treatment outcomes in Ethiopia was found to be high. Smoking cigarettes and medication-related problems are significant predictors of these adverse outcomes. Comprehensive health education and improved clinical pharmacy services are essential for addressing these issues.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023437397, PROSPERO (CRD42023437397).

Machine learning-based 30-day readmission prediction models for patients with heart failure: a systematic review

AIMS

Heart failure (HF) is one of the most frequent diagnoses for 30-day readmission after hospital discharge. Nurses have a role in reducing unplanned readmission and providing quality of care during HF trajectories. This systematic review assessed the quality and significant factors of machine learning (ML)-based 30-day HF readmission prediction models.

METHODS AND RESULTS

Eight academic and electronic databases were searched to identify all relevant articles published between 2013 and 2023. Thirteen studies met our inclusion criteria. The sample sizes of the selected studies ranged from 1778 to 272 778 patients, and the patients' average age ranged from 70 to 81 years. Quality appraisal was performed.

CONCLUSION

The most commonly used ML approaches were random forest and extreme gradient boosting. The 30-day HF readmission rates ranged from 1.2 to 39.4%. The area under the receiver operating characteristic curve for models predicting 30-day HF readmission was between 0.51 and 0.93. Significant predictors included 60 variables with 9 categories (socio-demographics, vital signs, medical history, therapy, echocardiographic findings, prescribed medications, laboratory results, comorbidities, and hospital performance index). Future studies using ML algorithms should evaluate the predictive quality of the factors associated with 30-day HF readmission presented in this review, considering different healthcare systems and types of HF. More prospective cohort studies by combining structured and unstructured data are required to improve the quality of ML-based prediction model, which may help nurses and other healthcare professionals assess early and accurate 30-day HF readmission predictions and plan individualized care after hospital discharge.

REGISTRATION

PROSPERO: CRD 42023455584.

Regional Differences in the Epidemiology of Heart Failure

Heart failure (HF) epidemiology, patient characteristics, and clinical outcomes exhibit substantial regional variations, reflecting diverse etiologies and health system capacities. This review comprehensively analyses these variations, drawing on data from recent global registries and clinical trials. Our review indicates that ischemic and hypertensive heart diseases are prevalent globally but differ in dominance depending on the region. Notably, regions such as Africa and Latin America show higher instances of HF from hypertensive heart disease and Chagas cardiomyopathy, respectively. Moreover, disparities in age and comorbidity profiles across regions highlight younger populations with HF in lower-income countries compared to older populations in high-income regions. This review also highlights the global disparity in guideline-directed medical and device therapy, underscoring significant underuse in lower-income regions. These insights emphasize the need for targeted HF management strategies considering regional clinical and demographic characteristics to enhance global HF care and outcomes.

Heart failure, the global pandemic: A call to action consensus statement from the global presidential conclave at the platinum jubilee conference of cardiological society of India 2023

Heart failure (HF) is emerging as a major public health problem both in high- and low - income countries. The mortality and morbidity due to HF is substantially higher in low-middle income countries (LMICs). Accessibility, availability and affordability issues affect the guideline directed therapy implementation in HF care in those countries. This call to action urges all those concerned to initiate preventive strategies as early as possible, so that we can reduce HF-related morbidity and mortality. The most important step is to have better prevention and treatment strategies for diseases such as hypertension, ischemic heart disease (IHD), type-2 diabetes, and rheumatic heart disease (RHD) which predispose to the development of HF. Setting up dedicated HF-clinics manned by HF Nurses, can help in streamlining HF care. Subsidized in-patient care, financial assistance for device therapy, use of generic medicines (including polypill strategy) will be helpful, along with the use of digital technologies.

Global longitudinal strain and plasma biomarkers for prognosis in heart failure complicated by diabetes: a prospective observational study

BACKGROUND

Heart failure (HF) and diabetes are associated with increased incidence and worse prognosis of each other. The prognostic value of global longitudinal strain (GLS) measured by cardiovascular magnetic resonance (CMR) has not been established in HF patients with diabetes.

METHODS

In this prospective, observational study, consecutive patients (n = 315) with HF underwent CMR at 3T, including GLS, late gadolinium enhancement (LGE), native T1, and extracellular volume fraction (ECV) mapping. Plasma biomarker concentrations were measured including: N-terminal pro B-type natriuretic peptide(NT-proBNP), high-sensitivity troponin T(hs-TnT), growth differentiation factor 15(GDF-15), soluble ST2(sST2), and galectin 3(Gal-3). The primary outcome was a composite of all-cause mortality or HF hospitalisation.

RESULTS

Compared to those without diabetes (n = 156), the diabetes group (n = 159) had a higher LGE prevalence (76 vs. 60%, p < 0.05), higher T1 (1285±42 vs. 1269±42ms, p < 0.001), and higher ECV (30.5±3.5 vs. 28.8±4.1%, p < 0.001). The diabetes group had higher NT-pro-BNP, hs-TnT, GDF-15, sST2, and Gal-3. Diabetes conferred worse prognosis (hazard ratio (HR) 2.33 [95% confidence interval (CI) 1.43-3.79], p < 0.001). In multivariable Cox regression analysis including clinical markers and plasma biomarkers, sST2 alone remained independently associated with the primary outcome (HR per 1 ng/mL 1.04 [95% CI 1.02-1.07], p = 0.001). In multivariable Cox regression models in the diabetes group, both GLS and sST2 remained prognostic (GLS: HR 1.12 [95% CI 1.03-1.21], p = 0.01; sST2: HR per 1 ng/mL 1.03 [95% CI 1.00-1.06], p = 0.02).

CONCLUSIONS

Compared to HF patients without diabetes, those with diabetes have worse plasma and CMR markers of fibrosis and a more adverse prognosis. GLS by CMR is a powerful and independent prognostic marker in HF patients with diabetes.

Angiotensin receptor neprilysin inhibitor in chronic heart failure and comorbidity management: Indian consensus statement

Heart failure (HF) is a significant public health concern characterized by notable rates of morbidity and mortality. Multimorbidity, ranging from 43% to 98% among HF patients, significantly impacts prognosis and treatment response. HF management requires a holistic approach, including guideline-directed medical therapy. Sacubitril/valsartan (angiotensin receptor neprilysin inhibitor [ARNI]) is a cornerstone of HF treatment, supported by robust evidence from large-scale clinical trials across different levels of left ventricular ejection fraction. The recommendations presented in this paper have been developed by a group of cardiologists in India who convened in expert opinion meetings to discuss the utilization of ARNI in chronic HF patients with five different comorbid conditions like type 2 diabetes mellitus (T2DM), chronic kidney disease, myocardial infarction (MI), obesity, and hypertension. Key focus areas include initiation, dose titration, and management across different HF phenotypes and comorbidities. Emphasis is placed on the efficacy of ARNI irrespective of glycemic status in the T2DM population, its role in HF patients with obesity, and addressing challenges related to renal function decline and hyperkalemia. Additionally, the document highlights ARNI's potential benefits in hypertensive and post-MI HF patients, alongside observations on the obesity paradox in HF prognosis. Overall, these recommendations aim to optimize ARNI therapy in HF patient populations with different comorbidities, addressing specific challenges and considerations to improve outcomes and quality of life.

Cardiomyopathy in Asian Cohorts: Genetic and Epigenetic Insights

Previous studies on cardiomyopathies have been particularly valuable for clarifying pathological mechanisms in heart failure, an etiologically heterogeneous disease. In this review, we specifically focus on cardiomyopathies in Asia, where heart failure is particularly pertinent. There has been an increase in prevalence of cardiomyopathies in Asia, in sharp contrast with the decline observed in Western countries. Indeed, important disparities in cardiomyopathy incidence, clinical characteristics, and prognosis have been reported in Asian versus White cohorts. These have been accompanied by emerging descriptions of a distinct rare and common genetic basis for disease among Asian cardiomyopathy patients marked by an increased burden of variants with uncertain significance, reclassification of variants deemed pathogenic based on evidence from predominantly White cohorts, and the discovery of Asian-specific cardiomyopathy-associated loci with underappreciated pathogenicity under conventional classification criteria. Findings from epigenetic studies of heart failure, particularly DNA methylation studies, have complemented genetic findings in accounting for the phenotypic variability in cardiomyopathy. Though extremely limited, findings from Asian ancestry-focused DNA methylation studies of cardiomyopathy have shown potential to contribute to general understanding of cardiomyopathy pathophysiology by proposing disease and cause-relevant pathophysiological mechanisms. We discuss the value of multiomics study designs incorporating genetic, methylation, and transcriptomic information for future DNA methylation studies in Asian cardiomyopathy cohorts to yield Asian ancestry-specific insights that will improve risk stratification in the Asian population.