Heart Failure Clinical Trials in East and Southeast Asia: Understanding the Importance and Defining the Next Steps

Current and Future of Heart Failure Care in Asia

Heart failure (HF) is a significant global health concern, particularly in Asia, where over half of the world's population resides. Despite advances in treatment, the burden of HF is expected to rise in the region due to the aging population and an increase in non-communicable diseases associated with HF risk. This narrative review examines the current state of HF in Asia, highlighting differences in treatment utilization, underrepresentation of Asian individuals in clinical trials, emerging therapies, and implementation strategies, including the potential use of polypills and the need for expanded HF training opportunities for healthcare providers.

Reassessing heart failure therapy in Thailand: Patient insights and treatment outcomes from the Thai heart failure registry

BACKGROUND

This research analyzed the demographics, management, and outcomes of patients with heart failure (HF) in Thailand.

METHODS

The Thai Heart Failure Registry prospectively enrolled patients diagnosed with HF from 36 hospitals in Thailand. Follow-up data were recorded at 6, 12, 18, and 24 months. This study primarily focused on two outcomes: mortality and HF-related hospitalizations.

RESULTS

The study included 2639 patients aged at least 18. Their mean age was 59.2 ± 14.5 years, and most were male (68.4%). Patients were classified as having HF with reduced ejection fraction (HFrEF, 80.7%), HF with preserved ejection fraction (HFpEF, 9.0%), or HF with mildly reduced ejection fraction (HFmrEF, 10.3%). Guideline-directed medical therapy utilization varied. Beta-blockers had the highest usage (93.2%), followed by mineralocorticoid receptor antagonists (65.7%), angiotensin-converting enzyme inhibitors (39.3%), angiotensin receptor blockers (28.2%), angiotensin receptor-neprilysin inhibitors (16.1%), and sodium-glucose cotransporter-2 inhibitors (8.0%). The study monitored a composite of mortality and HF incidents, revealing incidence rates of 11.74, 12.50, and 8.93 per 100 person-years for the overall, HFrEF, and HFmrEF/HFpEF populations, respectively.

CONCLUSIONS

Despite high guideline-directed medical therapy adherence, the Thai Heart Failure Registry data revealed high mortality and recurrent HF rates. These findings underscore limitations in current HF treatment efficacy. The results indicate the need for further investigation and improvements of HF management to enhance patient outcomes.

Body mass index, frailty, and outcomes in heart failure with preserved ejection fraction

AIMS

Relationship between body mass index (BMI), frailty, and clinical adverse events remains unclear in patients with heart failure (HF) with preserved ejection fraction (HFpEF) in different patient populations. We aimed to compare the association of BMI, frailty, and clinical adverse events between a US cohort from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) study and a Chinese cohort from the Heart Failure Registry of Patient Outcomes (HERO) study.

METHODS AND RESULTS

We used data of 1715 participants enrolled from America in the TOPCAT study and 1487 patients with HFpEF in the Chinese registry study, the HERO. We evaluated the relationship between BMI and frailty using multivariate restricted cubic spline logistic regression. Association between frailty and BMI categories and primary outcomes including HF hospitalization, aborted sudden death, and cardiovascular death, all-cause mortality, and HF hospitalization were analysed by Cox proportional hazards models. The patients' mean age was 72 ± 11 years for both study populations, with 50% and 46% female for the TOPCAT study and the HERO study, respectively. Patients in the TOPCAT study had a higher mean BMI (33.9 vs. 24 kg/m2), with 72.3% vs. 52.9% defined as moderately to severely frail (frailty index > 0.3). In the TOPCAT study, risk of frailty rose as BMI increased, but not in the HERO study. Patients with frailty were at significant higher risk for the primary composite outcomes [hazard ratio (HR) 1.84 (95% confidence interval: 1.46-2.32)], all-cause mortality [HR 1.73 (1.34-2.25)], and HF hospitalization [HR 1.83 (1.40-2.40)] in the TOPCAT study. The corresponding numbers in the HERO study were 1.26 (1.01-1.57), 2.21 (1.45-3.35), and 1.15 (0.81-1.37), respectively. The association of frailty with clinical outcomes did not vary with BMI categories in the two studies.

CONCLUSIONS

BMI distribution and association between BMI and frailty risk were different between the two study populations. Frailty was associated with clinical adverse events and this association was consistent across different BMI categories in both studies.

Lower doses of carvedilol in Japanese heart failure patients with reduced ejection fraction could show the potential to be non-inferior to higher doses in US patients: An international collaborative observational study

The Japanese national guidelines recommend significantly lower doses of carvedilol for heart failure with reduced ejection fraction (HFrEF) management than the US guidelines. Using real-world data, we determined whether initial and target doses of carvedilol in Japanese patients (JPNs) differ from those in US patients (USPs), especially in Asian Americans (ASA) and Caucasians (CA), and investigated differences in outcomes. We collected data from the electronic medical records, including demographics, carvedilol dosing, tolerability, cardiac functional indicators like EF, cardiovascular events including all-cause deaths, and laboratory values from the University of California, San Diego Health and Osaka University. JPNs had significantly lower doses (mg/day) of carvedilol initiation (66 USPs composed of 38 CAs and 28 ASAs, 17.1±16.2; 93 JPNs, 4.3±4.2, p<0.001) and one year after initiation (33.0±21.8; 11.2±6.5, p<0.001), and a significantly lower relative rate (RR) of dose discontinuation and reduction than USPs (RR: 0.406, 95% confidence interval (CI): 0.181-0.911, p<0.05). CAs showed the highest reduction rate (0.184), and ASAs had the highest discontinuation rate (0.107). A slight mean difference with narrow 95% CI ranges straddling zero was observed between the two regions in the change from the baseline of each cardiac functional indicator (LVEF, -0.68 [-5.49-4.12]; LVDd, -0.55 [-3.24-2.15]; LVDd index, -0.25 [-1.92-1.43]; LVDs, -0.03 [-3.84-3.90]; LVDs index, -0.04 [-2.38-2.30]; heart rate, 1.62 [-3.07-6.32]). The event-free survival showed no difference (p = 0.172) among the races. Conclusively, despite JPNs exhibiting markedly lower carvedilol doses, their dose effectiveness has the potential to be non-inferior to that in USPs. Dose de-escalation, not discontinuation, could be an option in some Asian and ASA HFrEF patients intolerable to high doses of carvedilol.

Effects of Dapagliflozin in Patients in Asia: A Post Hoc Subgroup Analysis From the DELIVER Trial

Background

Patients with heart failure (HF) with mildly reduced or preserved ejection fraction in Asia may have different clinical characteristics and outcomes compared with patients from other parts of the world.

Objectives

The purpose of this study was to investigate the clinical characteristics, safety, and efficacy of dapagliflozin in patients in Asia vs outside Asia in the DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure) trial.

Methods

In the DELIVER trial, patients with HF and left ventricular ejection fraction >40% were enrolled across 353 sites in 20 countries. The effects of dapagliflozin vs placebo on primary (composite of worsening HF or cardiovascular death) and secondary outcomes were compared in patients from Asia vs outside Asia.

Results

Among 6,263 participants, 1,226 (19.6%) were enrolled in Asia. Participants from Asia were less likely to have diabetes, hypertension, history of myocardial infarction, or obesity. After adjusting for clinically relevant characteristics, those in Asia had similar risks of primary composite outcome compared with those from outside Asia (HR: 0.97; 95% CI: 0.82-1.15). Those in Asia had a lower risk of all-cause mortality compared with those enrolled outside Asia (HR: 0.54; 95% CI: 0.44-0.66). Enrollment from Asia did not modify the effect of dapagliflozin on the primary outcome (Pinteraction = 0.54). Serious adverse events and rates of drug discontinuation were also balanced in both treatment arms, irrespective of enrollment in Asia vs outside Asia.

Conclusions

In the global DELIVER trial, dapagliflozin reduced the risk of CV death or worsening HF events and was well tolerated among participants enrolled in both Asia and other geographic regions.

Combination of low muscle strength and malnutrition is associated with longer length of hospital stay among older patients with heart failure

BACKGROUND

Muscle strength and nutritional status are associated with length of hospital stay (LOHS) in older patients with heart failure (HF).

OBJECTIVES

The purpose of the study was to examine the association of the combination of muscle strength and nutritional status on LOHS in older patients with HF.

METHODS

This retrospective cohort study included 414 older inpatients with HF (men, 57.2%; median age, 81 years; interquartile range, 75-86 years). Patients were categorized into four groups according to their muscle strength and nutritional status: group 1, high muscle strength and normal nutritional status; group 2, low muscle strength and normal nutritional status; group 3, high muscle strength and malnutrition; and group 4, low muscle strength and malnutrition. The outcome variable was the LOHS, and an LOHS of >16 days was defined as long LOHS.

RESULTS

Multivariate logistic regression analysis adjusted for baseline characteristics (reference, group 1) showed that group 4 was associated with a more significant risk of long LOHS (odds ratio [OR], 3.54 [95% confidence interval, 1.85-6.78]). In the subgroup analysis, this relationship was maintained for the first admission HF group (OR, 4.65 [2.07-10.45]) but not for the HF readmission group (OR, 2.80 [0.72-10.90]).

CONCLUSIONS

Our results suggest that the long LOHS for older patients with HF at first admission was associated with a combination of low muscle strength and malnutrition but not by either factor individually.

Lagging behind the Western countries: the knowledge gaps of gender differences in heart failure in Asia

Gender differences in heart failure (HF), ranging from epidemiological and pathophysiological factors to therapeutic response and prognosis, have been well documented in Western countries, especially in Europe and North America. The above gender differences in HF found in Westerners are rarely investigated in Asians. In this review, we explore the worrying knowledge gap on the gender differences in HF that existed in Asia in contrast with Western populations based on the following four aspects: epidemiology, risk factors, therapy, and prognosis. Finally, we conclude that investigations of gender differences in HF in Asia lag behind those in Europe and North America. Future work is required to establish and better use the high-level, population-based cohorts and develop our own high-quality, convincing clinical trials to deliver robust gender-specific conclusions in Asia.

Predicting Heart Failure in Patients with Atrial Fibrillation: A Report from the Prospective COOL-AF Registry

BACKGROUND

This study aimed to determine risk factors and incidence rate and develop a predictive risk model for heart failure for Asian patients with atrial fibrillation (AF).

METHODS

This is a prospective multicenter registry of patients with non-valvular AF in Thailand conducted between 2014 and 2017. The primary outcome was the occurrence of an HF event. A predictive model was developed using a multivariable Cox-proportional model. The predictive model was assessed using C-index, D-statistics, Calibration plot, Brier test, and survival analysis.

RESULTS

There were a total of 3402 patients (average age 67.4 years, 58.2% male) with mean follow-up duration of 25.7 ± 10.6 months. Heart failure occurred in 218 patients during follow-up, representing an incidence rate of 3.03 (2.64-3.46) per 100 person-years. There were ten HF clinical factors in the model. The predictive model developed from these factors had a C-index and D-statistic of 0.756 (95% CI: 0.737-0.775) and 1.503 (95% CI: 1.372-1.634), respectively. The calibration plots showed a good agreement between the predicted and observed model with the calibration slope of 0.838. The internal validation was confirmed using the bootstrap method. The Brier score indicated that the model had a good prediction for HF.

CONCLUSIONS

We provide a validated clinical HF predictive model for patients with AF, with good prediction and discrimination values.

Cost-Utility Analysis of Combination Empagliflozin and Standard Treatment Versus Standard Treatment Alone in Thai Heart Failure Patients with Reduced or Preserved Ejection Fraction

BACKGROUND

Clinical trials reported the benefit of empagliflozin when combined with standard treatment relative to cardiovascular death or heart failure (HF) hospitalization in patients with heart failure with reduced or preserved ejection fraction (HFrEF and HFpEF, respectively). We conducted a cost-utility analysis of combination empagliflozin and standard treatment (ST) versus ST alone in Thai HF patients with HFrEF or HFpEF.

METHODS

A Markov model was employed to capture lifetime direct medical costs and outcomes from a healthcare system perspective. Two cohorts (HFrEF and HFpEF) with an average age of 60 years were enrolled. The clinical inputs were the results of the EMPEROR-Reduced and EMPEROR-Preserved studies, and a Thai database. Costs were gathered from published studies or from a Thai hospital database. Utilities were obtained from published studies. All costs and outcomes were discounted at a rate of 3% per annum. Incremental cost-effectiveness ratios (ICERs) were estimated, and sensitivity analyses were performed.

RESULTS

In patients with HFrEF, add-on empagliflozin yielded a life-year gain of 0.26, and a quality-adjusted life-year (QALY) gain of 0.20 at an increased total cost of 409.82 USD compared to ST alone [ICER: 69,218 THB/QALY (2064.98 USD/QALY gained)]. Among HFpEF patients, add-on empagliflozin yielded a life-year gain of 0.07, and a QALY gain of 0.05 at an increased total cost of 622.49 USD compared to ST alone [ICER: 395,826 THB/QALY (11,809 USD/QALY gained)].

CONCLUSIONS

At the local Thai threshold of 4773.27 USD/QALY, empagliflozin is a cost-effective add-on treatment for patients with HFrEF, but not for patients with HFpEF.

Relationship between body roundness index and the risk of heart failure in Chinese adults: the Kailuan cohort study

AIMS

Body roundness index (BRI) is an obesity-related anthropometric index that combines waist circumference and height to better reflect body fat. This study aims to prospectively explore the relationship between BRI and the risk of heart failure (HF) based on a community-based cohort.

METHODS AND RESULTS

A total of 140 362 individuals without tumour and HF at baseline were included from the Kailuan cohort study. Their demographic information, anthropometric parameters, and biochemical indexes were collected or measured. The participants were followed up until 31 December 2016 or death or diagnosed with HF, whichever came first. Cox proportional hazards model was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for incident HF. Restricted cubic spline analysis was applied to further evaluate the possible non-linear dose-response relationship between BRI and the risk of HF. After a median follow-up period of 9.84 years, we identified 1990 HF events. The participants were grouped into four groups according to the quartiles of BRI (Q1: ≤2.93, Q2: 2.93-3.59, Q3: 3.59-4.38, and Q4: ≥4.38). After adjustment for potential confounders, compared with the group of participants in the lowest quartile of BRI, the adjusted HRs (95%CI) were 1.03 (95%CI: 0.87-1.22), 1.27 (95%CI: 1.07-1.49), and 1.50 (95%CI: 1.26-1.78) for subjects in the Q2, Q3, and Q4 groups, respectively. With each standard deviation (here is 1.10) of BRI increasing, the risk of HF increased by 18% (HR: 1.18, 95%CI: 1.12-1.24). Subgroup analysis indicated that the association between BRI and HF was more prominent in younger people (HR: 2.94, 95%CI: 1.80-4.80) than older (HR: 1.89, 95%CI: 1.57-2.27) (P for interaction < 0.001). A significant linear dose-response relationship between BRI and HF was also observed (P for non-linearity = 0.730).

CONCLUSIONS

Our study suggests that higher BRI is associated with an increased risk of HF. If these findings can be replicated in other populations, future studies need to examine whether lowering the BRI may lower the risk of incident HF.

Hospitalization for Heart Failure in the United States, UK, Taiwan, and Japan: An International Comparison of Administrative Health Records on 413,385 Individual Patients

BACKGROUND

Registries show international variations in the characteristics and outcome of patients with heart failure (HF), but national samples are rarely large, and case selection may be biased owing to enrolment in academic centers. National administrative datasets provide large samples with a low risk of bias. In this study, we compared the characteristics, health care resource use (HRU) and outcomes of patients with primary HF hospitalizations (HFH) using electronic health records (EHR) from 4 high-income countries (United States, UK, Taiwan, Japan) on 3 continents.

METHODS AND RESULTS

We used electronic health record to identify unplanned HFH between 2012 and 2014. We identified 231,512, 10,991, 36,900, and 133,982 patients with a primary HFH from the United States, the UK, Taiwan, and Japan, respectively. HFH per 100,000 population was highest in the United States and lowest in Taiwan. Fewer patients in Taiwan and Japan were obese or had chronic kidney disease. The length of hospital stay was shortest in the United States (median 4 days) and longer in the UK, Taiwan, and Japan (medians of 7, 9, and 17 days, respectively). HRU during hospitalization was highest in Japan and lowest in UK. Crude and direct standardized in-hospital mortality was lowest in the United States (direct standardized rates 1.8, 95% confidence interval 1.7%-1.9%) and progressively higher in Taiwan (direct standardized rates 3.9, 95% CI 3.8%-4.1%), the UK (direct standardized rates 6.4, 95% CI 6.1%-6.7%), and Japan (direct standardized rates 6.7, 95% CI 6.6%-6.8%). The 30-day all-cause (25.8%) and HF (7.2%) readmissions were highest in the United States and lowest in Japan (11.9% and 5.1%, respectively).

CONCLUSIONS

Marked international variations in patient characteristics, HRU, and clinical outcomes exist; understanding them might inform health care policy and international trial design.

The Prognostic Impact of Hospital Transfer after Admission due to Acute Heart Failure

The prognostic impact of transfer to another hospital among acute heart failure (AHF) patients has not been well elucidated.Of the 800 AHF patients analyzed, 682 patients were enrolled in this study for analysis. The subjects were divided into two groups according to their discharge location: discharge home (Group-H, n = 589) or transfer to another hospital for rehabilitation (Group-T, n = 93). The Kaplan-Meier curves revealed a poorer prognosis, including all-cause death and heart failure (HF) events (death, readmission-HF), in Group-T than that in Group-H (P < 0.001, respectively). A multivariate Cox regression model showed that Group-T was an independent predictor of 365-day all-cause death (hazard ratio: 2.618, 95% confidence interval [CI]: 1.510-4.538, P = 0.001). The multivariate logistic regression analysis showed that aging (per 1-year-old increase, odds ratio [OR]: 1.056, 95% CI: 1.028-1.085, P < 0.001), female gender (OR: 2.128, 95% CI: 1.287-3.521, P = 0.003), endotracheal intubation during hospitalization (OR: 2.074, 95% CI: 1.093-3.936, P = 0.026), and increased Controlling Nutritional Status score on admission (per 1.0-point increase, OR: 1.247, 95% CI: 1.131-1.475, P < 0.001) were associated with transfer to another hospital after AHF admission. The prognosis, including all-cause death, was determined to be significantly poorer in patients who were transferred to another hospital, as their activities of daily living were noted to lessen before discharge (n = 11) compared to others (n = 82).Elderly AHF patients suffering from malnutrition were difficult to discharge home after AHF admission, and transfer to another hospital only led to adverse outcomes. Appropriate rehabilitation during definitive hospitalization appears necessary for managing elderly patients in the HF pandemic era.

Hypertensive Heart Failure in Asia

Hypertension (HT) is an important risk factor for heart failure (HF). The prevalence of HT among the HF population is higher in Asia than in other regions around the world. In Asia, HT is the most common cause of HF after ischemic heart disease. Hypertensive HF (HHF) results from structural and functional adaptations of the heart, which lead to left ventricular (LV) hypertrophy (LVH). Hypertensive LVH can cause ventricular diastolic dysfunction and becomes a risk factor for myocardial infarction, which is a well-known cause of LV systolic dysfunction. Asymptomatic systolic and diastolic LV dysfunction easily progress to clinically overt HF with other precipitating factors. Although the precise pathophysiology of HHF is still unclear, we have known that HHF can be reversed by effective control of blood pressure (BP). Thus, HT control is essential not only for primary prevention but also for the secondary prevention of HF. Here, we reviewed the epidemiology, pathophysiology, outcome, and implication of BP management in HHF patients, especially in the Asian population.

Outcomes of patients with atrial fibrillation with and without diabetes: A propensity score matching of the COOL-AF registry

BACKGROUND

To investigate the clinical outcomes of patients with non-valvular atrial fibrillation (NVAF) compared between those with and without diabetes mellitus (DM).

METHODS

We conducted a prospective multicenter nationwide registry for patients with NVAF from 27 hospitals in Thailand. Patients were followed-up every 6 months until 3 years. The outcome measurements were ischemic stroke (IS) or transient ischemic attack (TIA), major bleeding, and heart failure (HF). All reported events were confirmed by the adjudication committee. DM was diagnosed by history or laboratory data.

RESULTS

We studied 3402 patients. DM was diagnosed in 923 patients (27.1%). The average follow-up duration was 25.74 ± 10.57 months (7912 persons-year). The rate of IS/TIA, major bleeding, and HF was 1.42, 2.11, and 3.03 per 100 person-years. Patients with DM had a significantly increased risk of IS/TIA, major bleeding, and HF. After adjusting for age, gender, comorbid conditions, and the use of oral anticoagulant (OAC) using propensity score matching, DM remained a significant predictor of ischemic stroke/TIA, major bleeding and HF with Hazard ratio and 95% confidence interval of 1.67 (1.02, 2.73), 1.65 (1.13, 2.40), and 1.87 (1.34, 2.59), respectively. The net clinical benefit of OAC was more pronounced in DM patients (0.88 events per 100 person-years) than in those without DM (-0.73 events per 100 person-years).

CONCLUSIONS

DM increases the risk of adverse clinical outcomes in NVAF patients. The benefit of OAC outweighs the risk in DM patients.

Clinical Phenotypes and Age-Related Differences in Presentation, Treatment, and Outcome of Heart Failure with Preserved Ejection Fraction: A Vietnamese Multicenter Research

Background

Heart failure with preserved ejection fraction (HFpEF) is a rising health problem with heterogeneous presentation and no evidence-based treatment. While Southeast Asia reported the highest mortality and morbidity among Asian population, little is known about the Vietnamese population, including patient characteristics, prescribing pattern and mortality rate.

Methods

We conducted an observational study on 477 patients diagnosed with HFpEF from seven hospitals in Southern Vietnam from January 2019 to December 2019.

Results

Mean age was 67.6 (40.9% < 65 years). 62.3% were female. 82.4% were diagnosed within 5 years. Dyspnea, congestion, and hypoperfusion on admission were noted in 63.9%, 48.8%, and 4.6% of the patients, respectively. Median ejection fraction was 63%. Valvular heart disease (VHD) was the leading cause of heart failure (35.9%). 78.6% had at least two comorbidities, mostly hypertension (68.6%). 30.6% of the patients were hospitalized, with a median stay of 7.0 (4.0–10.0) days and inhospital mortality of 4.8%. Older patients (≥65 years) were more likely to be females (OR = 1.52); had multimorbid conditions (OR = 3.14), including hypertension (OR = 4.28), diabetes (OR = 1.73), coronary artery disease (CAD) (OR = 2.50), dyslipidemia (OR = 1.94), and chronic kidney disease (OR = 2.44); and were more frequently prescribed statin (OR = 3.15). Younger individuals (<65 years) were associated with higher mineralocorticoid antagonist uptake (OR = 0.52) and VHD (OR = 0,40). Prescription rate for renin-angiotensin-aldosterone system inhibitor, beta blocker, mineralocorticoid antagonist, and loop diuretic was 72.5%, 59.1%, 43.0%, and 60.6%, respectively. Four phenotypes were identified, including the lean/elderly/multimorbid; congestive/metabolic; CAD-induced; and younger/atrial fibrillation (AF)/VHD. The novel phenotype “younger/AF/VHD” exhibited high symptom burden and poor functional capacity despite being the youngest and least multimorbid. The “lean/elderly/multimorbid” phenotype demonstrated the highest symptom severity and inhospital mortality.

Conclusions

Our research highlights a younger, predominantly female population with high disease burden. The four novelly identified phenotypes provide contemporary and pragmatic insights into a phenotype-guided approach, exclusively targeting the Vietnamese population.

Acute decompensated heart failure in a non cardiology tertiary referral centre, Sarawak General Hospital (SGH-HF)

Background

Data on clinical characteristics of acute decompensated heart failure (ADHF) in Malaysia especially in East Malaysia is lacking.

Methods

This is a prospective observational study in Sarawak General Hospital, Medical Department, from October 2017 to September 2018. Patients with primary admission diagnosis of ADHF were recruited and followed up for 90 days. Data on patient’s characteristics, precipitating factors, medications and short-term clinical outcomes were recorded.

Results

Majority of the patients were classified in lower socioeconomic group and the mean age was 59 years old. Hypertension, diabetes mellitus and dyslipidaemia were the common underlying comorbidities. Heart failure with ischemic aetiology was the commonest ADHF admission precipitating factor. 48.6% of patients were having preserved ejection fraction HF and the median NT-ProBNP level was 4230 pg/mL. Prescription rate of the evidence-based heart failure medication was low. The in-patient mortality and the average length of hospital stay were 7.5% and 5 days respectively. 43% of patients required either ICU care or advanced cardiopulmonary support. The 30-day, 90-day mortality and readmission rate were 13.1%, 11.2%, 16.8% and 14% respectively.

Conclusion

Comparing with the HF data from West and Asia Pacific, the short-term mortality and readmission rate were high among the ADHF patients in our study cohort. Maladaptation to evidence-based HF prescription and the higher prevalence of cardiovascular risk factors in younger patients were among the possible issues to be addressed to improve the HF outcome in regions with similar socioeconomic background.

Safety and Tolerability of Sacubitril/Valsartan Initiation in Inpatient Versus Outpatient Setting: A Retrospective Real World Study

BACKGROUND

The Comparison of Pre- and Post-discharge Initiation of LCZ696 Therapy in HFrEF Patients After an Acute Decompensation Event (TRANSITION) and PIONEER-HF trials^a have shown that sacubitril/valsartan can be initiated early and safely in patients with heart failure with reduced ejection fraction (HFrEF) shortly after an acute heart failure episode during hospitalisation. However, it is unclear whether the results can be translated to Asian populations. Hence, this real-world study was designed with the aim of comparing the safety and tolerability of sacubitril/valsartan initiation in an inpatient versus outpatient setting.

METHODS

A retrospective review for all patients initiated with sacubitril/valsartan from 1 November 2015 to 30 September 2018 was conducted in a tertiary health care institution in Singapore. Patients with HFrEF and aged ≥21 years were included. Incidence of adverse drug reactions (ADRs) and discontinuation rate of sacubitril/valsartan were compared between initiation of sacubitril/valsartan in inpatient and outpatient settings. Reasons for discontinuation were investigated. Subgroup analysis was performed. Cox regression was used to analyse the primary outcomes.

RESULTS

Of the 1,022 patients who were screened, 840 (289 inpatient group; 551 outpatient group) were included. The inpatient group experienced significantly higher ADRs (34.6% vs 22.7%; adjusted hazard ratio [HR], 2.28; 95% confidence interval [CI], 1.68-3.10; p<0.01) and discontinuation rate (18.0% vs 10.3%; adjusted HR, 2.11; 95% CI, 1.37-3.26; p<0.01) than the outpatient group. The safety outcomes were consistent across all the subgroups.

CONCLUSIONS

Initiation of sacubitril/valsartan in an inpatient group was associated with higher ADRs and discontinuation rate as compared with an outpatient group in an Asian population. However, given that the majority of patients in the inpatient cohort could tolerate sacubitril/valsartan, it would still be feasible to initiate this drug with close monitoring. Further randomised clinical trials in Asian populations are required to confirm this finding.

Sacubitril-Valsartan Compared With Enalapril for the Treatment of Heart Failure: A Decision-Analytic Markov Model Simulation in China

Objectives

Heart failure with reduced ejection fraction (HFrEF) is a major health concern globally due to high mortality rates, frequent hospitalization and considerable medical expenditure. The prevalence of HFrEF is steadily rising in Asian countries, and populous, developing countries like China are facing a significant socio-economic burden as a result. Sacubitril-valsartan (Sac-Val) is currently a class I recommendation for treating HFrEF in major guidelines, although it has not been pharmaco-economically evaluated in China. To this end, we compared the cost-effectiveness of Sac-Val and enalapril based on the negotiated prices in order to fully assess the expected costs and benefits of the clinical use of Sac-Val in China.

Method

A Markov model was constructed to estimate long-term clinical and economic outcomes of Sac-Val versus enalapril for HFrEF patients in China over a 10-year horizon. Primary model outcomes were total costs and quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER).

Results

Treatment with Sac-Val resulted in 4.67 QALYs at the cost of $4,684.25, while enalapril yielded 4.40 QALYs at the cost of $4,014.47. Compared to enalapril, Sac-Val was associated with a gain of 0.27 QALYs, resulting in an ICER of $ 2,480.67 per QALY. Deterministic sensitivity analysis showed robust results. Probabilistic sensitivity analysis suggested that Sac-Val has a 99.99% probability of being cost-effective at the willingness-to-pay threshold of $10,276.

Conclusion

From Chinese patients’ perspective, Sac-Val is a cost-effective treatment option for HFrEF in China compared to enalapril. Our findings can aid clinicians plan the Sac-Val regimen, as well as decision makers to discuss the value and position of novel angiotensin receptor neprilysin inhibitors (ARNIs) in future.

Cost-utility analysis of add-on dapagliflozin treatment in heart failure with reduced ejection fraction

BACKGROUND

Dapagliflozin is an antidiabetic medication that has been shown to reduce the risk of heart failure hospitalization and cardiovascular death in patients with heart failure with reduced ejection fraction (HFrEF). This study aimed to determine the cost-utility of add-on dapagliflozin treatment for HFrEF.

METHODS

An analytical decision model was constructed to assess lifetime costs and outcomes from a healthcare system perspective. The cohort comprised HFrEF patients with left ventricular ejection fraction (LVEF) ≤40%, and New York Heart Association (NYHA) class II-IV with an average age of 65 years. Clinical inputs were derived from the results of the Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure (DAPA-HF) trial. Risk of non-cardiovascular death data, readmission rate data, and treatment-related cost data were based on Thai population. The outcomes and costs were discounted at 3% annually. A series of sensitivity analyses were also conducted.

RESULTS

The increased cost of dapagliflozin add-on treatment from 17,442 THB (559 USD) to 54,405 THB (1745 USD) was associated with a QALY gain from 6.33 to 6.92 compared to standard therapy, yielding an ICER of 62,090 THB/QALY (1991 USD/QALY). Sensitivity analyses revealed that the addition of dapagliflozin to the standard treatment demonstrated an 87% cost-effectiveness strategy at a level of willingness to pay (WTP) of 160,000 THB/QALY (5131 USD/QALY). ICER was higher in non-diabetes compared to diabetes (68,304 vs 47,613 THB/QALY or 2191 vs 1527 USD/QALY).

CONCLUSIONS

Dapagliflozin is a cost-effective add-on therapy for patients with HFrEF at a WTP of 160,000 THB/QALY (5131 USD/QALY).

Risk stratification in patients hospitalized for acute heart failure in Asian population

BACKGROUND

The AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score may be suboptimal in predicting long-term mortality in Asian patients with acute heart failure (AHF). We aimed to propose and validate a risk score incorporating easily available echocardiographic parameters to improve risk stratification in Asian patients with AHF.

METHODS

A total of 3537 patients hospitalized for AHF were enrolled and divided into generation and validation cohorts. Independent predictors of all-cause mortality were identified by Cox regression analysis and scored by hazard ratios to constitute the model. Model performance was validated and evaluated by receiver operating characteristic (ROC) curves and net reclassification improvement (NRI).

RESULTS

In the generation cohort of 1775 patients (74.3±13.0 years, 69.9% men), there were 870 deaths (49.0%) during a mean follow-up of 24.7±13.8 months. Age, anemia, estimated glomerular filtration rate <50 ml/min/1.73 m, hyperuricemia, left ventricular ejection fraction <50% and right ventricular systolic pressure (RVSP) >40 mmHg were independently related to mortality, which constituted "UR-HEARt" (U: uric acid, R: renal function, H: hemoglobin, E: ejection fraction of left ventricle, A: age, Rt: RVSP) score. Model performance was evaluated in the validation cohort (n = 1762), which outperformed AHEAD score by comparison of ROC curves in predicting all-cause mortality (area under curve [AUC] of UR-HEARt vs. AHEAD: 0.66 [95% CI 0.62-0.70] vs. 0.58 [95% CI 0.54-0.62]; p < 0.001), with NRI by 10.9% for all-cause mortality (p < 0.001) and 18.4% for cardiovascular death (p < 0.001).

CONCLUSION

UR-HEARt score, an easily accessible racial-specific risk score with integration of echocardiographic indices, improved risk stratification in Asian patients hospitalized for AHF.

Validation of Three European Risk Scores to Predict Long-Term Outcomes for Patients Receiving Cardiac Resynchronization Therapy in an Asian Population

To validate externally and recalibrate three European risk scores for all-cause mortality and transplantation in patients receiving cardiac resynchronization therapy (CRT) in an Asian population. Data were collected at our institution between January 2010 and December 2017. The primary endpoints were all-cause mortality and heart transplantation. Of the 506 patients who were followed for 2 years, 104 reached the primary endpoint. The Kaplan-Meier event-free survival analysis, stratified according to the three scores, yielded significant results (log-rank test, all P < 0.05), with a good fit between the predicted and observed event rates (Hosmer-Lemeshow goodness-of-fit test, all P > 0.05). The ScREEN score yielded the best discriminatory power for the primary endpoints compared with the VALID-CRT and EAARN scores. ScREEN was the best predictor of all-cause mortality and heart transplantation. Risk scores based on different populations should be selected cautiously. Graphical Abstract.

Clinical Approach to Shortening Length of Hospital Stay in Elderly Patients With Acute Heart Failure Requiring Intensive Care

Background: The length of hospital stay (LOHS) after acute heart failure (AHF) is too long in Japan. The clinical approach to shortening LOHS is an urgent issue in the aging Japanese society.

Methods and Results: Of 1,473 AHF patients screened, 596 patients >75 years old were enrolled. They were divided by LOHS: <28 days (<28-day group, n=316) and ≥28 days (≥28-day group, n=280). Systolic blood pressure and serum hemoglobin were significantly higher and serum blood urea nitrogen and creatinine significantly lower in the <28-day group than in the ≥28-day group. Non-invasive positive pressure ventilation (NPPV) use was significantly more frequent in the <28-day group than in the ≥28-day group. Furthermore, newly initiated tolvaptan in <12 h was significantly more frequent in the <28-day group than in the ≥28-day group (P=0.004). On multivariate logistic regression analysis, newly initiated tolvaptan in <12 h (OR, 2.574; 95% CI: 1.146–5.780, P=0.022) and NPPV use (OR, 1.817; 95% CI: 1.254–2.634, P=0.002) were independently associated with the <28-day group. The same result was found after propensity score matching for LOHS.

Conclusions: LOHS was prolonged in patients with severe HF but could be shortened by early tolvaptan treatment.

Regional Variation of Mortality in Heart Failure With Reduced and Preserved Ejection Fraction Across Asia: Outcomes in the ASIAN-HF Registry

Background

Data comparing outcomes in heart failure (HF) across Asia are limited. We examined regional variation in mortality among patients with HF enrolled in the ASIAN‐HF (Asian Sudden Cardiac Death in Heart Failure) registry with separate analyses for those with reduced ejection fraction (EF; <40%) versus preserved EF (≥50%).

Methods and Results

The ASIAN‐HF registry is a prospective longitudinal study. Participants with symptomatic HF were recruited from 46 secondary care centers in 3 Asian regions: South Asia (India), Southeast Asia (Thailand, Malaysia, Philippines, Indonesia, Singapore), and Northeast Asia (South Korea, Japan, Taiwan, Hong Kong, China). Overall, 6480 patients aged >18 years with symptomatic HF were recruited (mean age: 61.6±13.3 years; 27% women; 81% with HF and reduced rEF). The primary outcome was 1‐year all‐cause mortality. Striking regional variations in baseline characteristics and outcomes were observed. Regardless of HF type, Southeast Asians had the highest burden of comorbidities, particularly diabetes mellitus and chronic kidney disease, despite being younger than Northeast Asian participants. One‐year, crude, all‐cause mortality for the whole population was 9.6%, higher in patients with HF and reduced EF (10.6%) than in those with HF and preserved EF (5.4%). One‐year, all‐cause mortality was significantly higher in Southeast Asian patients (13.0%), compared with South Asian (7.5%) and Northeast Asian patients (7.4%; P<0.001). Well‐known predictors of death accounted for only 44.2% of the variation in risk of mortality.

Conclusions

This first multinational prospective study shows that the outcomes in Asian patients with both HF and reduced or preserved EF are poor overall and worst in Southeast Asian patients. Region‐specific risk factors and gaps in guideline‐directed therapy should be addressed to potentially improve outcomes.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01633398.

9-Year Trend in the Management of Acute Heart Failure in Japan: A Report From the National Consortium of Acute Heart Failure Registries

Background

Acute heart failure (AHF) is a heterogeneous condition, and its characteristics and management patterns differ by region. Furthermore, limited evidence is available on AHF outside of Western countries. A project by the National Consortium of Acute Heart Failure Registries was designed to evaluate the trends over time in patient backgrounds, in‐hospital management patterns, and long‐term outcomes of patients with AHF over 9 years in Japan.

Methods and Results

Between 2007 and 2015, registry data for patients with AHF were collected from 3 large‐scale quality AHF registries (ATTEND/WET‐HF/REALITY‐AHF). Predefined end points were trends over time in age, sex, and clinical outcomes, including short‐ and long‐term mortality and readmission for heart failure. The final data set consisted of 9075 patients with AHF. No significant differences in patient backgrounds and laboratory findings (eg, anemia or renal function) were observed, with the exception of patient age; mean age became substantially higher over 9 years (71.6–77.0 years; P for trend, <0.001). On the contrary, length of hospital stay became shorter (mean, 26–16 days). These changes were not associated with in‐hospital mortality (4.7–7.5%) or 30‐day heart failure readmission rate (4.8–5.4%), as well as 1‐year mortality and heart failure readmission rate (20.1–23.3% and 23.6–26.2%, respectively).

Conclusions

Length of hospital stay in patients with AHF shortened over the 9‐year period despite the increasing age of the patients. However, short‐ and long‐term outcomes do not seem to be affected; continuous efforts to monitor clinical outcomes in patients with AHF are needed.

Trends in the Management of Acute Heart Failure Requiring Intensive Care

The aim of the present study was to elucidate trends in managing acute heart failure (AHF) patients who require intensive care over a 19-year period. We evaluated a total of 1,475 AHF patients, comparing patient backgrounds, in-hospital management, and prognosis according to the year of admission (2000s group, n = 608 and 2010s group, n = 867). A multivariate logistic regression analysis revealed that age (≥75 years; odds ratio [OR] 1.334, 95% confidence interval [CI] 1.048 to 1.700), systolic blood pressure (<100 mm Hg; OR 1.934, 95% CI 1.170 to 3.198), left ventricular ejection fraction (>40%; OR 1.441, 95% CI 1.125 to 1.847), and prognostic nutritional index (severe; OR 1.865, 95% CI 1.224 to 2.841) were independently associated with admission in the 2010s group. The use of intra-aortic balloon pumping and noninvasive positive pressure ventilation increased significantly, whereas the need for endotracheal intubation and administration of furosemide and carperitide in the 2010s group decreased significantly compared with the 2000s group. Tolvaptan therapy was introduced from 2010. The duration of intensive care unit admission and total hospitalization in the 2010s group (4 [3 to 6] and 23 [15 to 40] days, respectively) were significantly shorter than in the 2000s group (5 [4 to 8] and 30 [20 to 54] days, respectively). A Kaplan-Meier survival curve analysis showed the survival rate of the 2010s group was significantly poorer compared with the 2000s group (hazards ratio 1.435, 95% CI 1.113 to 1.851). After propensity score matching, the 365-day mortality rates of the 2 groups did not significantly differ. In conclusion, the condition of AHF patients became more critical year by year, leading to poorer long-term prognosis despite improved treatment strategy. These findings will be useful for managing AHF in the next pandemic era.

Effect of coenzyme Q10 in Europeans with chronic heart failure: A sub-group analysis of the Q-SYMBIO randomized double-blind trial

BACKGROUND

Geographical differences in patient characteristics, management and outcomes in heart failure (HF) trials are well recognized. The aim of this study was to assess the consistency of the treat- ment effect of coenzyme Q10 (CoQ10) in the European sub-population of Q-SYMBIO, a randomized double-blind multinational trial of treatment with CoQ10, in addition to standard therapy in chronic HF.

METHODS

Patients with moderate to severe HF were randomized to CoQ10 300 mg daily or placebo in addition to standard therapy. At 3 months the primary short-term endpoints were changes in New York Heart Association (NYHA) functional classification, 6-min walk test, and levels of N-terminal pro-B type natriuretic peptide. At 2 years the primary long-term endpoint was major adverse cardiovascular events (MACE).

RESULTS

There were no significant changes in short-term endpoints. The primary long-term endpoint of MACE was reached by significantly fewer patients in the CoQ10 group (n = 10, 9%) compared to the placebo group (n = 33, 27%, p = 0.001). The following secondary endpoints were significantly improved in the CoQ10 group compared with the placebo group: all-cause and cardiovascular mortality, NYHA classification and left ventricular ejection fraction (LVEF). In the European sub-population, when compared to the whole group, there was greater adherence to guideline directed therapy and similar results for short- and long-term endpoints. A new finding revealed a significant improvement in LVEF.

CONCLUSIONS

The therapeutic efficacy of CoQ10 demonstrated in the Q-SYMBIO study was confirmed in the European sub-population in terms of safely reducing MACE, all-cause mortality, cardiovascular mortality, hospitalization and improvement of symptoms.

Prediction of Survival in Asian Patients Hospitalized With Heart Failure: Validation of the OPTIMIZE-HF Risk Score

BACKGROUND

Risk scores predicting in-patient mortality in heart failure patients have not been designed specifically for Asian patients. We aimed to validate and recalibrate the OPTIMIZE-HF risk model for in-hospital mortality in a multiethnic Asian population hospitalized for heart failure.

METHODS AND RESULTS

Data from the Singapore Cardiac Databank Heart Failure on patients admitted for heart failure from January 1, 2008, to December 31, 2013, were included. The primary outcome studied was in-hospital mortality. Two models were compared: the original OPTIMIZE-HF risk model and a modified OPTIMIZE-HF risk model (similar variables but with coefficients derived from our cohort). A total of 15,219 patients were included. The overall in-hospital mortality was 1.88% (n = 286). The original model had a C-statistic of 0.739 (95% CI 0.708-0.770) with a good match between predicted and observed mortality rates (Hosmer-Lemeshow statistic 13.8; P = .086). The modified model had a C-statistic of 0.741 (95% CI 0.709-0.773) but a significant difference between predicted and observed mortality rates (Hosmer-Lemeshow statistic 17.2; P = .029). The modified model tended to underestimate risk at the extremes (lowest and highest ends) of risk.

CONCLUSIONS

We provide the first independent validation of the OPTIMIZE-HF risk score in an Asian population. This risk model has been shown to perform reliably in our Asian cohort and will potentially provide clinicians with a useful tool to identify high-risk heart failure patients for more intensive management.

Sacubitril/Valsartan in Asian Patients with Heart Failure with Reduced Ejection Fraction

The Prospective comparison of Angiotensin Receptor-neprilysin inhibitor (ARNI) with Angiotensin converting enzyme inhibitor (ACEI) to Determine Impact on Global Mortality and morbidity in Heart Failure (HF) trial (PARADIGM-HF) showed that adding a neprilysin inhibitor (sacubitril) to a renin-angiotensin system blocker (and other standard therapy) reduced morbidity and mortality in ambulatory patients with chronic HF with reduced ejection fraction (HFrEF). In PARADIGM-HF, valsartan combined with sacubitril (a so-called ARNI) was superior to the current gold standard of an ACEI, specifically enalapril, reducing the risk of the primary composite outcome of cardiovascular (CV) death or first HF hospitalization by 20% and all-cause death by 16%. Following the results of PARADIGM-HF, sacubitril/valsartan was approved by American and European regulatory authorities for the treatment of HFrEF. The burden of HF in Asia is substantial, both due to the huge population of the region and as a result of increasing CV risk factors and disease. Both the prevalence and mortality associated with HF are high in Asia. In the following review, we discuss the development of sacubitril/valsartan, the prototype ARNI, and the available evidence for its efficacy and safety in Asian patients with HFrEF.

Relationship Between Enrolling Country Income Level and Patient Profile, Protocol Completion, and Trial End Points

BACKGROUND

Globalization of clinical trials fosters inclusion of higher and lower income countries, but the influence of enrolling country income level on heart failure trial performance is unclear. This study sought to evaluate associations between enrolling country income level, acute heart failure patient profile, protocol completion, and trial end points.

METHODS AND RESULTS

The ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial included 7141 patients with acute heart failure from 30 countries. Country income data in gross national income per capita in current US dollars from the year 2007 (ie, the year trial enrollment began) were abstracted from the World Bank. Patients were grouped by enrolling country income level (ie, high [>$11 455], upper middle [$3706-$11 455], lower middle [$936-$3705], and low [<$936]). Income data were available for 29 (97%) countries (N=7064). There were 3996 (57%), 1518 (21%), and 1550 (22%) patients from high-income, upper-middle-income, and lower-middle-income countries, respectively. There were no patients from low-income countries. Patients from lower-middle-income countries tended to be younger with fewer comorbidities and lower utilization of guideline-directed therapies. Rates of adverse events (13.8%) and protocol noncompletion (4.9%) during 180-day follow-up were highest among high-income countries (all P <0.01). After adjustment for race, geographic region, and clinical characteristics, compared with lower-middle-income countries, enrollment from higher income countries was associated with increased 30-day mortality or rehospitalization (high income: odds ratio, 1.70; 95% CI, 1.02-2.85; upper-middle-income: odds ratio, 2.16; 95% CI, 1.23-3.81), driven by higher rates of rehospitalization. Mortality was similar at 30 and 180 days. The association between higher country income and the 30-day composite end point was similar across geographic regions, with exception of Latin America ( P for interaction, 0.03).

CONCLUSIONS

In this global acute heart failure trial, patients from higher income countries had lower rates of protocol completion, higher rates of adverse events, and similar mortality rates. After adjustment for race, geographic region, and clinical factors, enrollment from a higher income country was associated with worse clinical outcomes, driven by higher rates of rehospitalization. Variation in enrolling country income level may influence study end points and trial performance independent of geographic region.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT00475852.

Heart failure with preserved ejection fraction in Asia

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a global public health problem. Unfortunately, little is known about HFpEF across Asia.

METHODS AND RESULTS

We prospectively studied clinical characteristics, echocardiographic parameters and outcomes in 1204 patients with HFpEF (left ventricular ejection fraction ≥50%) from 11 Asian regions, grouped as Northeast Asia (Hong Kong, Taiwan, China, Japan, Korea, n = 543), South Asia (India, n = 252), and Southeast Asia (Malaysia, Thailand, Singapore, Indonesia, Philippines, n = 409). Mean age was 68 ±12 years (37% were < 65 years) and 50% were women. Seventy per cent of patients had ≥2 co-morbidities, most commonly hypertension (71%), followed by anaemia (57%), chronic kidney disease (50%), diabetes (45%), coronary artery disease (29%), atrial fibrillation (29%) and obesity (26%). Southeast Asian patients had the highest prevalence of all co-morbidities except atrial fibrillation, South Asians had the lowest prevalence of all co-morbidities except anaemia and obesity, and Northeast Asians had more atrial fibrillation. Left ventricular hypertrophy and concentric remodelling were most prominent among Southeast and South Asians, respectively (P < 0.001). Overall, 12.1% of patients died or were hospitalized for heart failure within 1 year. Southeast Asians were at higher risk for adverse outcomes, independent of co-morbidity burden and cardiac geometry.

CONCLUSION

These first prospective multinational data from Asia show that HFpEF affects relatively young patients with a high burden of co-morbidities. Regional differences in types of co-morbidities, cardiac remodelling and outcomes of HFpEF across Asia have important implications for public health measures and global HFpEF trial design.

Symptom Clusters and Their Impacts on Hospital Readmission in Patients With Heart Failure: A Cross-Sectional Study

Background and Purpose:

Readmissions after hospitalization due to multiple symptoms in heart failure (HF) are common and costly. Patients have difficulty differentiating HF symptoms from comorbid illness or aging. Therefore, early identification of symptom clusters could improve symptom recognition and reduce hospital readmission. However, little is known about the relationship between symptom clusters and readmission in HF patients. This study aimed to identify symptom clusters among Korean patients with HF and the relationship between symptom clusters and hospital readmission.

Methods:

This cross-sectional study included 306 HF outpatients within 12 months after discharge. Exploratory factor analysis was used to identify the symptom clusters. Multiple logistic regression analysis was used to examine the effect of symptom clusters on readmission, after adjusting for sociodemographic and clinical characteristics.

Results:

Three symptom clusters were identified in HF patients: the “respiratory distress” cluster, “bodily pain and energy insufficiency” cluster, and “circulatory and gastrointestinal distress” cluster. Patients with class III or IV of HF functional class experienced three symptom clusters at a higher level. This study showed that the “bodily pain and energy insufficiency” cluster was the strongest predictor of hospital readmission in HF patients (adjusted odds ratio = 6.59, 95% confidence interval (CI) [1.29, 32.79]).

Implications for Practice:

A higher level of “bodily pain and energy insufficiency” cluster was associated with hospital readmission in Korean HF patients. Health-care providers should be encouraged to consider patients’ cultural backgrounds to recognize differences in symptom clusters. Further studies are needed to evaluate symptom clusters across international cohorts and their impacts on patients’ outcomes.

Influence of Race in the Association of Diabetes and Heart Failure

Heart failure is a global public health problem with high mortality and readmission rates. Race and ethnicity are useful concepts when attempting to understand differential health risks and health disparities. With cardiovascular diseases accounting for most deaths globally, eliminating racial disparities in cardiac care has become a new challenge in cardiology. Significant racial differences exist in patients with heart failure. African American patients in the US have a significantly higher incidence of heart failure, lower ejection fraction and are younger at presentation compared to White, Hispanic and Chinese American patients. These findings are explained by a higher burden of risk factors such as diabetes mellitus, hypertension, obesity and lower household incomes among African Americans. The authors believe that these findings are applicable to other racial groups across the globe. The prevalence of predisposing risk factors probably has a stronger influence on the incidence of heart failure than the racial factor alone. The interaction between race and diabetes mellitus has important public health implications for the management and prevention of heart failure.

Cost-effectiveness of sacubitril/valsartan versus enalapril in patients with heart failure and reduced ejection fraction

BACKGROUND

Sacubitril/valsartan reduces cardiovascular death and hospitalizations for heart failure (HF). However, decision-makers need to determine whether its benefits are worth the additional costs, given the low-cost generic status of traditional standard of care.

AIMS

To evaluate the cost-effectiveness of sacubitril/valsartan compared to enalapril in patients with HF and reduced ejection fraction, from the Singapore healthcare payer perspective.

METHODS

A Markov model was developed to project clinical and economic outcomes of sacubitril/valsartan vs enalapril for 66-year-old patients with HF over 10 years. Key health states included New York Heart Association classes I-IV and deaths; patients in each state incurred a monthly risk of hospitalization for HF and cardiovascular death. Sacubitril/valsartan benefits were modeled by applying the hazard ratios (HRs) in PARADIGM-HF trial to baseline probabilities. Primary model outcomes were total and incremental costs and quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) for sacubitril/valsartan relative to enalapril Results: Compared to enalapril, sacubitril/valsartan was associated with an ICER of SGD 74,592 (USD 55,198) per QALY gained. A major driver of cost-effectiveness was the cardiovascular mortality benefit of sacubitril/valsartan. The uncertainty of this treatment benefit in the Asian sub-group was tested in sensitivity analyses using a HR of 1 as an upper limit, where the ICERs ranged from SGD 41,019 (USD 30,354) to SGD 1,447,103 (USD 1,070,856) per QALY gained. Probabilistic sensitivity analyses showed the probability of sacubitril/valsartan being cost-effective was below 1%, 12%, and 71% at SGD 20,000, SGD 50,000, and SGD 100,000 per QALY gained, respectively.

CONCLUSIONS

At the current daily price sacubitril/valsartan may not represent good value for limited healthcare dollars compared to enalapril in reducing cardiovascular morbidity and mortality in HF in the Singapore healthcare setting. This study highlights the cost-benefit trade-off that healthcare professionals and patients face when considering therapy.

Chronic obstructive pulmonary disease and β-blocker treatment in Asian patients with heart failure

Aims

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are increasingly frequent in Asia and commonly coexist in patients. However, the prevalence of COPD among Asian patients with HF and its impact on HF treatment are unclear.

Methods and results

We compared clinical characteristics and treatment approaches between patients with or without a history of COPD, before and after 1:2 propensity matching (for age, sex, geographical region, income level, and ethnic group) in 5232 prospectively recruited patients with HF and reduced ejection fraction (HFrEF, <40%) from 11 Asian regions (Northeast Asia: South Korea, Japan, Taiwan, Hong Kong, and China; South Asia: India; Southeast Asia: Thailand, Malaysia, Philippines, Indonesia, and Singapore). Among the 5232 patients with HFrEF, a history of COPD was present in 8.3% (n = 434), with significant variation in geography (11.0% in Northeast Asia vs. 4.7% in South Asia), regional income level (9.7% in high income vs. 5.8% in low income), and ethnicity (17.0% in Filipinos vs. 5.2% in Indians) (all P < 0.05). Use of mineralocorticoid receptor antagonists and diuretics was similar between groups, while usage of all β‐blockers was lower in the COPD group than in the non‐COPD group in the overall (66.3% vs. 79.9%) and propensity‐matched cohorts (66.3% vs. 81.7%) (all P < 0.05). A striking exception was the Japanese cohort in which β‐blocker use was high in COPD and non‐COPD patients (95.2% vs. 91.2%).

Conclusions

The prevalence of COPD in HFrEF varied across Asia and was related to underuse of β‐blockers, except in Japan.

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.

Multinational and multiethnic variations in health-related quality of life in patients with chronic heart failure

BACKGROUND

Assessing health-related quality of life (HRQoL) in patients with heart failure (HF) is an important goal of clinical care and HF research. We sought to investigate ethnic differences in perceived HRQoL and its association with mortality among patients with HF and left ventricular ejection fraction ≤35%, controlling for demographic characteristics and HF severity.

METHODS AND RESULTS

We compared 5697 chronic HF patients of Indian (26%), white (23%), Chinese (17%), Japanese/Koreans (12%), black (12%), and Malay (10%) ethnicities from the HF-ACTION and ASIAN-HF multinational studies using the Kansas City Cardiomyopathy Questionnaire (KCCQ; range 0-100; higher scores reflect better health status). KCCQ scores were lowest in Malay (58±22) and Chinese (60±23), intermediate in black (64±21) and Indian (65±23), and highest in white (67±20) and Japanese or Korean patients (67±22) after adjusting for age, sex, educational status, HF severity, and risk factors. Self-efficacy, which measures confidence in the ability to manage symptoms, was lower in all Asian ethnicities (especially Japanese/Koreans [60±26], Malay [66±23], and Chinese [64±28]) compared to black (80±21) and white (82±19) patients, even after multivariable adjustment (P<.001). In all ethnicities, KCCQ strongly predicted 1-year mortality (HR 0.45, 95% CI 0.30-0.67 for highest vs lowest quintile of KCCQ; P for interaction by ethnicity .101).

CONCLUSIONS

Overall, HRQoL is inversely and independently related to mortality in chronic HF but is not modified by ethnicity. Nevertheless, ethnic differences exist independent of HF severity and comorbidities. These data may have important implications for future global clinical HF trials that use patient-reported outcomes as endpoints.

Understanding the Epidemiology of Heart Failure to Improve Management Practices: An Asia-Pacific Perspective

Heart failure (HF) is a major global healthcare problem with an estimated prevalence of approximately 26 million. In Asia-Pacific regions, HF is associated with a significant socioeconomic burden and high rates of hospital admission. Epidemiological data that could help to improve management approaches to address this burden in Asia-Pacific regions are limited, but suggest patients with HF in the Asia-Pacific are younger and have more severe signs and symptoms of HF than those of Western countries. However, local guidelines are based largely on the European Society of Cardiology and American College of Cardiology Foundation/American Heart Association guidelines, which draw their evidence from studies where Western patients form the major demographic and patients from the Asia-Pacific region are underrepresented. Furthermore, regional differences in treatment practices likely affect patient outcomes. In the following review, we examine epidemiological data from existing regional registries, which indicate that these patients represent a distinct subpopulation of patients with HF. In addition, we highlight that patients with HF are under-treated in the region despite the existence of local guidelines. Finally, we provide suggestions on how data can be enriched throughout the region, which may positively affect local guidelines and improve management practices.