Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study

Heart failure in low-income and middle-income countries

Heart failure (HF) is a complex syndrome which leads to significant morbidity and mortality, poor quality of life and extremely high costs to healthcare systems worldwide. Although progress in the management of HF in high-income countries is leading to an overall reduction in the incidence and mortality of HF, there is a starkly different scenario in low- and middle-income countries (LMICs). There is a substantial lack of data on HF in LMICs, as well as a scarcity of diagnostic tools, limited availability and affordability of healthcare and high burdens of cardiovascular risk factors and communicable diseases. Patients in this setting present with more advanced HF at much younger ages and are, more often, women. In this review, we aim to comprehensively describe the burden of HF from an LMIC perspective, based on the more recent available data. We summarise the major causes of HF that are endemic in these regions, including hypertension, cardiomyopathy, rheumatic heart disease, HIV-associated heart disease and endomyocardial fibrosis. Finally, we discuss the challenges faced by the least developed health systems and highlight interventions that may prove to be more efficient in changing the paradigm of HF of the more vulnerable populations.

Reducing heart failure events via individualized patient education program in patients with reduced ejection fraction

BACKGROUND

Disease management programs for heart failure (HF) often include various strategies such as medication management and lifestyle modifications, and are known to improve clinical outcomes.

OBJECTIVES

To evaluate the effectiveness of an individualized patient education program (IPEP) specifically designed for patients with reduced ejection fraction (HFrEF) on clinical outcomes.

METHODS

In our prospective interventional study involving 164 patients, participants were divided into control (CG) and intervention (IG) groups. The IG received the IPEP facilitated by the academic pharmacist, while both the IG and the CG continued to receive standard care from the healthcare team without any differences in the care provided. Self-care practices, medication adherence, quality of life, and clinical outcomes were assessed at both the 6th and 12th months. Statistical analysis included Chi-square tests, Kaplan-Meier survival plots, and Multivariable Cox proportional regression analysis. Data analysis was conducted using JAMOVI and R software.

RESULTS

The demographic and clinical characteristics of sample population were largely homogeneous in both the groups. The unadjusted 1-year rehospitalization (RH) rate was significantly lower in the IG at 33 % compared to 48 % in the CG, with a hazard ratio of 0.55 (95 % CI: 0.34-0.90, p = 0.018). Kaplan-Meier survival analysis depicts a higher RH rate for HFrEF participants over time, with a significant difference observed between CG and IG (log-rank P = 0.017). Notable disparities in self-care practices emerged & at the 6th and 12th-month assessments medication adherence & QoL were significantly improved in the IG (p ≤ 0.001).

CONCLUSION

IPEP led by an academic pharmacist resulted in improved self-care practices, enhanced quality of life, and reduced one-year rehospitalization rates.

Hospitalized Advanced Heart Failure With Preserved vs Reduced Left Ventricular Ejection Fraction: A Global Perspective

BACKGROUND

Outcomes of hospitalized patients with heart failure (HF) and characteristics of advanced HF stage may vary across left ventricular ejection fraction (LVEF) and world regions.

OBJECTIVES

This study sought to analyze characteristics of hospitalized advanced HF patients across LVEF spectrum, world regions, and country income.

METHODS

Among 18,553 hospitalized patients with acute HF (7,902 new-onset HF and 10,651 decompensated chronic HF) enrolled in the global registry REPORT-HF (International Registry to Assess Medical Practice With Longitudinal Observation for Treatment of Heart Failure), the authors analyzed characteristics and outcomes of patients with advanced HF, defined as previously diagnosed HF; severe symptoms before current admission (NYHA functional class III/IV); and ≥1 HF-related hospitalization in the preceding 12 months, excluding the current. Differences among hospitalized advanced HF subgroups stratified by LVEF, world region, and country income were examined.

RESULTS

Among 6,999 patients with decompensated chronic HF and available previous NYHA functional class and HF hospitalization status, 3,397 (48.5%; 18.3% of the total population) had advanced HF. Of these, 44.5% had severely reduced (≤30%), 34.9% mildly/moderately reduced (31%-49%), and 20.7% preserved (≥50%) LVEF. Patients from Eastern Europe had the lowest 1-year mortality (23%), whereas those from Southeast Asia had the highest (37%). Patients from lower-middle-income countries were younger, with shorter HF duration and lower comorbidity prevalence, received fewer beta-blockers and HF-devices, and had higher 1-year mortality (34%) than upper-middle-income (26%) or high-income countries (27%; P = 0.018). Adjusted 1-year mortality risk did not differ among LVEF subgroups (all P > 0.05), nor did 1-year HF hospitalization rate (P = 0.56).

CONCLUSIONS

Hospitalized patients with advanced HF and preserved LVEF had similarly adverse outcomes as those with reduced LVEF. Patients from lower-middle-income countries had less implementation of HF therapies and higher 1-year mortality.

Quality of care delivery in patients with acute heart failure: insights from the international REPORT-HF registry

Background

Heart Failure (HF) quality of care (QoC) is associated with clinical outcomes. Therefore, we investigated differences in HF QoC across worldwide regions (with differing national income) and the association of quality indicators with outcomes.

Methods

We examined the quality of care (QoC) in acute heart failure (HF) patients across different regions using quality indicators (QIs) from the European Society of Cardiology (ESC) and the American Heart Association (AHA) to evaluate QoC. The analysis included 17,632 patients enrolled from 358 medical centres in 44 countries between 23 July 2014 and 24 March 2017, all part of the prospective REPORT-HF cohort study. We investigated how QoC varied by region and its relationship with mortality rates at 30 days and 1 year after hospital discharge. For each QI, percentage attainment of QI among eligible patients was calculated and compared across regions.

Findings

Among 17,632 patients (median age: 67 years; 61% women) followed up for a median of two years, we assessed 16 QIs. QIs that were least often achieved included measurement of natriuretic peptides, performance of echocardiography, treatment with guideline medical therapy, and a scheduled follow-up consultation after discharge. QI achievement was significantly lower in lower-than higher-income countries. Higher (≥50% vs. <50%) achievement of cumulative QIs was associated with lower 30-day (hazard ratio [HR] 0.58, 95% Confidence Interval [CI] 0.40-0.83; p < 0.001), and 1-year mortality (HR 0.58, 95% CI 0.50-0.68; p < 0.001).

Interpretation

QoC is lower in lower-than higher-income countries and lower QoC is associated with worse outcomes. Improving QoC by addressing structural barriers and quality improvement programs may improve the outcomes of patients with HF.

Funding

Novartis.

One-year mortality and re-admission rate by disease etiology in National Heart Failure Registry of India

Survival outcomes of patients with heart failure (HF) based on their disease etiology are not well described. Here, we provide one-year mortality outcomes of 10850 patients with HF (mean age = 59.9 years, 31% women) in India. Ischemic heart disease (71.9%), dilated cardiomyopathy (17.3), rheumatic heart disease (5.4), non-rheumatic valvular heart disease (1.9), hypertrophic cardiomyopathy (0.8), congenital heart disease (0.7), peri-partum cardiomyopathy (0.5), restrictive cardiomyopathy (0.4), and infective endocarditis (0.1) were the main disease etiologies. Mortality rate per 100-person years of follow-up varied from 13.8 (95% CI: 6.2-30.7) in peri-partum cardiomyopathy to 92.9 (46.5-185.9) in infective endocarditis. Compared to ischemic heart disease, the mortality was two to five times higher in rheumatic heart disease (HR = 2.0; 95% CI: 1.6-2.4), congenital heart disease (2.9; 1.9-4.2), and infective endocarditis (4.8; 2.4-9.8). The wide variations in mortality rate in HF patients may bring possible clinical applicability of risk stratification.

Race in Heart Failure: A Pooled Participant-Level Analysis of the Global PARADIGM-HF and PARAGON-HF Trials

BACKGROUND

Mechanisms of disease pathobiology, prognosis, and potentially treatment responses might vary by race in patients with heart failure (HF).

OBJECTIVES

The authors aimed to examine the safety and efficacy of sacubitril/valsartan among patients with HF by self-reported race.

METHODS

PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) and PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF With Preserved Ejection Fraction) were global, randomized clinical trials testing sacubitril/valsartan against a renin-angiotensin system inhibitor (RASi) (enalapril or valsartan, respectively) in patients with HF and left ventricular ejection fraction ≤40% (PARADIGM-HF) or left ventricular ejection fraction ≥45% (PARAGON-HF). Patients with self-reported race were categorized as White, Asian, or Black. We assessed the composite of first HF hospitalization or cardiovascular death, its components, and angioedema across races.

RESULTS

Among 12,097 participants, 9,451 (78.1%) were White, 2,116 (17.5%) were Asian, and 530 (4.4%) were Black. Over a median follow-up of 2.5 years, Black (adjusted HR: 1.68; 95% CI: 1.42-1.98) and Asian patients (adjusted HR: 1.32; 95% CI: 1.18-1.47) experienced higher risks of the primary outcome compared with White patients. Treatment effects of sacubitril/valsartan vs RASi on the primary endpoint were consistent among White (HR: 0.84; 95% CI: 0.77-0.91), Asian (HR: 0.92; 95% CI: 0.78-1.10), and Black patients (HR: 0.79; 95% CI: 0.58-1.07; Pinteraction = 0.58). Rates of severe angioedema were higher with sacubitril/valsartan vs RASi (White: 0.2% vs 0.1%; Black: 1.5% vs 0.0%; Asian: 0.1% vs 0.1%).

CONCLUSIONS

In a pooled experience of 2 global trials, Black and Asian patients exhibited a higher risk of cardiovascular events than White patients. The benefits of sacubitril/valsartan were consistent across races. Risks of severe angioedema were low but numerically higher with sacubitril/valsartan. (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF]; NCT01035255; Prospective Comparison of ARNI with ARB Global Outcomes in HF With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).

Global, regional, and national burdens of heart failure in adolescents and young adults aged 10-24 years from 1990 to 2021: an analysis of data from the Global Burden of Disease Study 2021

Background

Prior studies suggest prevalence of heart failure (HF) has remained steady or progressively decreased over past 30 years in the general population. Whether this favourable trend occurred in adolescents and young adults aged 10-24 years has yet to be elucidated. We aim to identify the trends in the burden of HF in this young population from 1990 to 2021 to inform areas for targeted intervention and prevention efforts.

Methods

We analyzed data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021. The case number and rates per 100,000 population of prevalence and years lived with disability (YLDs) of HF at the global, regional, and national level in the population aged 10-24 years from 1990 to 2021 were reported. In addition, the HF trends by age, sex, and socio-demographic index (SDI) were analyzed. Furthermore, we calculated the average annual percentage changes (AAPC) and identified the year with the most pronounced changes in the trends with the joinpoint regression analysis. In detail, we divided the study population into three age groups: 10-14 years old, 15-19 years old, and 20-24 years old. We also employed the Bayesian age-period-cohort models (BAPC) to predict the future burden of HF up to 2030.

Findings

Globally, the prevalence and YLDs rates of HF among adolescents and young adults in 2021 were 148.1 (95% uncertainty interval [UI]: 118.8-185.7) and 14.4 (9.2-21.2) per 100 000 population, increased from 125.5 (100.0-157.7) and 12.2 (7.8-17.8) in 1990 respectively. Noticeable changes in HF prevalence were found in 1994, 2001, 2004, 2010, and 2018. Regionally, East Asia had the most pronounced increase in HF prevalence rate (AAPC = 1.35 [1.28-1.43]) and YLDs rate (AAPC = 1.32 [1.27-1.38]), while the highest HF prevalence rates per 100,000 population were observed in High-income North America (232 [185.4-292]). The prevalence and YLDs of HF increased in most countries except Australia, Canada, and Spain. The largest increase in HF prevalence rate was observed in China (AAPC = 1.39 [1.31-1.48]). By SDI quintile, the middle-SDI quintile countries had the largest increase in prevalence and YLDs rates. By sex, males had a higher prevalence rate per 100,000 population than females (158.0 [95% UI: 126.7-198.9] vs 137.6 [95% UI: 110.0-172.2]) in 2021. Among three age groups, the largest increase in HF prevalence from 1990 to 2021 was found in individuals aged 20-24 years (AAPC = 0.61 [0.6-0.61]). Among all causes of HF, cardiomyopathy and myocarditis accounted for the highest proportion (32.7%) of prevalence cases of HF in 2021, followed by congenital birth defects (27.3%), and rheumatic heart disease (23.8%). The BAPC analysis predicted that the cases of HF prevalence and YLDs would show a rising trend from 2022 to 2030.

Interpretation

The burden of HF in adolescents and young adults aged 10-24 years was still increasing globally, which may be obscured by the burden trend of general population. According to different underlying causes of HF, both high-income countries and low- and middle-income countries need to better prevent HF in adolescents and young adults.

Funding

National Natural Science Foundation of China (grant 81900452) and Training Fund for Open Projects at Clinical Institutes and Departments of Capital Medical University (grant CCMU2022ZKYXY003).

Latent profile analysis of anticipatory grief in family caregivers of patients with chronic heart failure and its influencing factors

BACKGROUND

Anticipatory grief has been shown to be highly prevalent among family caregivers of patients with advanced illness. However, there is less research on the anticipatory grief of family caregivers with chronic heart failure. Therefore, the purpose of this study was to explore the profile of anticipatory grief among family caregivers of patients with chronic heart failure and to analyze the influencing factors of different profiles.

METHODS

A convenience sampling method was adopted to select 205 family caregivers of chronic heart failure patients hospitalized in a tertiary general hospital in Nanchong, China as the research subjects. A general information questionnaire, Anticipatory Grief Scale (AGS), and Fear of Progression Questionnaire-Short Form (FoP-Q-SF) were used for the survey. Latent profile analysis was conducted on the anticipatory grief of family caregivers of chronic heart failure patients, and univariate analysis and multinomial logistic regression analysis were used to explore the influencing factors of anticipatory grief in each subgroup.

RESULTS

The anticipatory grief of family caregivers of chronic heart failure patients has been divided into three latent classes: low anticipatory grief class (16.4%), moderate anticipatory grief class (58.7%), and high anticipatory grief and loss class (24.8%). Gender, education, relationship with the patient, course of disease, and fear of progression were the influencing factors of the latent profile of anticipatory grief among family caregivers of chronic heart failure patients (all P < 0.05).

CONCLUSION

There were differences in the level of anticipatory grief among different subgroups of family caregivers of chronic heart failure patients. Medical staff can develop personalized intervention measures on the basis of the influencing factors of different categories to alleviate anticipatory grief of family caregivers and promote physical and mental health of caregivers in chronic heart failure patients.

Impact of SGLT2 inhibitors on cardiovascular outcomes and metabolic events in Chinese han patients with chronic heart failure

OBJECTIVE

This study aimed to evaluate the real-world impact of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on the efficacy, safety, and metabolic profiles of patients with chronic heart failure (CHF), both with and without type 2 diabetes mellitus (T2DM).

METHODS

A cohort of 1,130 patients with reduced ejection fraction chronic heart failure (HFrEF) was recruited from Zhongnan Hospital of Wuhan University, spanning January 2021 to August 2023. Among these, 154 patients received SGLT2i therapy, while 131 patients were assigned to a non-SGLT2i group, following specified inclusion and exclusion criteria. The association between SGLT2i therapy and the risk of primary and secondary endpoints was analyzed, alongside the effect of guideline-recommended heart failure medications at varying dosages on Major Adverse Cardiovascular Events (MACE).

RESULTS

SGLT2i treatment led to reductions in blood pressure, uric acid, NT-proBNP, and pulmonary artery pressure, while increasing body mass index (BMI) and left ventricular ejection fraction (LVEF) in CHF patients. Multivariate Cox regression analysis revealed that SGLT2i therapy reduced the primary endpoint risk by 40.3% (HR 0.597, 95% CI 0.356-0.973, p = 0.047). Univariate Cox regression indicated that SGLT2i might also reduce the incidence of new diagnoses of atrial fibrillation, non-fatal acute myocardial infarction, and MACE in CHF patients. Moreover, the use of a four-drug combination for heart failure management was associated with a lower risk of MACE compared to monotherapy.

CONCLUSION

SGLT2i therapy not only enhances LVEF but also significantly reduces ambulatory blood pressure, uric acid, fasting blood glucose, pulmonary artery pressure, and NT-proBNP levels in CHF patients. Additionally, SGLT2i improves prognosis by lowering the risk of both primary and secondary endpoints. Compared to monotherapy, a four-drug regimen for CHF substantially reduces the risk of MACE, supporting the effectiveness of comprehensive treatment strategies.

A non-invasive nomogram for predicting heart failure with preserved ejection fraction in taiwanese outpatients with unexplained dyspnea and fatigue

BACKGROUND

While Reddy proposed the H2FPEF diagnostic algorithm to aid in diagnosing heart failure with preserved ejection fraction (HFpEF), certain parameters like age and obesity are not suitable for Asian population, especially given the increasing incidence of HFpEF in younger individuals. Therefore, this study aimed to develop an easy-to-use nomogram with non-invasive indices that can be used in outpatient clinics in Taiwan to quickly estimate the probability of HFpEF and help decide whether further invasive cardiopulmonary exercise test (CPET) is needed.

METHODS

Outpatients with unexplained dyspnea and fatigue were recruited divided into HFpEF (n = 64) and non-HFpEF (n = 34) groups based on invasive CPET and echocardiography. Multivariate logistic regression analyses identified independent noninvasive variables for developing an HFpEF nomogram. The nomogram's performance was assessed and validated using the concordance index (C-index), area under the curve (AUC), calibration curves, and decision curve analysis.

RESULTS

Multivariate logistic regression analyses identified five independent noninvasive variables for developing an HFpEF nomogram, including dyslipidemia (OR = 5.264, p = 0.010), diabetes (OR = 3.929, p = 0.050), left atrial area (OR = 1.130, p = 0.046), hemoglobin <13 g/dL (OR = 5.372, p = 0.010), and NT-proBNP ≥245 pg/mL (OR = 5.108, p = 0.027). The nomogram showed good discriminatory ability (C-index = 0.842) and calibration performance (p = 0.873) and high net benefit (0.1-0.95). Notably, the HFpEF nomogram showed better diagnostic accuracy than the H2FPEF score model in predicting Taiwanese HFpEF patients (AUC: 0.873 vs. 0.608, p = 0.0006).

CONCLUSION

The noninvasive HFpEF nomogram provides a preliminary estimation of the probability of HFpEF in Taiwanese outpatients with unexplained dyspnea and fatigue, which may help the decision-making on further invasive CPET.

Sub-Saharan Africa's Contribution to Clinical Trials in International Acute Coronary Syndromes and Heart Failure Guidelines

Background

There is a growing burden of acute coronary syndrome (ACS) and heart failure (HF) in sub-Saharan Africa (SSA), yet outcomes remain poor compared to high-income countries. The European Society of Cardiology (ESC) international guidelines are pivotal to the delivery of evidence-based care; however, their representation of populations from SSA remains unclear.

Objectives

The purpose of the study was to evaluate the representation of populations from SSA in randomized controlled trials (RCTs) that inform ESC ACS and HF guidelines.

Methods

We systematically analyzed pharmacotherapeutic RCTs contributing to the 2021 ESC HF and 2023 ACS guidelines, extracting data from ClinicalTrials.gov. We assessed the proportion of RCTs that included contributions from countries in each World Bank income group, focusing on the involvement of SSA countries and examining temporal trends.

Results

Among the RCTs underpinning the ESC HF guidelines (n = 119) and ACS guidelines (n = 343), 75.9% were conducted exclusively in high-income countries. Middle-income countries were included in 22.2% of the trials, but none featured low-income countries. Within SSA, only South Africa was represented, contributing to 14.2% of HF and 8.2% of ACS RCTs. The number of HF RCTs involving populations from SSA has risen, from 2.6% in the 1990s to 50% post-2020 (P for trend< 0.05). For ACS RCTs, the proportion of trials involving populations in SSA increased from 1.8% pre-1990 to 23.4% during 2000 to 2009 (P for trend = 0.003), then declined to 11.3% in the following decade.

Conclusions

There is a marked underrepresentation of SSA countries in ACS and HF pharmacotherapy RCTs. South Africa is the sole contributor from the region, which may affect applicability and generalizability of global guidelines to populations in SSA.

Prevalence and risk factors of mortality among heart failure patients in low resource setting hospitals: a multicenter prospective observational study

Background

Heart failure is a significant worldwide health problem that leads to mortality. Therefore, this study aimed to evaluate treatment outcomes and associated factors of heart failure patients who were admitted to hospitals in the southwest of Ethiopia.

Methods and participants

A multicenter prospective observational study was conducted from 1 February to 1 August 2021. Drug therapy problems were assessed as per the Cipolle, Strands, and Morley drug therapy problems classification method. The drug therapy was registered by using the drug-related problem registration format. The results of logistic regression analysis was interpreted as crude odds ratio and adjusted odds ratio (AOR) at 95% confidence interval (CI) to determine the association between dependent and independent variables.

Results

In our study settings, a total of 205 (85.1%) heart failure patients showed improvement and 36 (14.9%) died at hospital discharge. Being ≥65 years (AOR = 7.14, 95% CI: 2.04-.25.01, P = 0.002), a previous hospitalization (AOR = 6.20, 95% CI: 1.81-21.21, P = 0.004), and the presence of medication-related problems (AOR = 3.65, 95% CI: 1.13-11.73, P = 0.03) were the predictors of mortality.

Conclusion

The prevalence of in-hospital mortality among heart failure patients was found to be high. Previous hospitalization, older age, and the presence of drug therapy problems were the predictors of mortality among heart failure patients. Therefore, proper attention should be given to the management of elderly and re-admitted heart failure patients in addition to their regular care. In addition, hospitals should implement clinical pharmacy services to address any drug-related problems.

Impact of pharmacist-led pharmaceutical care on health-related and pharmaceutical therapy-related quality of life in patients with heart failure: A randomized controlled trial

BACKGROUND

Data on the impact of pharmacist-led pharmaceutical care (PC) on pharmaceutical therapy-related and health-related quality of life (HRQoL) and their sensitivities to PC provision in patients with heart failure (HF) are scarce.

OBJECTIVES

This study aimed to assess the impact of pharmacist-led PC on HRQoL employing the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and 5-level EuroQol 5 dimension (EQ-5D-5L) and on pharmaceutical therapy-related quality of life using the Patient-Reported Outcomes Measure of Pharmaceutical Therapy (PROMPT) in HF patients and compare sensitivities to the PC provision of these three tools.

METHODS

A single-blinded randomized controlled trial was conducted at a tertiary public hospital in Thailand between November 2022 and May 2023. Overall, 250 patients were randomly divided into the usual care (UC) (N = 124) and PC (N = 126) groups. Mixed effects models were used to investigate the differences in the mean change scores of PROMPT, EQ-5D-5L, and MLHFQ between the UC and PC groups. The sensitivities to PC provision of the three measures were evaluated using standardized effect sizes (SESs).

RESULTS

Significant differences were found in five of eight domains and the total score of the PROMPT between the PC and UC groups (all p < 0.05). However, no significant differences were found in the EQ-5D-5L and MLHFQ between the two groups (both p > 0.05). The SESs of the five domains and total score of PROMPT ranged from 0.29 to 1.65, considered small-to-large effect sizes, whereas the SESs of EQ-5D-5L and MLHFQ were -0.4 to 0, considered small effect sizes.

CONCLUSIONS

Pharmacist-led PC can positively affect pharmaceutical therapy-related quality of life using PROMPT in HF patients. Additionally, PROMPT is more sensitive to PC provision than EQ-5D-5L and MLHFQ.

Healthcare performance for patients with heart failure in Iran: addressing the tip of the iceberg

BACKGROUND

Chronic diseases, such as heart failure with reduced ejection fraction (HFrEF), remain significant factors in the healthcare burden in Iran. Healthcare systems must have comprehensive data on the current usage, costs, and quality of care to tackle these challenges and formulate strategic plans effectively.

METHODS

The study included 209 patients with a mean age of 58 years (SD = 16.5) who met the inclusion criteria of having an ejection fraction of less than 40% and a confirmed diagnosis of HFrEF. This study used nationally representative data to assess the healthcare usage, costs, and quality of HFrEF management in Iran.

RESULTS

The most used services were medication dispensing (76%) and outpatient visits (53%), while rehabilitation (3%) and homecare (2%) were used less frequently. The annual per-patient direct medical cost was $1,464, with $308 (21%) paid out-of-pocket (OOP). Hospitalization accounted for most of the total cost (68%), and pharmacy expenses comprised the largest portion of OOP payments (46%). Echocardiography was performed for 91.1% of patients upon admission. Only 71.6% of patients had arrangements for a cardiology visit within seven days following hospital discharge. Additionally, only 67.5% of patients received prescriptions for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and 85% were prescribed beta-blockers.

CONCLUSION

Patients with heart failure in Iran face challenges in accessing adequate cardiac care, including a lack of care continuity and advanced cardiac services. The study provided an essential benchmark for future healthcare reform.

Rivaroxaban in Valvular Atrial Fibrillation - a Critical Appraisal of the INVICTUS Trial

PURPOSE

The efficacy of factor Xa inhibitors in patients with atrial fibrillation (AF) and rheumatic heart disease (RHD) is unknown.

METHODS/RESULTS

The objective of this article was to conduct a comprehensive evaluation of the INVICTUS trial, an open-label randomized controlled study that compared vitamin K antagonists (VKA) to rivaroxaban in patients with AF and RHD while also considering the existing evidence from literature in this particular area of research.

CONCLUSION

The findings of the INVICTUS trial indicated that rivaroxaban was found to be inferior in efficacy to VKA. However, it is important to note that the primary outcome of the trial was driven by sudden death and death caused by mechanical pump failure. As a result, it is necessary to approach the data from this study with caution, and it would be inappropriate to draw parallel conclusions for other causes of valvular AF. Particularly, the perplexing issue of how rivaroxaban could have contributed to both pump failure and sudden cardiac death requires further explanation. Additional data regarding changes in heart failure medication and ventricular function would be essential for proper interpretation.

Global epidemiology of heart failure

Heart failure (HF) is a heterogeneous clinical syndrome marked by substantial morbidity and mortality. The natural history of HF is well established; however, epidemiological data are continually evolving owing to demographic shifts, advances in treatment and variations in access to health care. Although the incidence of HF has stabilized or declined in high-income countries over the past decade, its prevalence continues to increase, driven by an ageing population, an increase in risk factors, the effectiveness of novel therapies and improved survival. This rise in prevalence is increasingly noted among younger adults and is accompanied by a shift towards HF with preserved ejection fraction. However, disparities exist in our epidemiological understanding of HF burden and progression in low-income and middle-income countries owing to the lack of comprehensive data in these regions. Therefore, the current epidemiological landscape of HF highlights the need for periodic surveillance and resource allocation tailored to geographically vulnerable areas. In this Review, we highlight global trends in the burden of HF, focusing on the variations across the spectrum of left ventricular ejection fraction. We also discuss evolving population-based estimates of HF incidence and prevalence, the risk factors for and aetiologies of this disease, and outcomes in different geographical regions and populations.

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.

Use of Guideline-Recommended Heart Failure Drugs in High-, Middle-, and Low-Income Countries: A Systematic Review and Meta-Analysis

Optimal use of guideline-directed medical therapy (GDMT) can prevent hospitalization and mortality among patients with heart failure (HF). We aimed to assess the prevalence of GDMT use for HF across geographic regions and country-income levels. We systematically reviewed observational studies (published between January 2010 and October 2020) involving patients with HF with reduced ejection fraction. We conducted random-effects meta-analyses to obtain summary estimates. We included 334 studies comprising 1,507,849 patients (31% female). The majority (82%) of studies were from high-income countries, with Europe (45%) and the Americas (33%) being the most represented regions, and Africa (1%) being the least. Overall prevalence of GDMT use was 80% (95% CI 78%-81%) for β-blockers, 82% (80%-83%) for renin-angiotensin-system inhibitors, and 41% (39%-43%) for mineralocorticoid receptor antagonists. We observed an exponential increase in GDMT use over time after adjusting for country-income levels (p < 0.0001), but significant gaps persist in low- and middle-income countries. Multi-level interventions are needed to address health-system, provider, and patient-level barriers to GDMT use.

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.

Heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all heart failure cases and has a prevalence that is expected to rise with the growing ageing population. HFpEF is associated with significant morbidity and mortality. Specific HFpEF risk factors include age, diabetes, hypertension, obesity and atrial fibrillation. Haemodynamic contributions to HFpEF include changes in left ventricular structure, diastolic and systolic dysfunction, left atrial myopathy, pulmonary hypertension, right ventricular dysfunction, chronotropic incompetence, and vascular dysfunction. Inflammation, fibrosis, impaired nitric oxide signalling, sarcomere dysfunction, and mitochondrial and metabolic defects contribute to the cellular and molecular changes observed in HFpEF. HFpEF impacts multiple organ systems beyond the heart, including the skeletal muscle, peripheral vasculature, lungs, kidneys and brain. The diagnosis of HFpEF can be made in individuals with signs and symptoms of heart failure with abnormality in natriuretic peptide levels or evidence of cardiopulmonary congestion, facilitated by the use of HFpEF risk scores and additional imaging and testing with the exclusion of HFpEF mimics. Management includes initiation of guideline-directed medical therapy and management of comorbidities. Given the significant impact of HFpEF on quality of life, future research efforts should include a particular focus on how patients can live better with this disease.

Clinical profile, treatment patterns and one-year outcome of heart failure patients admitted in tertiary care hospital of North India

Introduction

Because of wide heterogeneity in the epidemiology of heart failure among different populations, it is imperative to establish population-specific databases.

Aims and Objectives

To describe the clinical profile, treatment patterns, and outcomes of heart failure patients admitted to our tertiary care hospital.

Material and Methods

The study was a prospective observational study conducted over two years at our tertiary care hospital. It included patients admitted with acute and acute-on-chronic heart failure.

Results

We recruited 264 patients. Mean age of the study population was 57.8 ± 15.14 years. Males were 157 (59.5%). Dilated cardiomyopathy was the most common cause followed by ischemic heart disease. Most common risk factors were hypertension, tobacco use, anemia, and diabetes. Heart failure with reduced ejection fraction was present in 154 (62%) patients. Acute de novo heart failure was present in 91 (34.5%) patients. The most common precipitant for heart failure exacerbation was infection, followed by ischemic causes and non-adherence to drugs. The mean duration of hospital stay was 7.5 ± 3.1 days. The in-hospital mortality was 8.7%, and cumulative six-month and one-year mortality was 23% and 28%, respectively. In multivariate analysis, renal failure, readmission, and not being on guideline-directed medical treatment were significant predictors of mortality.

Conclusion

Our patients were younger, predominantly males, with dilated and ischemic cardiomyopathy as commonest etiology. Hypertension and tobacco smoking were most common risk factors, with infections as most common precipitants. Only one-third of patients were on guideline-directed medical therapy. The one-year mortality was 28% and was higher in those without guideline-directed medical therapy.

Multi-year population-based analysis of Asian patients with acute decompensated heart failure and advanced chronic kidney disease

BACKGROUND

Data on disparities in outcomes and risk factors in Asian patients with advanced chronic kidney disease admitted for heart failure are scare.

METHODS

This was a retrospective cohort study that utilized data from the National Inpatient Sample between January 2016 and December 2019. Patients who had a primary diagnosis of acute decompensated heart failure and a concomitant diagnosis of advanced CKD were included. The primary outcome of interest was in-hospital mortality. Secondary outcomes include hospital cost, length of stay, and other clinical outcomes. Weighted multivariable logistic regression was used to adjust for comorbidities.

RESULTS

There were 251,578 cases of ADHF with advanced CKD, out of which 2.6 % were from individuals of Asian ethnicity. Asian patients exhibited a higher burden of comorbidities in comparison to other UREM patients, but a lower burden than White patients. Regardless of differences in comorbidity burden, Asian patients exhibited a higher likelihood of experiencing severe consequences. After adjusting for comorbidies, White (OR:1.11; 95 % CI 1.03-1.20;0.009) patients had higher odds of mortality than Asian patients. However, Blacks (OR: 0.58; 95 % CI 0.53 to 0.63; p < 0.001) and Hispanics (OR: 0.69; 95 % CI 0.62 to 0.78; p < 0.001) had lower odds of mortality.

CONCLUSION

This first population-based studies shows that Asian patients with advanced CKD admitted for ADHF have greater comorbidity burden and poorer outcomes Black and Hispanic patients. This data underscores the importance of comprehensive approaches in phenotyping, and ethnic specific interventions.

Real-World Clinical Burden of Newly Diagnosed Heart failure in Thai Patients

INTRODUCTION

There are limited data on the burden of newly diagnosed patients with heart failure (HF) in Thailand. Thus, this study aimed to fully understand the hospitalization, rehospitalization, mortality rates, demographics and characteristics, and quality of care in these patients.

METHOD

A retrospective review of all eligible adult patients' medical records from 2018 and 2019 was conducted at five hospitals. The patients were newly diagnosed with HF, as indicated by the International Classification of Diseases (ICD)-10 code "I50." Descriptive statistics was used to investigate patients' hospital burden and clinical outcome data.

RESULTS

There were 1134 patients newly diagnosed with HF, classified as HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and HF with mildly reduced ejection fraction (HFmrEF) (44.0, 40.0, and 16.0%, respectively). The male-to-female ratios in HFmrEF and HFpEF were similar. In contrast, the proportion of men with HFrEF was greater. The mean age of all patients was 66.0 years. The hospitalization rate was 1.3. Rehospitalization rates for HF-related issues were 0.1, 0.2, 0.4, and 0.5 at 30 days, 60 days, 180 days, and 1 year, respectively. The percentage of deaths from all causes among these patients was 9.8%, while the percentage of deaths from cardiovascular-related causes was 8.5%. Only a small proportion of patients received a target dose of guideline-directed medical therapy (GDMT).

CONCLUSIONS

The study revealed that the characteristics, hospitalization rate for HF, and in-hospital mortality rate among newly diagnosed patients with HF were higher compared to similar studies conducted in Thailand and other countries. Moreover, a high quality of care is needed to improve the morbidity and mortality associated with HF in Thailand.

Delivering effective, comprehensive, multi-exercise component cardiac rehabilitation (CR) for chronic heart failure patients in low resource settings in sub-Saharan Africa: Queen Elizabeth Central Hospital-(QECH-CR) randomised CR study, Malawi

BACKGROUND

The delivery of Cardiac Rehabilitation (CR) and attaining evidence-based treatment goals are challenging in developing countries, such as Malawi. The aims of this study were to (i) assess the effects of exercise training/ CR programme on cardiorespiratory and functional capacity of patients with chronic heart failure (CHF), and (ii) examine the effectiveness of a novel, hybrid CR delivery using integrated supervised hospital- and home-based caregiver approaches.

METHODS

A pre-registered (UMIN000045380), randomised controlled trial of CR exercise therapy in patients with CHF was conducted between September 2021 and May 2022. Sixty CHF participants were randomly assigned into a parallel design-exercise therapy (ET) (n = 30) or standard of care (n = 30) groups. Resting hemodynamics, oxygen saturation, distance walked in six-minutes (6MWD) and estimated peak oxygen consumption (VO2 peak) constituted the outcome measures. The exercise group received supervised, group, circuit-based ET once weekly within the hospital setting and prescribed home-based exercise twice weekly for 12 weeks. Participants in both arms received a group-based, health behaviour change targeted education (usual care) at baseline, 8-, 12- and 16-weeks.

RESULTS

Most of the participants were female (57%) with a mean age of 51.9 ±15.7 years. Sixty-five percent (65%) were in New York Heart Association class III, mostly with preserved left ventricular ejection fraction (HFpEF) (mean Left Ventricular Ejection Fraction 52.9 ±10.6%). The 12-weeks ET led to significant reductions in resting haemodynamic measures (all P <0.05). The ET showed significantly higher improvements in the 6MWD (103.6 versus 13.9 m, p<0.001) and VO2 peak (3.0 versus 0.4 ml·kg-1·min-1, p <0.001). Significant improvements in 6MWD and VO2 peak (both p<0.001), in favour of ET, were also observed across all follow-up timepoints.

CONCLUSION

This novel, randomised, hybrid ET-based CR, delivered to mainly HFpEF patients using an integrated hospital- and home-based approach effectively improved exercise tolerance, cardiorespiratory fitness capacities and reduced perceived exertion in a resource-limited setting.

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.

Economic Evaluations of Digital Health Interventions for Patients With Heart Failure: Systematic Review

BACKGROUND

Digital health interventions (DHIs) have shown promising results in enhancing the management of heart failure (HF). Although health care interventions are increasingly being delivered digitally, with growing evidence on the potential cost-effectiveness of adopting them, there has been little effort to collate and synthesize the findings.

OBJECTIVE

This study's objective was to systematically review the economic evaluations that assess the adoption of DHIs in the management and treatment of HF.

METHODS

A systematic review was conducted using 3 electronic databases: PubMed, EBSCOhost, and Scopus. Articles reporting full economic evaluations of DHIs for patients with HF published up to July 2023 were eligible for inclusion. Study characteristics, design (both trial based and model based), input parameters, and main results were extracted from full-text articles. Data synthesis was conducted based on the technologies used for delivering DHIs in the management of patients with HF, and the findings were analyzed narratively. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for this systematic review. The reporting quality of the included studies was evaluated using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines.

RESULTS

Overall, 27 economic evaluations were included in the review. The economic evaluations were based on models (13/27, 48%), trials (13/27, 48%), or a combination approach (1/27, 4%). The devices evaluated included noninvasive remote monitoring devices (eg, home telemonitoring using digital tablets or specific medical devices that enable transmission of physiological data), telephone support, mobile apps and wearables, remote monitoring follow-up in patients with implantable medical devices, and videoconferencing systems. Most of the studies (24/27, 89%) used cost-utility analysis. The majority of the studies (25/27, 93%) were conducted in high-income countries, particularly European countries (16/27, 59%) such as the United Kingdom and the Netherlands. Mobile apps and wearables, remote monitoring follow-up in patients with implantable medical devices, and videoconferencing systems yielded cost-effective results or even emerged as dominant strategies. However, conflicting results were observed, particularly in noninvasive remote monitoring devices and telephone support. In 15% (4/27) of the studies, these DHIs were found to be less costly and more effective than the comparators (ie, dominant), while 33% (9/27) reported them to be more costly but more effective with incremental cost-effectiveness ratios below the respective willingness-to-pay thresholds (ie, cost-effective). Furthermore, in 11% (3/27) of the studies, noninvasive remote monitoring devices and telephone support were either above the willingness-to-pay thresholds or more costly than, yet as effective as, the comparators (ie, not cost-effective). In terms of reporting quality, the studies were classified as good (20/27, 74%), moderate (6/27, 22%), or excellent (1/27, 4%).

CONCLUSIONS

Despite the conflicting results, the main findings indicated that, overall, DHIs were more cost-effective than non-DHI alternatives.

TRIAL REGISTRATION

PROSPERO CRD42023388241; https://tinyurl.com/2p9axpmc.

Machine learning approach for predicting cardiovascular disease in Bangladesh: evidence from a cross-sectional study in 2023

BACKGROUND

Cardiovascular disorders (CVDs) are the leading cause of death worldwide. Lower- and middle-income countries (LMICs), such as Bangladesh, are also affected by several types of CVDs, such as heart failure and stroke. The leading cause of death in Bangladesh has recently switched from severe infections and parasitic illnesses to CVDs.

MATERIALS AND METHODS

The study dataset comprised a random sample of 391 CVD patients' medical records collected between August 2022 and April 2023 using simple random sampling. Moreover, 260 data points were collected from individuals with no CVD problems for comparison purposes. Crosstabs and chi-square tests were used to determine the association between CVD and the explanatory variables. Logistic regression, Naïve Bayes classifier, Decision Tree, AdaBoost classifier, Random Forest, Bagging Tree, and Ensemble learning classifiers were used to predict CVD. The performance evaluations encompassed accuracy, sensitivity, specificity, and area under the receiver operator characteristic (AU-ROC) curve.

RESULTS

Random Forest had the highest precision among the five techniques considered. The precision rates for the mentioned classifiers are as follows: Logistic Regression (93.67%), Naïve Bayes (94.87%), Decision Tree (96.1%), AdaBoost (94.94%), Random Forest (96.15%), and Bagging Tree (94.87%). The Random Forest classifier maintains the highest balance between correct and incorrect predictions. With 98.04% accuracy, the Random Forest classifier achieved the best precision (96.15%), robust recall (100%), and high F1 score (97.7%). In contrast, the Logistic Regression model achieved the lowest accuracy of 95.42%. Remarkably, the Random Forest classifier achieved the highest AUC value (0.989).

CONCLUSION

This research mainly focused on identifying factors that are critical in impacting patients with CVD and predicting CVD risk. It is strongly advised that the Random Forest technique be implemented in a system for predicting cardiac diseases. This research may change clinical practice by providing doctors with a new instrument to determine a patient's CVD prognosis.

Mortality in patients admitted to hospital with heart failure in China: a nationwide Cardiovascular Association Database-Heart Failure Centre Registry cohort study

BACKGROUND

China has the largest burden of heart failure worldwide. However, large-scale studies on heart failure mortality are scarce. We aimed to investigate mortality and identify risk factors for mortality among patients with heart failure in China.

METHODS

This prospective cohort study used data from the China Cardiovascular Association (CCA) Database-Heart Failure Centre Registry, which were linked to the National Mortality Registration Information Management System by the Chinese Centre for Disease Control and Prevention. We included patients enrolled from Jan 1, 2017, to Dec 31, 2021, across 572 CCA Database-Heart Failure Centre certified hospitals in 31 provinces of mainland China. Eligible patients were aged 18 years or older (younger than 100 years) with a principal discharge diagnosis of heart failure based on Chinese heart failure guidelines. All-cause mortality at 30 days, 1 year, and 3 years for patients with heart failure were calculated and the causes of death were recorded. Multivariable analysis was used to analyse factors associated with all-cause mortality and cardiovascular mortality. This study was registered with the Chinese Clinical Trial Registry, ChiCTR2200066305.

FINDINGS

Of the 327 477 patients in the registry, 230 637 eligible adults with heart failure were included in our analyses. Participant mean age was 69·3 years (SD 13·2), 94 693 (41·1%) participants were female, and 135 944 (58·9%) were male. The median follow-up time was 531 days (IQR 251-883). Post-discharge all-cause mortality of patients with heart failure at 30 days was 2·4% (95% CI 2·3-2·5), at 1 year was 13·7% (13·5-13·9), and at 3 years was 28·2% (27·7-28·6). Cardiovascular death accounted for 32 906 (71·5%) of 46 006 all-cause deaths. Patients with heart failure with reduced ejection fraction had the highest all-cause mortality. A lower guideline adherence score was independently associated with the increase of all-cause and cardiovascular mortality.

INTERPRETATION

In China, mortality for patients with heart failure is still high, especially in patients with reduced ejection fraction. Our findings suggest that guideline-directed medical therapy needs to be improved.

FUNDING

National High Level Hospital Clinical Research Funding, the Capital's Funds for Health Improvement and Research, and the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

ACE Gene I/D Polymorphism and Cardiometabolic Risk Factors: A Cross Sectional Study of Rural Population

The D allele has been identified as being linked to cardiovascular disease since the discovery of an insertion/deletion (I/D) polymorphism in the ACE gene, this polymorphism has been found to have significant associations with a variety of cardiovascular risk factors. Recent findings indicate a rising prevalence of metabolic disorders among rural populations in developing nations. Research on health matters has been predominantly focused on urban populations, with relatively less attention given to their rural counterparts Hence, the present study attempts to estimate the prevalence of ACE gene I/D polymorphism and explore its association with various cardiovascular risk factors among Rural Yadav population from India. In the present study, 207 (Male 47, Female 160) members of the Yadav community participated in the cross-sectional study. All the socio-demographic factors, somatometric (anthropometric) variables, and the intravenous blood was collected and Physiological (blood pressure), and biochemical (fasting glucose and lipid profile) parameters were measured as recommended by the American Heart Association, allele-specific PCR of the ACE gene I/D polymorphism was carried out, the PCR products were genotyped on 2% agarose gel Electrophoresis and ACE gene polymorphism was analysed for its association with various cardiovascular risk factors. Among the analysed individuals, 34 (16.4%) were found to have the II genotype, 58 (28.0%) had the ID genotype, and 115 (55.6%) had the DD genotype. The allele frequency of the I allele was found to be 0.31, and the frequency of the D allele was 0.69. The frequency of the DD genotype was found to be significantly higher among individuals with high TC, high TG, and low non-HDL levels (p value < 0.05). When considered collectively, the findings of this study are consistent with the hypothesis that the DD genotype of ACE polymorphism represents a correlation with cardiovascular disease risk factors in this population.

Epidemiology and Burden of Heart Failure in Asia

Heart failure (HF) represents a complex clinical syndrome affecting multiple organs and systems of the body, which is a global public health concern because of its high prevalence, mortality, and medical cost. Asia, with its vast population, diverse ethnicities, and complex health care systems, faces challenges in the prevention and management of HF. However, unlike in Western nations, data on HF epidemiology is still limited in Asia. In this review, we will summarize available information regarding the burden of HF in Asia from the aspects of occurrence, etiology and risk factors, outcome, and management of HF, to provide insights for reducing the burden of HF and improving the prognosis of patients with HF.

Determinants of depressive symptoms in patients with heart failure based on the hopelessness theory of depression

AIMS

Depressive symptoms are common in patients with heart failure (HF) and are associated with adverse outcomes in this group. This study examined depressive symptoms and associated determinants in patients with HF based on the hopelessness theory of depression.

METHODS AND RESULTS

In this cross-sectional study, a total of 282 patients with HF were recruited from 3 cardiovascular units of a university hospital. Symptom burden, optimism, maladaptive cognitive emotion regulation strategies (MCERSs), hopelessness, and depressive symptoms were assessed using self-reported questionnaires. A path analysis model was established to evaluate the direct and indirect effects. The prevalence of depressive symptoms was 13.8% in the patients. Symptom burden had the greatest direct effect on depressive symptoms (β = 0.406; P < 0.001), optimism affected depressive symptoms both directly and indirectly with hopelessness as the mediator (direct: β = -0.360; P = 0.001; indirect: β = -0.169; P < 0.001), and MCERSs only had an indirect effect on depressive symptoms with hopelessness as the mediator (β = 0.035; P < 0.001).

CONCLUSION

In patients with HF, symptom burden, decreased optimism, and hopelessness contribute to depressive symptoms directly. What is more, decreased optimism and MCERS lead to depressive symptoms indirectly via hopelessness. Accordingly, interventions aimed at decreasing symptom burden, enhancing optimism, and reducing the use of MCERSs, while declining hopelessness, may be conducive to relieving depressive symptoms in patients with HF.

Effects of the family customised online FOCUS programme on patients with heart failure and their informal caregivers: a multicentre, single-blind, randomised clinical trial

Background

Living with heart failure can severely affect the physical and mental health of patients with heart failure and their caregivers. Available dyadic self-care interventions for heart failure are scarce, especially in China. We aimed to develop and test the family FOCUS programme.

Methods

This single-blind, randomised, controlled study was conducted at four hospitals in Tianjin, China. Patients with heart failure (aged at least 18 years) and their caregiver (dyads) were randomly assigned to either the intervention (n = 71) or control (n = 71) group in a 1:1 ratio. The primary outcomes of this study were patient self-care, with three specific dimensions (self-care maintenance, symptom perception, and self-care management), and caregiver contribution to self-care, mirroring these three dimensions. The outcomes were assessed at baseline (T0) and 4 (T1), 12 (T2), and 24 (T3) weeks post-discharge, respectively. This work is registered on ChiCTR, ChiCTR2100053168.

Findings

Between May 20, 2022, and September 30, 2022, 142 dyads with heart failure were enrolled. The intervention group exhibited dropout rates of 6%, 8.5%, and 18.3% at 4, 12, and 24 weeks after discharge, while the control group showed 9.9%, 12.3%, and 25.4%. Compared with the control group, patients in the intervention group reported improved self-care maintenance (β: 8.5, 95% CI: 0.7, 16.4) and management (β: 7.2, 95% CI: 0.1, 14.3) at T1, as well as improved symptom perception at both T1 (β: 9.7, 95% CI: 1.5, 17.9) and T2 (β: 9.6, 95% CI: 0.6, 18.6). Furthermore, caregiver contributions to self-care maintenance, self-care management, and symptom perception (excluding T3) exhibited significant improvements at all timepoints.

Interpretation

Although the significant improvements in patients' self-care were not long-lasting, this study suggested that the family FOCUS programme consistently enhanced caregivers' contributions to self-care. Future work could explore the effect of the family FOCUS programme on families with multiple chronic conditions.

Funding

The National Natural Science Foundation of China.

The 'Surprise question' in heart failure: a prospective cohort study

OBJECTIVE

The Surprise Question (SQ) is a prognostic screening tool used to identify patients with limited life expectancy. We assessed the SQ's performance predicting 1-year mortality among patients in ambulatory heart failure (HF) clinics. We determined that the SQ's performance changes according to sex and other demographic (age) and clinical characteristics, mainly left ventricular ejection fraction (LVEF) and the New York Heart Association (NYHA) functional classifications.

METHODS

We conducted a prospective cohort study in two HF clinics. To assess the performance of the SQ in predicting 1-year mortality, we calculated the sensitivity, specificity, positive and negative likelihood ratios, and the positive and negative predictive values. To illustrate if the results of the SQ changes the probability that a patient dies within 1 year, we created Fagan's nomograms. We report the results from the overall sample and for subgroups according to sex, age, LVEF and NYHA functional class.

RESULTS

We observed that the SQ showed a sensitivity of 85% identifying ambulatory patients with HF who are in the last year of life. We determined that the SQ's performance predicting 1-year mortality was similar among women and men. The SQ performed better for patients aged under 70 years, for patients with reduced or mildly reduced ejection fraction, and for patients NYHA class III/IV.

CONCLUSIONS

We consider the tool an easy and fast first step to identify patients with HF who might benefit from an advance care planning discussion or a referral to palliative care due to limited life expectancy.

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.

Exploring the Epidemiology of Atrial Fibrillation in Nigeria: A Focus on Atrial Fibrillation in Heart Failure Patients and Its Association With Stroke

Atrial fibrillation (AF) represents a significant global public health concern, particularly due to its association with adverse health outcomes such as stroke and heart failure. In Nigeria, where the burden of cardiovascular diseases is rising, understanding the prevalence and impact of AF is crucial for effective healthcare planning and intervention strategies. This review examines the epidemiology of AF in Nigeria, comparing it with global and African data. It explores demographic and regional variations, comorbidity factors, and the impact of AF on the healthcare system, mortality, and quality of life. Notably, the prevalence of AF in Nigeria generally falls just under 5%, but this figure rises to approximately 9% in stroke patients and 11-20% among those with heart failure (HF). Rheumatic heart disease (RHD) is identified as a significant AF risk factor within Africa, affecting around 20% of AF patients - a stark contrast to the 2% in North America. AF's association with higher mortality rates and functional deterioration highlights the urgent need for improved diagnostic and therapeutic approaches, alongside broader public health measures. In conclusion, the review emphasises the significant public health concern AF represents in Nigeria, especially among HF and stroke patients, and stresses the importance of tailored healthcare policies and interventions to mitigate AF's impact and improve patient outcomes.

Geographic variation in aortic stenosis treatment and outcomes among Medicare beneficiaries in the United States

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has changed the landscape of aortic stenosis (AS) management.

AIM

To describe and evaluate geographic variation in AS treatment and outcomes among a sample of Medicare beneficiaries.

METHODS

A retrospective analysis of administrative claims data was conducted on a 20% sample of Medicare fee-for-service beneficiaries aged 65 and older with a diagnosis of AS (2015-2018). Estimates of demographic, comorbidity, and healthcare resources were obtained from Medicare claims and the Dartmouth Atlas of Health Care at the hospital referral region (HRR), which represents regional tertiary medical care markets. Linear regression was used to explain HRR-level variation in rates of surgical aortic valve replacement (SAVR) and TAVR, and 1-year mortality and readmission rates.

RESULTS

A total of 740,899 beneficiaries with AS were identified with a median prevalence of AS of 39.9 per 1000 Medicare beneficiary years. The average HRR-level rate of SAVR was 26.3 procedures per 1000 beneficiary years and the rate of TAVR was 20.3 procedures per 1000 beneficiary years. HRR-level comorbidities and number of TAVR centers were associated with a lower SAVR rate. Demographics and comorbidities explained most of the variation in HRR-level 1-year mortality (15.2% and 18.8%) and hospitalization rates (20.5% and 16.9%), but over half of the variation remained unexplained.

CONCLUSION

Wide regional variation in the treatment and outcomes of AS was observed but were largely unexplained by patient factors and healthcare utilization. Understanding the determinants of AS treatment and outcomes can inform population health efforts for these patients.

The Characteristics and Outcomes of Nonhospitalized Patients With Heart Failure in Saudi Arabia: A Contemporary Single-Center Study

Background Contemporary data on patients with heart failure (HF) in Saudi Arabia is limited. Methods This was a retrospective study of patients who were followed in the HF Clinic at our center after January 1, 2022. The study end date was August 31, 2023. Patients who were alive and followed for <6 months were excluded. We reported the clinical characteristics, utilization of established therapies for HF, proportion of potential candidates for ancillary HF treatments, and rates of HF events and mortality. Results A total of 202 patients met the study criteria. The mean age was 56.0 ± 15.2 years. The median follow-up from the initial visit to the study end date was 47 months (interquartile range {IQR}: 29-58 months). Coronary artery disease (CAD) was the cause of HF in 85 (42%) patients. At their latest visit, 103 (51%) patients had diabetes, 82 (41%) were obese, and 134 (66%) received quadruple therapy. Iron deficiency was present in 143 (71%) patients during follow-up. At their latest visit, moderate-to-severe or severe functional mitral regurgitation (MR) and hyperkalemia were present in 15 (7%) and 20 (10%) patients, respectively. The combined annual rate of HF hospitalization and emergency visits for HF was 20%. At least one hospitalization for HF within a year before the study end date occurred in 19 (9%) patients. The annual all-cause mortality was 1.8%. Conclusion This contemporary cohort of outpatients with HF was relatively young and had a high prevalence of diabetes, obesity, and iron deficiency. An estimate of potential candidates for iron replacement, transcatheter repair of the mitral valve, novel potassium binders, and the implantation of the pulmonary artery pressure monitor was among the first reported regionally. All-cause mortality was low, yet the burden of HF-related events was significant.

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.

What Do We Know About Heart Failure in Latin American Women?

Data about heart failure in Latin America is scarce. Women living in this region of the world are exposed to a mix of traditional risk factors for heart failure, neglected diseases, and social determinants of health. The aim of this review is to present what we know about heart failure in Latin American women and to establish the needs for future research.

Key Cell Types and Biomarkers in Heart Failure Identified through Analysis of Single-Cell and Bulk RNA Sequencing Data

Heart failure (HF) is a complex clinical syndrome resulting from various cardiac diseases and a significant medical issue worldwide. Although the role of inflammation in HF pathogenesis is well-known, the specific cell types and regulatory molecules involved remain poorly understood. Here, we identified key cell types and novel biomarkers via an analysis of single-cell and bulk RNA sequencing data obtained from patients with two major HF types of ischemic cardiomyopathy and dilated cardiomyopathy. Myeloid cells were identified as the primary cell population involved in HF through cellular fraction and gene set enrichment analysis. Additionally, differential analysis of myeloid cells revealed crosstalk between cellular communication and cytokine-regulated immune responses in HF, with the MIF pathway emerging as a crucial immune regulatory pathway. The CD74/CXCR4 receptor complex in myeloid cell subgroup Mφ2 was significantly upregulated, potentially acting as a crucial regulator in HF. Upon receiving the MIF signal molecule, the CD74/CXCR4 receptor can activate NF-κB signaling to produce chemokines and thereby enhance the inflammatory response. CD74 and CXCR4 may serve as biomarkers and treatment targets for HF.

Higher-risk SIPAT score predicts increased risk of long-term mortality in orthotopic heart transplant recipients

BACKGROUND

Orthotopic heart transplantation (OHT) improves survival in eligible patients. Organ scarcity necessitates extensive clinical and psychosocial evaluations before listing. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) predicts risk for poor psychosocial outcomes and morbidity in the first year post-transplant, yet it is unknown whether it predicts long-term outcomes.

METHODS

Blinded examiners obtained data from a retrospective cohort of 51 OHT recipients from a high-volume center. Patients with "Excellent" or "Good" SIPAT score indicating low psychosocial risk for transplant (E/G) were compared with those who met "Minimum Acceptable Criteria" or were "High Risk" (MAC/HR). Associations were examined between SIPAT group and outcomes.

RESULTS

MAC/HR versus E/G recipients had significantly reduced survival in the 10 years post-OHT (mean 6.7 vs 8.8 years, p = 0.027; 55% vs 82% survival proportions, p = 0.037). MAC/HR patients were more likely to live in a county with greater income inequality (p = 0.025) and have psychiatric history pre-OHT (p = 0.046). Both groups had otherwise similar demographics and medical history. A lower proportion of MAC/HR patients adhered to medications post-OHT and a greater proportion had psychiatric illness, though differences were not significant.

CONCLUSIONS

Higher-risk SIPAT scores predict reduced long-term survival post-OHT. Further efforts are crucial to improve outcomes in higher-risk patients.

Self-care behaviour and associated factors among heart failure patients in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

This study aimed to estimate the pooled level of self-care behaviour among heart failure patients in Ethiopia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed/MEDLINE, HINARI, Web of Sciences, Scopus, Google Scholar, Science Direct, African journals online and University repositories were searched from 1 January 2000 to 1 November 2023.

ELIGIBILITY CRITERIA

We include studies that examined self-care behaviour among heart failure patients, studies that report factors associated with self-care behaviour and observational studies (cross-sectional, case-control and cohort) with full text available.

DATA EXTRACTION AND SYNTHESIS

The data were extracted with Microsoft Excel and analysed by using STATA V.11 software. The weighted inverse variance random-effects model at 95% CI was used to estimate the pooled level of self-care behaviour and its associated factors among heart failure patients. Tests of heterogeneity, test of publication bias and subgroup analyses were also employed.

RESULTS

Thirteen cross-sectional studies with 4321 study participants were included; and the pooled level of good self-care behaviour among heart failure patients in Ethiopia was found to be 38.3% (95% CI 31.46 to 45.13). Only 68.8% of heart failure patients were knowledgeable about heart failure. Knowledge about heart failure (Adjusted Odds Ratio (AOR)=3.39; 95% CI 2.42 to 4.74) and absence of comorbidity (AOR=2.69; 95% CI 1.35 to 5.37) were significantly associated with good self-care behaviour among heart failure patients in Ethiopia.

CONCLUSION

The majority of heart failure patients in Ethiopia did not adhere to the recommended self-care behaviours. Nearly one-third of heart failure patients were not knowledgeable about heart failure. Knowledge about heart failure and the absence of comorbidities were significantly associated with good self-care behaviour. Therefore, efforts should be devoted to increasing knowledge and preventing comorbidities among heart failure patients.

PROSPERO REGISTRATION NUMBER

CRD42023394373.

National Trends in Mortality and Urgent Dialysis after Acute Hypertension in Japan From 2010 Through 2019

BACKGROUND

Despite increasing incidences of hypertension, recent trends in mortality and urgent dialysis following acute hypertension (AHT) remain undetermined.

METHODS

This retrospective observational cohort study evaluated 50 316 hospitalized AHT patients from 2010 to 2019, using an administrative claims database in Japan. We examined trends in incidence, urgent dialysis, mortality, and its risk factors using Poisson regression models. Using International Classification of Disease and Related Health Problems, 10th Revision codes, AHT was categorized into 5 spectrums: malignant hypertension (n=1792), hypertensive emergency (n=17 907), hypertensive urgency (n=1562), hypertensive encephalopathy (n=6593), and hypertensive heart failure (HHF; n=22 462).

RESULTS

The median age of the patients was 76 years, and 54.9% were women. The total AHT incidence was 70 cases per 100 000 admission year. The absolute death rate increased from 1.83% (95% CI, 1.40-2.40) to 2.88% ([95% CI, 2.42-3.41]; Cochran-Armitage trend test, P<0.0001). Upward trends were observed in patients aged ≥80, with lean body mass index ≤18.4, and with HHF. Urgent dialysis rates increased from 1.52% (95% CI, 1.12-2.06) to 2.60% (2.17-3.1; Cochran-Armitage trend test; P=0.0071) in 48 235 patients, excluding maintenance dialysis patients. Older age, men, lean body mass, malignant hypertension, HHF, and underlying chronic kidney disease correlated with higher mortality risk; greater hospital volume correlated with lower mortality risk; and malignant hypertension, HHF, diabetes, chronic kidney disease, and scleroderma correlated with a higher risk of urgent dialysis.

CONCLUSIONS

Mortality and urgent dialysis rates following AHT have increased. Aging, complex comorbidities, and HHF-type AHT contributed to the rising trend of mortality.

Health-related quality of life and its influencing factors among people with heart failure in Ethiopia: using the revised Wilson and Cleary model

Heart failure is a challenging public health problem associated with poor health-related quality of life (HRQoL). Data on the quality of life of people with heart failure are limited in Ethiopia. This study aimed to assess the HRQoL and its influencing factors in people with heart failure in Ethiopia. A hospital-based, cross-sectional study design was conducted in the cardiac outpatient clinics of two tertiary-level hospitals in Addis Ababa, Ethiopia. Data were collected from people with heart failure who met the inclusion criteria using an interviewer-administered questionnaire. The HRQoL was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). A multiple linear regression model was fitted to identify factors that influenced HRQoL. All statistical analyses were conducted using STATA version 17 software. A total of 383 people with heart failure participated in the study. The mean age of the participants was 55 years. The MLHFQ score was 48.03±19.73, and 54% of participants had poor HRQoL. Multiple linear regression analysis revealed that age (β= 0.12, 95% CI 0.11, 0.28), diabetes mellitus comorbidity (β= 4.47, 95% CI 1.41, 7.54), social support score (β= - 1.48, 95% CI - 1.93, - 1.03), and depression score (β = 1.74, 95% CI 1.52, 1.96) were significant factors influencing overall HRQoL (p < 0.05). This study found that people in Ethiopia with heart failure had poor HRQoL, influenced by several factors. The findings can help health professionals identify appropriate interventions to improve the HRQoL of people with heart failure.

Epidemiology, Clinical Characteristics and Cause-specific Outcomes in Heart Failure with Preserved Ejection Fraction

Heart failure (HF) is a global pandemic affecting 64 million people worldwide. HF with preserved ejection fraction (HFpEF) has traditionally received less attention than its main counterpart, HF with reduced ejection fraction (HFrEF). The incidence and prevalence of HFpEF show geographic variation and are increasing over time, soon expected to surpass those of HFrEF. Morbidity and mortality rates of HFpEF are considerable, albeit lower than those of HFrEF. This review focuses on the burden of HFpEF, providing contemporary data on epidemiology, clinical characteristics and comorbidities, cause-specific outcomes, costs and pharmacotherapy.

Recent successes in heart failure treatment

Remarkable recent advances have revolutionized the field of heart failure. Survival has improved among individuals with heart failure and a reduced ejection fraction and for the first time, new therapies have been shown to improve outcomes across the entire ejection fraction spectrum of heart failure. Great strides have been taken in the treatment of specific cardiomyopathies such as cardiac amyloidosis and hypertrophic cardiomyopathy, whereby conditions once considered incurable can now be effectively managed with novel genetic and molecular approaches. Yet there remain substantial residual unmet needs in heart failure. The translation of successful clinical trials to improved patient outcomes is limited by large gaps in implementation of care, widespread lack of disease awareness and poor understanding of the socioeconomic determinants of outcomes and how to address disparities. Ongoing clinical trials, advances in phenotype segmentation for precision medicine and the rise in technology solutions all offer hope for the future.