Clinical characteristics and management of hospitalized and ambulatory patients with heart failure-results from ESC heart failure long-term registry-Egyptian cohort

Comparative Analysis of Heart Failure with Preserved Vs Reduced Ejection Fraction: Patient Characteristics, Outcomes, Mortality Prediction, and Machine Learning Model Development in the JoHFR

Background

Heart failure (HF) is a global health challenge affecting millions, with significant variations in patient characteristics and outcomes based on ejection fraction. This study aimed to differentiate between HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) with respect to patient characteristics, risk factors, comorbidities, and clinical outcomes, incorporating advanced machine learning models for mortality prediction.

Methodology

The study included 1861 HF patients from 21 centers in Jordan, categorized into HFrEF (EF <40%) and HFpEF (EF ≥ 50%) groups. Data were collected from 2021 to 2023, and machine learning models were employed for mortality prediction.

Results

Among the participants, 29.7% had HFpEF and 70.3% HFrEF. Significant differences were noted in demographics and comorbidities, with a higher prevalence of males, younger age, smoking, and familial history of premature ASCVD in the HFrEF group. HFpEF patients were typically older, with higher rates of diabetes, hypertension, and obesity. Machine learning analysis, mainly using the Random Forest Classifier, demonstrated significant predictive capability for mortality with an accuracy of 0.9002 and an AUC of 0.7556. Other models, including Logistic Regression, SVM, and XGBoost, also showed promising results. Length of hospital stay, need for mechanical ventilation, and number of hospital admissions were the top predictors of mortality in our study.

Conclusion

The study underscores the heterogeneity in patient profiles between HFrEF and HFpEF. Integrating machine learning models offers valuable insights into mortality risk prediction in HF patients, highlighting the potential of advanced analytics in improving patient care and outcomes.

Anemia in Heart Failure: A Perspective from 20-Year Bibliometric Analysis

Background & Objective

Anemia in patients with heart failure (HF) is a growing concern. However, there has no bibliometric analysis in this area up to now. The aim of this study is to explore the status and trends in the field of anemia in HF through the bibliometric analysis, and to provide an outlook on future research.

Methods

We retrieved publications from the Web of Science Core Collection database, and the following data analysis and visualization tools were utilized to perform data processing, statistical computing and graphics generation: VOSviewer (v.1.6.18), CiteSpace (v.6.2 R5), Scimago Graphica (v.1.0.36), Biblimatrix and Microsoft Excel.

Results

We identified a total of 3490 publications from 2004 to 2023. The publications in the field of anemia in HF are growing steadily. The United States, the United Kingdom, and Italy were the leading countries in this area. Stefan D Anker, as the most influential author, held the most total citations and publications. Harvard University was the most productive institution in this area. The European Journal of Heart Failure had published the most papers. Through the analysis of co-citations, 14 major clusters based on cluster labels were identified. Keyword analysis showed that mortality, outcome, prevalence, and risk were the most frequent keywords, and the potential research hotspots in the future will be intravenous iron and iron deficiency.

Conclusion

This study provides a comprehensive analysis of countries, authors, institutions, journals, co-cited references, and keywords in the field of anemia in HF through bibliometric analysis and data visualization. The status, hotspots and future trends in this field offer a reference for in-depth research. Further studies are necessary in the future to broaden the spectrum of research in this field, to evaluate comprehensive approaches to treating anemia in patients with HF, and to find rational targets for the management of anemia.

Non-Pharmacological Treatment of Heart Failure-From Physical Activity to Electrical Therapies: A Literature Review

Heart failure (HF) represents a significant global health challenge that is still responsible for increasing morbidity and mortality despite advancements in pharmacological treatments. This review investigates the effectiveness of non-pharmacological interventions in the management of HF, examining lifestyle measures, physical activity, and the role of some electrical therapies such as catheter ablation, cardiac resynchronization therapy (CRT), and cardiac contractility modulation (CCM). Structured exercise training is a cornerstone in this field, demonstrating terrific improvements in functional status, quality of life, and mortality risk reduction, particularly in patients with HF with reduced ejection fraction (HFrEF). Catheter ablation for atrial fibrillation, premature ventricular beats, and ventricular tachycardia aids in improving left ventricular function by reducing arrhythmic burden. CRT remains a key intervention for selected HF patients, helping achieve left ventricular reverse remodeling and improving symptoms. Additionally, the emerging therapy of CCM provides a novel opportunity for patients who do not meet CRT criteria or are non-responders. Integrating non-pharmacological interventions such as digital health alongside specific medications is key for optimizing outcomes in HF management. It is imperative to tailor approaches to individual patients in this diverse patient population to maximize benefits. Further research is warranted to improve treatment strategies and enhance patient outcomes in HF management.

Expert Recommendations to Bridge Gaps in Heart Failure Patient Support in the Middle East and Africa Region

Heart failure (HF) remains a serious health and socioeconomic problem in the Middle East and Africa (MEA). The age-standardized prevalence rate for HF in the MEA region is higher compared to countries in Eastern Europe, Latin America, and Southeast Asia. Also cardiovascular-related deaths remain high compared to their global counterparts. Moreover, in MEA, 66% of HF readmissions are elicited by potentially preventable factors, including delay in seeking medical attention, nonadherence to HF medication, suboptimal discharge planning, inadequate follow-up, and poor social support. Patient support in the form of activation, counseling, and caregiver education has been shown to improve outcomes in patients with HF. A multidisciplinary meeting with experts from different countries across the MEA region was convened to identify the current gaps and unmet needs for patient support for HF in the region. The panel provided insights into the real-world challenges in HF patient support and contributed strategic recommendations for optimizing HF care.

Regional expert opinion: Management of heart failure with preserved ejection fraction in the Middle East, North Africa and Turkey

Although epidemiological data on heart failure (HF) with preserved ejection fraction (HFpEF) are scarce in the Middle East, North Africa and Turkey (MENAT) region, Lancet Global Burden of Disease estimated the prevalence of HF in the MENAT region in 2019 to be 0.78%, versus 0.71% globally. There is also a high incidence of HFpEF risk factors and co-morbidities in the region, including coronary artery disease, diabetes, obesity, hypertension, anaemia and chronic kidney disease. For instance, 14.5-16.2% of adults in the region reportedly have diabetes, versus 7.0% in Europe. Together with increasing life expectancy, this may contribute towards a higher burden of HFpEF in the region than currently reported. This paper aims to describe the epidemiology and burden of HFpEF in the MENAT region, including unique risk factors and co-morbidities. It highlights challenges with diagnosing HFpEF, such as the prioritization of HF with reduced ejection fraction (HFrEF), the specific profile of HFpEF patients in the region and barriers to effective management associated with the healthcare system. Guidance is given on the diagnosis, prevention and management of HFpEF, including the emerging role of sodium-glucose co-transporter-2 inhibitors. Given the high burden of HFpEF coupled with the fact that its prevalence is likely to be underestimated, healthcare professionals need to be alert to its signs and symptoms and to manage patients accordingly. Historically, HFpEF treatments have focused on managing co-morbidities and symptoms, but new agents are now available with proven effects on outcomes in patients with HFpEF.

Different Continuous Training Intensities Improve Echocardiographic Parameters, Quality of Life, and Functional Capacity in Heart Failure Patients with Reduced Ejection Fraction

Background

Multiple comorbidities and physiological changes play a role in a range of heart failure conditions and influence the most effective approach to exercise-based rehabilitation. This research aimed to examine and compare the outcomes of continuous training at three different intensities, focusing on left ventricular (LV) remodeling, functional capacity, and quality of life among patients with heart failure with reduced ejection fraction (HFrEF).

Methods

In this randomized control trial, a total of 60 male patients (average age: 54.33 ±2.35 years) with HFrEF were randomly allocated into three groups: 1) High-intensity continuous training group (HICT), 2) Moderate-intensity continuous training group (MICT), and 3) Low-intensity continuous training group (LICT). All the training was performed on a bicycle ergometer 3 times/week for 12 weeks. Echocardiographic parameters (left ventricular ejection fraction, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, N-terminal pro-B-type natriuretic peptide (NT-proBNP), quality of life (Minnesota Living with Heart Failure Questionnaire), and functional capacity (6-minute walking test) were assessed before and the end of the study.

Results

The HICT group demonstrated the greatest improvements in all measured variables when compared to the other two groups (P < 0.05). These findings were consistent across all measured outcomes.

Conclusion

It was determined that HICT appears to yield the most favorable outcomes in enhancing echocardiographic measures, NT-proBNP levels, quality of life, and functional capacity among HFrEF patients.

The predictive value of precipitating factors on clinical outcomes in hospitalized patients with decompensated heart failure: insights from the Egyptian cohort in the European Society of Cardiology Heart Failure long-term registry

BACKGROUND

Knowledge of the frequency of precipitating factors for acute heart failure (AHF) is important (either new-onset heart failure [NOHF] or worsening heart failure [WHF]), as this can guide strategies for prevention and treatment. Most data come only from Western Europe and North America; nevertheless, geographic differences do exist. We set out to study the prevalence of precipitating factors of AHF and their connection to patient characteristics and in-hospital and long-term mortality in patients from Egypt hospitalized for decompensated HF. Using the ESC-HF-LT Registry which is a prospective, multicenter, observational study of patients confessed to cardiology centers in the nations of Europe and the Mediterranean, patients presenting with AHF were recruited from 20 centers all over Egypt. Enrolling physicians were requested to report possible precipitants from among several predefined reasons.

RESULTS

We included 1515 patients (mean age 60 ± 12 years, 69% males). The mean LVEF was 38 ± 11%. Seventy-seven percent of the total population had HFrEF, 9.8% had HFmrEF, and 13.3% had HFpEF. The commonly reported precipitating factors for AHF hospitalization among study population were as follows (in decreasing order of frequency): infection in 30.3% of patients, acute coronary syndrome/myocardial ischemia (ACS/MI) in 26%, anemia in 24.3%, uncontrolled hypertension in 24.2%, atrial fibrillation (AF) in 18.3%, renal dysfunction in 14.6%, and non-compliance in 6.5% of patients. HFpEF patients had significantly higher rates of AF, uncontrolled hypertension, and anemia as precipitants for acute decompensation. ACS/MI were significantly more frequent in patients with HFmrEF. WHF patients had significantly higher rates of infection and non-compliance, whereas new-onset HF patients showed significantly higher rates of ACS/MI and uncontrolled hypertension. One-year follow-up revealed that patients with HFrEF had a significantly higher rate of mortality compared to patients with HFmrEF and HFpEF (28.3%, 19.5, and 19.4%, P = 0.004). Patients with WHF had a significantly higher rates of 1-year mortality when compared to those with NOHF (30.0% vs. 20.3%, P < 0.001). Renal dysfunction, anemia, and infection were independently connected to worse long-term survival.

CONCLUSIONS

Precipitating factors of AHF are frequent and substantially influence outcomes after hospitalization. They should be considered goals for avoiding AHF hospitalization and depicting those at highest risk for short-term mortality.

Acute Right Ventricular Failure: Pathophysiology, Diagnostic Approach with Emphasis on the Role of Echocardiography

Right ventricular function is one of the important predictors of survival in heart failure patients. In the past, there has been only limited knowledge regarding right-sided heart failure when compared to left-sided failure. However, there are more emerging data in recent years, and several studies have emphasized the unique features of the right ventricle regarding its anatomy, pathophysiology, clinical consequences, diagnostic modalities, and treatment options. Despite that, management of acute right ventricular failure is still challenging. This article summarizes an overview of acute right heart failure including pathophysiology, causes, clinical features, and diagnostic work-up with emphasis on the role of echocardiography.

Contemporary Data on the Status and Medical Management of Acute Heart Failure

PURPOSE OF REVIEW

Acute heart failure (AHF) is among the leading causes for unplanned hospital admission. Despite advancements in the management of chronic heart failure, the prognosis of AHF remains poor with high in-hospital mortality and increased rates of unfavorable post-discharge outcomes. With this review, we aim to summarize current data on AHF epidemiology, focus on the different patient profiles and classifications, and discuss management, including novel therapeutic options in this area.

RECENT FINDINGS

There is significant heterogeneity among patients admitted for AHF in their baseline characteristics, heart failure (HF) aetiology and precipitating factors leading to decompensation. A novel classification scheme based on four distinct clinical scenarios has been included in the most recent ESC guidelines, in an effort to better risk stratify patients and guide treatment. Intravenous diuretics, vasodilators, and inotropes remain the cornerstone of management in the acute phase, and expansion of use of mechanical circulatory support has been noted in recent years. Meanwhile, many treatments that have proved their value in chronic heart failure demonstrate promising results in the setting of AHF and research in this field is currently ongoing. Acute heart failure remains a major health challenge with high in-hospital mortality and unfavorable post-discharge outcomes. Admission for acute HF represents a window of opportunity for patients to initiate appropriate treatment as soon as possible after stabilization. Future studies are needed to elucidate which patients will benefit the most by available therapies and define the optimal timing for treatment implementation.

A transitive perspective on the relief of psychosomatic symptoms

A key element of successful psychotherapy for the treatment of psychosomatic disorders is that patients recognize and change the meaning of their experiences. Such changes are brought about by appropriate verbal referencing of symptoms currently experienced within a given narrative. The present theoretical paper argues that changes are not based on better, more adaptive narratives per se, but on the transition (or linkage) process itself that is experienced between different narratives. This view is theoretically justified in various ways: first, it is accounted for through contemporary spatiotemporal neuroscience, which aims to connect mental and structural aspects via a common dynamic property or, according to Northoff, the "common currency" of a brain's orientation along its embeddedness in its contextual world, i.e., body and environment. Second, it is justified through the physics concept of "spontaneous symmetry breaking," which is used analogously to "suffering from symptoms." If the sufferer is willing to experience a process of "going back," that is, moving away from the previous narrative (or aspect) by verbally relating to the felt aspects of the symptom in question (i.e., approaching its meaning), they are moving toward symmetry or an underlying dynamic alignment with their world context. Clinical predictions are derived from the theoretical arguments.

Development and validation of a clinical predictive model for 1-year prognosis in coronary heart disease patients combine with acute heart failure

Background

The risk factors for acute heart failure (AHF) vary, reducing the accuracy and convenience of AHF prediction. The most common causes of AHF are coronary heart disease (CHD). A short-term clinical predictive model is needed to predict the outcome of AHF, which can help guide early therapeutic intervention. This study aimed to develop a clinical predictive model for 1-year prognosis in CHD patients combined with AHF.

Materials and methods

A retrospective analysis was performed on data of 692 patients CHD combined with AHF admitted between January 2020 and December 2020 at a single center. After systemic treatment, patients were discharged and followed up for 1-year for major adverse cardiovascular events (MACE). The clinical characteristics of all patients were collected. Patients were randomly divided into the training (n = 484) and validation cohort (n = 208). Step-wise regression using the Akaike information criterion was performed to select predictors associated with 1-year MACE prognosis. A clinical predictive model was constructed based on the selected predictors. The predictive performance and discriminative ability of the predictive model were determined using the area under the curve, calibration curve, and clinical usefulness.

Results

On step-wise regression analysis of the training cohort, predictors for MACE of CHD patients combined with AHF were diabetes, NYHA ≥ 3, HF history, Hcy, Lp-PLA2, and NT-proBNP, which were incorporated into the predictive model. The AUC of the predictive model was 0.847 [95% confidence interval (CI): 0.811–0.882] in the training cohort and 0.839 (95% CI: 0.780–0.893) in the validation cohort. The calibration curve indicated good agreement between prediction by nomogram and actual observation. Decision curve analysis showed that the nomogram was clinically useful.

Conclusion

The proposed clinical prediction model we have established is effective, which can accurately predict the occurrence of early MACE in CHD patients combined with AHF.

Factors influencing prescribing by critical care physicians to heart failure patients in Egypt: a cross-sectional survey

Background

Heart failure (HF) guideline-led prescribing improves patient outcomes; however, little is known about the factors influencing guideline-led prescribing in critical care settings. This study used a cross-sectional survey to assess the factors that influence physicians when prescribing to heart failure patients in a critical care setting in Egypt.

Results

The response rate was 54.8%. The international HF guidelines were the primary source of prescribing information for 84.2% of respondents. Staff were more familiar with the latest guideline recommendations than associate staff (86.7% vs 36.8%, p = 0.012) and considered patient’s perspectives more often (86.7% vs 26.3%, p = 0.036). Renal function was the clinical factor that most frequently influenced the prescribing of loop diuretics or renin–angiotensin–aldosterone system inhibitors. Pulmonary function influenced beta-blockers prescription. The most frequently cited barrier to guideline-led prescribing was the absence of locally drafted guidelines. A majority of prescribers agreed that implementation of clinical pharmacy services, physician education and electronic reminders may improve the implementation of guideline-led prescribing.

Conclusions

Although experienced physicians are familiar with and use international guidelines, physicians would welcome local guidance on HF prescribing and greater clinical pharmacist input.

Egyptian expert opinion for the use of sodium-glucose cotransporter-2 inhibitors in patients with heart failure with reduced ejection fraction

Sodium-glucose cotransporter-2 inhibitor (SGLT2i) in patients with type 2 diabetes reduces the risk of serious heart failure events, specifically the risk of hospitalization for heart failure, and cardiovascular death. The benefit is most apparent in patients with a heart failure with reduced ejection fraction (HFrEF). Dapagliflozin and empagliflozin reduced the risk of cardiovascular death and hospitalizations for heart failure in patients with established HFrEF, including those without diabetes. Considering the magnitude of the problem and the expected benefit on the target population, an Egyptian consensus document was conducted to demonstrate the importance of and the critical knowledge needed for effective and safe implementation of SGLT2i in the daily practice for the management of patients with HFrEF.

Prevalence of obesity and its association with cardiometabolic risk factors, heart failure phenotype and mortality among patients hospitalized for heart failure in Egypt

BACKGROUND

Obesity is an established risk factor for cardiometabolic disease and heart failure (HF). Nevertheless, the relationship between obesity and HF mortality remains controversial.

RESULTS

The goal of this study was to describe the prevalence of obesity in patients hospitalized for HF in Egypt and investigate the relationship of obesity to cardiometabolic risk factors, HF phenotype and mortality. Between 2011 and 2014, 1661 patients hospitalized for HF across Egypt were enrolled as part of the European Society of Cardiology HF Long-term Registry. Obese patients, defined by a BMI ≥ 30 kg/m2, were compared to non-obese patients. Factors associated with mortality on univariate analysis were entered into a logistic regression model to identify whether obesity was an independent predictor of mortality during hospitalization and at one-year follow-up. The prevalence of obesity was 46.5% and was higher in females compared to males. Obese as compared to non-obese patients had a higher prevalence of diabetes mellitus (47.0% vs 40.2%, p = 0.031), hypertension (51.3% vs 33.0%, p < 0.001) and history of myocardial infarction (69.2% vs 62.8% p = 0.005). Obese patients as compared to non-obese patient were more likely to have acute coronary syndrome on admission (24.8% vs 14.2%, p <  < 0.001). The dominant HF phenotype in obese and non-obese patients was HF with reduced ejection fraction (EF); however, obese patients as compared to non-obese patient had higher prevalence of HF with preserved EF (22.3% vs 12.4%, p < 0.001). Multivariable analysis demonstrated that obesity was associated with an independent survival benefit during hospitalization, (OR for mortality 0.52 [95% CI 0.29-0.92]). Every point increase in BMI was associated with an OR = 0.93 [95% CI 0.89-0.98] for mortality during hospitalization. The survival benefit was not maintained at one-year follow-up.

CONCLUSIONS

Obesity was highly prevalent among the study cohort and was associated with higher prevalence of cardiometabolic risk factors as compared to non-obese patients. Obesity was associated with an independent "protective effect" from in-hospital mortality but was not a predictor of mortality at 1-year follow-up.

Management, survival, and predictors of mortality among hospitalized heart failure patients at Debre Markos comprehensive specialized hospital, Northwest Ethiopia: Prospective cohort study

Introduction:

Heart failure is a major public health problem worldwide. Since heart failure with reduced ejection fraction and preserved ejection fraction are different clinical entities, in-hospital mortality may occur at different rates. This study aimed to assess the management, survival, and predictors of mortality among hospitalized heart failure patients at Debre Markos comprehensive specialized medical ward.

Methods:

A prospective cohort study was conducted on 228 heart failure patients at Debre Markos Comprehensive Specialized Hospital medical wards. A structured data collection tool was used to collect data. Data were analyzed using SPSS version 21.0. The Kaplan–Meier survival curve was used to investigate if there was a difference in the in-hospital survival between heart failure with a reduced ejection fraction and heart failure with a preserved ejection fraction. Those variables having p-value < 0.05 were considered statistically significant.

Results:

From the 228 participants, 126 (55.3%) were females with a mean age of 53.32 ± 15.68 years. One hundred thirty-three (58.3%) patients were presented with preserved (⩾50%) level of ejection fraction. The all-cause in-hospital death rate was 12.7%, and the risk of in-hospital mortality was higher in heart failure patients with reduced ejection fraction (7.4% vs 5.3%; p = 0.005). Current occupation (p = 0.041), elevated serum creatinine (p = 0.010), reduced ejection fraction (p = 0.017), and asthma/chronic obstructive pulmonary disease comorbidity (p = 0.002) were the independent predictors of high hospital mortality.

Conclusion:

The rate of in-hospital mortality among heart failure patients was high. Healthcare providers should provide effective education activities and define disease management strategies for patients with reduced ejection fractions.

Higher Serum Phosphorus Is Not an Independent Risk Factor of Mortality in Heart Failure with Reduced Ejection Fraction

Higher serum phosphorus has detrimental health effects. Even high-normal rage sP is associated with worse outcomes. The relationship of serum phosphorus with prognostic markers in heart failure remains unclear. We investigated the association of serum phosphorus with heart failure prognostic factors and risk of mortality related to serum phosphorus. In 1029 stable heart failure patients, we investigated the distribution of markers of more advanced heart failure stage across quintiles of serum phosphorus and estimated the relative risk of mortality in comparison to reference. Higher serum phosphorus levels sP were associated with markers of a worse outcome. The best survival was observed in low-normal serum levels. The unadjusted hazard ratio for mortality increased toward higher phosphorus quintiles but not to lower levels of sP. The correction for age, sex, BMI, percent weight loss, inflammation, kidney function, and LVEF did not modify the risk profile substantially. The adjustment for NYHA, natriuretic peptides, serum sodium, and treatment characteristics broke down the risk relationship completely. A higher serum phosphorus is associated with markers of a more risky profile of heart failure. Elevated serum levels of phosphorus sP does not provide independent prognostic information beyond the strongest markers of the severity of the syndrome. The potential involvement of higher serum phosphorus as a mediator in the pathophysiology of heart failure warrants further study.

Heart failure disease: An African perspective

Heart failure remains a health challenge in Africa, associated with significant rates of hospitalization, morbidity and mortality. The current review aims to summarize the most recent data on the epidemiology, aetiology, risk factors and management of heart failure, comparing countries in North Africa and sub-Saharan Africa. There is a paucity of data on heart failure epidemiology, aetiology and management, and on the sociodemographic characteristics of African patients with heart failure. Heart failure prevalence has been evaluated among all medical admissions or admissions to cardiac units or emergency departments in a few hospital-based studies conducted in countries in North Africa and sub-Saharan Africa. Common causes of heart failure in Africa include ischaemic heart disease, hypertensive heart disease, dilated cardiomyopathy and valvular heart disease. The aetiology of heart failure differs between countries in North Africa and sub-Saharan Africa. Diagnosing heart failure proves challenging in Africa because of a lack of basic tools and the necessary human resources. The principal drugs used frequently for heart failure therapy are lacking in sub-Saharan Africa. The clinical profile of heart failure in sub-Saharan Africa differs from that in North African countries; this is related to aetiological factors, socioeconomic status and availability of diagnostic tools. There is an evident need to establish a large multicentre registry to evaluate the heart failure burden in almost all African countries, and to highlight the major cardiovascular risk factors and co-morbidities. The present review highlights the importance of this syndrome in Africa, and calls for improvements in its early diagnosis, treatment and, possibly, prevention.

Heart Failure in the Middle East Arab Countries: Current and Future Perspectives

For many years, data about heart failure (HF) was only limited to Western countries but in the last few years, well designed heart failure registries have been conducted in many developing countries. The purpose of this review is to summarize the current status regarding the epidemiology and management of heart failure in Middle East Arab countries (MEACs) by analysis of the results of the latest HF registries performed in these countries and to anticipate future perspectives, quality initiatives and areas of research and development. Data has shown that the average age of affected individuals is at least 10 years younger than their Western counterparts. Heart failure with preserved ejection fraction was generally under-represented in these registries to less than 30% of the whole population of heart failure. Coronary artery disease (CAD) constitutes about 55% of causes of heart failure in this region in comparison to about 70% in Western countries. An area that needs development is the investment in establishing specialized heart failure programs to cut the circle of non-compliance and repeated HF admissions to the hospitals. Advances in heart transplantation and mechanical circulatory support will continue to slow down and we are not expecting major changes in the near future but on the other hand, implantation of electronic devices like ICD and CRT is expected to increase significantly in the coming years in these countries.

Plasma amino acid metabolomic pattern in heart failure patients with either preserved or reduced ejection fraction: The relation to established risk variables and prognosis

Communication between amino acids (AAs) and heart failure (HF) is unclear. We evaluate the plasma metabolomic profile of AAs in HF and its subgroups and association with clinical features. This is a case-control study in which 90 patients with HF, 63 with reduced ejection fraction (HFrEF) and 27 with preserved ejection fraction (HFpEF), were compared with 60 controls. The quantitative measurement of plasma concentrations of AA metabolites was performed using an AA analyzer. Compared with controls, HF patients had significantly higher levels of nine AAs and significantly lower levels of seven AAs. Leu, phenylalanine (Phe), and methionine (Met) were the independent predictors of HF that remained significant after adjustment for confounding factors in multivariate analysis. There was a significant difference in 10 AAs and some clinical features between HFpEF and HFrEF. The plasma levels of six AAs were significantly increased across the different New York Heart Association (NYHA) classes, (class II, class III, class IV) but they were not predictor of reduced EF and NYHA in multivariate regression analysis. There were significant associations between Leu, Phe, and Met with cardiovascular risk variables and prognosis. In conclusion, plasma Leu, Phe, and Met provide early prediction and prognostic values of HF. The plasma AAs could have significant impact on the risk-stratifying HFrEF and HFpEF and NYHA functional class but do not predict them.

Heart Failure Prescribing Quality at Discharge from a Critical Care Unit in Egypt: The Impact of Multidisciplinary Care

Discharge prescriptions for heart failure (HF) patients may not adhere to the clinical practice guidelines. This study aimed to assess the impact of the clinical pharmacist as a member of a multidisciplinary team on the quality of prescribing to HF patients at discharge from a Critical Care Unit (CCU) in Egypt. This was a retrospective cohort study of HF patients discharged from the CCU between January 2013 and December 2017. Guideline Adherence Index (GAI-3) was used to assess guideline-directed prescribing at discharge. Multidisciplinary care was introduced to the CCU on 1 January 2016. The study included 284 HF patients, mean (±SD) age 66.7 ± 11.5 years, 53.2% male. Heart failure with reduced ejection fraction affected 100 patients (35.2%). At discharge, loop diuretics were prescribed to 85.2% of patients; mineralocorticoid receptor antagonists to 54.9%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers to 51.4%; and β-blockers to 29.9%. Population Guideline Adherence Index (GAI-3) was 45.5%. High-GAI was prescribed to 136 patients (47.9%). Patients with High-GAI were younger; less affected by chronic kidney disease and had fewer comorbidities than those without High-GAI. Prescription of β-blocker increased (24.1% vs. 38.6%, p < 0.001) and digoxin utilization decreased (34.7% vs. 23.7%, p < 0.049) after the introduction of the multidisciplinary care. The inclusion of a clinical pharmacist in the multidisciplinary care team may have a role in optimizing the prescribing of HF guideline-directed therapies at discharge from this setting.

Demographics, clinical characteristics, and outcomes among hospitalized heart failure patients across different regions of Egypt

Background

Regional level data on hospitalized heart failure (HHF) patients in Egypt is scarce. The aim of this study was to compare the demographics, clinical characteristics, and outcomes of HHF patients from four distinct geographical regions of Egypt.

Results

Study participants were part of the European Society of Cardiology Heart Failure Long Term (ESC-HF-LT) Registry, which enrolled patients from April 2011 to February 2014. A total of 1661 HHF patients from Egypt were enrolled, of whom 1645 were eligible for analysis: 914 from Alexandria, 249 from Cairo, 409 from the Delta region, and 73 from Upper Egypt.

The mean age ranged from 52.2 to 62.8 years and differed significantly between the 4 groups (P < 0.01). Females represented one-third of the cohort (P = 0.5 between groups). The prevalence of obesity, diabetes, and hypertension also varied significantly across the groups (P < 0.01). The most common etiology of heart failure (HF) was ischemic heart disease. HF with reduced systolic function was the leading type of HF in the 4 groups (P = 0.6). The most common valvular abnormality in all regions was mitral regurgitation. For patients with prior history of HF, community-acquired infection was the most common reason for a HF exacerbation in all 4 groups.

In-hospital mortality ranged from 2.9 to 7.7% in the 4 groups (P = 0.06). Only Alexandria and Delta groups provided reliable 1-year follow-up data, given low patient retention in Cairo and Upper Egypt groups. At one-year, 32% of patients from Alexandria compared to 22.6% from Delta were re-hospitalized for HF (P < 0.01). Mortality at 1 year was also significantly higher in Alexandria compared to Delta, 31.8 vs 13.2% respectively (P < 0.01).

Conclusions

HHF patients from different geographic regions of Egypt differed significantly in their demographics, clinical characteristics, and outcomes. Those differences underscore the importance of region-specific HF prevention and management strategies.

Preliminary results of the acute Heart Failure registry in the DELTA region of Egypt (DELTA-HF): a database and a quality initiative project

Background

Data about heart failure in Egypt is scarce. We aimed to describe the clinical characteristics and diagnostic and treatment options in patients with acute heart failure in the Delta region of Egypt and to explore the gap in the management in comparison to the international guidelines.

Results

DELTA-HF is a prospective observational cohort registry for all consecutive patients with acute heart failure (AHF) who were admitted to three tertiary care cardiac centers distributed in the Delta region of Egypt. All patients were recruited in the period from April 2017 to May 2018, during which, data were collected and short-term follow-up was done.

A total of 220 patients (65.5% were males with a median age of 61.5 years and 50.9% had acute decompensation on top of chronic heart failure) was enrolled in our registry. The risk factors for heart failure included rheumatic valvular heart disease (10.9%), smoking (65.3%), hypertension (48.2%), diabetes mellitus (42.7%), and coronary artery disease (28.2%). Left ventricular ejection fraction (LVEF) was less than 40% in 62.6%. Etiologies of heart failure included ischemic heart disease (58.1%), valvular heart disease (16.3%), systemic hypertension (9.1%), and dilated non-ischemic cardiomyopathy (15.5%). Exacerbating factors included infections (28.1%), acute coronary syndromes (25.5%), non-compliance to HF medications (19.6%), and non-compliance to diet (23.2%) in acute decompensated heart failure (ADHF) patients. None of our patients had been offered heart failure device therapy and only 50% were put on beta-blockers upon discharge. In-hospital, 30 days and 90 days all-cause mortality were 18.2%, 20.7%, and 26% respectively.

Conclusions

There is a clear gap in the management of patients with acute heart failure in the Delta region of Egypt with confirmed under-utilization of heart failure device therapy and under-prescription of guideline-directed medical therapies particularly beta-blockers. The short-term mortality is high if compared with Western and other local registries. This could be attributed mainly to the low-resource health care system in this region and the lack of formal heart failure management programs.

Heart failure prevalence in the general population: SOBOTA-HF study rationale and design

Aims

Epidemiological heart failure (HF) data in the era of natriuretic peptides and echocardiography are scarce. The primary aim of this study is to evaluate the HF prevalence in the general population. We will also investigate natriuretic peptide cut‐off for diagnosis of HF. Finally, we will be able to identify left ventricular function phenotypes and study relations between cardiac function, clinical presentation, and health‐related quality of life.

Methods and results

Screening Of adult urBan pOpulation To diAgnose Heart Failure (SOBOTA‐HF) is a cross‐sectional prevalence study in a representative sample of Murska Sobota residents aged 55 years or more. Individuals will be invited to attend screening visit with point‐of‐care N‐terminal pro‐b‐type natriuretic peptide (NT‐proBNP) testing. All subjects with NT‐proBNP ≥ 125 pg/mL will be invited for a diagnostic visit that will include history and physical examination, electrocardiogram, echocardiography, blood and urine sampling, ankle brachial index, pulmonary function tests, body composition measurement, physical performance tests, and questionnaires. To validate the screening procedure, a control group (NT‐proBNP < 125 pg/mL) will undergo the same diagnostic evaluation. An external centre will validate echocardiography results, and the HF diagnosis will be adjudicated within an international HF expert panel. Overall and age‐specific HF prevalence will be calculated in individuals ≥ 55 years and extrapolated to the whole population.

Conclusions

The SOBOTA‐HF study will test the latest HF guideline diagnostic criteria in the general population sample. Next to HF prevalence, it will provide insight into left ventricular function and general patient phenotype; we will also extend current understanding of natriuretic peptides for HF screening.

Design and Rationale of Gulf Documentation of Ambulatory Sick Patients with Heart Failure (Gulf DYSPNEA) Registry

Aim:

The aim of this study is to describe the clinical characteristics of ambulatory patients with chronic heart failure (HF) in the Arabian Gulf and to examine several aspects including types of HF, causes, and adherence to management guidelines.

Methods:

Gulf documentation of ambulatory sick patients with HF (Gulf DYSPNEA) registry is a multicenter, cross-sectional study, recruiting adult ambulatory HF patients from 24 hospitals in five Arabian Gulf countries. Consecutive patients are recruited prospectively from participating clinics with no follow-up data collection. Recruitment started on November 07, 2016 and will stop when 3,500 patients are enrolled in this study. Collected data explore demographics, baseline patient characteristics, symptoms, previous medical history, comorbidities, physical signs, presenting electrocardiogram, echocardiographic findings, types of HF, and management.

Conclusion:

This registry is expected to provide useful data on several important aspects and features of ambulatory patients with chronic HF in Arabian Gulf countries. The trial registration number is “ClinicalTrials.gov number, NCT02793180”.

Gender differences in Egyptian patients hospitalized with heart failure: insights from the European Society of Cardiology Heart Failure Long-Term Registry

Aims

This analysis evaluates gender differences in the Egyptian cohort of patients hospitalized for acute heart failure (AHF) in the European Society of Cardiology Heart Failure Long‐Term Registry.

Methods and results

From April 2011 to September 2014, 1634 patients hospitalized with AHF were enrolled by 20 hospitals all over Egypt. Of these patients, 1112 (68%) patients were male and 522 (32%) were female. Women presented with a higher admission systolic blood pressure and resting heart rate. Compared with men, women had a higher body mass index (32.5 ± 9.0 vs. 29.3 ± 4.9, P < 0.001), more frequent atrial fibrillation (34.7% vs. 22.4%, P < 0.001), and anaemia defined by haemoglobin < 12 g/dL (83.1% vs. 58.4%, P < 0.001). Women were more likely to present with heart failure with preserved ejection fraction (29.7% vs. 10.6%, P < 0.001). Women had more frequent diabetes mellitus (48.1% vs. 41.6%, P < 0.05) and hypertension (48.7% vs. 39.3%, P < 0.001) than had men, whereas smoking was rare among them (8.8% vs. 82.9%, P < 0.005). There was no significant difference in the primary aetiology of heart failure between both sexes. ACE inhibitors, beta‐blockers, mineralocorticoid receptor antagonists, antiplatelets, statins, and nitrates were less frequently prescribed to women, whereas they more often received digoxin, amiodarone, anticoagulants, and calcium channel blockers. There was no significant difference in in‐hospital (5.7% vs. 4.6%, P = 0.39) and 1 year mortality (27.9% vs. 25.9%, P = 0.48) between women and men, respectively.

Conclusions

Men and women with AHF differ significantly in baseline clinical characteristics and management but not in adverse outcomes. These findings emphasize the importance of individualized management and need for more comprehensive recruitment of women in clinical trials.

Prevalence of P wave dispersion and interatrial block in patients with systolic heart failure and their relationship with functional status, hospitalization and one year mortality

Background and objectives

P-wave dispersion (PWD) and Interatrial block (IAB) are common in heart failure (HF), and could be associated with adverse cardiac events. We aimed to assess the prevalence of PWD and IAB and their relationship with functional status, hospitalization and mortality rate in patients with systolic HF.

Methods

We enrolled 110 HF patients in sinus rhythm & LVEF <50%. Patients had undergone clinical evaluation, 6 min walking test (6MWT), 12-lead electrocardiography (ECG), 24-h Holter ECG & echocardiogram. Hospitalization and mortality rate were followed-up for one year. PWD was defined as the difference between maximum & minimum P-wave duration >40 ms. IAB was defined as maximum P duration >110 ms. Measurements were done by 2 blinded investigators using a caliber, a ruler and a magnifying lens.

Results

Mean age was 58.9 ± 9.7 years and 67.3% were males. Prevalence of PWD and IAB was 68.2% and 57.3%, respectively. Patients with PWD showed these features: 84% in NYHA class III or IV HF, 77.4% had LVEF <35%, 78.7% had paroxysmal Atrial Fibrillation (AF) and 89.4% couldn’t complete >200 m (m) in 6MWT. Patients with PWD had more hospitalizations (72% vs 28.6%, P value <0.02) and higher 1-year mortality rate (20% vs 8.6%, P value <0.04) than patients without PWD. Likewise, patients with IAB had nearly similar clinical features, hospitalization and mortality as patients with PWD.

Conclusion

PWD and IAB are prevalent in patients with systolic HF and they are significantly associated with low LVEF, paroxysmal AF, poor functional capacity, hospitalization and mortality rate.

Iron therapy in heart failure patients without anaemia: possible implications for chronic kidney disease patients

Iron deficiency anaemia is a global health problem that manifests as fatigue and poor physical endurance. Anaemia can be caused by dietary iron deficiency, blood loss or a combination of poor iron absorption and ineffective iron mobilization in patients with chronic disease. Nephrologists caring for patients with impaired renal function understand that iron treatment is necessary to provide adequate iron for erythropoiesis during the treatment of overt anaemia. However, a less well-understood health problem is iron deficiency, which creates symptoms that overlap with those of anaemia and often occurs in concert with chronic disease. Recently, several randomized controlled clinical trials have been conducted to investigate the effects of treatment with intravenous iron in heart failure patients with iron deficiency who may or may not also have anaemia. Given that heart and kidney disease are often comorbid, these clinical trials may have implications for the way nephrologists view their patients with iron deficiency. In this article, we review several clinical studies of intravenous iron therapy for patients with iron deficiency and heart failure and discuss possible implications for the treatment of patients with kidney disease.

Clinical and laboratory characteristics of short-term mortality in Egyptian patients with acute heart failure

Objective

To identify the clinical and laboratory predictors of short-term mortality in patients with acute heart failure (AHF).

Subjects and methods

We conducted a prospective, single center study on 120 consecutive patients presented with acute heart failure to the emergency department. All patients had clinical, laboratory, electrocardiographic and echocardiographic evaluation. Short-term mortality was reported within 30 days of presentation.

Results

Mean age was 59.29 ± 10.1 years, 55.8% were males and 50.8% were smokers. The common AHF presentations were dyspnea (91.7%), chest tightness (62.5%) and lower limb edema (54.2%). Ischemic heart disease, diabetes and hypertension were present in 72.5%, 43.3% and 35% of patients, respectively.

Short-term mortality was reported in 29 patients (24.16%); most of them died in-hospital (19 patients, 65.52%). The following parameters were significantly associated with short-term mortality: hypoxia (P < 0.001), tachycardia (P < 0.01), raised jugular venous pressure (JVP) (P < 0.001), low systolic blood pressure (P < 0.01), prolonged PR interval (P < 0.007), atrial fibrillation (AF) (P < 0.038), left bundle branch block (LBBB) (P < 0.04), impaired kidney function (P < 0.007), anemia (P < 0.029), hyponatremia (P < 0.006), hypoalbuminemia (P < 0.005), dilated left ventricle (LV) (P < 0.001), low LV ejection fraction (LVEF) (P < 0.001), and dilated left atrium (LA) (P < 0.002).

ROC curve analysis showed that low LVEF (≤24%), dilated LV end diastolic diameter (LVESD) ≥ 66.5 mm, dilated LV end systolic diameter (LVESD) ≥ 53.5 mm, dilated LA diameter ≥ 48 mm, increased serum creatinine ≥ 1.6 mg/dl, and decreased serum albumin ≤ 3 g/dl can significantly predict short-term mortality in patients with acute heart failure.

Conclusion

Variable clinical, laboratory, electrocardiographic and echocardiographic parameters were associated with short-term mortality. Our study showed that low LVEF, dilated LV diameter, dilated LA diameter, impaired kidney function and low serum albumin can predict short-term mortality in patients with acute heart failure.

Publication trends in cachexia and sarcopenia in elderly heart failure patients

The loss of skeletal mass - sarcopenia and cachexia - is considered to be a major contributor to morbidity and mortality in chronic heart failure (CHF). Unfortunately, sarcopenia is generally considered to be a geriatric syndrome, but not necessarily seen as a comorbidity in CHF, even though it has a wide range of adverse health outcomes. While there were 15,574 publication with the title word "heart failure" in PubMed in the 5‑year period from 1 June 2011 to 31 May 2016, only 22 or 71 publications were found with the search combination "sarcopenia" or "cachexia" (title word) and "heart failure" (all fields), respectively. This shows very clearly that loss of muscle quality and function due to heart failure is still an underappreciated problem in the medical field.

Sleep-disordered breathing and cardiovascular disease

Sleep-disordered breathing (SDB) is a common comorbidity in a number of cardiovascular diseases, and mounting clinical evidence demonstrates that it has important implications in the long-term outcomes of patients with cardiovascular disease (CVD). While recognition among clinicians of the role of SDB in CVD is increasing, it too often remains neglected in the routine care of patients with CVD, and therefore remains widely undiagnosed and untreated. In this article, we provide an overview of SDB and its relationship to CVD, with the goal of helping cardiovascular clinicians better recognize and treat this important comorbidity in their patients. We will describe the two major types of SDB and discuss the pathophysiologic, diagnostic, and therapeutic considerations of SDB in patients with CVD.

Clinical characteristics and management of hospitalized and ambulatory patients with heart failure-results from ESC heart failure long-term registry-Egyptian cohort

Aims

Our aim is to describe the clinical characteristics and management of patients hospitalized with acute heart failure (HHF) and ambulatory patients with chronic heart failure (CHF) in Egypt and compare them with heart failure (HF) patients from other countries in the European Society of Cardiology‐Heart Failure (ESC‐HF) registry.

Methods and results

The ESC‐HF Long‐term Registry is a prospective, multi‐centre, observational study of patients presenting to cardiology centres in member countries of the ESC. From April 2011 to February 2014, a total of 2145 patients with HF were recruited from 20 centres all over Egypt. Of these patients, 1475 (68.8%) were hospitalized with HHF, while 670 (31.2%) had CHF. Less than one‐third (32.1%) of all patients were females. HHF patients {median age of 61 years [interquartile range (IQR), 53–69]} were older than CHF patients [median age of 57 years (IQR,46‐64)]; P < 0.0001. They had more diabetes mellitus (45.4% vs. 31.8%; P < 0.0001). Left ventricular ejection fraction > 45% was present in 22% of HHF vs. 25.6% of CHF (P = 0.17). Atrial fibrillation existed in about a quarter of all patients (24.5%). Ischaemic heart disease was the main cause of HF in Egyptian patients. All‐cause in‐hospital mortality was 5%. Egyptian patients presented at a much earlier age than in other regions in the registry. They had more diabetes mellitus. Atrial fibrillation prevalence was remarkably lower. Other co‐morbidities (renal dysfunction, stroke, and peripheral arterial disease) occurred less frequently.

Conclusion

Patients in the Egyptian cohort exhibited distinct features from HF patients in other countries in the ESC‐HF Long‐term Registry.