Characterization of heart failure patients with preserved ejection fraction: a comparison between ADHERE-US registry and ADHERE-International registry

Regional variations in heart failure: a global perspective

Heart failure (HF) is a global public health concern that affects millions of people worldwide. While there have been significant therapeutic advancements in HF over the last few decades, there remain major disparities in risk factors, treatment patterns and outcomes across race, ethnicity, socioeconomic status, country and region. Recent research has provided insight into many of these disparities, but there remain large gaps in our understanding of worldwide variations in HF care. Although the majority of the global population resides across Asia, Africa and South America, these regions remain poorly represented in epidemiological studies and HF trials. Recent efforts and registries have provided insight into the clinical profiles and outcomes across HF patterns globally. The prevalence of HF and associated risk factors has been reported and varies by country and region ranges, with minimal data on regional variations in treatment patterns and long-term outcomes. It is critical to improve our understanding of the different factors that contribute to global disparities in HF care so we can build interventions that improve our general cardiovascular health and mitigate the social and economic cost of HF. In this narrative review, we hope to provide an overview of the global and regional variations in HF care and outcomes.

Impact of Cardiac Troponin Elevation on Mortality of Patients with Acute Heart Failure: Insights from the Korea Acute Heart Failure (KorAHF) Registry

We aimed to conduct the largest study evaluating the impact of cardiac troponin (TnI) status on mid- and long-term mortality in patients admitted for acute heart failure (AHF) as compared between patients with ischemic (IHF) vs. non-ischemic heart failure (non-IHF). Among 5625 patients from the Korea Acute Heart Failure (KorAHF) registry, 4396 eligible patients with TnI measurement were analyzed. The patients were included on admission with the diagnosis of AHF, and TnI level was measured on the day of admission. A TnI value of <0.05 ng/mL was considered normal. The patients were divided into four groups according to the etiology of heart failure and the status of TnI: non-IHF with normal TnI (n = 1009) vs. non-IHF with elevated TnI (n = 1665) vs. IHF with normal TnI (n = 258) vs. IHF with elevated TnI (n = 1464). The primary outcome was death from all causes according to the etiology (non-IHF vs. IHF) and TnI elevation during the entire follow-up period of 784 days (IQR 446−1116). Elevation of TnI was observed in 71.2% of all patients with AHF. Patients with IHF had higher all-cause mortality compared to those with non-IHF. Elevated TnI was associated with higher 90-day and post-90-day mortality in the non-IHF group. IHF as compared to non-IHF and elevation of TnI were independent predictors of mortality also in the adjustment analysis. In the IHF group, however, elevated TnI had a higher mortality with only 90-day follow-up (18.6% vs. 25.9%, log-rank p < 0.001), not in the post-90-day follow-up (31.1% vs. 32.5%, log-rank p = 0.799). In conclusion, elevated TnI in patients with heart failure is associated with increased all-cause mortality regardless of the etiology of HF. Elevation of TnI was associated to a higher post-90 day mortality in patients with non-IHF but not in patients with IHF.

Acute heart failure – The ‘real’ Malaysian experience: An observational study from a single non-cardiac centre

Background:

Cardiovascular care in Malaysia adopts a ‘spoke-and-hub’ model, leaving the majority of acute heart failure (AHF) care to non-cardiac centres. Granular data on AHF care are essential and yet remain scarce.

Objectives:

This study aimed to illustrate the baseline characteristics, management and outcome of AHF patients.

Methods:

A retrospective, cross-sectional study was conducted on 1307 AHF patients admitted between 1 January 2012 and 31 December 2016.

Results:

The younger and Malay-predominant population reflects the distribution of ischaemic heart disease in Malaysia, highlighting the need to tackle metabolic risks factors. The majority are precipitated by ischaemia (61.8%). Common co-morbidities include hypertension (70.9%), coronary artery disease (57.8%) and diabetes (62.2%). The majority were of New York Heart Association Class II (31.9%) and Class III (25.6%). A total of 14.5% required inotropes and vasopressors, 12.9% required intravenous nitrates and 8.6% required dialysis. A further 4.9% of patients required intubation and mechanical ventilation, and 25.9% required non-invasive ventilation. Readmission and mortality were extremely high in our population. Short inpatient stays, restricting optimisation of medication, and gaps in the provision of coronary intervention and stress testing are possible contributing factors. When compared to global and regional registries, disparities were noted specifically surrounding mortality rate and optimum use of guideline-directed medical therapy.

Conclusion:

Although smaller and single centred, our study provides a unique insight into a pure Malaysian-only cohort from a hospital with no cardiology services in-house, which is more reflective of the majority of hospitals in Malaysia, unlike previous studies and registries.

Current status of heart failure: global and Korea

Heart failure (HF) is a condition in which the heart is unable to pump enough blood to meet the body's needs for blood and oxygen. Thus, HF is a grave disease with high morbidity and mortality. Because the prevalence of and exposure to the risk factors for HF increase with age, the prevalence of HF has been increasing in an aging society, including Korea. The vast advancement of medical and device therapy has improved the outcomes of HF, but significant residual risk still exists, and the benefit is confined to patients with reduced ejection fraction. Finding effective treatment for HF with preserved ejection fraction and identification of groups who benefit from drug and device therapy remain challenging. In this review, we illustrate the epidemiology, temporal trends, and current status of medical and device therapy, including heart transplantation, as well as emerging treatments for HF in Korea and worldwide.

The role of M-mode echocardiography in patients with heart failure and preserved ejection fraction: A prospective cohort study

Epicardial movement during diastole is inversely proportional to myocardial stiffness but systolic regional thickening cannot precisely identify ischemic territories. The aim of the present study was to test the hypothesis that a correlation may be present between M-mode echocardiography parameters and poor outcomes in patients with heart failure and preserved ejection fraction. Patients with known cardiovascular disease were included in the test group (n=1,244) and patients without known cardiovascular disease were included in the control group (n=1,952). Patient records of routine measurements, M-mode echocardiography and mortality were collected. The control population and test population had the same left ventricular end-diastolic dimension (P=0.062) and left ventricular end-diastolic volume (P=0.053). A lower mitral flow velocity (P<0.05), higher Tei index (P<0.0001) and reduced distribution of diastolic wall strain (P<0.0001) were reported in the test populations compared with the control population. Patients of the test population with lower diastolic wall strain (<0.28) demonstrated a higher mortality rate than those with higher diastolic wall strain (≥0.28; P<0.0001) at the 3-year follow-up. M-mode echocardiographic parameters may be of use for predicting poor outcomes in patients with heart failure and preserved ejection fraction.

Rate of Rehospitalization in 60 Days of Discharge and It's Determinants in Patients with Heart Failure with Reduced Ejection Fraction in a Tertiary Care Centre in India

Background and Objectives

Identifying the patients with acute heart failure (HF) at high risk for rehospitalization after hospital discharge will enable proper optimization of treatment. This study is aimed to evaluate the rehospitalization rate at 60 days of discharge and their predictors in patients of chronic heart failure with reduced ejection fraction (HFrEF).

Methods

This prospective observational study enrolled patients with left ventricle ejection fraction (LVEF) <40%, who were admitted because of acute decompensation. Patients were followed for 60 days to analyze rehospitalization rate and its predictors.

Results

Of 103 HFrEF patients (74% male; mean age 55.8 years) enrolled, 7 patients died during index admission and 3 patients lost to follow up. The 60-day rehospitalization rate was 37% (34/93). We studied 23 clinical and 9 biochemical predictors of rehospitalization. Out of 34 events of rehospitalization, 79.41% (n=28) was due to cardiac cause followed by respiratory 5.8% (n=2), renal 5.8% (n=2) and others 5.8% (n=2). Among all the parameters, on logistic regression analysis having longer length of index hospital stay (>7 days) (52.8% vs. 28.8%; odds ratio [OR], 1.79; confidence interval [CI], 1.2–7.25; p=0.040) and chronic kidney disease (CKD) (26.5% vs. 8.5%; OR, 3.06; CI, 1.1–57.04; p=0.050) independently increased the risk of rehospitalization at 60 days of discharge. Further higher haemoglobin level (11.3 vs. 9.9 gm/dL; OR, 0.71; CI, 0.48–0.97; p=0.050) and higher LVEF at index admission (30.4% vs. 26.5%; OR, 0.87; CI, 0.75–0.99; p=0.049) were associated with decreased the risk of rehospitalization.

Conclusions

Our study reveals that patients with HFrEF have significantly higher rehospitalization rate (37%) and in-hospital mortality rates (6.78%) of any chronic cardiac disease conditions. Correction of low hemoglobin and special care in those who are having very low LVEF, CKD and longer length of stay, including tailored therapy and frequent visits may play an important role in preventing future rehospitalization in these patients.

Electrocardiographic characteristics in patients with heart failure and normal ejection fraction: A systematic review and meta-analysis

BACKGROUND

Little is known about ECG abnormalities in patients with heart failure and normal ejection fraction (HeFNEF) and how they relate to different etiologies or outcomes.

METHODS AND RESULTS

We searched the literature for peer-reviewed studies describing ECG abnormalities in HeFNEF other than heart rhythm alone. Thirty five studies were identified and 32,006 participants. ECG abnormalities reported in patients with HeFNEF include atrial fibrillation (prevalence 12%-46%), long PR interval (11%-20%), left ventricular hypertrophy (LVH, 10%-30%), pathological Q waves (11%-18%), RBBB (6%-16%), LBBB (0%-8%), and long JTc (3%-4%). Atrial fibrillation is more common in patients with HeFNEF compared to those with heart failure and reduced ejection fraction (HeFREF). In contrast, long PR interval, LVH, Q waves, LBBB, and long JTc are more common in patients with HeFREF. A pooled effect estimate analysis showed that QRS duration ≥120 ms, although uncommon (13%-19%), is associated with worse outcomes in patients with HeFNEF.

CONCLUSIONS

There is high variability in the prevalence of ECG abnormalities in patients with HeFNEF. Atrial fibrillation is more common in patients with HeFNEF compared to those with HeFREF. QRS duration ≥120 ms is associated with worse outcomes in patients with HeFNEF. Further studies are needed to address whether ECG abnormalities correlate with different phenotypes in HeFNEF.

Do Patients With Acute Heart Failure and Preserved Ejection Fraction Have Heart Failure at Follow-Up: Implications of the Framingham Criteria

BACKGROUND

Heart failure (HF) with preserved ejection fraction (HFpEF) may be misdiagnosed. We assessed prevalence and consistency of Framingham criteria signs and symptoms in acute vs subsequent stable HFpEF.

METHODS

Three hundred ninety-nine patients with acute HFpEF according to Framingham criteria were re-assessed in stable condition. Four definitions of HFpEF at follow-up: (1) Framingham criteria alone, (2) Framingham criteria and natriuretic peptides (NPs), (3) Framingham criteria, NPs, and European Society of Cardiology HF guidelines echocardiographic criteria, (4) Framingham criteria, NPs, and the Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction (PARAGON) trial echocardiographic criteria.

RESULTS

At follow-up, HFpEF was still present in 27%, 22%, 21%, and 22%, respectively. Most prevalent in acute HFpEF were dyspnea at exertion (90%), pulmonary rales (71%), persisting at follow-up in 70% and 13%, respectively. Characteristics at acute HF with greater or lesser odds of stable HFpEF; (1) jugular venous distention (odds ratio [OR] 1.80, 95% confidence interval [CI] 1.13-2.87; P = .013) and pleural effusion (OR 0.45, 95% CI 0.24-0.85; P = .014) and (4), older age (1.04, 95% CI 1.01-1.08; P = .014) and tachycardia (>100 bpm) 0.52, 95% CI 0.27-1.00; P = .048).

CONCLUSIONS

In patients with acute HFpEF, one-quarter met the HF definition according to Framingham criteria at ambulatory follow-up. The proportion of patients with postdischarge HFpEF was largely unaffected by additional echocardiographic or NP criteria Older age and jugular venous distention at acute presentation predicted persistent HFpEF at follow-up, whereas pleural effusion and tachycardia may yield false HFpEF diagnoses. This finding has implications for HFpEF trial design.

Hyponatremia at discharge is associated with adverse prognosis in acute heart failure syndromes with preserved ejection fraction: a report from the JASPER registry

INTRODUCTION

Hyponatremia predicts adverse prognosis in patients with heart failure in particular with reduced ejection fraction. In contrast, it has recently been reported that hyponatremia on admission is not a predictor of post-discharge mortality in patients with heart failure with preserved ejection fraction. We investigated the prognostic impact of hyponatremia at discharge in patients with heart failure with preserved ejection fraction and its clinical characteristics.

METHODS AND RESULTS

The Japanese Heart Failure Syndrome with Preserved Ejection Fraction (JASPER) registry is a nationwide, observational, prospective registration of consecutive Japanese patients hospitalised with heart failure with preserved ejection fraction and left ventricular ejection fraction of 50% or greater. Five hundred consecutive patients were enrolled in this analysis. We divided the patients into two groups based on their sodium serum levels at discharge: hyponatremia group (sodium <135 mEq/L, n=50, 10.0%) and control group (sodium ⩾135 mEq/L, n=450, 90.0%). This present analysis had two primary endpoints: all-cause death and all-cause death or rehospitalisation for heart failure. At discharge, the hyponatremia group had lower systolic blood pressure (110.0 mmHg vs. 114.5 mmHg, P=0.014) and higher levels of urea nitrogen (31.9 mg/dL vs. 24.2 mg/dL, P=0.032). In the Kaplan-Meier analysis, more patients in the hyponatremia group reached the primary endpoints than those in the control group (log rank <0.01, respectively). In the Cox proportional hazard analysis, hyponatremia at discharge was a predictor of the two endpoints (all-cause death, hazard ratio 2.708, 95% confidence interval 1.557-4.708, P<0.001; all-cause death or rehospitalisation for heart failure, hazard ratio 1.829, 95% confidence interval 1.203-2.780, P=0.005).

CONCLUSIONS

Hyponatremia at discharge is associated with adverse prognosis in hospitalised patients with heart failure with preserved ejection fraction.

Patients Characteristics and Preliminary Outcomes of Heart Failure Registry in A Middle-Income Country: Persian Registry of Cardiovascular Disease/Heart Failure (PROVE/HF)

Background

The Persian Registry of Cardiovascular disease/Heart Failure (PROVE/HF) aimed to studied the demographic, clinical, and diagnostic characteristics and treatment of patients hospitalized for heart failure (HF) and to follow them for short- and long-term outcomes. Its pilot phase started in 2015 in Isfahan aiming to evaluate its feasibility to be scaled up at the national level in later stages. This article describes the method and preliminary results of the first year registry.

Materials and Methods

Information of hospitalized patients with preserved and low ejection fraction, were gathered. Patients were followed for 1, 6, and 12 months. During follow-up, information of the patients' current status, medications used during hospitalization, and in case of death, the cause and place were assessed.

Result

PROVE/ HF enrolled 787 patients in the first year. The mean age of patients was 70.74 ±12.01 years, and 60.7% of them were men. The most frequent risk factors for the development of HF in the recruited patients was ischemic heart disease (77.9%), and hypertension (63.7%), respectively. The re-admission rate for patients with HF was at least once in 16% and continued until the fifth to ninth re-admission over a one-year period. Among 787 registered patients, 30.9% died in the first year of follow-up, and the in-hospital mortality was 6.2%. The mean hospitalization period was 4.88 days, and 64.2% were hospitalized for >3 days.

Conclusion

The annual rate of re-admission and mortality was high, and the use of medication was less than the recommended one inaccordance with the guidelines for the treatment of heart failure.

Precipitating factors of decompensation of heart failure related to treatment adherence: multicenter study-EMBRACE

OBJECTIVE

To describe the precipitating factors of heart failure decompensation between adherent and non-adherent patients to treatment.

METHODS

Cross-sectional study of a multicenter cohort study. Patients over 18 years of age with decompensated heart failure (functional class III/IV) were eligible. The structured questionnaire was used to collect the data and evaluate the reasons for decompensation. The irregular use of medication prior to hospitalization and inadequate salt and fluid intake were considered as poor adherence to treatment.

RESULTS

A total of 556 patients were included, mean age 61 ± 14 years old, 362 (65%) male. The main factor of decompensation was poor adherence, representing 55% of the sample. Patients who reported irregular use of medications in the last week had a 22% greater risk of being hospitalized due to poor adherence than the patients who adhered to treatment.

CONCLUSION

The EMBRACE study showed that in patients with heart failure, poor adherence was the main factor of exacerbation.

Is heart failure with mid range ejection fraction (HFmrEF) a distinct clinical entity or an overlap group?

Background

The new category of heart failure (HF), Heart Failure with mid range Ejection Fraction (HFmrEF) has recently been proposed with recent publications reporting that HFmrEF represents a transitional phase. The aim of this study was to determine the prevalence and clinical characteristics of patients with HFmrEF and to establish what proportion of patients transitioned to other types of HF, and how this affected clinical outcomes.

Methods and results

Patients were diagnosed with HF according to the 2016 ESC guidelines. Clinical outcomes and variables were recorded for all consecutive in-patients referred to the heart failure service. In total, 677 patients with new HF were identified; 25.6% with HFpEF, 21% with HFmrEF and 53.5% with HFrEF. While clinical characteristics and prognostic factors of HFmrEF were intermediate between HFrEF and HFpEF, HFmrEF patients had the best outcome, with higher mortality in the HFrEF population (p 0.02) and higher HF rehospitalisation rates in the HFpEF population (p < 0.01).38.7% of the HFmrEF patients transitioned (56.4% to HFpEF and 43.6% to HFrEF) with fewest deaths in the patients that transitioned to HFpEF (p 0.04), and fewest HF readmissions in the patients that remained as HFmrEF (<0.01).

Conclusion

HFmrEF patients had the best outcomes, compared to high rates of mortality seen in patients with HFrEF and high rates of HF readmissions seen in patients with HFpEF. Only 1/3 of HFmrEF patients transitioned during follow up, with the lowest mortality seen in patients transitioning to HFpEF.

The China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE) retrospective heart failure study design

INTRODUCTION

Heart failure (HF) is a leading cause of hospitalisation in China, which is experiencing a rapid increase in cardiovascular disease prevalence. Yet, little is known about current burden of disease, quality of care and treatment outcomes of HF in China. The objective of this paper is to describe the study methodology, data collection and abstraction, and progress to date of the China Patient-centered Evaluative Assessment of Cardiac Events 5 Retrospective Heart Failure Study (China PEACE 5r-HF).

METHODS AND ANALYSIS

The China PEACE 5r-HF Study will examine a nationally representative sample of more than 10 000 patient records hospitalised for HF in 2015 in China. The study is a retrospective cohort study. Patients have been selected using a two-stage sampling design stratified by economic-geographical regions. We will collect patient characteristics, diagnostic testing, treatments and in-hospital outcomes, including death and complications, and charges of hospitalisation. Data quality will be monitored by a central coordinating centre and will address case ascertainment, data abstraction and data management. As of October 2017, we have sampled 15 538 medical records from 189 hospitals, and have received 15 057 (96.9%) of these for data collection, and completed data abstraction and quality control on 7971.

ETHICS AND DISSEMINATION

The Central Ethics Committee at the Chinese National Center for Cardiovascular Diseases approved the study. All collaborating hospitals accepted central ethics committee approval with the exception of 15 hospitals, which obtained local approval by internal ethics committees. Findings will be disseminated in future peer-reviewed papers and will serve as a foundation for improving the care for HF in China.

TRIAL REGISTRATION NUMBER

NCT02877914.

Epidemiology, Pathophysiology, and Prognosis of Heart Failure in Older Adults

Heart failure is the quintessential cardiovascular syndrome of aging that results from common cardiovascular conditions in older adults in conjunction with age-associated changes in cardiovascular structure and function. To a large extent, heart failure is a geriatric syndrome in much the same way that dementia, falls, and frailty are geriatric syndromes. The incidence and prevalence of heart failure increase strikingly with age and make heart failure the most common reason for hospitalization among older adults. Although outcomes for older adults with heart failure have improved over time, mortality, hospitalization, and rehospitalization rates remain high.

Comprehensive healthcare resource use among newly diagnosed congestive heart failure

BACKGROUND

Congestive heart failure (CHF) is among the most common causes of hospital admissions and readmissions in the Western world. However, the burden of ambulatory care has not been as well investigated. The objective of this study was to assess the relative burden and direct medical costs of CHF including inpatient and outpatient care.

METHODS

We used longitudinal clinical data from a two-million member health organization in Israel (Maccabi Healthcare Services) to identify adults with newly diagnosed CHF between January 2006 and December 2012, either in the in- or outpatient setting. Adults without CHF were age- and sex-matched to CHF patients and healthcare utilization and all modes of healthcare costs were compared among them, excluding those in their last year of life.

RESULTS

The burden posed by 6592 CHF patients was significantly (p < 0.001) larger than that of 32,960 matched controls. CHF patients had significantly higher rates of baseline comorbidity and healthcare utilization compared to non-CHF controls. This was evident in all categories of healthcare services and expenses, including in- and outpatient visits, laboratory expenses, medication costs, among younger and older, men and women. Among those who incurred any healthcare costs, younger (45-64y) and older (65 + y) subjects with CHF were observed to have about 3.25 (95% CI: 2.96-3.56) and 2.08 (95% CI: 1.99-2.17) times the healthcare costs, respectively, compared to subjects without CHF after adjusting for patient characteristics.

CONCLUSION

CHF is associated with an overall two- to three-fold higher cost of healthcare services depending on patient age, accounting for over half of all healthcare costs incurred by elderly CHF patients, and more than two-thirds of all costs among younger CHF patients. Observations of the large burden posed on one of the youngest societies in the developed world are profound, implicative of great opportunities to control the costs of CHF. Further research to understand how resource use impacts health outcomes and quality of care is warranted.

Clinical Characteristics and Outcome of Acute Heart Failure in Korea: Results from the Korean Acute Heart Failure Registry (KorAHF)

Background and Objectives

The burden of heart failure has increased in Korea. This registry aims to evaluate demographics, clinical characteristics, management, and long-term outcomes in patients hospitalized for acute heart failure (AHF).

Subjects and Methods

We prospectively enrolled a total of 5625 consecutive subjects hospitalized for AHF in one of 10 tertiary university hospitals from March 2011 to February 2014. Descriptive statistics were used to determine the baseline characteristics of the study population and to compare them with those from other registries.

Results

The mean age was 68.5±14.5 years, 53.2% were male, and 52.2% had de novo heart failure. The mean systolic and diastolic blood pressures were 131.2±30.3 mmHg and 78.6±18.8 mmHg at admission, respectively. The left ventricular ejection fraction was ≤40% in 60.5% of patients. Ischemia was the most frequent etiology (37.6%) and aggravating factor (26.3%). Angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and aldosterone antagonists were prescribed in 68.8%, 52.2%, and 46.6% of the patients at discharge, respectively. Compared with the previous registry performed in Korea a decade ago, extracorporeal membrane oxygenation (ECMO) and heart transplantation have been performed more frequently (ECMO 0.8% vs. 2.8%, heart transplantation 0.3% vs. 1.2%), and in-hospital mortality decreased from 7.6% to 4.8%. However, the total cost of hospital care increased by 40%, and one-year follow-up mortality remained high.

Conclusion

While the quality of acute clinical care and AHF-related outcomes have improved over the last decade, the long-term prognosis of heart failure is still poor in Korea. Therefore, additional research is needed to improve long-term outcomes and implement cost-effective care.

Anticoagulation in atrial fibrillation and chronic heart failure: the risk and drug of choice

PURPOSE OF REVIEW

This review seeks to provide an evidence-based update on the issue of atrial fibrillation and chronic heart failure with an emphasis on anticoagulation and the expanding use of the novel oral anticoagulants (NOACs).

RECENT FINDINGS

There is an increasing appreciation of the important reciprocal relationship between atrial fibrillation and heart failure and the negative prognostic impact that each condition has on the other. There are now four NOACs approved for stroke prevention in atrial fibrillation. There are increasing data to support their use in atrial fibrillation with heart failure, including in patients with nonmechanical or rheumatic valvular disease, and to facilitate direct current cardioversion. The choice of NOAC is heavily dependent on individual patient characteristics.

SUMMARY

The use of and indications for NOACs for patients with heart failure and atrial fibrillation are rapidly increasing.

Heart Transplant in Asia

The prevalence of heart failure has increased in Asia. A significant proportion of patients with heart failure and left ventricular dysfunction end up with advanced heart failure or end-stage heart disease. These patients may be placed on the waiting list for heart transplant. There are more than 10 countries in Asia that have an active heart transplant program. The number of heart transplants performed is limited despite an increase in the number of patients with end-stage heart failure mainly because of donor shortage, which may be related to religious belief and inefficient allocation policy.

Heart Failure: Diagnosis, Management and Utilization

Despite the advancement in medicine, management of heart failure (HF), which usually presents as a disease syndrome, has been a challenge to healthcare providers. This is reflected by the relatively higher rate of readmissions along with increased mortality and morbidity associated with HF. In this review article, we first provide a general overview of types of HF pathogenesis and diagnostic features of HF including the crucial role of exercise in determining the severity of heart failure, the efficacy of therapeutic strategies and the morbidity/mortality of HF. We then discuss the quality control measures to prevent the growing readmission rates for HF. We also attempt to elucidate published and ongoing clinical trials for HF in an effort to evaluate the standard and novel therapeutic approaches, including stem cell and gene therapies, to reduce the morbidity and mortality. Finally, we discuss the appropriate utilization/documentation and medical coding based on the severity of the HF alone and with minor and major co-morbidities. We consider that this review provides an extensive overview of the HF in terms of disease pathophysiology, management and documentation for the general readers, as well as for the clinicians/physicians/hospitalists.

Chronic Heart Failure and Inflammation

As a greater proportion of patients survive their initial cardiac insult, medical systems worldwide are being faced with an ever-growing need to understand the mechanisms behind the pathogenesis of chronic heart failure (HF). There is a wealth of information about the role of inflammatory cells and pathways during acute injury and the reparative processes that are subsequently activated. We discuss the different causes that lead to chronic HF development and how the sum of initial inflammatory and reparative responses only sets the trajectory for disease progression. Unfortunately, comparatively little is known about the contribution of the immune system once the trajectory has been set, and chronic HF has been established—which clinically represents the majority of patients. It is known that chronic HF is associated with circulating inflammatory cytokines that can predict clinical outcomes, yet the causative role inflammation plays in disease progression is not well defined, and the majority of clinical trials that target aspects of inflammation in patients with chronic HF have largely been negative. This review will present what is currently known about inflammation in chronic HF in both humans and animal models as a means to highlight the gap in our knowledge base that requires further examination.

Breakthrough in heart failure with preserved ejection fraction: are we there yet?

Heart failure with preserved ejection fraction (HFPEF) is a global health problem of considerable socioeconomic burden. It is projected to worsen with the aging population worldwide. The lack of effective therapies underscores our incomplete understanding of this complex heterogeneous syndrome. A novel paradigm has recently emerged, in which central roles are ascribed to systemic inflammation and generalized endothelial dysfunction in the pathophysiology of HFPEF. In this review, we discuss the role of the endothelium in cardiovascular homeostasis and how deranged endothelial-related signaling pathways contribute to the development of HFPEF. We also review the novel therapies in various stages of research and development that target different components of this signaling pathway.

Spectrum of epidemiological and clinical findings in patients with heart failure with preserved ejection fraction stratified by study design: a systematic review

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) represents a major global and economic burden, but its epidemiological, clinical, and outcome data have varied according to study design.

METHODS AND RESULTS

We conducted a systematic review of published HFpEF clinical trials and observational studies (community-based studies and registries) from August 1998 to July 2013 using PubMed and EMBASE databases. Two independent investigators manually screened and extracted relevant data. We included 62 articles (19 describing clinical trials, 12 describing community-based observational studies, and 31 describing registries). The ejection fraction (EF) cut-off values ranged widely for HFpEF from >40% to >55%. However, differences in EF cut-offs were not clearly associated with incidence and prevalence data across studies. Of all patients with heart failure in community studies, 33-84% had HFpEF, which tended to be higher than reported in registries. The HFpEF patients in included studies were primarily older, white (>70%) patients with hypertension (∼50-90%) and coronary artery disease (up to 60%). All-cause mortality and all-cause hospitalizations ranged from 13% to 23% (26-50 months follow-up) and 55% to 67% (37-50 months follow-up), respectively, in clinical trials; cardiovascular causes accounted for 70% of both outcomes. All-cause mortality tended to be higher in registries than in clinical trials and community-based observational studies up to 5 years into follow-up.

CONCLUSIONS

Important differences in EF thresholds, epidemiological indices, clinical profiles, treatment patterns, and outcomes exist across contemporary HFpEF clinical trials, observational studies, and registries. Precision in definition and inclusion of more uniform populations may facilitate improved profiling of HFpEF patients.

Epidemiology of heart failure with preserved ejection fraction

The prevalence of heart failure (HF) and its subtype, HF with preserved ejection fraction (HFpEF), is on the rise due to aging of the population. HFpEF is convergence of several pathophysiological processes, which are not yet clearly identified. HFpEF is usually seen in association with systemic diseases, such as diabetes, hypertension, atrial fibrillation, sleep apnea, renal and pulmonary disease. The proportion of HF patients with HFpEF varies by patient demographics, study settings (cohort vs. clinical trial, outpatient clinics vs. hospitalised patients) and cut points used to define preserved function. There is an expanding body of literature about prevalence and prognostic significance of both cardiovascular and non-cardiovascular comorbidities in HFpEF patients. Current therapeutic approaches are targeted towards alleviating the symptoms, treating the associated comorbid conditions, and reducing recurrent hospital admissions. There is lack of evidence-based therapies that show a reduction in the mortality amongst HFpEF patients; however, an improvement in exercise tolerance and quality of life is seen with few interventions. In this review, we highlight the epidemiology and current treatment options for HFpEF.

Baseline distribution of participants with depression and impaired quality of life in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial

BACKGROUND

Previous studies have demonstrated the psychosocial effect of heart failure in patients with reduced ejection fraction. However, the effects on patients with preserved ejection fraction have not yet been elucidated. This study aimed to determine the baseline characteristics of participants with heart failure with preserved ejection fraction as it relates to impaired quality of life (QOL) and depression, identify predictors of poor QOL and depression, and determine the correlation between QOL and depression.

METHODS AND RESULTS

Among patients enrolled in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial (TOPCAT), 3400 patients completed the Kansas City Cardiomyopathy Questionnaire, 3395 patients completed European QOL 5D Visual Analog Scale, and 1431 patients in United States and Canada completed the Patient Health Questionnaire-9. The mean summary score on the Kansas City Cardiomyopathy Questionnaire was 54.8, and on European QOL 5D Visual Analog Scale, it was 60.3; 27% of patients had moderate to severe depression. Factors associated with better Kansas City Cardiomyopathy Questionnaire and European QOL 5D Visual Analog Scale via multiple logistic regression analysis were American region, older age, no history of angina pectoris or asthma, no use of hypoglycemic agent, more activity level, and lower New York Heart Association class. Factors associated with depression via multiple logistic regression analysis included younger age, female sex, comorbid angina, chronic obstructive pulmonary disease, use of a hypoglycemic agent, lower activity level, higher New York Heart Association class, and selective serotonin reuptake inhibitor use. There were significant correlations between each of the QOL scores and depression.

CONCLUSIONS

Patients with heart failure with preserved ejection fraction, who were younger had higher New York Heart Association class or comorbid angina pectoris, had lower activity levels, lived in Eastern Europe or were taking hypoglycemic agents, were more likely to have impaired QOL and depression.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00094302.

Understanding the epidemic of heart failure: past, present, and future

Heart failure (HF) is a major public health problem affecting more than five million Americans and more than 23 million patients worldwide. The epidemiology of HF is evolving. Data suggests that the incidence of HF peaked in the mid-1990s and has since declined. Survival after HF diagnosis has improved, leading to an increase in prevalence. The case mix is also changing, as a rising proportion of patients with HF have preserved ejection fraction and multimorbidity is increasingly common. After diagnosis, HF can have a profound associated morbidity. Hospitalizations in HF remain both frequent and costly, though they may be declining as a result of preventive efforts. The need for skilled nursing facility care in HF has risen. The role of palliative medicine in the care of patients with advanced HF is evolving as we learn how to best care for this population with a large symptom burden.

Designing effective drug and device development programs for hospitalized heart failure: a proposal for pretrial registries

Recent international phase III clinical trials of novel therapies for hospitalized heart failure (HHF) have failed to improve the unacceptably high postdischarge event rate. These large studies have demonstrated notable geographic and site-specific variation in patient profiles and enrollment. Possible contributors to the lack of success in HHF outcome trials include challenges in selecting clinical sites capable of (1) providing adequate numbers of appropriately selected patients and (2) properly executing the study protocol. We propose a "pretrial registry" as a novel tool for improving the efficiency and quality of international HHF trials by focusing on the selection and cultivation of high-quality sites. A pretrial registry may help assess a site's ability to achieve adequate enrollment of the target patient population, integrate protocol requirements into clinical workflow, and accomplish appropriate follow-up. Although such a process would be associated with additional upfront resource investment, this appropriation may be modest in comparison with the downstream costs associated with maintenance of poorly performing sites, failed clinical trials, and the global health and economic burden of HHF. This review is based on discussions between scientists, clinical trialists, and regulatory representatives regarding methods for improving international HHF trials that took place at the United States Food and Drug Administration on January 12th, 2012.

Risk factors for rehospitalization in heart failure with preserved ejection fraction compared with reduced ejection fraction

Although there have been several studies regarding heart failure with preserved ejection fraction (HFpEF), investigations of the risk factors for readmission of Japanese patients with HFpEF remain scarce. Therefore, our goal was to identify the risk factors for readmission of Japanese patients with heart failure (HF), particularly those with HFpEF. We analyzed 310 patients who were hospitalized for the first time with HF. Preserved EF was defined EF ≥50 %, and reduced EF (rEF) was EF <50 %. The study endpoint was readmission for HF after discharge. Medical history, vital signs, electrocardiograms, chest radiographs, blood tests and echocardiograms were compared between patients with HFpEF and with HFrEF. Among the 142 patients who had HFpEF, 43 reached the endpoint within 1 year. Multivariate analysis revealed depression (HR: 7.185), high brain natriuretic peptide (BNP) levels at discharge (HR: 1.003), and dilated inferior vena cava (HR: 1.100) as independent risk factors for readmission. In contrast, 39 of the 168 patients with HFrEF reached the endpoint. Risk factors for readmission of HFrEF patients were low sodium (HR: 0.856), high blood urea nitrogen (HR: 1.045), high BNP levels at discharge (HR: 1.003) and absence of beta-blocker prescription (HR: 0.395). In conclusion, our study suggests that the predictors of HF readmission differ between HFpEF and HFrEF patients.

Heart failure with preserved ejection fraction: the impact of stricter definitions

AIMS

To determine the impact of internationally recognized criteria for the diagnosis of heart failure with preserved ejection fraction (HF-PEF) on the feasibility of recruitment into a HF-PEF trial.

METHODS AND RESULTS

We reviewed the medical records of 5883 consecutive patients admitted with heart failure across eight hospitals in the U.K. From those who had an EF ≥50% (filter 1), patients who had an alternative cardiac cause of symptoms or an over-riding co-morbidity were excluded (filter 2). The remaining patients had to satisfy the following selection criteria (filter 3): the presence of a non-dilated left ventricle; structural remodelling (LV hypertrophy or dilated left atrium); and evidence of impaired diastolic function or raised BNP. Overall, 20.5% (n = 1203) of patients admitted with heart failure had an EF ≥50%. There was significant heterogeneity between the hospitals as this proportion varied from 42.4% in the teaching hospitals to 13.8% in the district general hospitals (P < 0.0001). Applying filter 2, the cohort size was reduced from 1203 to 122 patients. Of the latter 122, only 45 people had evidence of structural cardiac remodelling and evidence of either raised cardiac filling pressures on echocardiography or raised BNP consistent with HF-PEF.

CONCLUSION

Applying our filters, only 0.8% of all patients admitted with heart failure would be eligible for a HF-PEF trial. These data have important implications for the feasibility of clinical trials for HF-PEF and for the generalizability of the results of such studies.

A multicentre cohort study of acute heart failure syndromes in Korea: rationale, design, and interim observations of the Korean Acute Heart Failure (KorAHF) registry

AIMS

The Korean Acute Heart Failure registry (KorAHF) aims to evaluate the clinical characteristics, management, hospital course, and long-term outcomes of patients hospitalized for acute heart failure syndrome (AHFS) in Korea.

METHODS AND RESULTS

This is a prospective observational multicentre cohort study funded by the Korea National Institute of Health. Patients hospitalized for AHFS in 10 tertiary university hospitals across the country have been consecutively enrolled since March 2011. The study is expected to complete the scheduled enrolment of 5000 patients some time in 2014, and follow-up is planned through 2016. As of April 2012, the interim analysis of 2066 consecutive subjects was performed to understand the baseline characteristics of the population. The mean age was 69 ± 14 years; 55% were male; and 50% were de novo heart failure. The mean left ventricular ejection fraction (LVEF) was 40 ± 18%. Ischaemia was both the leading cause (38%) and the most frequent aggravating factor (26%) of AHFS. ACE inhibitors/ARBs and beta-blockers were prescribed at discharge in 65% and 51% of the patients, respectively. In-hospital mortality was 5.2%, and 0.9% of patients received urgent heart transplantation. Low blood pressure and azotaemia were the most important predictors of in-hospital mortality. The post-discharge 30-day and 180-day all-cause mortality were 1.2% and 9.2%, respectively.

CONCLUSIONS

Our analysis reveals that the prognosis of AHFS in Korea is poor and that there are specific features, including lower blood pressures at admission and lower rates of heart failure related to hypertension, compared with other registries. Adherence to current guidelines should be improved.

Heart failure in East Asia

Heart failure (HF) carries a major burden of disease in East Asia, with high associated risk of mortality and morbidity. In recent decades, the epidemiology of HF has changed with social and economical development in East Asia. The burden of HF is still severe in East Asia.

The prevalence of HF ranges from 1.3% to 6.7% throughout the region. As aetiological factors, ischaemic heart disease has increased and valvular disease reduced in most East Asian countries. Diuretics are the most commonly used drugs (51.0%-97%), followed by renin-angiotensin system (RAS) inhibitors (59%-77%), with angiotensin-converting enzyme inhibitors, ACEI, (32%-52%) and has angiotensin-2 receptor blockers, ARBs (31%-44%) in similar proportions. β-blocker use has also increased in recent years.

Total mortality from HF ranges from 2% to 9% in China, Taiwan, Singapore, Thailand, and Japan. Age>65 years, diabetes mellitus, anaemia, renal dysfunction and atrial fibrillation (AF) are associated with adverse outcome. More prospective, region-specific data are still required, particularly regarding new drug therapies such as eplerenone and ivabradine.

Examining risk factor goal attainment and adherence to treatment among US heart failure patients: the National Health and Nutrition Examination Survey 2007-2010

PURPOSE

Data are limited regarding the adequacy of risk factor control and adherence to recommended therapies among adults with heart failure (HF). We evaluated the adequacy of risk factor control and adherence to recommended pharmacologic therapies among non-institutionalized US adults with HF.

METHODS

We examined data from US adults aged 18 years and older with a self-reported history of HF from the US National Health and Nutrition Examination Survey 2007-2008 and 2009-2010. We estimated the proportions of subjects who reported recommended lifestyle modification and medications and were at target levels of blood pressure, low-density lipoprotein cholesterol (LDL-C), and hemoglobin A1c.

RESULTS

Among 371 subjects with HF in our study, 73.7 % were non-smokers, while only 69.1, 51.9, and 56.2 % were at goal for blood pressure, LDL-C, and hemoglobin A1c (if diabetic), respectively; only 9.0 % were at goal for all measures. The proportions of non-smokers were lower in males (p < 0.01) and lowest in non-Hispanic blacks (p < 0.01). Subjects with less than a high school education (p < 0.05) were least likely to be at recommended blood pressure levels. The proportions exercising moderately, with recommended alcohol and sodium intakes, and with a normal body mass index were 8.3, 41.4, 28.9, and 17.5 %, respectively. 83.3 % of HF patients were taking only one of the recommended four classes of drugs [β-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), diuretics, and digoxin]; only 50.1 % were additionally on a lipid-lowering agent.

CONCLUSION

We observed a significant gap between adherence and control of HF risk factors and treatment among non-institutionalized US adults.

Baseline characteristics of patients with heart failure and preserved ejection fraction included in the Karolinska Rennes (KaRen) study

BACKGROUND

Karolinska Rennes (KaRen) is a prospective observational study to characterize heart failure patients with preserved ejection fraction (HFpEF) and to identify prognostic factors for long-term mortality and morbidity.

AIMS

To report characteristics and echocardiography at entry and after 4-8 weeks of follow-up.

METHODS

Patients were included following an acute heart failure presentation with B-type natriuretic peptide (BNP)>100 ng/L or N-terminal pro-BNP (NT-proBNP)>300 ng/L and left ventricular ejection fraction (LVEF)>45%.

RESULTS

The mean ± SD age of 539 included patients was 77 ± 9 years and 56% were women. Patient history included hypertension (78%), atrial tachyarrhythmia (44%), prior heart failure (40%) and anemia (37%), but left bundle branch block was rare (3.8%). Median NT-proBNP was 2448 ng/L (n=438), and median BNP 429 ng/L (n=101). Overall, 101 patients did not return for the follow-up visit, including 13 patients who died (2.4%). Apart from older age (80 ± 9 vs. 76 ± 9 years; P=0.006), there were no significant differences in baseline characteristics between patients who did and did not return for follow-up. Mean LVEF was lower at entry than follow-up (56% vs. 62%; P<0.001). At follow-up, mean E/e' was 12.9 ± 6.1, left atrial volume index 49.4±17.8mL/m(2). Mean global left ventricular longitudinal strain was -14.6 ± 3.9%; LV mass index was 126.6 ± 36.2g/m(2).

CONCLUSIONS

Patients in KaRen were old with slight female dominance and hypertension as the most prevalent etiological factor. LVEF was preserved, but with increased LV mass and depressed LV diastolic and longitudinal systolic functions. Few patients had signs of electrical dyssynchrony (ClinicalTrials.gov.- NCT00774709).

The Singapore Heart Failure Outcomes and Phenotypes (SHOP) study and Prospective Evaluation of Outcome in Patients with Heart Failure with Preserved Left Ventricular Ejection Fraction (PEOPLE) study: rationale and design

BACKGROUND

Heart failure (HF) with preserved ejection fraction (EF) accounts for a substantial proportion of cases of HF, and to date no treatments have clearly improved outcome. There are also little data comparing HF cohorts of differing ethnicity within the Asia-Pacific region.

METHODS

The Singapore Heart Failure Outcomes and Phenotypes (SHOP) study and Prospective Evaluation of Outcome in Patients with Heart Failure with Preserved Left Ventricular Ejection Fraction (PEOPLE) study are parallel prospective studies using identical protocols to enroll patients with HF across 6 centers in Singapore and 4 in New Zealand. The objectives are to determine the relative prevalence, characteristics, and outcomes of patients with HF and preserved EF (EF ≥50%) compared with those with HF and reduced EF, and to determine initial data on ethnic differences within and between New Zealand and Singapore. Case subjects (n = 2,500) are patients hospitalized with a primary diagnosis of HF or attending outpatient clinics for management of HF within 6 months of HF decompensation. Control subjects are age- and gender-matched community-based adults without HF from Singapore (n = 1,250) and New Zealand (n = 1,073). All participants undergo detailed clinical assessment, echocardiography, and blood biomarker measurements at baseline, 6 weeks, and 6 months, and are followed over 2 years for death or hospitalization. Substudies include vascular assessment, cardiopulmonary exercise testing, retinal imaging, and cardiac magnetic resonance imaging.

CONCLUSIONS

The SHOP and PEOPLE studies are the first prospective multicenter studies defining the epidemiology and interethnic differences among patients with HF in the Asia-Oceanic region, and will provide unique insights into the pathophysiology and outcomes for these patients.

Epidemiology of heart failure

Heart failure (HF) has been singled out as an epidemic and is a staggering clinical and public health problem, associated with significant mortality, morbidity, and healthcare expenditures, particularly among those aged ≥ 65 years. The case mix of HF is changing over time with a growing proportion of cases presenting with preserved ejection fraction for which there is no specific treatment. Despite progress in reducing HF-related mortality, hospitalizations for HF remain frequent and rates of readmissions continue to rise. To prevent hospitalizations, a comprehensive characterization of predictors of readmission in patients with HF is imperative and must integrate the impact of multimorbidity related to coexisting conditions. New models of patient-centered care that draw on community-based resources to support HF patients with complex coexisting conditions are needed to decrease hospitalizations.