Temporal trends in epidemiology, clinical presentation and management of acute heart failure: results from the Greek cohorts of the Acute Heart Failure Global Registry of Standard Treatment and the European Society of Cardiology-Heart Failure pilot survey

Cardiorenal multimorbidity in hospitalized cardiology patients: The Hellenic Cardiorenal Morbidity Snapshot (HECMOS) study

PURPOSE

Cardiovascular disease is commonly accompanied by renal dysfunction. Multimorbidity in hospitalized patients impacts unfavorably on prognosis and hospital stay. We aimed to illustrate the contemporary burden of cardiorenal morbidity across inpatient cardiology care in Greece.

METHODS

The Hellenic Cardiorenal Morbidity Snapshot (HECMOS) used an electronic platform to collect demographic and clinically relevant information about all patients hospitalized on March 3, 2022, in Greece. The participating institutions covered all levels of inpatient cardiology care and most of the country's territories to collect a real-world, nation representative sample.

RESULTS

A total of 923 patients (men 68.4%, median age 73 ± 14.8 years) were admitted to 55 different cardiology departments. 57.7% of the participants were aged >70 years. Hypertension was highly prevalent and present in 66% of the cases. History of chronic HF, diabetes mellitus, atrial fibrillation, and chronic kidney disease was present in 38%, 31.8%, 30%, and 26%, respectively. Furthermore, 64.1% of the sample exhibited at least one of these 4 entities. Accordingly, a combination of ≥2 of these morbid conditions was recorded in 38.7%, of ≥3 in 18.2%, whereas 4.3% of the sample combined all 4 in their medical history. The most common combination was the coexistence of heart failure-atrial fibrillation accounting for 20.6% of the sample. Nine of 10 nonelectively admitted patients were hospitalized due to acute HF (39.9%), acute coronary syndrome (33.5%), or tachyarrhythmias (13.2%).

CONCLUSION

HECMOS participants carried a remarkable burden of cardio-reno-metabolic disease. HF in conjunction with atrial fibrillation was found to be the most prevalent combination among the studied cardiorenal nexus of morbidities in the whole study population.

Angiotensin receptor-neprilysin inhibition in patients with acute decompensated heart failure: an expert consensus position paper

The short-term mortality and rehospitalization rates after admission for acute heart failure (AHF) remain high, despite the high level of adherence to contemporary practice guidelines. Observational data from non-randomized studies in AHF strongly support the in-hospital administration of oral evidence-based modifying chronic heart failure (HF) medications (i.e., b-blockers, ACE inhibitors, mineralocorticoid receptor antagonists) to reduce morbidity and mortality. Interestingly, a well-designed prospective randomized multicenter study (PIONEER-HF) showed an improved clinical outcome and stress/injury biomarker profile after in-hospital administration of sacubitril/valsartan (sac/val) as compared to enalapril, in hemodynamically stable patients with AHF. However, sac/val implementation during hospitalization remains suboptimal due to the lack of an integrated individualized plan or well-defined appropriateness criteria for transition to oral therapies, an absence of specific guidelines regarding dose selection and the up-titration process, and uncertainty regarding patient eligibility.

In the present expert consensus position paper, clinical practical recommendations are proposed, together with an action plan algorithm, to encourage and facilitate sac/val administration during hospitalization after an AHF episode with the aim of improving efficiencies of care and resource utilization.

Utilisation of real-world data from heart failure registries in OECD countries - A systematic review

BACKGROUND

Heart failure represents a major public health issue that impacts 26 million people globally. Currently, real-world data represents a key instrument for providing the verification of both internal and external validity, yet there is still a lack of understanding regarding its scope in complementing evidence of treatments for heart failure. This study aims to increase understanding of the utilisation of real-word data from heart failure registries in Organisation for Economic Co-operation and Development (OECD) countries.

METHOD

This was a systematic review of existing observational studies from heart failure registries in 35 OECD member countries. Studies from 2000 to March 2017 were identified through electronic databases (MEDLINE (Ovid), EMBASE, Web of Science Core Collection, CINAHL (Ebsco), Cochrane CENTRAL) and appraised according to eligibility criteria.

RESULTS

Two-hundred and two studies met the inclusion criteria, in which the majority were published from 2013 to 2016. All 202 studies were observational, among which 98% were cohort studies (198). The median sample size of all studies was 5152 (2417 to 32,890) and median study period 55 months (33.0 to 72.0). Swedish heart failure registry had the most publications (24, 12%).

CONCLUSION

Since 2000 there has been an upward trend in the number of published observational studies on heart failure registries in OECD countries with increasingly diverse outcomes and advanced statistical methods to improve their validity and reliability. This indicates that the utilisation of real-world data has experienced a significant upsurge in complementing the findings of clinical trials for improved research of heart failure treatments.

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.

Temporal Trends of Hospitalized Patients with Heart Failure in Korea

Heart failure (HF) is an important cardiovascular disease because of its increasing prevalence, significant morbidity, high mortality and rapidly expanding health care costs. The number of HF patients is increasing worldwide and Korea is no exception. Temporal trends of four representative Korean hospitalized HF registries-the Hallym HF study, the Korean Multicenter HF study, the Korean Heart Failure (KorHF) registry and the Korean Acute Heart Failure (KorAHF) registry showed mild survival improvement reflecting overall HF patient care development in Korea despite the increased severity of enrolled patients with higher incidence of multiple comorbidities. Moreover, device therapies such as implantable cardioverter defibrillator and cardiac resynchronization therapy and definitive treatment such as heart transplantation have been increasing in Korea as well. To prevent HF burden increase, it is essential to set up long term effective prevention strategies for better control of ischemic heart disease, hypertension and diabetes, which might be risk factors for HF development. Moreover, proper HF guidelines, performance measures, and performance improvement programs might be necessary to limit HF burden as well.

Nutritional status is related to heart failure severity and hospital readmissions in acute heart failure

BACKGROUND

Malnutrition is common in hospitalized heart failure (HF) patients and predicts adverse outcomes. The relationship between nutritional status and outcomes in HF has been partially studied. Our aim was to determine the relationship between the nutritional status and the long-term prognosis in patients hospitalized for acute HF.

METHODS

We analyzed 145 patients admitted consecutively to a cardiology department for acute HF. Nutritional status was measured with the CONUT method, a validated scale based on laboratory testing (albumin; cholesterol; lymphocytes) during hospitalization. Patients were classified as normal, mildly, moderately or severely malnourished, and followed in a HF clinic.

RESULTS

The mean aged of the population was 69.6years and 61% of patients were men, 54 had previous HF hospitalization (37%), 112 had hypertension (77%), 67 were diabetic (46%) and 135 had class III or IV NYHA (93%). Forty eight patients (33%) had normal nutritional status, 75 were mildly malnourished (52%), and 22 were moderately or severely malnourished (15%). Age, sex, hypertension, diabetes mellitus, or NYHA class among the three groups were not statistically different. ProBNP was directly correlated with the nutritional status. After a mean follow-up of 326days, 27 had a HF hospitalization (19%) and 61 (42,1%) had a hospitalization not related to HF. The analysis by Kaplan-Meier curves and log rank test showed that these differences were statistically significant.

CONCLUSION

Malnutrition is common in patients hospitalized for HF. It seems to be a mediator of disease progression and determines a poor prognosis especially in advanced stages.

Body mass index in acute heart failure: association with clinical profile, therapeutic management and in-hospital outcome

BACKGROUND

Increased body mass index (BMI) is a risk factor for heart failure, but evidence regarding BMI in acute heart failure (AHF) remains inconclusive. We sought to compare the clinical profile, treatment and in-hospital outcome across BMI categories in a large international AHF cohort.

METHODS

The Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF) is a retrospective survey on 4953 patients admitted for AHF from nine countries in Europe, Latin America, and Australia. Patients with unavailable BMI data or BMI <18.5 kg/m(2) were excluded. Clinical data and in-hospital mortality were compared among the following BMI categories: 18.5-24.9 kg/m(2) (normal weight), 25-29.9 kg/m(2) (overweight) and ≥30 kg/m(2) (obese).

RESULTS

Overweight/obese patients represented 75.7% of patients and had worse New York Heart Association class (P < 0.001) and higher admission systolic blood pressure (P < 0.001). The prevalence of comorbidities increased in parallel with BMI and included arterial hypertension, diabetes mellitus, dyslipidaemia (all P < 0.001), chronic obstructive pulmonary disease (P = 0.041) and chronic kidney disease (P = 0.056). Use of guideline-recommended medications also increased in parallel with BMI (angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, P < 0.001; β-blockers P < 0.001; mineralocorticoid receptors antagonist, P = 0.002). In-hospital mortality had a U-shaped relationship with BMI, with overweight patients having significantly lower rate (log-rank P = 0.027); this relationship vanished after adjustment for confounders.

CONCLUSIONS

Overweight/obese patients represented the vast majority of AHF cases, had a higher prevalence of non-cardiovascular comorbidities and were more likely to receive guideline-recommended medications. The U-shaped relationship between in-hospital mortality and BMI may be explained by differences in clinical profile and treatment and not by an effect of body composition per se.

The medical and socioeconomic burden of heart failure: A comparative delineation with cancer

Cardiovascular disease and cancer represent the two leading causes of death in the Western World. Still, cardiovascular disease causes more deaths and more hospitalizations than cancer. Although mortality rates of both conditions are generally declining, this is not true for heart failure (HF). The prevalence of HF is increasing, although its incidence has been stabilized, mainly because of the population aging. The survival of patients with HF is overall worse than those with cancer. In addition, HF failure is the most common reason for hospitalization in the elderly, while hospitalization for HF is followed by adverse prognosis and represents the main contributor to the huge financial expenditure caused by the syndrome. The outcome of HF patients and thus its medical and socioeconomic burden may be improved by the more efficient in-hospital management of patients, the enhancement of adherence to guideline-recommended therapies, the identification and treatment of comorbid conditions and the introduction of more effective medical therapies.

International REgistry to assess medical Practice with lOngitudinal obseRvation for Treatment of Heart Failure (REPORT-HF): rationale for and design of a global registry

Aims

The clinical characteristics, initial presentation, management, and outcomes of patients hospitalized with new‐onset (first diagnosis) heart failure (HF) or decompensation of chronic HF are poorly understood worldwide. REPORT‐HF (International REgistry to assess medical Practice with lOngitudinal obseRvation for Treatment of Heart Failure) is a global, prospective, and observational study designed to characterize patient trajectories longitudinally during and following an index hospitalization for HF.

Methods

Data collection for the registry will be conducted at ∼300 sites located in ∼40 countries. Comprehensive data including demographics, clinical presentation, co‐morbidities, treatment patterns, quality of life, in‐hospital and post‐discharge outcomes, and health utilization and costs will be collected. Enrolment of ∼20 000 adult patients hospitalized with new‐onset (first diagnosis) HF or decompensation of chronic HF over a 3‐year period is planned with subsequent 3 years follow‐up.

Perspective

The REPORT‐HF registry will explore the clinical characteristics, management, and outcomes of HF worldwide. This global research programme may have implications for the formulation of public health policy and the design and conduct of international clinical trials.

Drug therapy for patients with systolic heart failure after the PARADIGM-HF trial: in need of a new paradigm of LCZ696 implementation in clinical practice

Heart failure represents a primary cause of morbidity and mortality in older people and despite significant therapeutic advances, it is still characterized by important unmet needs, thus remaining a challenging field of clinical research. The recent PARADIGM-HF trial compared the novel compound LCZ696, a combination of the angiotensin receptor blocker valsartan and the neprilysin inhibitor sacubitril, versus the angiotensin-converting enzyme inhibitor enalapril in 8,442 patients with symptomatic chronic systolic heart failure. LCZ696 led to a 20% reduction in the rate of death or hospitalization for heart failure and a 16% reduction in the rate of all-cause death compared to enalapril at 3.5 years of follow-up. Despite those impressive results, the clinical application of this novel agent that requires the substitution of a cornerstone of current heart failure therapy, the angiotensin-converting enzyme inhibitors, should follow careful steps as imposed by the study design, the recruited population and the outcome in specific patient subgroups. Further insights into the effects of LCZ696 will be provided by the ongoing PARAGON-HF trial in patients with diastolic heart failure.

Determinants of the direct cost of heart failure hospitalization in a public tertiary hospital

BACKGROUND

Heart failure (HF) is the first reason for hospital admission in the elderly and represents a major financial burden, the greatest part of which results from hospitalization costs. We sought to analyze current HF hospitalization-related expenditure and identify predictors of cost in a public tertiary hospital in Europe.

METHOD

We performed a retrospective chart review of 197 consecutive patients, aged 56±16years, 80% male, with left ventricular ejection fraction (LVEF) of 30±10%, hospitalized for HF in a major university hospital in Athens, Greece. The survey involved the number of hospitalization days, laboratory investigations and medical therapies. Patients who were hospitalized in CCU/ICU or underwent interventional procedures or device implantations were excluded from analysis. Costs were estimated based on the Greek healthcare system perspective in 2013.

RESULTS

Patients were hospitalized for a median of 7 days with a total direct cost of €3198±3260/patient. The largest part of the expenses (79%) was attributed to hospitalization (ward), while laboratory investigations and medical treatment accounted for 17% and 4%, respectively. In multivariate analysis, pre-admission New York Heart Association NYHA class (p=0.001), serum creatinine (p=0.003) and NT-proBNP (p=0.004) were significant independent predictors of hospitalization cost.

CONCLUSION

Direct cost of HF hospitalization is high particularly in patients with more severe symptoms, profound neurohormonal activation and renal dysfunction. Strategies to lower hospitalization rates are warranted in the current setting of financial constraints faced by many European countries.