Clinical characteristics, management, and outcome of patients with high risk chronic heart failure referred to heart failure clinic in Saudi Arabia Abdelfatah Elasfar MD, FACP Consultant Heart Failure Cardiologist Prince Salman Heart Center King Fahad Medical City Riyadh, Saudi Arabia
Background ďƒ˜ Despite major advances in the treatment of heart failure patients, morbidity and mortality remain high. ďƒ˜ HFCs with specialized multidisciplinary management programs have been proposed to improve the prognosis of heart failure. ďƒ˜ The heart function assessment registry trial in Saudi Arabia (HEARTS) is the first multicenter national project in the Arab world to study the clinical features, management, short and long-term outcomes of patients admitted with acute and chronic heart failure
Purpose • We aimed to describe the clinical features, management and outcomes of patients with high risk chronic HF referred to HFC in a large tertiary care center in Riyadh City in Saudi Arabia.
Study Population ď ą High-risk chronic heart failure (H-CHF): Patients at high-risk for hospital re-admission and/or death who were referred to the heart failure clinic (HFC) .
Referral Criteria
• Severe LVD + persistent HF symptoms. • HF + severe valvular HD. • HF + significant renal impairment • Poor tolerance or nonadherence to Medications. • Difficulty in up-titration of medications. • Multiple HF hospitalizations.
Structure of the heart failure clinic • The HFC in our center is a physician-led HFC with involvement of other disciplines including: two qualified HF nurse practitioners, two clinical pharmacists, one dietitian, and one physiotherapist. • 2 clinics/week.
HFC concept • The concept is focusing on systems and procedures most likely to contribute to the consistent application of clinical guidelines and, consequently, optimal patient care. • This includes: proper assessment of functional class and QOL, medical therapy and device evaluation, nutritional assessment, flexible follow-up and communication programs, and extensive education for patients and caregivers.
Patient follow-up and outcome • Patients were followed in the HFC at a frequency according to the clinical severity of their heart failure manifestation. • One year follow-up included assessment of the functional class, medications and ICD/CRT implantation, readmissions and mortality. • Trans-telephonic follow-up was done for patients who are lost for follow-up in the HFC.
Statistical methods • Continuous variables that are normally distributed were summarized using mean and SD while those not normally distributed were presented as median and IQR. • Categorical variables were summarized using frequency and percentages. • Data were entered and analysed using SPSS version 17 (SPSS Inc., USA).
Demographics (N=436) Over all Mean age ± SD years
56.5 ± 15.9
Male
70.3 %
Saudi
95.3 %
Body Mass Index (SD) (kg/m²)
29.13 ± 6.04
Site of Referral To HFC (N=436)
%
Reasons for referral (N=436)
%
HF Risk Factors (N=436)
%
70 60 50 40 30 20 10 0
69.1 43 15.5
12.9
9.7
4.5
1.3
1.3
1.3
Other risk factors (N=436)
%
(Associated Comorbidities (N=436
%
(Devices (N=436
%
(NYHA class (N=436
%
Vital signs on presentation Over all (SBP, median (IQR
(33) 116
(DBP, median (IQR
(16)67
(HR, median (IQR
(21) 78
Signs of HF
%
N=436) LV systolic function)
%
Medications
Evidence based therapies
BB
ACE-I
%
ARBs
%
Medications at 1 year
Target Dose; Bisoprolol
Target Dose; Carvedilol
Heart Failure Etiology
Re-admission rate N=347
Mortality at 1year of follow-up (N=347)
Where are we? IMPROVE HF ICONS (US) (Canada) (N= 34810) (N=984)
Mean age, years
68 ±13
)%(History of DM
34
History of HTN )%(
)%(IHD
, %Median EF
68
14±
ESC-HF Pilot HFC Survey (KSA) (Europe) (N= (N= 436) (3226
67±13
56±15
34
29
53.3
62
57
58
68.8
65
37
40.4
39
25±7
35±17
36
26±13
Limitations • • • •
Small sample size. limited geographic representation. The observational nature. Tertiary care center might be more enthusiastic about adherence to guidelines and evidence based practice.
Limitations • However, the aim of this report was to describe this early experience with this kind of HFCs and to describe the clinical characteristics of this cohort. • The view of chronic heart failure epidemiology in Saudi Arabia may be more obvious in future with after establishing more heart failure clinics in different geographical areas of the Kingdom.
Conclusions • Compared with HF patients in western countries, outpatients with high-risk HF in Saudi Arabia are younger, have much higher prevalence of diabetes mellitus and hypertension, and predominantly have LV systolic dysfunction. • The rate of evidence-based therapies use was reasonable, but the ICD/CRT implantation rate was low. • The study is limited by its small sample size, its location in only tertiary-care hospitals, and limited geographic representation. • Further improvements in management; and potentially clinical outcomes, are yet to be shown with long-term follow-up at the HFC
Thank you