Acute Heart Failure Globally Isn't All the Same: REPORT-HF Survey

May 28, 2018

VIENNA — Patients with acute heart failure (AHF) and their management can vary widely around the world, partly because of regional differences in care processes and access to care, suggests a new international survey that may also convey some good news.

Compared with findings from prior international surveys, patients with AHF today "are more similar than we expected" in terms of their age, comorbidities, and treatments they receive, Sean P. Collins, MD, MSc, Vanderbilt University, Nashville, Tennessee, told | Medscape Cardiology.

But there were telling differences among world regions in AHF precipitants, that is the conditions or events that led to decompensation and hospitalization, he said.

For example, infections like pneumonia or urinary tract infections were the most likely triggers in the Western Pacific region. Acute coronary syndromes (ACS) tended to be the precipitant in Southeast Asia. But it was likely to be nonadherence to dietary recommendations or prescribed medications in North America.

Outside of North America, "adherence is less of an issue," said Collins. He presented results from the hospital phase of AHF care in the International Registry to Assess Medical Practice with Longitudinal Observation for Treatment of Heart Failure, dubbed REPORT-HF, here at the European Society of Cardiology (ESC HF) Heart Failure 2018.

The 44-nation survey is following 18,805 patients with AHF as a primary diagnosis who were hospitalized at 358 centers; they could have a new heart failure (HF) diagnosis or decompensation of previously diagnosed chronic HF.

"The results tell us that acute heart failure is not acute heart failure around the world," said Mitja Lainscak, MD, PhD, University of Ljubljana, Slovenia, emphasizing the observed regional variations as co-moderator of the session with Collins' presentation.

"Also, the management, including treatments, of the patients is not the same around the world. Maybe this has to do with the patients being not the same, or that the translation of guidelines around the world is not the same," he said. 

Table. Clinical Presentation by Region in REPORT-HF

Presentation Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7
n 3661 2810 2265 2369 3392 1622 2686
De novo HF (%) 37 33 38 79 47 20 40
Decompensated chronic ischemic HF (%) 39 48 42 37 40 24 28
Resting dyspnea (%) 70 88 91 88 84 72 84
Regions: 1, Western Europe; 2, Eastern Europe; 3, Eastern Mediterranean and Africa; 4, Southeast Asia; 5, Western Pacific; 6, North America; 7, Central and South America.

To others at the ESC-HF sessions who focused on the regional similarities, REPORT-HF demonstrates progress. It shows AHF management is becoming more consistent around the world compared with the results of earlier surveys, observed Alexandre Mebazaa, MD, PhD, Hôpital Lariboisière, Paris, France, for | Medscape Cardiology.

"I think this is very good news," said Mebazaa, a principle investigator for the Global Research on Acute Conditions Team (GREAT) Network registry studies, which has also tracked patients arriving at the emergency department (ED) with AHF.

"The two are complementary," Mebazaa said of the REPORT-HF and GREAT registry initiatives, "because they show that over the years, the acute heart failure phenotype and acute heart failure outcomes are now more and more close together across all the continents."

That's in contrast to, say, 15 years ago, he said, when there was "huge heterogeneity" in the features and prognosis of patients with AHF across the world.

De Novo or Decompensated Chronic HF

Still, some heterogeneity remains today. For example, about 80% of the patients in Southeast Asia presented with de novo HF, Collins observed. "That's the polar opposite of North America, where 20% of people presenting with symptoms didn't previously know they had heart failure."

Regions also varied widely in how long it took patients with AHF, from their first contact with the medical system, to be admitted to an intensive care or coronary care unit (ICU or CCU). North America and Eastern Europe were the standouts for the longest and shortest median times, respectively.

Similarly, compared with the midrange Western Pacific region as an index, the time to first IV treatment from first medical contact was significantly longer in North America and significantly shorter in Eastern Europe (P < .0001 for both differences).

Patients in North America, Collins explained, tended to spend longer in the ED with all the attendant delays. That's probably because their presentations were less specific, and because their route to the CCU is generally less expeditious than in, for example, Eastern Europe.

"I think the patients in the US probably had less pulmonary symptoms — they had less congestion on their chest X-ray and less dyspnea at rest. But it also speaks to the crowding in US hospitals," Collins said.

In the United States, he said, presenting to the ED with weight gain, stomach bloating, leg swelling, or other nonspecific AHF signs, but without dyspnea, "won't get you to the top of the list as quickly as, 'I'm having a hard time breathing,' " Collins said. 

"What it suggests is that people with acute heart failure don't come in as floridly sick in the US as they do in other regions." So in a crowded ED, more apparently serious cases — "I'm thinking about the sepsis patient, the trauma patient" — will be triaged ahead of them.

The opposite seemed to be true in Eastern Europe, where it's common to have physicians in ambulances make a prehospital diagnosis and initiate therapy. "They admit them right to the ICU instead of going to the ED like we do in North America." 

Table. Admission Medical Therapy by Region in REPORT-HF

Parameter or endpoint Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7
n 3661 2810 2265 2369 3392 1622 2686
ACE/ARB (%) 59 56 54 27 39 50 61
Beta blockers (%) 64 61 52 25 37 71 56
Regions: 1, Western Europe; 2, Eastern Europe; 3, Eastern Mediterranean and Africa; 4, Southeast Asia; 5, Western Pacific; 6, North America; 7, Central and South America.

Nonadherence to dietary recommendations or chronic medications was the predominant trigger of AHF in North America, accounting for about 19% of cases, whereas ACS was the precipitant in only 3.5% and infections in 4%.

In contrast, ACS was the precipitant in about 26% of cases in Southeast Asia; nonadherence was responsible in only 5.4% and infections in 4.5%.

Nonadherence figured as a major precipitant in the United States largely because of limitations on access to care, Collins proposed. Many patients didn't have regular doctors or couldn't afford to fill prescriptions.

Table. Precipitating Factors by Region in REPORT-HF

Precipitant Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7
n 3661 2810 2265 2369 3392 1622 2686
Infection (%) 8 6 15 5 19 4 8
Ischemic event (%) 7 11 16 26 17 4 8
Nonadherence to diet/meds (%) 4 9 14 5 7 19 10
Regions: 1, Western Europe; 2, Eastern Europe; 3, Eastern Mediterranean and Africa; 4, Southeast Asia; 5, Western Pacific; 6, North America; 7, Central and South America.

Adjusted hospital mortality was highest in Central America and South America at 4.4% and lowest in Eastern Europe at 1.5%.

The median hospital length-of-stay was longest in Western Europe, Eastern Europe, and Western Pacific at 9 days each, and the shortest in the Eastern Mediterranean and Africa, South East Asia, and North America at 6 days each.

"Probably we need to do another global survey like this in 5 or 10 years," Mebazaa said. "Then we really might be surprised to see that patients are really similar all around the world, treated in the same way."

That would increase the effectiveness of AHF clinical trials with international enrolments, he proposed. The success of such trials today is often limited because of regional variations in AHF phenotype and processes of care. As different world regions converge in those respects, Mebazaa proposed, conclusions based on the trials will be more universally relevant.

REPORT-HF was supported by Novartis. Collins discloses receiving research support from Cardiorentis, Cardioxyl, Intersection Medical, and Novartis, and consulting for Cardiorentis, Cardioxyl, Intersection Medical, Medtronic, Novartis, Insys Therapeutics, and Abbott Point-of-Care. Lainscak has recently reported no conflicts. Mebazaa has recently disclosed serving as a speaker or member of a speaker's bureau for Novartis, Orion, and AbbVie.

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