Prevalence of stroke in systolic heart failure.

BACKGROUND: Heart disease is a major independent risk factor for stroke, ranking third after age and hypertension. Heart failure (HF) patient constitutes an important subgroup of patients with stroke, because of their poor outcome and high rates of mortality and stroke recurrence. We examined the prevalence of stroke in patients with heart failure from 3 different geographic regions. METHODS AND RESULTS: We compared the prevalence of self-reported history of stroke in participants with systolic HF from 3 different geographic regions (Houma, LA; Miami, FL; and Tbilisi, Georgia, Eastern Europe). We examined the prevalence of stroke/adjusting for patient demographic and health characteristics. Stroke prevalence was reported by 79 (7.8%) of 1017 participants from Louisiana, 51 (9.2%) of 556 participants from Florida, and 5 (1.3%) of 383 participants from Georgia. After multivariable adjustment, the prevalence of stroke was significantly lower in Georgia compared to Florida and Louisiana sites. Patients on ß-blocker medication were 3.58 times (95% CI 1.96-6.55) more likely to report stroke compared to those without ß-blockers (×2 = 19.5, P ≤ .0001). There were significantly fewer participants on ß-blockers from Georgia (7%) compared to participants from Florida (87%) and Louisiana (94%; (×2 = 24.3, P<.001). CONCLUSIONS: Self-reported stroke prevalence in participants with HF was not consistent among the 3 sites. These differences in prevalence may in part be explained by the lower reported use of ß-blockers in the Georgia site. Longitudinal studies are needed to determine whether ß-blockers increase the risk of stroke in HF population.

Prevalence of erectile dysfunction in systolic heart failure patients in a developing country: Tbilisi, Georgia, Eastern Europe.

INTRODUCTION: In the past decade, there has been an increasing amount of published information regarding erectile dysfunction (ED) and heart failure (HF) in economically advanced, westernized populations. However, there is a paucity of data regarding ED and HF in developing countries. The country of Georgia is categorized as a lower-middle-income country (LMIC) with an emerging and developing economy. AIM: To examine the prevalence of ED in patients with HF from a developing and LMIC and assess the association with depression. METHODS: We conducted an observational, cross-sectional study that included male patients 18 years of age or older with an ejection fraction ≤40% by echocardiogram in a heart failure disease management program in Tbilisi, Georgia. The Sexual Health Inventory for Men (SHIM) survey was used to categorize men according to degree of ED. Baseline clinical characteristics known to be associated with ED, such as New York Heart Association functional classification, were also documented. MAIN OUTCOME MEASURES: The SHIM survey and the nine-question Patient Health Questionnaire. RESULTS: The prevalence of ED was found to be 61.7%. Patients with ED were generally older, had more peripheral vascular disease, and had greater levels of depression than those without ED. CONCLUSIONS: There is a high prevalence of ED in patients with HF living in Tbilisi, Georgia. In comparison to previously published data on HF populations, our Georgian population showed lesser degrees of ED. More research is needed to better explain the causality for lower prevalence of ED, but explanations may include lower degrees of diabetes and aspects of treatment such as beta-blocker medication. Health care providers in LMICs should screen all of their male HF patients for ED and provide appropriate therapy.

Depression and quality of life among heart failure patients in Georgia, Eastern Europe.

The goal of the study was to assess longitudinal changes in quality of life among patients who screened positive for depression and patients who did not enroll in an outpatient heart failure disease management program (HFDMP). Patients with an ejection fraction ≤40% and clinical signs and symptoms of heart failure were enrolled over 11 months from August 2007 to July 2008. Study participants (n=314) were divided at baseline into "depressed" (9-Question Patient Health Questionnaire [PHQ-9] ≥10) and "nondepressed" (PHQ-9 <10) groups. The two cohort groups had quality of life assessed by the Minnesota Living With Heart Failure Questionnaire at baseline and at 1 year while enrolled in the HFDMP. Both groups showed improved quality of life scores, with the depressed group experiencing a greater mean score decrease (14.4 vs 10.8 for nondepressed patients; P<.01). Both patients who screened positive for depression and those who did not enroll in an HFDMP improved their quality of life scores, with depressed patients experiencing a statistically significant greater mean score reduction (better quality of life).

Pathways in heart failure disease management across socioeconomic spectra.

Caring for heart failure patients with a low socioeconomic status presents a unique set of challenges for health care providers. Heart failure disease management programs can integrate the use of teaching DVDs to overcome deficiencies in health literacy and take advantage of the Wal-Mart/Target $4 dollar medication program to provide life-saving medical therapy. In addition, open discussions with the patient and family regarding the costs of medications and the reality of what they can afford to pay monthly on a long term basis can guide the physician to prescribing medications by prioritizing use with a focus on evidence-based data for the medications with the highest mortality reduction. Finally, connecting inpatient visits to outpatient visits through the use of electronic medical records systems can facilitate avoidance of unnecessary repeat lab and diagnostic testing.

Feasibility of a heart failure disease management program in eastern Europe: Tbilisi, Georgia.

BACKGROUND: Little is known about the importation of a heart failure disease management program (HFDMP) into low- and middle-income countries. We examined the feasibility of importing a HFDMP into the country of Georgia, located in the Caucuses. METHODS AND RESULTS: Patients with ejection fraction ≤40% were enrolled into a prospective, observational study consisting of a new HFDMP staffed by local cardiologists. Medications, emergency department use, hospital admissions, and mortality were assessed by interviews with patients or their families. Screening resulted in 400 patients who were followed for 10.2±3.5 months. ß-Blocker prescriptions increased from 7.4-80.7% (P<0.001), angiotensin-converting enzyme inhibitor prescriptions increased from 18.4-92.6% (P<0.001), and mean systolic blood pressure declined from 145 to 114 mm Hg (P<0.001). Patients visiting the emergency department and hospitalizations were lowered by 40.7% and 52.5%, respectively, but were also influenced by the outbreak of war, during which 17.5% (n=70) of patients received follow-up in refugee tents. All-cause mortality extended to 7% of patients, with 12 of 28 deaths caused by war-related events. CONCLUSIONS: Importation of a Western HFDMP was demonstrated to be feasible, with a 5-fold increase in the use of recommended therapies, reduction of blood pressure, decrease of emergency department visits, and hospitalizations for heart failure. These measures could result in substantial cost savings in resource-limited settings, but assessment is complicated in unstable areas. Translating effective interventions to low- and middle-income countries requires sensitivity to regional cultures and flexibility to adapt both clinical goals and strategies to unexpected conditions.