Global Variations in Heart Failure Etiology, Management, and Outcomes.

Importance: Most epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries. Objective: To examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development. Design, Setting, and Participants: Multinational HF registry of 23 341 participants in 40 high-income, upper-middle-income, lower-middle-income, and low-income countries, followed up for a median period of 2.0 years. Main Outcomes and Measures: HF cause, HF medication use, hospitalization, and death. Results: Mean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a ß-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper-middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower-middle-income countries (39.5%) (P < .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper-middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower-middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper-middle-income countries (ratio = 2.4), similar in lower-middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper-middle-income countries (9.7%), then lower-middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower-middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies. Conclusions and Relevance: This study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally.

Heart failure in low- and middle-income countries: background, rationale, and design of the INTERnational Congestive Heart Failure Study (INTER-CHF).

BACKGROUND: Although heart failure (HF) has been referred to as a global epidemic, most HF information comes from high-income countries, with little information about low-income countries (LIC) and middle-income countries (MIC) in Africa, Asia, the Middle East, and South America, which make up the majority of the world's population. METHODS: The INTERnational Congestive Heart Failure Study is a cohort study of 5,813 HF patients enrolled in 108 centers in 16 LIC and MIC. At baseline, data were recorded on sociodemographic and clinical risk factors, HF etiology, laboratory variables, management, and barriers to evidence-based HF care at the patient, physician, and system levels. We sought to enroll consecutive and consenting patients ≥18 years of age with a clinical diagnosis of HF seen in outpatient clinics (2/3 of patients) or inpatient hospital wards (1/3 of patients). Patients were followed up at 6 and 12 months post-enrollment to record clinical status, treatments, and clinical outcomes such as death and hospitalizations. In the 5,813 enrolled HF patients, the mean age was 59 ± 15 years, 40% were female, 62% had a history of hypertension, 30% had diabetes, 21% had prior myocardial infarction, 64% were recruited from outpatient clinics, 36% lived in rural areas, and 29% had HF with preserved left ventricular ejection fraction. CONCLUSIONS: This unique HF registry aims to systematically gather information on sociodemographic and clinical risk factors, etiologies, treatments, barriers to evidence-based care, and outcomes of HF in LIC and MIC. This information will help improve the management of HF globally.

Assessment of the American Society of Echocardiography-European Association of Echocardiography guidelines for diastolic function in patients with depressed ejection fraction: an echocardiographic and invasive haemodynamic study.

AIMS: There is controversy surrounding the accuracy of echo-Doppler variables, including early mitral inflow/mitral annular velocity (E/e'), for estimating left ventricular filling pressure (LVFP) in patients with depressed ejection fraction (EF < 50%). METHODS AND RESULTS: The American Society of Echocardiography-European Association of Echocardiography (ASE-EAE) algorithm for diastolic function in depressed LVEF was retrospectively applied to a database of patients who underwent echocardiography ≤20 min of cardiac catheterization. LV pre-atrial contraction pressure (pre-A) ≥15 mmHg was elevated. Of 62 patients studied, the mean age was 53.6 ± 10.6 years and the mean LVEF was 27.2 ± 11.8%. The correlations of E/e' (R = 0.43, P = 0.0005) and E (R = 0.39, P = 0.002) with LV pre-A were modest, compared with pulmonary artery pressure (PAP, R = 0.69, P = 0.0006), E/late mitral (A) velocity (R = 0.52, P < 0.0001), and mitral deceleration time (DT, R = -0.51, P < 0.0001). Using the ASE-ESE algorithm starting with E/A, E, and DT, 54 of 62 patients were accurately classified to predict LV pre-A >15 or <15 mmHg (sensitivity = 84%, specificity = 80%, area under the curve = 0.86, P < 0.001). The 6 of 6 patients with E/A < 1 and E < 50 and the 14 of 15 (93%) patients with E/A> 2 and DT < 150 were correctly classified as having normal and elevated LVFP, respectively, while 34 of 41 (83%) patients with E/A = 1-2 or E/A<1 and E>50 cm/s were correctly classified using the addition of E/e' and PAP. CONCLUSION: This retrospective study shows that in this population with depressed LVEF, no single echo-Doppler variable had high accuracy for predicting LV pre-A ≥15 mmHg. However, the ASE-EAE algorithm using multiple variables predicted LVFP with good accuracy, superior to any single echo-Doppler variable alone.

Assessment of left ventricular systolic function using echocardiography in patients with preserved ejection fraction and elevated diastolic pressures.

There is controversy regarding the nature of systolic function in patients with elevated filling pressure and preserved left ventricular (LV) ejection fraction. In this study, tissue Doppler variables and 2-dimensional echocardiographic systolic strain (SS) and systolic strain rate (SSr) were measured in patients who underwent cardiac catheterization to determine correlations with invasively measured LV end-diastolic pressure (LVEDP), dP/dt, and LV mass. Forty patients were studied. Their mean age was 55.9+/-9.9 years, and their mean LV ejection fraction was 59.8+/-5.2%. Tissue Doppler systolic annular velocity (5.4+/-1.1 vs 6.4+/-1.0 cm/s, p=0.04), SS (13.4+/-3.7% vs 18.8+/-2.3%, p <0.001), and SSr (0.73+/-0.17 vs 0.98+/-0.14 s(-1), p <0.001) were significantly lower in patients with LVEDP >20 mm Hg compared with those with LVEDP <20 mm Hg. Tissue Doppler systolic velocity, SSr, and SS were correlated with LV mass (R=0.58, R=0.57, and R=0.52, respectively, all p values <0.001) and with LVEDP (R=0.49, p=0.002; R=0.79, p<0.001; and R=0.70, p<0.001, respectively). However, dP/dt was not significantly different between patients with LVEDP >20 mm Hg and those with LVEDP <20 mm Hg (1,387+/-520 vs 1,495+/-594 mm Hg/s, respectively, p=0.55) and was not correlated with LV mass (R=0.18, p=0.25). The optimum cut-off values for LVEDP >20 mm Hg were SSr <0.85 s(-1) (area under the curve 0.88, p<0.001, positive predictive value 89%, negative predictive value 86%) and SS<16% (area under the curve 0.84, p=0.002, positive predictive value 88%, negative predictive value 79%). In conclusion, as opposed to invasively measured dP/dt, tissue Doppler systolic velocity and 2-dimensional echocardiographic SS and SSr are significantly depressed in patients with preserved LV ejection fraction and LVEDP >20 mm Hg, suggesting that systolic abnormalities are present in at least some of these patients. These differences are likely because invasively measured dP/dt and these echocardiographic variables measure different systolic properties in patients with preserved LV ejection fraction.

Comparative cost-effectiveness of B-type natriuretic peptide and echocardiography for predicting outcome in patients with congestive heart failure.

Two-dimensional echocardiographic and Doppler variables and B-type natriuretic peptide (BNP) can predict outcomes in patients with congestive heart failure (CHF). However, there is a paucity of data on the relative cost-effectiveness of these modalities in predicting outcome. One hundred sixteen patients hospitalized with CHF underwent simultaneous BNP and Doppler echocardiographic examinations once ready for discharge. The ability of these variables to determine the primary end point (cardiac death or rehospitalization for CHF) was determined. The cost-effectiveness ratios (CER) of 2-dimensional variables, Doppler indexes, and BNP were calculated for prediction of the primary end point. Follow-up was completed in 110 of 116 patients at a mean of 527 days after hospital discharge. Fifty-four patients (50%) reached the primary end point (37 rehospitalizations for CHF and 17 cardiac deaths). When added to a history of admission to the hospital in the preceding year for CHF, a comprehensive Doppler echocardiographic study predicted 52 of 54 events, with a CER of 729.10 dollars, whereas BNP predicted 47 of 54 events (CER 49.98 dollars; p < 0.001 for CER comparison). In patients admitted to hospitals with CHF, predischarge BNP is more cost-effective than comprehensive Doppler echocardiographic examination for the prediction of future cardiac death or rehospitalization for CHF.

Optimal noninvasive assessment of left ventricular filling pressures: a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters.

BACKGROUND: Early transmitral velocity/tissue Doppler mitral annular early diastolic velocity (E/Ea) and B-type natriuretic peptide (BNP) have been correlated with left ventricular filling pressures, yet there are no data on how these 2 estimates of left ventricular filling pressures compare. METHODS AND RESULTS: Patients admitted to intensive care underwent simultaneous tissue Doppler echocardiography, BNP measurement, and pulmonary capillary wedge pressure (PCWP) determination. The ability of mitral E/Ea and BNP to predict PCWP >15 mm Hg was assessed. Fifty patients were studied. Ln BNP had a correlation of r=0.32 (P=0.02) with PCWP compared with r=0.69 (P<0.001) between E/Ea and PCWP. E/Ea >15 was the optimal cutoff to predict PCWP >15 mm Hg (sensitivity, 86%; specificity, 88%), whereas the optimal BNP cutoff was >300 pg/mL (sensitivity, 91%; specificity, 56%). The correlation between change in PCWP and change in E/Ea at 48 hours was r=0.87 (P=0.003) compared with r=-0.59 (P=0.39) for BNP. In the 36 patients with cardiac disease, E/Ea >15 (sensitivity, 92%; specificity, 91%) appeared more accurate than BNP >400 pg/mL (sensitivity, 92%; specificity, 51%), whereas in patients without cardiac disease, BNP (sensitivity, 81%; specificity, 83%) appeared more accurate than E/Ea >15 (sensitivity, 74%; specificity, 72%) for PCWP >15 mm Hg. CONCLUSIONS: In intensive care unit patients, mitral E/Ea has a better correlation than BNP with PCWP. Both BNP and mitral E/Ea have high sensitivity for PCWP >15 mm Hg; however, E/Ea appears more specific in this patient population. In patients without cardiac disease, BNP appears more accurate than E/Ea for PCWP >15 mm Hg, whereas E/Ea appears more accurate in patients with cardiac disease.