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.

Routine serial echocardiography in systolic heart failure: is it time for the heart failure guidelines to change?

The authors sought to obtain objective evidence for impacting the American College of Cardiology Heart Failure Guidelines for the routine use of serial echocardiography by assessing the reliability of the use of clinician-assessed patient symptoms and New York Heart Association (NYHA) functional classification compared with ejection fraction (EF) measured by echocardiography. A prospective study in 256 patients with systolic heart failure (HF) enrolled into an HF disease management program with EF ≤40% and at least 2 annual echocardiograms were included. Only 86 of 256 (33.5%) patients were correctly classified by NYHA class as showing improvement, no change, or deterioration as compared with echocardiographic assessments. Patients whose NYHA class showed no change between echocardiograms had the lowest survival rate. Quantification in patient's status with NYHA classification is not always a reliable assessment to evaluate prognosis and guide medical therapy for patients with systolic HF.

Epidemiology and survival of the five stages of chronic kidney disease in a systolic heart failure population.

AIMS: The epidemiology of the five stages of chronic kidney disease (CKD) in systolic heart failure (HF) patients has predominantly been described in hospitalized White patients, with little known about the prevalence in outpatient Blacks and Hispanics. The purpose of this study was to compare the prevalence of the five stages of CKD by race, ethnicity (Whites, Blacks, and Hispanics), and gender in an outpatient systolic HF population and also to evaluate the impact of CKD on mortality. METHODS AND RESULTS: We conducted a prospective study of 1301 patients recruited from two hospital facilities in Louisiana and Florida, USA. All patients were enrolled in a systolic HF disease management programme (HFDMP), which enrolled patients with an ejection fraction of < or =40% by echocardiography. The estimated glomerular filtration rate was calculated using the abbreviated Modification of Diet in Renal Disease Study equation. Patients were classified into five stages of CKD according to the National Kidney Foundation classification system. A total of 338 patients (26%) were found to have CKD. Patients with CKD were older, more likely to be Hispanics, to have less education, New York Heart Association class III, elevated systolic blood pressure, and diabetes. There was no statistical difference in prevalence by gender. Survival was reduced in patients with CKD. CONCLUSION: The prevalence of CKD in an outpatient systolic HFDMP is high, with over one in four patients affected. CKD patients had significantly lower survival rates compared with patients without CKD.