Multimorbidity in patients with acute heart failure across world regions and country income levels (REPORT-HF): a prospective, multicentre, global cohort study.

BACKGROUND: Multimorbidity (two or more comorbidities) is common among patients with acute heart failure, but comprehensive global information on its prevalence and clinical consequences across different world regions and income levels is scarce. This study aimed to investigate the prevalence of multimorbidity and its effect on pharmacotherapy and prognosis in participants of the REPORT-HF study. METHODS: REPORT-HF was a prospective, multicentre, global cohort study that enrolled adults (aged ≥18 years) admitted to hospital with a primary diagnosis of acute heart failure from 358 hospitals in 44 countries on six continents. Patients who currently or recently participated in a clinical treatment trial were excluded. Follow-up data were collected at 1-year post-discharge. The primary outcome was 1-year post-discharge mortality. All patients in the REPORT-HF cohort with full data on comorbidities were eligible for the present study. We stratified patients according to the number of comorbidities, and countries by world region and country income level. We used one-way ANOVA, χ2 test, or Mann-Whitney U test for comparisons between groups, as applicable, and Cox regression to analyse the association between multimorbidity and 1-year mortality. FINDINGS: Between July 23, 2014, and March 24, 2017, 18 553 patients were included in the REPORT-HF study. Of these, 18 528 patients had full data on comorbidities, of whom 11 360 (61%) were men and 7168 (39%) were women. Prevalence rates of multimorbidity were lowest in southeast Asia (72%) and highest in North America (92%). Fewer patients from lower-middle-income countries had multimorbidity than patients from high-income countries (73% vs 85%, p<0·0001). With increasing comorbidity burden, patients received fewer guideline-directed heart failure medications, yet more drugs potentially causing or worsening heart failure. Having more comorbidities was associated with worse outcomes: 1-year mortality increased from 13% (no comorbidities) to 26% (five or more comorbidities). This finding was independent of common baseline risk factors, including age and sex. The population-attributable fraction of multimorbidity for mortality was higher in high-income countries than in upper-middle-income or lower-middle-income countries (for patients with five or more comorbidities: 61% vs 27% and 31%, respectively). INTERPRETATION: Multimorbidity is highly prevalent among patients with acute heart failure across world regions, especially in high-income countries, and is associated with higher mortality, less prescription of guideline-directed heart failure pharmacotherapy, and increased use of potentially harmful medications. FUNDING: Novartis Pharma. TRANSLATIONS: For the Arabic, French, German, Hindi, Mandarin, Russian and Spanish translations of the abstract see Supplementary Materials section.

Global Variations According to Sex in Patients Hospitalized for Heart Failure in the REPORT-HF Registry.

BACKGROUND: Previous reports suggest that risk factors, management, and outcomes of acute heart failure (AHF) may differ by sex, but they rarely extended analysis to low- and middle-income countries. OBJECTIVES: In this study, the authors sought to analyze sex differences in treatment and outcomes in patients hospitalized for AHF in 44 countries. METHODS: The authors investigated differences between men and women in treatment and outcomes in 18,553 patients hospitalized for AHF in 44 countries in the REPORT-HF (Registry to Assess Medical Practice With Longitudinal Observation for the Treatment of Heart Failure) registry stratified by country income level, income disparity, and world region. The primary outcome was 1-year all-cause mortality. RESULTS: Women (n = 7,181) were older than men (n = 11,372), were more likely to have heart failure with preserved left ventricular ejection fraction, had more comorbid conditions except for coronary artery disease, and had more severe signs and symptoms at admission. Coronary angiography, cardiac stress tests, and coronary revascularization were less frequently performed in women than in men. Women with AHF and reduced left ventricular ejection fraction were less likely to receive an implanted device, regardless of region or country income level. Women were more likely to receive treatments that could worsen HF than men (18% vs 13%; P < 0.0001). In countries with low-income disparity, women had better 1-year survival than men. This advantage was lost in countries with greater income disparity (Pinteraction < 0.001). CONCLUSIONS: Women were less likely to have diagnostic testing or receive guideline-directed care than men. A survival advantage for women was observed only in countries with low income disparity, suggesting that equity of HF care between sexes remains an unmet goal worldwide.

Hospitalization for acute heart failure during non-working hours impacts on long-term mortality: the REPORT-HF registry.

AIMS: Hospital admission during nighttime and off hours may affect the outcome of patients with various cardiovascular conditions due to suboptimal resources and personnel availability, but data for acute heart failure remain controversial. Therefore, we studied outcomes of acute heart failure patients according to their time of admission from the global International Registry to assess medical practice with lOngitudinal obseRvation for Treatment of Heart Failure. METHODS AND RESULTS: Overall, 18 553 acute heart failure patients were divided according to time of admission into 'morning' (7:00-14:59), 'evening' (15:00-22:59), and 'night' (23:00-06:59) shift groups. Patients were also dichotomized to admission during 'working hours' (9:00-16:59 during standard working days) and 'non-working hours' (any other time). Clinical characteristics, treatments, and outcomes were compared across groups. The hospital length of stay was longer for morning (odds ratio: 1.08; 95% confidence interval: 1.06-1.10, P < 0.001) and evening shift (odds ratio: 1.10; 95% confidence interval: 1.07-1.12, P < 0.001) as compared with night shift. The length of stay was also longer for working vs. non-working hours (odds ratio: 1.03; 95% confidence interval: 1.02-1.05, P < 0.001). There were no significant differences in in-hospital mortality among the groups. Admission during working hours, compared with non-working hours, was associated with significantly lower mortality at 1 year (hazard ratio: 0.88; 95% confidence interval: 0.80-0.96, P = 0.003). CONCLUSIONS: Acute heart failure patients admitted during the night shift and non-working hours had shorter length of stay but similar in-hospital mortality. However, patients admitted during non-working hours were at a higher risk for 1 year mortality. These findings may have implications for the health policies and heart failure trials.

Current status of outpatient heart failure management in Egypt and recommendations for the future.

Heart failure (HF) represents one of the greatest healthcare burdens worldwide, and Egypt is no exception. HF healthcare programmes in Egypt still require further optimization to enhance diagnosis and management of the disease. Development of specialized HF clinics (HFCs) and their incorporation in the healthcare system is expected to reduce HF hospitalization and mortality rates and improve quality of care in Egypt. We conducted a literature search on PubMed on the requirements and essential infrastructure of HFCs. Retrieved articles deemed relevant were discussed by a panel of 10 expert cardiologists from Egypt and a basic HFC model for the Egyptian settings was proposed. A multidisciplinary team managing the HFC should essentially be composed of specialized HF cardiologists and nurses, clinical pharmacists, registered nutritionists, physiotherapists, and psychologists. Other clinical specialists should be included according to patients' needs and size and structure of individual clinics. HFCs should receive patients referred from primary care settings, emergency care units, and physicians from different specialties. A basic HFC should have the following fundamental investigations available: resting electrocardiogram, basic transthoracic echocardiogram, and testing for N-terminal pro-B-type natriuretic peptide. Fundamental patients' functional assessments are assessing the New York Heart Association functional classification and quality of life and conducting the 6 min walking test. guideline-directed medical therapy should be implemented, and device therapy should be utilized when available. In the first visit, once HF is diagnosed and co-morbidities assessed, guideline-directed medical therapy should be started immediately. Comprehensive patient education sessions should be delivered by HF nurses or clinical pharmacists. The follow-up visit should be scheduled during the initial visit rather than over the phone, and time from the initial visit to the first follow-up visit should be determined based on the patient's health status and needs. Home and virtual visits are only recommended in limited and emergency situations. In this paper, we provide a practical and detailed review on the essential components of HFCs and propose a preliminary model of HFCs as part of a comprehensive HF programme model in Egypt. We believe that other low-to-middle income countries could also benefit from our proposed model.

The predictive value of precipitating factors on clinical outcomes in hospitalized patients with decompensated heart failure: insights from the Egyptian cohort in the European Society of Cardiology Heart Failure long-term registry.

BACKGROUND: Knowledge of the frequency of precipitating factors for acute heart failure (AHF) is important (either new-onset heart failure [NOHF] or worsening heart failure [WHF]), as this can guide strategies for prevention and treatment. Most data come only from Western Europe and North America; nevertheless, geographic differences do exist. We set out to study the prevalence of precipitating factors of AHF and their connection to patient characteristics and in-hospital and long-term mortality in patients from Egypt hospitalized for decompensated HF. Using the ESC-HF-LT Registry which is a prospective, multicenter, observational study of patients confessed to cardiology centers in the nations of Europe and the Mediterranean, patients presenting with AHF were recruited from 20 centers all over Egypt. Enrolling physicians were requested to report possible precipitants from among several predefined reasons. RESULTS: We included 1515 patients (mean age 60 ± 12 years, 69% males). The mean LVEF was 38 ± 11%. Seventy-seven percent of the total population had HFrEF, 9.8% had HFmrEF, and 13.3% had HFpEF. The commonly reported precipitating factors for AHF hospitalization among study population were as follows (in decreasing order of frequency): infection in 30.3% of patients, acute coronary syndrome/myocardial ischemia (ACS/MI) in 26%, anemia in 24.3%, uncontrolled hypertension in 24.2%, atrial fibrillation (AF) in 18.3%, renal dysfunction in 14.6%, and non-compliance in 6.5% of patients. HFpEF patients had significantly higher rates of AF, uncontrolled hypertension, and anemia as precipitants for acute decompensation. ACS/MI were significantly more frequent in patients with HFmrEF. WHF patients had significantly higher rates of infection and non-compliance, whereas new-onset HF patients showed significantly higher rates of ACS/MI and uncontrolled hypertension. One-year follow-up revealed that patients with HFrEF had a significantly higher rate of mortality compared to patients with HFmrEF and HFpEF (28.3%, 19.5, and 19.4%, P = 0.004). Patients with WHF had a significantly higher rates of 1-year mortality when compared to those with NOHF (30.0% vs. 20.3%, P < 0.001). Renal dysfunction, anemia, and infection were independently connected to worse long-term survival. CONCLUSIONS: Precipitating factors of AHF are frequent and substantially influence outcomes after hospitalization. They should be considered goals for avoiding AHF hospitalization and depicting those at highest risk for short-term mortality.

Impact of left ventricular ejection fraction phenotypes on healthcare resource utilization in hospitalized heart failure: a secondary analysis of REPORT-HF.

AIM: Evidence on healthcare resource utilization (HCRU) for hospitalized patients with heart failure (HF) and reduced (HFrEF), mildly reduced (HFmrEF) and preserved (HFpEF) ejection fraction is limited. METHODS AND RESULTS: We analysed HCRU in relation to left ventricular ejection fraction (LVEF) phenotypes, clinical features and in-hospital and 12-month outcomes in 16 943 patients hospitalized for HF in a worldwide registry. HFrEF was more prevalent (53%) than HFmrEF (17%) or HFpEF (30%). Patients with HFmrEF and HFpEF were older, more often women, with milder symptoms and more comorbidities, but differences were not pronounced. HCRU was high in all three groups; two or more in- and out-of-hospital services were required by 51%, 49% and 52% of patients with HFrEF, HFmrEF and HFpEF, respectively, and intensive care unit by 41%, 41% and 37%, respectively. Hospitalization length was similar (median, 8 days). Discharge prescription of neurohormonal inhibitors was <80% for each agent in HFrEF and only slightly lower in HFmrEF and HFpEF (74% and 67%, respectively, for beta-blockers). Compared to HFrEF, 12-month all-cause and cardiovascular mortality were lower for HFmrEF (adjusted hazard ratios 0.78 [95% confidence interval 0.59-0.71] and 0.80 [0.70-0.92]) and HFpEF (0.64 [0.59-0.87] and 0.63 [0.56-0.71]); 12-month HF hospitalization was also lower for HFpEF and HFmrEF (21% and 20% vs. 25% for HFrEF). In-hospital mortality, 12-month non-cardiovascular mortality and 12-month all-cause hospitalization were similar among groups. CONCLUSIONS: In patients hospitalized for HF, overall HCRU was similarly high across LVEF spectrum, reflecting the subtle clinical differences among LVEF phenotypes during hospitalization. Discharge prescription of neurohormonal inhibitors was suboptimal in HFrEF and lower but significant in patients with HFpEF and HFmrEF, who had better long-term cardiovascular outcomes than HFrEF, but similar risk for non-cardiovascular events.

Association of time-to-intravenous furosemide with mortality in acute heart failure: data from REPORT-HF.

AIM: Acute heart failure can be a life-threatening medical condition. Delaying administration of intravenous furosemide (time-to-diuretics) has been postulated to increase mortality, but prior reports have been inconclusive. We aimed to evaluate the association between time-to-diuretics and mortality in the international REPORT-HF registry. METHODS AND RESULTS: We assessed the association of time-to-diuretics within the first 24 h with in-hospital and 30-day post-discharge mortality in 15 078 patients from seven world regions in the REPORT-HF registry. We further tested for effect modification by baseline mortality risk (ADHERE risk score), left ventricular ejection fraction (LVEF) and region. The median time-to-diuretics was 67 (25th-75th percentiles 17-190) min. Women, patients with more signs and symptoms of heart failure, and patients from Eastern Europe or Southeast Asia had shorter time-to-diuretics. There was no significant association between time-to-diuretics and in-hospital mortality (p > 0.1). The 30-day mortality risk increased linearly with longer time-to-diuretics (administered between hospital arrival and 8 h post-hospital arrival) (p = 0.016). This increase was more significant in patients with a higher ADHERE risk score (pinteraction  = 0.008), and not modified by LVEF or geographic region (pinteraction > 0.1 for both). CONCLUSION: In REPORT-HF, longer time-to-diuretics was not associated with higher in-hospital mortality. However, we did found an association with increased 30-day mortality, particularly in high-risk patients, and irrespective of LVEF or geographic region. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02595814.

Global disparities in prescription of guideline-recommended drugs for heart failure with reduced ejection fraction.

BACKGROUND: Heart failure (HF) is a global challenge, with lower- and middle-income countries (LMICs) carrying a large share of the burden. Treatment for HF with reduced ejection fraction (HFrEF) improves survival but is often underused. Economic factors might have an important effect on the use of medicines. METHODS AND RESULTS: This analysis assessed prescription rates and doses of renin-angiotensin system (RAS) inhibitors, ß-blockers, and mineralocorticoid receptor antagonists at discharge and 6-month follow-up in 8669 patients with HFrEF (1458 from low-, 3363 from middle-, and 3848 from high-income countries) hospitalized for acute HF in 44 countries in the prospective REPORT-HF study. We investigated determinants of guideline-recommended treatments and their association with 1-year mortality, correcting for treatment indication bias.Only 37% of patients at discharge and 34% of survivors at 6 months were on all three medication classes, with lower proportions in LMICs than high-income countries (19 vs. 41% at discharge and 15 vs. 37% at 6 months). Women and patients without health insurance, or from LMICs, or without a scheduled medical follow-up within 6 months of discharge were least likely to be on guideline-recommended medical therapy at target doses, independent of confounders. Being on ≥50% of guideline-recommended doses of RAS inhibitors, and ß-blockers were independently associated with better 1-year survival, regardless of country income level. CONCLUSION: Patients with HFrEF in LMICs are less likely to receive guideline-recommended drugs at target doses. Improved access to medications and medical care could reduce international disparities in outcome.

Quality of life assessed 6 months after hospitalisation for acute heart failure: an analysis from REPORT-HF (international REgistry to assess medical Practice with lOngitudinal obseRvation for Treatment of Heart Failure).

AIMS: Recovery of well-being after hospitalisation for acute heart failure (AHF) is a measure of the success of interventions and the quality of care but has rarely been quantified. Accordingly, we measured health status after discharge in an international registry (REPORT-HF) of AHF. METHODS AND RESULTS: The analysis included 4606 patients with AHF who survived to hospital discharge, had known vital status at 6 months, and were enrolled in the United States of America, Russian Federation, or Western Europe, where the Kansas City Cardiomyopathy Questionnaire (KCCQ) was administered. Median age was 69 years (quartiles 59-78), 40% were women, and 34% had a left ventricular ejection fraction (LVEF) <40%, and 12% patients died by 6 months. Of 2475 patients with a follow-up KCCQ, 28% were 'alive and well' (KCCQ >75), while 43% had poor health status (KCCQ ≤50). Being 'alive and well' was associated with new-onset AHF, LVEF <40%, younger age, higher baseline KCCQ, country, and race. Associations were similar for increasing health status, with the exception of country and addition of comorbidities. CONCLUSION: In this international global registry, health status recovery after AHF hospitalisation was highly variable. Those with the best health status at 6 months were younger, had new-onset heart failure, and higher baseline KCCQ; nearly one-third of survivors were 'alive and well'. Investigating reasons for changes in KCCQ after hospitalisation might identify new therapeutic targets to improve patient-centred outcomes.

Prevalence of obesity and its association with cardiometabolic risk factors, heart failure phenotype and mortality among patients hospitalized for heart failure in Egypt.

BACKGROUND: Obesity is an established risk factor for cardiometabolic disease and heart failure (HF). Nevertheless, the relationship between obesity and HF mortality remains controversial. RESULTS: The goal of this study was to describe the prevalence of obesity in patients hospitalized for HF in Egypt and investigate the relationship of obesity to cardiometabolic risk factors, HF phenotype and mortality. Between 2011 and 2014, 1661 patients hospitalized for HF across Egypt were enrolled as part of the European Society of Cardiology HF Long-term Registry. Obese patients, defined by a BMI ≥ 30 kg/m2, were compared to non-obese patients. Factors associated with mortality on univariate analysis were entered into a logistic regression model to identify whether obesity was an independent predictor of mortality during hospitalization and at one-year follow-up. The prevalence of obesity was 46.5% and was higher in females compared to males. Obese as compared to non-obese patients had a higher prevalence of diabetes mellitus (47.0% vs 40.2%, p = 0.031), hypertension (51.3% vs 33.0%, p < 0.001) and history of myocardial infarction (69.2% vs 62.8% p = 0.005). Obese patients as compared to non-obese patient were more likely to have acute coronary syndrome on admission (24.8% vs 14.2%, p < < 0.001). The dominant HF phenotype in obese and non-obese patients was HF with reduced ejection fraction (EF); however, obese patients as compared to non-obese patient had higher prevalence of HF with preserved EF (22.3% vs 12.4%, p < 0.001). Multivariable analysis demonstrated that obesity was associated with an independent survival benefit during hospitalization, (OR for mortality 0.52 [95% CI 0.29-0.92]). Every point increase in BMI was associated with an OR = 0.93 [95% CI 0.89-0.98] for mortality during hospitalization. The survival benefit was not maintained at one-year follow-up. CONCLUSIONS: Obesity was highly prevalent among the study cohort and was associated with higher prevalence of cardiometabolic risk factors as compared to non-obese patients. Obesity was associated with an independent "protective effect" from in-hospital mortality but was not a predictor of mortality at 1-year follow-up.

Regional differences in precipitating factors of hospitalization for acute heart failure: insights from the REPORT-HF registry.

AIMS: Few prior studies have investigated differences in precipitants leading to hospitalizations for acute heart failure (AHF) in a cohort with global representation. METHODS AND RESULTS: We analysed the prevalence of precipitants and their association with outcomes in 18 553 patients hospitalized for AHF in REPORT-HF (prospective international REgistry to assess medical Practice with lOngitudinal obseRvation for Treatment of Heart Failure) according to left ventricular ejection fraction subtype (reduced [HFrEF] and preserved ejection fraction [HFpEF]) and presentation (new-onset vs. decompensated chronic heart failure [DCHF]). Patients were enrolled from 358 centres in 44 countries stratified according to Latin America, North America, Western Europe, Eastern Europe, Eastern Mediterranean and Africa, Southeast Asia, and Western Pacific. Precipitants were pre-with mutually exclusive categories and selected according to the local investigator's discretion. Outcomes included in-hospital and 1-year mortality. The median age was 67 (interquartile range 57-77) years, and 39% were women. Acute coronary syndrome (ACS) was the most common precipitant in patients with new-onset heart failure in all regions except for North America and Western Europe, where uncontrolled hypertension and arrhythmia, respectively, were the most common precipitants, independent of confounders. In patients with DCHF, non-adherence to diet/medication was the most common precipitant regardless of region. Uncontrolled hypertension was a more likely precipitant in HFpEF, non-adherence to diet/medication, and ACS were more likely precipitants in HFrEF. Patients admitted due to worsening renal function had the worst in-hospital (5%) and 1-year post-discharge (30%) mortality rates, regardless of region, heart failure subtype and admission type (pinteraction >0.05 for all). CONCLUSION: Data on global differences in precipitants for AHF highlight potential regional differences in targets for preventing hospitalization for AHF and identifying those at highest risk for early mortality.

Mechanics of guided growth of the distal femur for correction of fixed knee flexion deformities: an extra-articular technique.

INTRODUCTION: Anterior distal femoral hemiepiphysiodesis using intra-articular plates for correction of pediatric fixed knee flexion deformities (FKFD) has two documented complications: postoperative knee pain and implant loosening. The aim of this study is to investigate the mechanical properties of a novel extra-articular technique for anterior distal femoral hemiepiphysiodesis in patients with FKFD and to compare them to the conventional technique. MATERIALS AND METHODS: Sixteen femoral sawbones were osteotomized at the level of the distal femoral physis and fixed by rail frames to allow linear distraction simulating longitudinal growth. Each sawbone was tested twice: first using the conventional technique with eight plates placed anteriorly just medial and lateral to the femoral sulcus (group A) and then with plates inserted in the proposed novel location at the most anterior part of the medial and lateral surfaces of the femoral condyles with screws in the coronal plane (group B). Gradual linear distraction was performed, and the resulting angular correction was measured. Strain gauges were attached to the plates, and the amount of strain (and equivalent stress) over the plates in response to linear distraction was recorded. The two groups were compared using the Wilcoxon signed-rank test. RESULTS: The amount of angular correction was statistically higher in group B (extra-articular plates) at 5, 10-, and 15-mm of distraction (p < 0.001). As regards stress over the plates, the maximum stress and the area under the curve (sum of all stresses measured throughout the distraction process) were significantly higher when the plates were inserted at the conventional position (group A) (p < 0.001). CONCLUSIONS: During anterior distal femoral hemiepiphysiodesis, the fixation of the eight plates in the coronal plane at the anterior part of the femoral condyles may produce a greater amount of correction and a lower degree of stress over the implants as compared to the conventional technique.

A global perspective of racial differences and outcomes in patients presenting with acute heart failure.

Important racial differences in characteristics, treatment, and outcomes of patients with acute heart failure (AHF) have been described. The objective of this analysis of the International Registry to assess medical Practice with longitudinal observation for Treatment of Heart Failure (REPORT-HF) registry was to investigate racial differences in patients with AHF according to country income level.

Patient with Acute Coronary Syndrome in the Setting of an Extremely Rare form of Complex Congenital Anomalous Coronaries.

A single coronary artery is an exceedingly rare anomaly. Hereby, we present an unusual case of a young patient with an acute coronary syndrome who was found to have a single coronary artery originating from a single ostium in the right sinus of Valsalva with dual left anterior descending (LAD) arteries arising from the right coronary artery with two different anatomical courses, and additionally one of those LADs running a malignant intra-arterial course.

Global Differences in Burden and Treatment of Ischemic Heart Disease in Acute Heart Failure: REPORT-HF.

OBJECTIVES: The primary aim of the current study was to investigate global differences in prevalence, association with outcome, and treatment of ischemic heart disease (IHD) in patients with acute heart failure (AHF) in the REPORT-HF (International Registry to Assess Medical Practice With Longitudinal Observation for Treatment of Heart Failure) registry. BACKGROUND: Data on IHD in patients with AHF are primarily from Western Europe and North America. Little is known about global differences in treatment and prognosis of patients with IHD and AHF. METHODS: A total of 18,539 patients with AHF were prospectively enrolled from 44 countries and 365 centers in the REPORT-HF registry. Patients with a history of coronary artery disease, an ischemic event causing admission for AHF, or coronary revascularization were classified as IHD. Clinical characteristics, treatment, and outcomes of patients with and without IHD were explored. RESULTS: Compared with 8,766 (47%) patients without IHD, 9,773 (53%) patients with IHD were older, more likely to have a left ventricular ejection fraction <40% (heart failure with reduced ejection fraction [HFrEF]), and reported more comorbidities. IHD was more common in lower income compared with high-income countries (61% vs. 48%). Patients with IHD from countries with low health care expenditure per capita or without health insurance less likely underwent coronary revascularization or used anticoagulants at discharge. IHD was independently associated with worse cardiovascular death (hazard ratio: 1.21; 95% confidence interval: 1.09 to 1.35). The association between IHD and cardiovascular death was stronger in HFrEF compared with heart failure with preserved ejection fraction (pinteraction <0.001). CONCLUSIONS: In this large global contemporary cohort of patients with AHF, IHD was more common in low-income countries and conveyed worse 1-year mortality, especially in HFrEF. Patients in regions with the greatest burden of IHD were less likely to receive coronary revascularization and treatment for IHD.

COVID-19 Infection in a Child Presenting With Functional Intestinal Obstruction.

This report describes the case of a 13-year-old male patient presenting with functional small bowel obstruction. The child was also observed to have persistent tachycardia, and repeat cardiac examination revealed a new-onset cardiac murmur and a gallop rhythm. Acute viral myocarditis was clinically suspected, prompting further cardiac evaluations including electrocardiogram (EKG), echocardiogram (echo), and cardiac enzyme panel. Both EKG and echo findings suggested acute myocardial injury, in addition to elevated levels of cardiac enzymes and other inflammatory markers. Considering the ongoing pandemic, coronavirus disease 2019 (COVID-19) infection was suspected, but reverse transcription-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was negative. Because multisystem inflammatory syndrome in children (MIS-C) may occur later in the course of COVID-19 illness, a SARS-CoV-2 antibody test was performed, with positive results. To our knowledge, this is the first pediatric case of COVID-19 presenting as functional intestinal obstruction. We present this case to share our findings on this unique manifestation of COVID-19 with pediatric colleagues. We also engage in a brief review of MIS-C.

Demographics, clinical characteristics, and outcomes among hospitalized heart failure patients across different regions of Egypt.

BACKGROUND: Regional level data on hospitalized heart failure (HHF) patients in Egypt is scarce. The aim of this study was to compare the demographics, clinical characteristics, and outcomes of HHF patients from four distinct geographical regions of Egypt. RESULTS: Study participants were part of the European Society of Cardiology Heart Failure Long Term (ESC-HF-LT) Registry, which enrolled patients from April 2011 to February 2014. A total of 1661 HHF patients from Egypt were enrolled, of whom 1645 were eligible for analysis: 914 from Alexandria, 249 from Cairo, 409 from the Delta region, and 73 from Upper Egypt. The mean age ranged from 52.2 to 62.8 years and differed significantly between the 4 groups (P < 0.01). Females represented one-third of the cohort (P = 0.5 between groups). The prevalence of obesity, diabetes, and hypertension also varied significantly across the groups (P < 0.01). The most common etiology of heart failure (HF) was ischemic heart disease. HF with reduced systolic function was the leading type of HF in the 4 groups (P = 0.6). The most common valvular abnormality in all regions was mitral regurgitation. For patients with prior history of HF, community-acquired infection was the most common reason for a HF exacerbation in all 4 groups. In-hospital mortality ranged from 2.9 to 7.7% in the 4 groups (P = 0.06). Only Alexandria and Delta groups provided reliable 1-year follow-up data, given low patient retention in Cairo and Upper Egypt groups. At one-year, 32% of patients from Alexandria compared to 22.6% from Delta were re-hospitalized for HF (P < 0.01). Mortality at 1 year was also significantly higher in Alexandria compared to Delta, 31.8 vs 13.2% respectively (P < 0.01). CONCLUSIONS: HHF patients from different geographic regions of Egypt differed significantly in their demographics, clinical characteristics, and outcomes. Those differences underscore the importance of region-specific HF prevention and management strategies.