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. 2020 Apr 1;5(4):401-410.
doi: 10.1001/jamacardio.2019.5108.

Global Differences in Characteristics, Precipitants, and Initial Management of Patients Presenting With Acute Heart Failure

Gerasimos Filippatos  1   2 , Christiane E Angermann  3 , John G F Cleland  4   5 , Carolyn S P Lam  6   7   8 , Ulf Dahlström  9 , Kenneth Dickstein  10 , Georg Ertl  3 , Mahmoud Hassanein  11 , Kimberly W Hart  12 , Christopher J Lindsell  12 , Sergio V Perrone  13 , Tadhg Guerin  14 , Mathieu Ghadanfar  15 , Anja Schweizer  15 , Achim Obergfell  15 , Sean P Collins  16
Affiliations

Global Differences in Characteristics, Precipitants, and Initial Management of Patients Presenting With Acute Heart Failure

Gerasimos Filippatos et al. JAMA Cardiol. .

Abstract

Importance: Acute heart failure (AHF) precipitates millions of hospital admissions worldwide, but previous registries have been country or region specific.

Objective: To conduct a prospective contemporaneous comparison of AHF presentations, etiologic factors and precipitants, treatments, and in-hospital outcomes among global regions through the International Registry to Assess Medical Practice with Longitudinal Observation for Treatment of Heart Failure (REPORT-HF).

Design, setting, and participants: A total of 18 553 adults were enrolled during a hospitalization for AHF. Patients were recruited from the acute setting in Western Europe (WE), Eastern Europe (EE), Eastern Mediterranean and Africa (EMA), Southeast Asia (SEA), Western Pacific (WP), North America (NA), and Central and South America (CSA). Patients with AHF were approached for consent and excluded only if there was recent participation in a clinical trial. Patients were enrolled from July 23, 2014, to March 24, 2017. Statistical analysis was conducted from April 18 to June 29, 2018; revised analyses occurred between August 6 and 29, 2019.

Main outcomes and measures: Heart failure etiologic factors and precipitants, treatments, and in-hospital outcomes among global regions.

Results: A total of 18 553 patients were enrolled at 358 sites in 44 countries. The median age was 67.0 years (interquartile range [IQR], 57-77), 11 372 were men (61.3%), 9656 were white (52.0%), 5738 were Asian (30.9%), and 867 were black (4.7%). A history of HF was present in more than 50% of the patients and 40% were known to have a prior left-ventricular ejection fraction lower than 40%. Ischemia was a common AHF precipitant in SEA (596 of 2329 [25.6%]), WP (572 of 3354 [17.1%]), and EMA (364 of 2241 [16.2%]), whereas nonadherence to diet and medications was most common in NA (306 of 1592 [19.2%]). Median time to the first intravenous therapy was 3.0 (IQR, 1.4-5.6) hours in NA; no other region had a median time above 1.2 hours (P < .001). This treatment delay remained after adjusting for severity of illness (P < .001). Intravenous loop diuretics were the most common medication administered in the first 6 hours of AHF management across all regions (65.4%-89.9%). Despite similar initial blood pressure across all regions, inotropic agents were used approximately 3 times more often in SEA, WP, and EE (11.3%-13.5%) compared with NA and WE (3.1%-4.3%) (P < .001). Older age (odds ratio [OR], 1.0; 95% CI, 1.00-1.02), HF etiology (ischemia: OR, 1.65; 95% CI, 1.11-2.44; valvular: OR, 2.10; 95% CI, 1.36-3.25), creatinine level greater than 2.75 mg/dL (OR, 1.85; 95% CI, 0.71-2.40), and chest radiograph signs of congestion (OR, 2.03; 95% CI, 1.39-2.97) were all associated with increased in-hospital mortality. Similarly, younger age (OR, -0.04; 95% CI, -0.05 to -0.02), HF etiology (ischemia: OR, 0.77; 95% CI, 0.26-1.29; valvular: OR, 2.01; 95% CI, 1.38-2.65), creatinine level greater than 2.75 mg/dL (OR, 1.16; 95% CI, 0.31-2.00), and chest radiograph signs of congestion (OR, 1.02; 95% CI, 0.57-1.47) were all associated with increased in-hospital LOS.

Conclusions and relevance: Data from REPORT-HF suggest that patients are similar across regions in many respects, but important differences in timing and type of treatment exist, identifying region-specific gaps in medical management that may be associated with patient outcomes.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Filippatos reported receiving research grants from the European Union, committee fees from Novartis related to REPORT-HF, and serving as a committee member in trials and/or registries sponsored by Servier, Boehringer Ingelheim, Medtronic, and Vifor. Dr Angermann reported receiving grants and personal fees from Novartis related to REPORT-HF; serving on steering committees in trials and/or registries sponsored by Abbott, Boehringer Ingelheim, Novartis, and Vifor outside of REPORT-HF; receiving grants and personal fees from Abbott, Boehringer Ingelheim, Novartis, and Vifor; nonfinancial support from the University Hospital Würzburg and the Comprehensive Heart Failure Center Würzburg; and grant support from the German Ministry for Education and Research. Dr Cleland reports receiving personal fees from Johnson & Johnson during the conduct of the study; grants and personal fees from Amgen, Bayer, Bristol Myers Squibb, Philips, Stealth Biopharmaceuticals, and Torrent Pharmaceuticals; personal fees from AstraZeneca, GSK, Myokardia, Sanofi, and Servier; grants, personal fees, and nonfinancial support from Medtronic, Novartis, and Vifor; and grants and nonfinancial support from Pharmacosmos and PharmaNord. Dr Lam is supported by a Clinician Scientist Award from the National Medical Research Council of Singapore; has received research support from Boston Scientific, Bayer, Roche Diagnostics, Medtronic, and Vifor Pharma; and has served as a paid consultant for Novartis, Astra Zeneca, Bayer, Amgen, Merck, Janssen Research & Development LLC, Menarini, Boehringer Ingelheim, Abbott Diagnostics, Corvia, Stealth BioTherapeutics, and Takeda. Dr Dahlström has received research support from Astra Zeneca and speaker´s honoraria and consultancies from Astra Zeneca and Novartis. Dr Dickstein serves as an unpaid consultant for Novartis. Dr Hassanein received honoraria serving as a lecturer from Novartis, Aventis, Amgen, MSD, AstraZeneca, and Merck. Dr Guerin is employed by Novartis Ireland Ltd. Dr Ghadanfar is employed by Novartis Pharma AG. Dr Schweizer is employed by Novartis Pharma AG and owns Novartis shares. Dr Obergfell was employed by Novartis Pharma AG. Dr Collins reports receiving research support from the National Institutes of Health, Association for Healthcare Research and Quality, American Heart Association, and Patient-Centered Outcomes Research Institute, and serving as a paid consultant for Novartis, Medtronic, and Vixiar.

Figures

Figure 1.
Figure 1.. Enrollment and Patient Flow Through the Study
AHF indicates acute heart failure; eCRF, electronic case report form.
Figure 2.
Figure 2.. Time to First Intravenous (IV) Treatment Based on Point of Entry
CSA indicates Central and South America; EE, Eastern Europe; EMA, Eastern Mediterranean Region and Africa; ICU, intensive care unit; NA, North America; SEA, Southeast Asia; WE, Western Europe; and WP, Western Pacific. aTime to IV therapy relative to the WP region, P < .001.
Figure 3.
Figure 3.. Type of Initial Therapy Stratified by Region
CSA indicates Central and South America; EE, Eastern Europe; EMA, Eastern Mediterranean Region and Africa; IV, intravenous; NA, North America; SEA, Southeast Asia; WE, Western Europe; and WP, Western Pacific.
See this image and copyright information in PMC

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