In the Journals

Region-specific gaps persist in acute HF management

Sean P. Collins
Gerasimos Filippatos

Patients from several regions across the world present similarly with acute HF, but differences were observed regarding the type and timing of treatment, according to a study published in JAMA Cardiology.

“I think we have some room to move regarding getting timely therapy to patients especially in North America where people waited on average more than 3 hours to get their first IV therapy,” Sean P. Collins, MD, MSc, professor and executive vice chair in the department of emergency medicine at Vanderbilt University Medical Center, told Healio. “A lot of things may lead to this delay such as not being sure of the diagnosis initially, but I think the system itself can be kind of cumbersome for patients to get through and navigate. We need to find means to treat patients earlier, I think is one of the biggest messages.”

REPORT-HF data

Collins, along with Gerasimos Filippatos, MD, dean of University of Cyprus School of Medicine in Greece and professor of cardiology at the National and Kapodistrian University of Athens School of Medicine in Greece, and colleagues analyzed data from 18,553 patients (median age, 67 years; 61% men; 52% white; 31% Asian; 5% black) from the REPORT-HF study at 358 sites in 44 countries. These patients were hospitalized with a primary diagnosis of acute HF from July 23, 2014, to March 24, 2017. Data that were assessed included clinical symptoms, hospital course, patient demographics, risk factors and comorbidities.

“We just asked the sites to provide the data they collected as part of routine care,” Collins said in an interview. “There were no study-specific labs or tests done. There were some patient-reported questionnaires collected. What they collected for labs, whether they got a chest X-ray and what medications they gave was completely up to the site and was not mandated as part of the study.”

More than 50% of patients had a history of HF, and a prior left ventricular ejection fraction of less than 40% was seen in 40% of patients.

A common cause of acute HF was ischemia in patients from Eastern Mediterranean and Africa (16.2%), Western Pacific (17.1%) and Southeast Asia (25.6%). Nonadherence to medications or diet played a factor in 19.2% of patients from North America.

The median time to first IV therapy for patients from North America was 3 hours irrespective of the point of entry. A median time above 1.2 hours was not seen in other regions of the world (P < .001). The most common medication administered within 6 hours of hospital presentation was IV loop diuretics, as seen in 65.4% of patients from the Western Pacific and 89.9% of those from Eastern Europe. Compared with North America and Western Europe (3.1% vs. 4.3%, respectively), inotropic agents were more often used in Western Pacific (13.4%), Eastern Europe (11.3%) and Southeast Asia regions (13.5%).

Factors that were associated with an increased in-hospital length of stay were HF etiology (valvular: OR = 2.01; 95% CI, 1.38-2.65; ischemia: OR = 0.77; 95% CI, 0.26-1.29); younger age (OR = –0.04; 95% CI, –0.05 to –0.02), chest radiograph signs of congestion (OR = 1.02; 95% CI, 0.57-1.47) and creatinine level greater than 2.75 mg/dL (OR = 1.16; 95% CI, 0.31-2).

For increased in-hospital mortality, associated factors included HF etiology (ischemia: OR = 1.65; 95% CI, 1.11-2.44; valvular: OR = 2.1; 95% CI, 1.36-3.25), older age (OR = 1; 95% CI, 1-1.02), chest radiograph signs of congestion (OR = 2.03; 95% CI, 1.39-2.97) and creatinine level greater than 2.75 mg/dL (OR = 1.85; 95% CI, 0.71-2.4).

Further research into treatment patterns

“What we didn’t see, which was a little bit surprising, was big differences in either in-hospital mortality and only a small difference in length of stay based on timing and types of therapy,” Collins told Healio. “Further research needs to look into why these treatment patterns are so much different. Are the patients really that different? Was it the doctors who were different in their practice styles? It’s not clear and may be related to the cost or availability of medications.” – by Darlene Dobkowski

For more information:

Sean P. Collins, MD, MSc, can be reached at sean.collins@vumc.org.

Disclosures: The REPORT-HF study was funded by Novartis Pharma AG. Collins reports he received research support from the American Heart Association, Association for Healthcare Research and Quality, NIH and Patient-Centered Outcomes Research Institute and served as a paid consultant for Medtronic, Novartis and Vixiar. Filippatos reports he received research grants from the European Union, committee fees from Novartis and served as a committee member in registries and/or trials for Boehringer Ingelheim, Medtronic, Servier and Vifor. Please see the study for all other authors’ relevant financial disclosures.

Sean P. Collins
Gerasimos Filippatos

Patients from several regions across the world present similarly with acute HF, but differences were observed regarding the type and timing of treatment, according to a study published in JAMA Cardiology.

“I think we have some room to move regarding getting timely therapy to patients especially in North America where people waited on average more than 3 hours to get their first IV therapy,” Sean P. Collins, MD, MSc, professor and executive vice chair in the department of emergency medicine at Vanderbilt University Medical Center, told Healio. “A lot of things may lead to this delay such as not being sure of the diagnosis initially, but I think the system itself can be kind of cumbersome for patients to get through and navigate. We need to find means to treat patients earlier, I think is one of the biggest messages.”

REPORT-HF data

Collins, along with Gerasimos Filippatos, MD, dean of University of Cyprus School of Medicine in Greece and professor of cardiology at the National and Kapodistrian University of Athens School of Medicine in Greece, and colleagues analyzed data from 18,553 patients (median age, 67 years; 61% men; 52% white; 31% Asian; 5% black) from the REPORT-HF study at 358 sites in 44 countries. These patients were hospitalized with a primary diagnosis of acute HF from July 23, 2014, to March 24, 2017. Data that were assessed included clinical symptoms, hospital course, patient demographics, risk factors and comorbidities.

“We just asked the sites to provide the data they collected as part of routine care,” Collins said in an interview. “There were no study-specific labs or tests done. There were some patient-reported questionnaires collected. What they collected for labs, whether they got a chest X-ray and what medications they gave was completely up to the site and was not mandated as part of the study.”

More than 50% of patients had a history of HF, and a prior left ventricular ejection fraction of less than 40% was seen in 40% of patients.

A common cause of acute HF was ischemia in patients from Eastern Mediterranean and Africa (16.2%), Western Pacific (17.1%) and Southeast Asia (25.6%). Nonadherence to medications or diet played a factor in 19.2% of patients from North America.

The median time to first IV therapy for patients from North America was 3 hours irrespective of the point of entry. A median time above 1.2 hours was not seen in other regions of the world (P < .001). The most common medication administered within 6 hours of hospital presentation was IV loop diuretics, as seen in 65.4% of patients from the Western Pacific and 89.9% of those from Eastern Europe. Compared with North America and Western Europe (3.1% vs. 4.3%, respectively), inotropic agents were more often used in Western Pacific (13.4%), Eastern Europe (11.3%) and Southeast Asia regions (13.5%).

Factors that were associated with an increased in-hospital length of stay were HF etiology (valvular: OR = 2.01; 95% CI, 1.38-2.65; ischemia: OR = 0.77; 95% CI, 0.26-1.29); younger age (OR = –0.04; 95% CI, –0.05 to –0.02), chest radiograph signs of congestion (OR = 1.02; 95% CI, 0.57-1.47) and creatinine level greater than 2.75 mg/dL (OR = 1.16; 95% CI, 0.31-2).

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For increased in-hospital mortality, associated factors included HF etiology (ischemia: OR = 1.65; 95% CI, 1.11-2.44; valvular: OR = 2.1; 95% CI, 1.36-3.25), older age (OR = 1; 95% CI, 1-1.02), chest radiograph signs of congestion (OR = 2.03; 95% CI, 1.39-2.97) and creatinine level greater than 2.75 mg/dL (OR = 1.85; 95% CI, 0.71-2.4).

Further research into treatment patterns

“What we didn’t see, which was a little bit surprising, was big differences in either in-hospital mortality and only a small difference in length of stay based on timing and types of therapy,” Collins told Healio. “Further research needs to look into why these treatment patterns are so much different. Are the patients really that different? Was it the doctors who were different in their practice styles? It’s not clear and may be related to the cost or availability of medications.” – by Darlene Dobkowski

For more information:

Sean P. Collins, MD, MSc, can be reached at sean.collins@vumc.org.

Disclosures: The REPORT-HF study was funded by Novartis Pharma AG. Collins reports he received research support from the American Heart Association, Association for Healthcare Research and Quality, NIH and Patient-Centered Outcomes Research Institute and served as a paid consultant for Medtronic, Novartis and Vixiar. Filippatos reports he received research grants from the European Union, committee fees from Novartis and served as a committee member in registries and/or trials for Boehringer Ingelheim, Medtronic, Servier and Vifor. Please see the study for all other authors’ relevant financial disclosures.