Global differences in acute heart failure patient characteristics, precipitants and initial therapy: primary results from REPORT-HF, a worldwide, prospective heart failure disease registry 7

//Presented at ESC Heart Failure 2018 in Vienna, Austria, by Sean Collins (Nashville, US).//

Introduction and methods

Existing acute heart failure (AHF) registries are country- or region-specific, none had simultaneous global enrollment. The goal of REPORT-HF is therefore to design a truly global study of AHF, to describe presentation, characteristics, co-morbidities and precipitants of decompensation, the treatment and outcome of the index hospitalization, and serial assessment of health status, care and outcomes.

To this end, a single protocol was followed in 44 countries, at 358 sites, in 7 regions according to modified WHO criteria. Observational, prospective data was collected using identical case report forms. After enrollment at the index hospitalization, follow-up took place at 6 months and periodically for up to 3 years. Broad eligibility criteria were used to enroll a heterogeneous sample, reflecting routine clinical practice. Patients admitted with AHF as primary diagnosis were included, and who signed informed consent. Patients could not enroll if they participated concomitantly in a clinical trial. HF therapy was at the discretion of the treating team. 18805 patients were enrolled.

The current analysis focuses on the index hospitalization, and studies regional differences in patient characteristics, presentation, precipitating factors for AHF, and type of initial therapy for AHF, timing, and associated outcomes. A mixed-effects generalized linear model was used to study regional outcomes, adjusting for age, systolic blood pressure, HF etiology, CXR congestion, BUN, serum creatinine, IV therapy and region.

Main results

• The age distribution in the registry was lower than in previous registries, ranging from a median of 61 (IQR: 53-70) in South East Asia, to 75 in Western Europe (IQR: 65-81).
• Quite some variation across regions was seen in baseline characteristics, as did etiology, presentation and precipitating factors. In particular, the percentage of patients with de novo HF ranged from 20% in North America to 79% in South East Asia. Examination and tests performed were more similar across the regions.
• Medication use at admission ranged from a median percentage of 27% in South East Asia to 61% in Central and South America for ACEi/ARB, and from 25% in South East Asia to 71% in North America.
• Outcome analysis for the index hospitalization showed that length of stay varied between 6 and 9 days. Mortality ranged from 1.5% in Eastern Europe to 4.4% in Central and South America.
• Statistically significant associations with mortality were observed for older age, ischemic and valvular etiology of HF, CXR signs of congestion and creatinine >2.75 mg/dL.
• A longer length of stay was associated to younger age, SBP <115 mmHg, ischemic and valvular etiology of HF, CXR signs of congestion, creatinine >2.75 mg/dL and no use of vasodilators/nitrates plus or minus diuretics.

Conclusions

REPORT-HF provides a global perspective on the HF pandemic, by combining the design of a global HF registry and a longitudinal cohort study. Dr. Collins concluded that overall, this analysis showed more similarities than differences across the regions, although the higher percentage of de novo cases in South East Asia was striking, which affects treatment decisions on admission. In North America, patients less often experience dyspnea at rest, which affects time to treatment.

Limitations of the analysis include that in-hospitality mortality was generally low, and the healthier and younger participant bias, which may be due to the requirement for consent. REPORT-HF will facilitate identification of opportunities to improve care and may inform future trial design. Care and outcomes after index hospitalization discharge will be presented in future analyses.

Discussion

The discussant concluded after the presentation that AHF is not AHF around the world. It is differently considered across the globe. Not all of the reasons for these differences may be medical; they are possibly also related to organizational or financial aspects. Also treatment varies; does this mean that the patients are not the same, or does translation from guideline recommendations to treatment differ between regions?

Thus, it is important to realize that these differences exist. At the same time, the population around the world may be more homogeneous than two or three decades ago, as a consequence of the guidelines. It will be interesting to see what happens in a few years; maybe even more people will benefit from existing insights.

//Our reporting is based on the information provided at the ESC Heart Failure 2018 congress.//