Heart failure (HF) is a global endemic affecting an estimated 26 million people worldwide. It is currently the leading cause of hospitalization with high early post-discharge mortality and readmission rates.1

There are multiple hospital-based worldwide registries that are the primary sources of real-world data on HF from America and Europe and even Africa and Asia-Pacific.2-5 However, there is no prospective large-scale data from the Middle-East with regard to etiology, presentation, management, and outcome of HF patients. From the recent Gulf registry of acute coronary events (Gulf RACE), we know that the average age of acute coronary syndrome (ACS) and diabetic patients from this region is a decade younger than their Western counterparts. It is intriguing to know how HF affects the younger population from this area, how they present, the etiology, and outcomes. Hence, the Gulf Heart Association initiated a large prospective registry called Gulf CARE (aCute heArt failuRe rEgistry). Gulf CARE is a multinational multicenter registry of patients admitted with the diagnosis of acute heart failure (AHF) to 47 hospitals in seven Middle Eastern countries including Oman.6,7

There is currently a lack of reliable statistics with regard to HF in Oman. The aim of this paper was to describe the demographics, clinical characteristics, management, and outcomes of AHF patients from the Oman CARE study (part of Gulf CARE).

Methods

Oman CARE was a prospective, hospital-based, multicenter registry of patients admitted with the diagnosis of AHF to 12 hospitals in Oman. In our previous publication, the main registry design paper, we detailed the methodology and hospital characteristics.6,7 Briefly, between 14 February and 14 November 2012 we recruited males and females aged > 18 years old with a diagnosis of AHF. We recorded demographic data, co-morbidities, risk factors, clinical presentation and investigations including troponin and B-type natriuretic peptide (BNP), medication history with dosages, interventions, in-hospital outcome, etiology, and precipitating factors for AHF. Follow-up was done by telephone at three months and either by phone or clinic visit at one-year. Data was entered online using a custom designed electronic case record form (CRF) at the Gulf CARE website (www.gulfcare.org). The Ministry of Health Research and Ethics Committee gave approval for the study. The study, as part of the overall Gulf CARE Registry, was registered at clinicaltrials.gov (NCT01467973).

HF was defined by the European Society of Cardiology (ESC) criteria.8 AHF was further sub-classified as either acute decompensated chronic heart failure (ADCHF) or new-onset acute heart failure (de novo AHF) based on ESC guidelines.8 ADCHF was defined as worsening of HF in patients with a previous diagnosis or hospitalization for HF. New-onset AHF was defined as AHF in patients with no prior history of HF.

Definitions of data variables in the CRF were based on the ESC 2008 guidelines and 2005 American College of Cardiology (ACC) clinical data standards.8,9 Idiopathic dilated cardiomyopathy was defined as a myocardial disorder in which the heart muscle is structurally and functionally abnormal (in the absence of coronary artery disease, hypertension, valvular disease, or congenital heart disease) sufficient to cause the observed myocardial abnormality.8 Khat chewing was defined as chewing khat plant/leaves (Catha edulis), which contain an amphetamine-like stimulant (which can cause euphoria, hypertension, myocardial infarction, and dilated cardiomyopathy) within one-month of the index admission. HF with preserved ejection fraction (HFpEF) was defined as presence of symptoms and/or signs of HF and a left ventricular ejection fraction (LVEF; ≥ 40%).8

Descriptive statistics were used to summarize the data. For categorical variables, frequencies and percentages were reported. For continuous variables, mean and standard deviation (SD) were used to summarize the data while for those variables that were not normally distributed, median and interquartile range (IQR; 25th and 75th percentiles) were used to present the data. Descriptive statistics were conducted using STATA version 13.1 (STATA Corporation, College Station, Texas, US).

Results

Twelve hospitals in Oman participated in the Gulf CARE project, with a total of 988 patients enrolled [Table 1]. The mean age of the cohort was 63±12 years, 57% (n = 563) were males, and 95% (n = 942) were Omani citizens. More than half of the patients (57%, n = 566) presented with ADCHF while the rest (43%; n = 422) had de novo AHF. Comorbid conditions were common, particularly hypertension (72%; n = 711), coronary artery disease (CAD) (55%; n = 547), diabetes mellitus (53%; n = 528), and hyperlipidemia (46%; n = 454). The three most common presenting signs and symptoms were dyspnea (97%; n = 958), basal lung crepitations (95%; n = 938), and orthopnoea (73%; n = 723). The other characteristics are shown in Table 1. On admission, patient’s mean heart rate was 97±23 beats per minute and the predominant New York Heart Association (NYHA) class was III/IV (75%;
n = 719). Table 2 shows the laboratory, electrocardiogram (ECG), and echocardiography findings. The median hemoglobin (Hb) of the cohort was 12.5 (11–14) g/dL. Eighty-two percent (n = 808) of patients were in sinus rhythm with 15% (n = 153) demonstrating atrial fibrillation or flutter. Overall, 80% (n = 791) of patients had QRS duration < 0.12 ms and 13.1% (n = 129) had left bundle branch block morphology on ECG. The overall median left ventricular ejection fraction (LVEF) of the cohort was 36% (range 27–45). Heart failure with reduced ejection fraction (HFrEF;
< 40%) was seen in 50.3% (n = 497) of patients.

The three most prevalent etiologies of HF were ischemic heart disease (IHD) (59.6%;
n = 589), hypertensive heart disease (HHD) (20.6%; n = 204) and idiopathic cardiomyopathy (13.5%; n = 133). Valvular heart disease, as an etiology, accounted for 4.8% (n = 47) of patients. The three most common precipitating causes of HF were ACS
(n = 267; 27.0%), non-compliance with medications (n = 234; 23.7%) and uncontrolled hypertension
(n = 103; 10.4%). The three most prevalent in-hospital events/courses included infection requiring therapy (n = 156; 15.8%), requirement of inotropes (n=126; 12.8%) and non-invasive ventilation (NIV) (n = 86; 8.7%) [Table 3].

Among the pre-admission medications, excluding aspirin (73.3%) and statins (71.3%), the three most prescribed medications were diuretics (72.4%, n = 715), angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB) (67.0%, n = 662) and beta-blockers (50.6%,
n = 500) [Table 4]. In-hospital intravenous furosemide and nitrates were administered in 90.9% and 20.6% of patients, respectively. The most medications prescribed on discharge, excluding aspirin (84.6%) and statins (83.9%), the most prescribed medications were diuretics (94.9%,
n = 839), ACEis/ARB (81.1%, n = 717), beta-blockers (68.4%, n = 605), and aldosterone antagonists (31.0%, n = 274).

Follow-up status was complete in 97% of patients at 12-months [Table 5]. The in-hospital mortality rate was 7.1% (n = 70) with a median hospital stay of four days. In-hospital device therapy rate was 0.3%
(n = 3) with percutaneous coronary intervention (PCI) in 35 patients (3.5%) and coronary artery bypass graft (CABG) in six (0.6%) patients.

At three-months follow-up, 155 patients (15.7%) had died. Hospitalization for HF was 30.0%. At 12-month follow-up, one in two patients were rehospitalized for AHF. At three months mortality had doubled to 15.7%, and reached 26.4% at one-year post discharge.

Discussion

Oman CARE was the first large, multicenter, prospective study of AHF from Oman providing a large amount of data that could be used to implement strategies to diagnose, treat and prevent AHF early and improve outcomes.

There were a number of key findings from our study. HF presented at a younger age, and its predominant presentation was ADCHF. HFrEF was more common than HFpEF. The main risk factors for HF were hypertension, coronary artery disease, and diabetes mellitus. Comorbid atrial fibrillation was less prevalent when compared to Western registries, and IHD, hypertensive heart disease, and idiopathic cardiomyopathy were the most common etiology of AHF. The most common precipitating factors were ACS and non-compliance with medications. At discharge, ACEi and beta-blockers were prescribed adequately, but aldosterone antagonists were under prescribed. Within 12-month follow-up, one in two patients were re-hospitalized for HF, and in-hospital mortality was 7.1%, which doubled to 15.7% at three months, and reached 26.4% at one-year post discharge.

Table 6 shows important differences between Oman CARE and the main Gulf CARE registry as well as the American, European, and Asia-pacific registries. The overall mean age of the cohort was 63 years, which is a decade less than the Western registries, but more than the overall Gulf CARE cohort (59 years) indicating younger age of HF onset in Oman.2-7 Patients from the African registry were even younger (52 years).5

The majority of patients presented with AHF and old age with co-morbidities such as hypertension, coronary artery disease, diabetes mellitus, hyperlipidemia, atrial fibrillation, valvular heart disease, and prior stroke/transient ischemic stroke, indicating uncontrolled severe comorbid conditions and precipitating factors leading to recurrent hospitalizations with decompensated AHF. All florid symptoms and signs of AHF were more prevalent among HF patients, which along with the lower median LVEF and a higher proportion of patients with HFrEF suggests inadequate control of risk factors and sub-optimal treatment. Younger HF patients were also smokers presenting with ACS or uncontrolled hypertension precipitating acute pulmonary edema. These results from Oman are very similar to the Euro Heart Failure Survey II (EHFS II) and the Italian registry, which showed that younger HF patients frequently presented with acute pulmonary edema, cardiogenic shock, and uncontrolled hypertension, with ACS as a predominant precipitating factor.10,11

Compared to all registries, the prevalence of diabetes mellitus in our study was highest at 53.4%. This is due to the very high prevalence of diabetes mellitus in Oman.12 In a recent study published from Oman, the age-adjusted prevalence of type 2 diabetes mellitus varied from 10.4% to 21.1% (when compared to the global average of 9%). The highest prevalence of impaired fasting glucose was found in males (35.1%).12 The prevalence of atrial fibrillation was low (15.5%) in the Oman population of AHF patients when compared with Western registries (30–40%).2–4 This low rate of atrial fibrillation can be attributed to the younger age of the cohort, low prevalence of valvular heart disease and the low prevalence of alcohol consumption in this region.IHD was the most prevalent etiology with ACS one of the most common precipitating factors while HHD was the second most common etiology as noted in the EHS II and IN-HF registries.10,11 Non-compliance with medications was one of the most prevalent precipitating causes in patients with HF, indicating the need for patient education and monitoring.

Evidence-based medications like ACEi/ARB (81.1%), beta-blockers (68.4%) were adequately prescribed, but aldosterone antagonists were prescribed in low numbers (31.0%). ACEi/ARBs prescription were comparable to other registries except ADHERE-I where it was low at 63%.2-5 However, in Oman, at discharge, beta-blockers were prescribed less than recorded in the European and American registries, but higher than the ADHERE-I and African registries.4,5

Even though AHF patients from Oman were treated adequately, the overall in-hospital mortality (7.1%) was higher when compared to other registries. This was possibly due to IHD etiology along with ACS as a precipitating factor and underlying comorbid conditions that are known to cause systolic and diastolic dysfunction.13 It has been observed that diabetic patients with HF may not respond well to standard HF therapy when compared to nondiabetic AHF patients.13

The Oman registry had an excellent follow-up status at 12 months (97%). Within 12-month follow-up, one in two patients were rehospitalized for HF, which was highest compared to other registries including the main Gulf CARE registry.2–6 The cumulative mortality of 15.7% at three months and 26.4% at one-year post-discharge were highest among all AHF registries indicating the very poor outcome of AHF patients from Oman, which may be due to the high prevalence of IHD/ACS and diabetes mellitus.

This high prevalence of diabetes and IHD are also noted as important causes of increasing HF in South Asian countries like India.14,15 These issues need to be addressed urgently so that preventive steps are initiated as soon as possible by health authorities. Starting HF clinics with early diagnosis, risk factor control, and specific treatment will help to reduce disease burden as well as morbidity and mortality in this region.15

Conclusions

Oman CARE was the first prospective multicenter registry of AHF in Oman and showed that HF patients present at a younger age with recurrent ADCHF and HFrEF. IHD was the most common etiology of HF with a low prevalence of AF, but high prevalence of ACS and non-compliance with medications precipitating HF. A quarter of patients died at one-year follow-up even though medical therapy was nearly optimal. This indicates an urgent need for prevention, early diagnosis, and treatment of AHF in Oman.

Disclosure

The authors declared no conflicts of interest. Oman CARE as part of Gulf CARE is an investigator-initiated study conducted under the auspices of the Gulf Heart Association and funded by Servier, Paris, France.

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