Suggested Link Between Regional Heart Failure Treatment Gaps, Patient Outcomes

The median time to first intravenous therapy for acute heart failure (AHF) is 3.0 hours in North America compared with 1.2 hours in all other regions, in the International Registry to Assess Medical Practice with Longitudinal Observation for Treatment of Heart Failure. Treatment timing and differences may affect outcomes in patients with AHF.

What is the current global burden of acute heart failure (AHF), and what can the differences mean for patients? According to recent research in JAMA Cardiology, treatment timing and differences may affect patient outcomes depending on which region of the world you live in.

The study authors used data from the global, prospective, observational International Registry to Assess Medical Practice with Longitudinal Observation for Treatment of Heart Failure on the index hospitalization for AHF in 18,553 patients from 358 hospitals in Western and Eastern Europe (EE), North America (NA), Central and South America, Eastern Mediterranean and Africa, Southeast Asia (SEA), and Western Pacific. Data were collected on demographics, clinical symptoms, risk factors/comorbidities, medical history, admission medications, vital signs, physical examination findings, lab values, acute therapies and procedures, and hospital course, including length of stay (LOS) and mortality. The median age was 67 years (interquartile range [IQR], 57-77).

More than 50% of patients had a history of HF, 40% had prior left ventricular ejection fraction below 40%, and most (65.4%-89.9%) received intravenous (IV) loop diuretics within 6 hours of AHF management. However, compared with NA, all other regions had a median time to first IV therapy that was 60% faster (3.0 [IQR, 1.4-5.6] vs 1.2 hours, respectively), even when adjusting for illness severity (P <.001).

Across all patient regions, similarities that were associated with greater rates of in-hospital mortality were 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 above 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).

For increased hospital LOS, except for younger age (OR, −0.04; 95% CI, −0.05 to −0.02), the factors were the same: HF etiology (ischemia: OR, 0.77; 95% CI, 0.26-1.29; valvular: OR, 2.01; 95% CI, 1.38-2.65), creatinine level above 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).

Differences were apparent in hospital point of entry and timing of treatment. Overall, patients received treatment quicker if they entered the hospital through the cardiac or intensive care unit. In EE and SEA, these times were especially apparent compared with patients who were hospitalized through the emergency department or via general admission: 0.0 (range, 0.0-0.5) and 0.4 hours (range, 0.0-0.4) versus 0.5 (range, 0.2-1.5) and 0.8 hours (range, 0.2-2.2), respectively.

The investigators arrived at 5 important conclusions:

  1. All patients with HF have a “complex burden of disease,” and diabetes, hypertension, and chronic kidney disease could be targets for prevention strategies.
  2. Etiology differed in patients with HF, but comorbidities, preexisting HF, and presenting signs and symptoms did not.
  3. Hospital point of entry and time to treatment depended on region, even when AHF severity was considered.
  4. Initial therapy differed among the regions.
  5. Routine measurements varied (eg, natriuretic peptide levels, renal function, cardiac troponin).

“These data might assist discussion and debate in the international research community about the nature of the patients they treat and the strengths and weaknesses of how patient care is managed in different regions. Learning from best practices around the world and implementing the findings, subject to available resources, may also help to improve outcomes for patients with HF,” they noted.


Filippatos G, Angermann CE, Cleland JG, et al. Global differences in characteristics, precipitants, and initial management of patients presenting with acute heart failure [published online January 8, 2020]. JAMA Cardiol. doi: 10.1001/jamacardio.2019.5108.

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