Prevalence of Heart Failure With Preserved Ejection Fraction in Latin American, Middle Eastern, and North African Regions in the I PREFER Study (Identification of Patients With Heart Failure and PREserved Systolic Function: An Epidemiological Regional Study)

doi:10.1016/j.amjcard.2011.06.044

The American Journal of Cardiology

Volume 108, Issue 9, 1 November 2011, Pages 1289-1296

https://doi.org/10.1016/j.amjcard.2011.06.044 Get rights and content

The aims of the present study were to estimate the prevalence of heart failure (HF) with preserved ejection fraction (HF-PEF) in patients with HF and to compare their clinical characteristics with those with reduced ejection fraction in non-Western countries. The left ventricular ejection fraction ≥45% if measured <1 year before the visit was used to qualify the patients as having HF-PEF. Of the 2,536 consecutive outpatients with HF, 1990 (79%) had the EF values recorded. Of these patients, 1291 had HF-PEF, leading to an overall prevalence of 65% (95% confidence interval 63% to 67%). Compared to the patients with HF and a reduced ejection fraction, those with HF-PEF were more likely to be older (65 vs 62 years, p <0.001), female (50% vs 28%, p <0.001), and obese (39% vs 27%, p <0.001). They more frequently had a history of hypertension (78% vs 53%, p <0.001) and atrial fibrillation (29% vs 24%, p = 0.03) and less frequently had a history of myocardial infarction (21% vs 44%, p <0.001). Only 29% of patients with HF-PEF and hypertension had optimal blood pressure control. Left ventricular hypertrophy was less frequent in those with HF-PEF (58% vs 69%, p <0.001). The prevalence of HF-PEF was lower in the Middle East (41%), where coronary artery disease was more often found than in Latin America (69%) and North Africa (75%), where the rate of hypertension was greater. In conclusion, in the present diverse non-Western study, HF-PEF represented almost 2/3 of all HF cases in outpatients. HF-PEF mostly affects older patients, women, and the obese. Hypertension was the most frequently associated risk factor, highlighting the need for optimal blood pressure control.

Section snippets

Methods

The I PREFER study was a multiregional, cross-sectional, observational study conducted in Latin America, the Middle East, and North Africa and designed to evaluate the prevalence of HF-PEF.

Consecutive eligible outpatients aged ≥21 years, with either a new diagnosis of HF or a previously documented diagnosis of chronic HF, were enrolled during a 3-month recruitment period. The diagnosis of HF had to be established according to the clinical Framingham criteria.¹⁵ Patients with acute

Results

A total of 2,539 patients were selected. Of these patients, 3 were excluded (because of age <21 years or acute HF). Therefore, 227 investigators (28% office based, 72% hospital based; 98% cardiologists), 92 in Latin America (33% office based, 67% hospital based; 95% cardiologists), 63 in the Middle East (8% office based, 92% hospital based; 99% cardiologists), and 72 in North Africa (40% office based, 60% hospital based; 100% cardiologists), included 2,536 patients in 10 countries: Latin

Discussion

The present cross-sectional I PREFER study has provided the prevalence of HF-PEF among outpatients with HF and a comparison of the clinical characteristics and treatment of patients with HF-PEF versus those with HF-REF encountered in routine clinical practice in Latin America, Middle East, and North Africa. Our results have confirmed that HF-PEF is common and accounts for a significant proportion of patients with HF, because 65% of our patients had preserved EF. This group of patients had

Acknowledgment

We acknowledge the contribution of all I PREFER national coordinators and investigators who have made this international study possible. The National Coordinators and Investigators of I PREFER are listed in Appendix 1. We also thank Nathalie Genès, MD, of Sanofi-Aventis, Paris, France, and Effi-Stat (Paris, France) for their support.

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Heart failure (HF) is a major public health problem affecting millions of adults worldwide. HF with preserved ejection fraction, i.e. > 50 %, (HFpEF) accounts for more than half of all HF cases, and its incidence and prevalence are increasing with the aging of the population and the growing prevalence of metabolic disorders such as obesity, diabetes and hypertension. Diagnosis of HFpEF requires a combination of numerous echocardiographic parameters and also results of natriuretic peptide assays, to which may be added the need for a stress test. HFpEF is characterized by complex, interrelated pathophysiological mechanisms, which must be understood. This complexity probably accounts for the lack of evidence-based medicine compared with HF with reduced EF. Nevertheless, significant progress has been made recently, with a high level of evidence obtained for the SGLT2 inhibitor class on the one hand, and promising data with new drugs targeting more specifically certain mechanisms such as obesity and inflammation on the other.
Revisiting Beta-Blocker Therapy in Heart Failure with Preserved Ejection Fraction
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Heart failure with preserved ejection fraction (HFpEF) is a heterogenous disorder and tends to be predominant in elderly, female, and obese patients. HFpEF has been classified using various cut-offs of left ventricular ejection fraction in the published studies with a current cut-off of ≥50%. The evidence of beta-blocker therapy in HFpEF patients showed conflicting findings with variably reported efficacy. This review aims to examine the published studies on the use of beta blockers for the treatment of patients with HFpEF.
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Over the past several decades, important advances have been made in the treatment of patients with heart failure (HF). Whereas in the past, the main goal of drug therapy was to relieve congestion, there is now compelling evidence from randomized clinical trials (RCTs) showing that several classes of drugs, most of which work predominantly by blocking or modulating neurohormonal activity, can substantially reduce morbidity and mortality as well as improve quality of life in patients with HF. Most of these trials, however, separated patients according to whether their ejection fraction (EF) was reduced (HFrEF) or preserved (HFpEF) and for the most part, favorable effects on clinical outcomes were demonstrated only in patients with HFrEF. In addition to the paucity of effective agents for managing patients with HFpEF, it has become apparent that underutilization of available therapies has greatly limited the overall impact of medical therapy on outcomes. This review provides an overview of current medical management of HF across the spectrum of EF, including the underutilization of treatment modalities. The focus is to provide clinicians the rationale for the use of specific agents and to present a practical approach for patient management. The strategies discussed are based on results of RCTs, guideline recommendations and the authors’ own experience in managing patients with HF over the years.
Atrial Fibrillation in Africa—An Under-Reported and Unrecognized Risk Factor for Stroke: A Systematic Review
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Citation Excerpt :
The studies identified mainly focused on different patient subgroups and only 3 of the included articles described a population that would be representative for the general population. The results are summarized in Table 1 [17-57]. AF prevalence in the older, general population was 0.30% to 0.70% [17-19].
Over three-quarters of deaths from cardiovascular disease and diabetes occur in low- and middle-income countries, which include many African countries. Global studies showed that the prevalence of the cardiac arrhythmia atrial fibrillation (AF) appeared to be lower in Africa. A systematic search of PubMed and African Journals Online was conducted to determine the prevalence of AF and associated stroke risk factors in Africa and to quantify the need for screening. The publications search yielded a total of 840 articles of which 41 were included. AF was often not identified as the disease of primary interest with its own risks. Data on prevalence in the general population was scarce. The prevalence of stroke risk factors showed a large variation between studies, as well as within clustered subpopulations. AF in Africa is under-reported in published reports. The study types and populations are highly heterogeneous, making it difficult to draw a definitive conclusion on AF prevalence.
Effects of carvedilol therapy in patients with heart failure with preserved ejection fraction – Results from the Croatian heart failure (CRO-HF) registry
2019, Medicina Clinica
According to recent guidelines, the best approach for treatment of heart failure patients with preserved ejection function is still not defined. The aim of this study was to investigate how carvedilol therapy influences the survival rate, ejection fraction and NYHA class in these patients.
We conducted study on heart failure patients with preserved systolic function from the Croatian heart failure registry who were hospitalized in the period between 2005 and 2010. We enrolled patients with carvedilol listed as treatment on their discharge letters and patients who had been using carvedilol for at least 4 years, while for the control group we selected patients with no beta-blockers on their discharge letters (113 vs 204 respectively). The primary outcome was the overall survival rate and the secondary outcome was the change in ejection fraction of the left ventricle and NYHA class during the study.
Patients in the carvedilol group had a higher overall survival rate compared to patients in the control group (chi-square = 14.1, P < 0.001). Patients in the carvedilol group in two measurements had a significantly higher ejection fraction compared to the control group (F = 148.04, P < 0.001). Also, patients in the carvedilol group showed improvement in NYHA class (chi-square = 29.768, P < 0.001).
Long term carvedilol therapy appears to be associated with a higher overall survival rate, improvement in ejection fraction and NYHA class in heart failure patients with preserved ejection fraction.
Según directrices recientes, todavía no se ha definido el mejor modo de tratar pacientes con insuficiencia cardíaca con función de eyección preservada. El objetivo de este estudio fue investigar cómo la terapia con carvedilol influye en la tasa de supervivencia, la fracción de eyección y la clase NYHA en estos pacientes.
A partir de los datos del registro croata de insuficiencia cardíaca, se realizó un estudio en pacientes con insuficiencia cardíaca con función sistólica preservada que fueron hospitalizados en el período de 2005 a 2010. Registramos a los pacientes que tuvieron carvedilol incluido en su tratamiento en las cartas de alta y a los pacientes que habían estado usando carvedilol durante al menos 4 años. Para el grupo de control, seleccionamos a los pacientes sin betabloqueantes en sus cartas de alta (113 versus 204, respectivamente). El resultado primario fue la tasa de supervivencia general, y el resultado secundario fue el cambio durante el estudio en la fracción de eyección del ventrículo izquierdo y la clase NYHA.
Los pacientes del grupo con carvedilol tuvieron una tasa de supervivencia general más alta que los pacientes del grupo control (Chi-cuadrado = 14,1; p < 0,001). Los pacientes del grupo con carvedilol en 2 mediciones tuvieron una fracción de eyección significativamente mayor en comparación con el grupo control (F = 148,04; p < 0,001). Además, los pacientes en el grupo de carvedilol mostraron mejoría en la clase NYHA (Chi-cuadrado = 29,768; p < 0,001).
La terapia con carvedilol a largo plazo parece estar asociada con una tasa de supervivencia general más alta y a una mejoría en la fracción de eyección y clase NYHA en pacientes con insuficiencia cardíaca con fracción de eyección preservada.

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: Supported by Sanofi-Aventis, Paris, France.

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Heart failurePrevalence of Heart Failure With Preserved Ejection Fraction in Latin American, Middle Eastern, and North African Regions in the I PREFER Study (Identification of Patients With Heart Failure and PREserved Systolic Function: An Epidemiological Regional Study)

Section snippets

Methods

Results

Discussion

Acknowledgment

J Am Coll Cardiol

J Am Coll Cardiol

Prog Cardiovasc Dis

Am Heart J

J Am Coll Cardiol

J Cardiol

Lancet

Lancet

Am J Cardiol

Clinical epidemiology of heart failure

Heart

Long-term trends in the incidence of and survival with heart failure

N Engl J Med

Heart failure
Prevalence of Heart Failure With Preserved Ejection Fraction in Latin American, Middle Eastern, and North African Regions in the I PREFER Study (Identification of Patients With Heart Failure and PREserved Systolic Function: An Epidemiological Regional Study)