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Original Investigation
January 8, 2020

Global Differences in Characteristics, Precipitants, and Initial Management of Patients Presenting With Acute Heart Failure

Author Affiliations
  • 1University of Cyprus School of Medicine, Cyprus, Greece
  • 2Attikon University Hospital, Department of Cardiology, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
  • 3Comprehensive Heart Failure Center, University Hospital, Department of Medicine I–Cardiology, University of Würzburg, Würzburg, Germany
  • 4Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Well-Being, University of Glasgow, Glasgow, United Kingdom
  • 5National Heart & Lung Institute, Imperial College London, London, United Kingdom
  • 6National Heart Centre Singapore, Singapore
  • 7Cardiovascular Academic Clinical Program, Duke-National University of Singapore, Singapore
  • 8Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
  • 9Department of Cardiology, Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
  • 10Stavanger University Hospital, University of Bergen, Bergen, Norway
  • 11Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
  • 12Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
  • 13El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad Miter, Buenos Aires, Argentina
  • 14Novartis Ireland Ltd, Dublin, Ireland
  • 15Novartis Pharma AG, Basel, Switzerland
  • 16Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
JAMA Cardiol. Published online January 8, 2020. doi:10.1001/jamacardio.2019.5108
Key Points

Question  What are the key similarities and differences in characteristics, comorbidities, therapies, and in-hospital outcomes in patients with chronic and acute heart failure?

Findings  In this cohort study including 18 553 patients from 7 global regions, there were similarities in many regions regarding prevalence of prior heart failure, ejection fraction, and comorbidities. However, there were key differences in outpatient treatment, hospital point of entry, acute heart failure precipitants, and timing and type of inpatient intravenous therapies.

Meaning  These data provide information on the current global burden of acute heart failure, identify region-specific gaps in management, and note differences in practice around the world associated with patient outcomes.


Importance  Acute heart failure (AHF) precipitates millions of hospital admissions worldwide, but previous registries have been country or region specific.

Objective  To conduct a prospective contemporaneous comparison of AHF presentations, etiologic factors and precipitants, treatments, and in-hospital outcomes among global regions through the International Registry to Assess Medical Practice with Longitudinal Observation for Treatment of Heart Failure (REPORT-HF).

Design, Setting, and Participants  A total of 18 553 adults were enrolled during a hospitalization for AHF. Patients were recruited from the acute setting in Western Europe (WE), Eastern Europe (EE), Eastern Mediterranean and Africa (EMA), Southeast Asia (SEA), Western Pacific (WP), North America (NA), and Central and South America (CSA). Patients with AHF were approached for consent and excluded only if there was recent participation in a clinical trial. Patients were enrolled from July 23, 2014, to March 24, 2017. Statistical analysis was conducted from April 18 to June 29, 2018; revised analyses occurred between August 6 and 29, 2019.

Main Outcomes and Measures  Heart failure etiologic factors and precipitants, treatments, and in-hospital outcomes among global regions.

Results  A total of 18 553 patients were enrolled at 358 sites in 44 countries. The median age was 67.0 years (interquartile range [IQR], 57-77), 11 372 were men (61.3%), 9656 were white (52.0%), 5738 were Asian (30.9%), and 867 were black (4.7%). A history of HF was present in more than 50% of the patients and 40% were known to have a prior left-ventricular ejection fraction lower than 40%. Ischemia was a common AHF precipitant in SEA (596 of 2329 [25.6%]), WP (572 of 3354 [17.1%]), and EMA (364 of 2241 [16.2%]), whereas nonadherence to diet and medications was most common in NA (306 of 1592 [19.2%]). Median time to the first intravenous therapy was 3.0 (IQR, 1.4-5.6) hours in NA; no other region had a median time above 1.2 hours (P < .001). This treatment delay remained after adjusting for severity of illness (P < .001). Intravenous loop diuretics were the most common medication administered in the first 6 hours of AHF management across all regions (65.4%-89.9%). Despite similar initial blood pressure across all regions, inotropic agents were used approximately 3 times more often in SEA, WP, and EE (11.3%-13.5%) compared with NA and WE (3.1%-4.3%) (P < .001). 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 greater than 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) were all associated with increased in-hospital mortality. Similarly, younger age (OR, −0.04; 95% CI, −0.05 to −0.02), HF etiology (ischemia: OR, 0.77; 95% CI, 0.26-1.29; valvular: OR, 2.01; 95% CI, 1.38-2.65), creatinine level greater than 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) were all associated with increased in-hospital LOS.

Conclusions and Relevance  Data from REPORT-HF suggest that patients are similar across regions in many respects, but important differences in timing and type of treatment exist, identifying region-specific gaps in medical management that may be associated with patient outcomes.