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Southeast Asian patients have the highest risk factor burden for HF

Roshini Claire Anthony
20 Jul 2017
Professor Carolyn Lam

There is significant heterogeneity among Asian patients with heart failure, with patients from Southeast Asia appearing to have the highest risk factor burden, according to findings of the ASIAN-HF* registry study presented at the 21st Asian Pacific Society of Cardiology Congress (APSC 2017) held in Singapore.

“These first prospective multinational data from Asia highlight the significant heterogeneity among Asian patients with [heart failure], the influence of regional income level and ethnicity on patient characteristics, and the large burden of comorbidities despite relatively young age,” said Professor Carolyn Lam from the National Heart Centre Singapore who presented the results. [APSC 2017, Late Breaking Trial 2]

“[T]hese data show that ‘Asian [heart failure]’ is not a single phenotype. Regional/ethnic differences may have important implications for the design of global [heart failure] clinical trials or allocation of resources for management of the [heart failure] ‘epidemic’ in Asia,” said ASIAN-HF researchers in a publication of their initial findings. [Eur Heart J 2016;37:3141-3153]

The ASIAN-HF registry was a prospective, multinational (46 sites), observational study of Asian patients with stage C heart failure and enrolled 5,276 patients with heart failure with reduced ejection fraction (HFrEF; EF <40 percent) and 1,204 patients with heart failure with preserved ejection fraction (HFpEF; EF ≥50 percent).

Countries were grouped according to region: Northeast (ie, South Korea, Japan, Taiwan, Hong Kong, and China; n=2,201); South (ie, India; n=1,688), and Southeast Asia (ie, Thailand, Malaysia, Philippines, Indonesia, and Singapore; n=2,591), as well as by national income level (lower: Indonesia, Philippines, and India; middle: China, Thailand, and Malaysia; and higher: Singapore, Hong Kong, Taiwan, South Korea, and Japan). 

Asian patients with heart failure were younger than their US or European counterparts be it patients with HFrEF (60, 70, and 64 years, respectively) or HFpEF (68, 73, and 69 years, respectively).

Participants from Southeast Asia appeared to have the highest risk factor burden among Asian patients with HFrEF with 64.2, 58.8, and 49.3 percent having hypertension, coronary artery disease (CAD), and diabetes, respectively, compared with patients from Northeast Asia (48.1, 38.2, and 31.8 percent, respectively) and South Asia (37.9, 51.1, and 37.1 percent, respectively).

Compared with Chinese participants with HFrEF, Malays and Indians had higher risks of CAD (adjusted odds ratio [adjOR], 1.97 and 1.44, respectively), while Koreans and Japanese had lower risks (adjOR, 0.38 and 0.44, respectively).

Among patients with HFpEF, participants from Southeast Asia also had the highest prevalence of hypertension, diabetes, CAD, chronic kidney disease (CKD), and anaemia, compared with participants from South and Northeast Asia.

Patients with CAD and CKD were more likely to have HFrEF, while patients of older age or those with hypertension, diabetes, anaemia, or atrial fibrillation were more likely to have HFpEF, said Lam. Women were three times more likely to have HFpEF, and individuals with two or more comorbidities had an almost 50 percent increased risk of HFpEF.

Patients from Southeast Asia also had the highest proportion of six-month all-cause mortality or hospitalization for heart failure (18.7 percent vs 12.5 percent [Northeast Asia] and 5.5 percent [South Asia]).

“[T]he ethnic groups who appeared most predisposed to premature [heart failure] were Malays, Filipinos, and indigenous Southeast Asians. The notable interactions between ethnicity and regional income level, a surrogate of epidemiologic transition, further support this concept and carry important public health implications for the management and prevention of cardiovascular risk factors in these communities,” said the researchers, who acknowledged that the findings may still underestimate the burden of heart failure in this region.

Only 12 percent of the 3,453 patients who were eligible for implantable cardiac defibrillators (ICDs; EF ≤35 percent and NYHA** status 2 or 3) actually had the device implanted, with the researchers noting a higher likelihood of ICD implantation in patients from higher income countries.

Results also demonstrated that ICD implantation reduced the risk of all-cause mortality (hazard ratio [HR], 0.71) and sudden cardiac deaths (HR, 0.33) over a median follow-up period of 417 days.

“Potentially life-saving ICDs are underutilized with disparity across geographic regions and socioeconomic status,” said Lam. “Modifiable risk factors, better patient education, and targeted healthcare reforms to address the underutilization of ICDs represent important opportunities for public health intervention to improve patient outcomes,” she said.

In his commentary, Professor Jeroen Bax from Leiden University Medical Center, Leiden, the Netherlands, and current President of the European Society of Cardiology stressed the importance of primary prevention and the modification of lifestyle and risk factors in tackling the high rate of heart failure in this region.

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