Clinical characteristics, management, and outcomes of patients with high risk chronic heart failure referred to a heart failure clinic in Saudi Arabia

Background: Patients with heart failure (HF) have a poor prognosis. Heart failure clinic (HFC) with specialized multidisciplinary management programs have been proposed to improve prognosis. Purpose: We aimed to describe the clinical features, management, and outcomes of patients with high risk chronic HF referred to a HFC in a large tertiary care center in Saudi Arabia. Methods: This is a sub-study of a prospective registry, heart function assessment registry trial in Saudi Arabia (HEARTS) and included all consecutive patients followed in the HFC between September 2009 and December 2011. Only patients with HF who were at high risk for re-admission were enrolled in the clinic. We evaluated clinical outcomes including death and re-admission rates in a subset of HF patients followed in the HFC at 1 year. Results: 436 patients were enrolled with mean age 56.14+/-15.4 years, 71.79% were men and 96.57% were Saudis. Risk factors included diabetes mellitus (51.4%), hypertension (68.8%), and current or ex-smoking (43%). The main etiologies of HF were ischemic heart disease (37.9%), non-ischemic dilated cardiomyopathy (42.7%), and hypertension (8.0%). Symptoms included NYHA class III/IV (63.3%), orthopnea/PND (28.4%), and generalized fatigue (47.5%). Left bundle branch block on ECG was present in 12.1%, median NT-proBNP was 2934.37 pg/ml (interquartile range 2512pg/ml), and severe LV dysfunction was present in 73.3%. The overall 1 year mortality rate in a subset of patients (347 patients) was 9 % and the 1 year re-admission rate 37% in the same subset. The prescription rate of evidence based therapies before admission to HFC, at discharge from 1st visit and at 1 year follow up was 90%, 91% and 94% for beta-blockers, 79%, 80% and 86 % for ACEi/ARBs and 44 %, 45 % and 42 % for spironolactone respectively. Conclusions: Our high-risk chronic heart failure patients were younger, have high rate of DM, and predominantly have LV systolic dysfunction compared with developed countries. The rate of evidence-based therapies use was reasonable, but the ICD/CRT implantation rate was low. Further improvements in management and potentially clinical outcomes, are yet to be shown with long-term follow-up at the HFC.