==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2339602010.5144/0256-4947.2012.583asm-6-583Original ArticleCharacteristics of Saudi patients with congestive heart failure and adherence to management guidelines in a tertiary hospital in Riyadh Alqahtani Mohammad aAlanazi Thari aBinsalih Salih aAljohani Naji bAlshammari Mohammed cAshagag Ali dAbdullah Mohammed eBuabbas Sara aAbdulbaqi Manar a a King Abdulaziz Medical City, Riyadh, Saudi Arabia b King Fahd Medical City, Riyadh, Saudi Arabia c King Fahad National Guard Hospital, Riyadh, Saudi Arabia d King Abdulaziz Medical City for National Guard, Riyadh, Saudi Arabia e National Guard Hospital, Riyadh, Saudi ArabiaCorrespondence: Dr. Mohammad Alqahtani, King Abdulaziz Medical City, Riyadh 11426 PO Box 22490, Saudi Arabia, drqahtani@yahoo.comNov-Dec 2012 32 6 583 587 Copyright © 2012, Annals of Saudi Medicine2012This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.BACKGROUND AND OBJECTIVES There is limited data available on the characteristics of local Saudi patients diagnosed with congestive heart failure (CHF) and on their adherence to guidelines for managing the disease. This study aimed to fill this gap. DESIGN AND SETTING Retrospective study of patients treated at King Abdulaziz Medical City from 2002–2008. SUBJECTS AND METHODS The records were reviewed of subjects admitted secondary to heart failure (defined as systolic heart failure [ejection fraction <55%] and/or heart failure with preserved ejection fraction diagnosed either clinically and/or by echocardiogram and/or cardiac catheterization) or who visited the outpatient department for the same complaint. RESULTS Of 392 CHF cases, the mean age was 67.8 (12.8) years and the majority were males (53.1%). Hypertension was the predominant comorbid illness, accounting for 84.9% of cases, followed by diabetes mellitus type 2 and hyperlipidemia. Almost three-fourths (73.7%) of the subjects had mild to severe left ventricular dysfunction, with 68.5% of the cases having right ischemic cardiomyopathy. Spironolactone, exercise and vaccination were the the least least adhered to recommendations (30.0%, 20.5% and 15.2%, respectively). CONCLUSIONS The study highlights the need for proper education of patients and caregivers to increase compliance to medications. Physicians are also encouraged to undergo continuing medical education and training courses to properly implement current recommendations in the management of heart failure. Further studies are needed on a larger scale in order to formulate an effective management scheme that will address the current challenges faced by both clinicians and CHF patients. ==== Body One of the mostly affected human organs in terms of rapid industrialization and urbanization is the heart.1 While the industrialized Western and European nations’ prevalence of heart diseases begin to taper off,2 the prevalence in developing nations is strikingly increasing, accounting for more than 80% of the cause of death in these nations.3 These vascular diseases are widely known not only as public health threats and economic burdens, but more so because these diseases increase morbidity and mortality, not to mention the over-all quality of life of the individual. To further complicate management of these diseases are the modifiable and non-modifiable cardiovascular risk factors (ie, age, family history, obesity, dyslipidemia, smoking). The presence of one risk factor alone can cause the disease, but the presence of other risk factors combined increases the likelihood of harboring these diseases. In Saudi Arabia alone, the recent epidemiologic study done by Al-Daghri and colleagues highlighted the worsening prevalence of diabetes mellitus, hypertension and coronary artery disease in the capital Riyadh as compared only to the previous decade. 4 Furthermore, the prevalence of metabolic syndrome (the clustering of cardiometabolic risk factors) is still alarmingly high in the country in both children5 and adults.6 Among the roster of chronic non-communicable diseases involving the heart is congestive heart failure (CHF). CHF, or heart failure, in general, is the weakening of the heart’s ability to effectively pump blood. Recent epidemiologic studies observed a declining trend in heart failure hospitalizations in US,7 but not in European nations such as England and Wales,8 indicating discrepancies in trends and management even in developed nations. While epidemiologic data in Saudi Arabia and the Middle East and North Africa are limited, the recent study of Magaña-Serrano and colleagues observed a lower incidence of heart failure with preserved systolic function in the Middle East as compared to Latin America and North Africa, where the prevalence of coronary artery disease and hypertension was observed to be greater.9 Furthermore, Arab patients presenting with acute coronary syndrome (ACS) with prior coronary artery bypass graft (CABG) were observed to have more severe left ventricular dysfunction but with a less prominent surge of cardiac biomarkers as compared to patients from other regions.10 In Saudi Arabia, hypertension is present in more than 80% of patients with heart failure, making it the single strongest predictor of CHF.11 This was later confirmed from a recent study by Assiri, indicating that both hypertension and ischemic heart disease are the major causes of heart failure among elderly Saudis.12 Despite these observations, little has been mentioned as to the adherence of Saudi CHF patients to current management guidelines. This single-center study, done at a major tertiary hospital in Riyadh aimed to fill this gap. SUBJECTS AND METHODS In this retrospective study done at King Abdulaziz Medical City, Riyadh, Saudi Arabia, we reviewed and screened the medical records of 500 patients admitted secondary to heart failure (defined as systolic heart failure [ejection fraction <55%] and/or heart failure with preserved ejection fraction diagnosed either clinically and/or by echocardiogram and/or cardiac catheterization) or who visited the outpatient department for the same complaint between the years 2002–2008. Cases were excluded if the heart failure was congenital in origin, end-stage renal disease (ESRD) was present, and if the patient was older than 90 years of age. From the roster of cases, a total of 392 cases met the criterion for this study. Information gathered included demographics, medical history, including functional classification of heart failure based on the recommendations of the New York Heart Association (NYHA)12 (Table 1) and medications taken. Laboratory results obtained during admission/evaluation were also obtained and included fasting plasma glucose, lipid and renal profiles as well as electrolytes. Raw data were encoded in a Microsoft Excel spreadsheet. Data was analyzed using SPSS, (IBM Corp, Armonk, New York, United States). Frequencies were presented as percentage (%) and continuous variables were presented as mean (standard deviation). The chi-square test was used for the comparison of frequencies. Significance was set at P<.05. RESULTS The majority of the subjects were elderly and more than half were male (Table 2). More than half (51.9%) had marked limitation in their physical activity (NYHA Class III), and 52.3% of the cases eventually died. Hypertension was the predominant comorbid illness, accounting for 84.9% of cases, followed by diabetes mellitus type 2 and hyperlipidemia. Consequently, almost three-fourths (73.7%) of the subjects suffered from mild-to-severe left ventricular dysfunction, with 68.5% of the cases having ischemic cardiomyopathy (Table 2). The majority of the subjects were taking diuretics (76.8%), statins (70.7%), β-blockers (69.3%) and aspirin (62.3%) (Table 3). Table 4 shows the metabolic profile of the subjects. Table 5 compares the subjects according to type of ventricular dysfunction. Those with reduced ejection fraction (EF < 55) had a higher incidence of coronary artery disease, but more were taking angiotensin-converting enzyme inhibitors, β-blockers, spironolactone and digitalis (P<.01) as compared to those with preserved EF (EF ≥55). The rest of the parameters were comparable. Figure 1 shows the number of percentage of subjects complying with the recommendations set by the American College of Cardiology and American Heart Association. Exercise and vaccination were the least complied with recommendations (20.5% and 15.2%, respectively), with barely one-fifth of the subjects adherent. DISCUSSION The major findings of this study highlight similarities done previously in the same ethnic group in terms of dominating risk factors (hypertension and diabetes mellitus) as well as the presentation of subjects (ie. elderly, male gender).13,14 What the present study adds to the literature is adherence to current recommendations. In the present study, the majority of subjects were compliant in terms of salt and fluid restriction, as well as intake of vasodilators. What was apparent was the decreased compliance to spironolactone, as well as exercise and vaccination. Current recommendations in both European and American cardiology societies are in agreement in terms of management of heart failure,15 and these consensuses are applied universally, including the tertiary hospital where this study was conducted. The difference therefore lies in the adherence of patients involved, as well as the dominant risk factors, which vary regionally. Both diabetes mellitus and hypertension are common in Saudi Arabia,4 and in the Middle East in general.16 Furthermore, dyslipidemia is extremely common in both adults and children,5,6 which means that CHF risk factors in the country start to manifest as early as childhood. Subjects included in this study also had a sedentary lifestyle, which is also very common in Saudi Arabia,17 and probably explains the lack of adherence to exercise. As to less compliance to medications, perhaps one of the issues that predispose heart failure patients not to adhere to current recommendations is polypharmacy. Patients harboring more than one disease are subject to multiple management schemes, making them prone to polypharmacy while at the same time increasing their risk of nonadherence. Regardless, polypharmacy by itself is rampant in different primary care centers in the country.18,19 Lastly, physicians themselves need to be educated about the standard recommendations for management of CHF. In one study done in Aseer, it was observed that only one-fifth of the physicians prescribed a diuretic as the preferred initial anti-hypertensive medication.20 This could have huge implications in the overall implementation of standard treatment. Patients and their respective care takers should be educated properly about the disease they harbor to increase compliance to medications. Physicians are also encouraged to undergo continuing medical education and training courses to properly implement current recommendations in the management of heart failure. Further studies are needed on a larger scale to formulate an effective management scheme that will address the current challenges faced by both clinicians and patients harboring heart failure. Acknowledgments The authors are grateful to King Abdullah International Medical Research Center for the approval and funding obtained to conduct this study. Figure 1 Percentage (%) Adherence to ACC/AHA guidelines in managing CHF patients with reduced EF. Table 1 The New York Heart Association Classification System.12 Class NYHA Functional Classification I Patients have cardiac disease but without the resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea or anginal pain II Patients have cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain III Patients have cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea or anginal pain IV Patients have cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased Table 2 Patient characteristics (n=392). Males 208 (53.1) Age (years) 67.8 (12.8) NYHA Class (mean, SD) 2.7 (0.9) NYHA 1 53 (13.6) NYHA2 67 (17.1) NYHA 3 203 (51.9) NYHA 4 68 (17.4) Mortality 205 (52.3) Hypertension 333 (84.9) Smokers 60 (15.3) Hyperlipidemia 233 (59.4) Diabetes mellitus type 2 242 (61.7) Left ventricular dysfunction (EF <55%) 289 (73.7) Normal ejection fraction (EF ≥55%) 101 (25.8) Valvular disease 45 (11.5) Ischemic cardiomyopathy 268 (68.5) Chronic atrial fibrillation 103 (26.3) PTCA/CABG 91 (23.2) Stroke/transient ischemic attack 89 (22.7) Data presented as N (%) or mean (SD). PTCA: percutaneous transluminal coronary angioplasty, CABG: coronary artery bypass graft Table 3 Medications taken by study subjects. Angiotensin-converting enzyme inhibitors 175 (45.1) Angiotensin receptor blocker 135 (34.8) β-blockers 269 (69.3) Diuretics 298 (76.8) Spironolactone 88 (22.7) Statins 273 (70.7) Nitrates 52 (17.7) Anti-arrhythmic 22 (5.7) Digitalis 55 (14.2) Aspirin 241 (62.3) Warfarin 70 (18.1) Plavix 85 (22.0) CRT, ICD, Combined 35 (9.0) Data are n (%). CRT: cardiac resynchronization therapy, ICD: intracardiac defribrillator. Table 4 Metabolic characteristics of subjects. Hemoglobin (g%) 117.3 (23.0) Creatinine (mg/dL) 150.9 (126.2) Blood urea nitrogen (mmol/L) 13.3 (9.4) Glucose (mmol/L) 10.0 (5.5) Total cholesterol (mmol/L) 3.6 (1.2) HDL-cholesterol (mmol/L) 1.0 (0.3) LDL-cholesterol (mmol/L) 2.3 (0.9) Triglycerides (mmol/L) 1.6 (0.9) Albumin (g/L) 34.8 (7.0) Potassium (mEq/L) 4.4 (0.7) Sodium (mEq/L) 137.4 (32.2) Data are mean (SD). Table 5 Comparison between subjects with heart failure and reduced ejection fraction versus heart failure and preserved ejection fraction. EF <55% EF ≥55% P Hypertension 245 88 .51 Diabetes mellitus 173 69 .11 Coronary artery disease 230 59 < .001 Atrial fibrillation 67 24 .54 Stroke/transient ischemic attack 64 25 .38 Dyslipidemia 175 88 .26 Mortality 143 44 .14 Angiotensin-converting enzyme inhibitors 147 28 < .001 β-blockers 223 46 < .001 Digitalis 240 94 .001 Spironoloctone 79 9 < .001 Diuretics 219 79 .40 Angiotensin receptor blocker 102 33 .35 ==== Refs REFERENCES 1 Sanderson JE Tse TF Heart failure: a global disease requiring global response Heart 2003 89 585 6 12748201 2 Lloyd-Jones D Adams R Carnethon M De Simone G Ferguson TB Flegal K Heart disease and stroke statistics—2009 update: a report from the American Heart Association Committee and Stroke Statistics Committee Circulation 2009 119 480 6 19171871 3 Fuster V Kelly BB Vedanthan R Global cardiovascular health: urgent need for an intersectoral approach J Am Coll Cardiol 2011 58 1208 1210 21903051 4 Al-Daghri NM Al-Attas OS Alokail MS Alkharfy KM Yousef M Sabico SL Diabetes mellitus type 2 and other chronic non-communicable disease in the central region, Saudi Arabia (Riyadh cohort 2): a decade of an epidemic BMC Medicine 2011 9 76 21689399 5 Al-Daghri NM Extremely high prevalence of metabolic syndrome manifestations among Arab youth: a call for early intervention Eur J Clin Invest 2010 40 1063 6 20624169 6 Al-Daghri NM Al-Attas OS Alokail MS ALkharfy KM Sabico SL Chrousos GP Decreasing prevalence of the full metabolic syndrome but a persistently high prevalence of dyslipidemia among Adult Arabs PLoS One 2010 5 e12159 20730053 7 Chen J Normand SL Wang Y Krumholz HM National and regional trends in heart failure hospitalization and mortality rates in Medicare beneficiaries, 1998–2008 JAMA 2011 306 1669 78 22009099 8 Cleland JG McDonagh T Rigby AS Yassin A Whittaker T Dargie HJ National Heart Failure Audit Team for England and Wales The national heart failure audit for England and Wales 2008–2009 Heart 2011 97 876 86 21173198 9 Magaña-Serrano JA Almahmeed W Gomez E Al-Shamiri M Adgar D Sosner P Prevalence of heart failure with preserved ejection fraction in Latin America, 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) Am J Cardiol 2011 108 1289 96 22000627 10 Al-Aqeedi R Sulaimani K Al Suwaidi J Al-Habib K El-Menyar A Pandurunga P Characteristics, management and outcomes of patients with acute coronary syndrome and prior coronary artery bypass surgery: findings from the second Gulf Registry of Acute Coronary Events Interact Cardiovasc Thirac Surg 2011 Epub ahead of print 11 Elshaer F Hassan W Fawzy ME Lockyer M Kharabsheh S AKhras N The prevalence, clinical characteristics, and prognosis of diastolic heart failure: a clinical study in elderly Saudi patients with up to 5 years follow-up Congest Heart Fail 2009 15 117 122 19522960 12 The Criteria Committee of the New York Heart Association Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Blood Vessels Boston Little Brown 1964 13 Assiri S Clinical and therapeutic profiles of heart failure patients admitted to a tertiary hospital, Aseer region, Saudi Arabia Sultan Qaboos Univ Med J 2011 11 230 5 21969895 14 Agarwala AK Venugopalana P De Bonob D Prevalence and aetiology of heart failure in an Arab population Eur Heart J Fail 2001 3 301 5 15 Mebazaa A Current ESC/EISICM and ACCF/AHA guidelines for the diagnosis and management of acute heart failure in adults—are there differences? Pol Arch Med Wewn 2009 119 569 73 19776702 16 Danaei G Finucane MM Lu Y Singh GM Cowan MJ Paciorek CJ National, regional and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants Lancet 2011 378 31 40 21705069 17 Al-Hazzaa HM Physical inactivity in Saudi Arabia. An underserved public health issue Saudi Med J 2010 31 1278 9 21063666 18 Asiri Y Al-Arifi MN Polypharmacy and patterns in drug prescribing at a primary healthcare centre in the Riyadh region of Saudi Arabia Int J Pharm Pract 2011 19 123 8 21385243 19 Al-Nasser AN Prescribing patterns in primary healthcare in Saudi Arabia DICP 1991 25 90 3 2008790 20 Al-Gelban KS Khan MY Al-Khaldi YM Mahfouz AA Abdelmoneim I Daffalia A Adherence of primary health care physicians to hypertension management guidelines in the Aseer region of Saudi Arabia Saudi J Kidney Dis Transpl 2011 22 941 8 21912023