Implementation of a multidisciplinary inpatient heart failure service and its association with hospitalized patient outcomes: First experience from the Middle East and North Africa region.

BACKGROUND: Multidisciplinary care models have been associated with improved clinical outcomes and an increase in adherence to guideline-directed medical therapy among patients hospitalized with heart failure (HF). OBJECTIVE: This study aims to evaluate the association between the creation of a multidisciplinary inpatient HF service and patient outcomes at a tertiary care center in the Middle East/ North Africa. METHODS: We used electronic health records to retrospectively identify patients hospitalized for acute HF between June-2015 and June-2018. Patients were categorized by whether they were hospitalized before (n = 71) or after (n = 86) the implementation of a multidisciplinary HF team (HF-MDT), starting on 1/1/2017. The groups were compared for optimal use of guideline-directed medical therapy, hospital length of stay, 30-day hospital readmission, and in-hospital mortality. RESULTS: The creation of the HF-MDT was associated with significantly better adherence to GDMT at discharge (27.5% vs. 55.4%, (OR 3.3, 95% CI [1.65-6.5]), P<0.001), shorter median hospital length of stay (8, IQR [4.8 - 19] vs. 5, IQR [3- 9], P = 0.02) and a reduction in 30-day hospital readmission (26.5% vs. 11%; OR 0.3, 95% CI [0.1-0.8], P = 0.02). However, there was no difference in-hospital mortality (10.5% vs. 3.5%; OR 0.3, 95% CI [0.1-1.2], P = 0.1). CONCLUSIONS: Implementing an HF-MDT in the care of patients hospitalized with HF is associated with better adherence to GDMT on discharge, reduced hospital length of stay, and lower 30-day readmission rates. The current data support the broader adoption of dedicated HF programs in the Middle East to improve outcomes of patients with HF.

Clinical and Haemodynamic Effects of Arteriovenous Shunts in Patients with Heart Failure with Preserved Ejection Fraction.

The arteriovenous shunt (AVS) is the most commonly used vascular access in patients receiving regular haemodialysis. The AVS may have a significant haemodynamic impact on patients with heart failure. Many studies have sought to understand the effect of AVS creation or closure on heart structure and functions, most of which use non-invasive methods, such as echocardiography or cardiac MRI. Data are mainly focused on heart failure with reduced ejection fraction and there are limited data on heart failure with preserved ejection fraction. The presence of an AVS has a significant haemodynamic impact on the cardiovascular system and it is a common cause of high-output cardiac failure. Given that most studies to date use non-invasive methods, invasive assessment of the haemodynamic effects of the AVS using a right heart catheter may provide additional valuable information.

Activation of the P38-MSK1 axis in colorectal adenocarcinoma determines a good prognostic outcome.

Colorectal cancer (CRC) is the third most common cancer worldwide and is associated with a high level of mortality and morbidity. In this study we evaluate expression of p-p38 and p-MSK1 in CRC and determine whether there is an association between expression of these markers and any clinicopathologic parameters that could be of prognostic value. Expression of p-p38, p-MSK1 and ki-67 were examined by immunohistochemistry in 135 archival CRC cases and the findings were correlated with the patient clinicopathological data. P-p38 and p-MSK1 were expressed at high level in 58.5 % and 60.7% of CRC cases respectively. A statistically significant negative correlation was found between expression of p-p38 and Ki-67 (p < 0.001, r = -0.63) and between p-MSK1 and Ki-67 expression (p < 0.001, r = -0.61). The majority of CRC cases expressing high levels of p-p38 also expressed high levels of p-MSK1 and this correlation was highly significant (p < 0.001, r = 0.863). The high expression of p-p38 and p-MSK1 was also significantly associated with low Dukes and TNM stage. The elevated expression of p-38 and p-MSK1 in CRC was associated with a good prognosis and prolonged overall survival (p < 0.001, each). Our finding showed that activation of the p38-MSK1 axis determines a good outcome in CRC.

A per-protocol initiation of sacubitril/valsartan in an advanced heart failure disease management programme in the Middle East Gulf Region.

AIMS: The aim of this study is to evaluate the utilization and success in therapy intensification after initiation of sacubitril/valsartan using a specified protocol within an advanced heart failure and transplant programme in the Middle East Gulf Region. METHODS AND RESULTS: We studied a single-centre, retrospective cohort in a 364-bedded multi-speciality hospital located in the United Arab Emirates (February 2016 to July 2017). The advanced heart failure and transplant programme formulated an institutional protocol for initiation of sacubitril/valsartan with defined criteria for switching from angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB). Prescribing this drug is intended for patients with heart failure with reduced ejection fraction with left ventricular ejection fraction ≤40%. We excluded patients (i) with age below 18 years or (ii) initiated on sacubitril/valsartan from an outside hospital with or without follow-up in our outpatient clinic. We included 102 patients with an average initial dose of 78.9 ± 44.2 mg twice daily. Only 17 patients were on target doses of ACEI or ARB prior to switching to sacubitril/valsartan. Up-titration was successful in 55 patients during the follow-up period. In addition, 6.9% patients were hospitalized with heart failure exacerbation. In patients with elevated baseline serum potassium prior to initiating this medication, the serum potassium levels decreased post-initiation by 0.5 ± 0.3 mmol/L (P = 0.0008). CONCLUSIONS: Initiating sacubitril/valsartan through a defined protocol selects for appropriate candidates and guides starting dose and titration. Overall, significant success can be achieved in replacing ACEI or ARB by sacubitril/valsartan in symptomatic heart failure with reduced ejection fraction patients.

A Cross-Sectional Study in Patients with Severe COPD to Assess the Perception of Symptom Variability (COPVAR) in the Middle East and Africa.

Purpose: This study was performed to assess symptom variability and its impact on morning activities in stable patients with severe COPD in the Middle East and Africa (MEA) countries. Patients and methods: Non-interventional, cross-sectional study (NCT03425760) in patients with severe COPD (GOLD 2015, C, or D categories). Symptom variability was assessed directly by interviewing the patient and using the Global Chest Symptoms Questionnaire (GCSQ). The impact on morning activities was assessed using the Capacity of Daily Living during the Morning (CDLM) and the Morning Activities and Symptoms Questionnaire (MASQ). Results: A total of 3253 patients (mean±SD age: 64.1±9.5 years, 90.3% males) were enrolled. Overall, 81.6% and 83.4% of patients reported weekly and daily symptom variability, respectively. The number of exacerbations in the previous year, smoking cessation, and COPD GOLD D were the most consistent factors associated with symptom variability. The GCSQ score was significantly higher (p<0.001) in GOLD D than in GOLD C patients at each time during the day. In GOLD D, the mean (±SD) GCSQ score was higher at night (1.6±1.2, p<0.001) and in the morning (1.5±1.0, p<0.001) than in the afternoon (1.3±0.9), suggesting daytime variability of breathlessness and chest tightness. Overall, 60.0% of GOLD D patients (versus 13.6% GOLD C, p<0.0001) had difficulty getting out of bed due to COPD. Patients with symptom variability had significantly more difficulty to get out of bed, especially patients with chest tightness variability (p<0.0001) and wheezing variability (p<0.0001). The CDLM global score was significantly lower (p<0.0001) in GOLD D than in GOLD C patients (3.5±1.1 and 4.6 ± 3.5, respectively). Daily variability in chest tightness and wheezing was also significantly associated with CDLM scores (p<0.0001). Conclusion: In MEA countries, patients with severe stable COPD reported significant daily and weekly symptom variability which affects morning activities, particularly in GOLD D patients.

Nurse-led education for heart failure patients in developing countries.

Heart failure readmissions are associated with significant morbidity and mortality. Adequate education on adherence and self-care behaviours can affect readmission rates positively and nurses are at the frontline of patient education. Such education is valuable when establishing heart failure programmes in developing countries, in light of the challenging socioeconomic circumstances in these. This study aimed to evaluate nurses' heart failure knowledge, to assess patients' baseline knowledge, and to evaluate the effectiveness of structured nurse-driven education. METHODS: a total of 131 cardiac centre-based nurses and 30 chronic heart failure patients participated in the study in Kuwait. Patients were surveyed a second time 3 to 6 months later, while being followed at an advanced heart failure clinic by dedicated heart failure nurses. RESULTS: the majority of the nurses (80%) had not received heart failure education previously, although they were able to recognise most heart failure symptoms. Significant improvement in patients' knowledge was noted between the initial and follow-up surveys. CONCLUSION: establishing a dedicated advanced heart failure programme to care for patients in a developing country can result in significant improvement in disease awareness and self-care behaviours when led by well-trained heart failure nurses. More research is needed to determine if these findings are shared by other countries in the Middle-East and other developing countries.