One-year real-world outcomes for patients undergoing transcatheter mitral valve repair: the Gulf MTEER registry (GULF Mitral Transcatheter Edge to Edge Repair).

BACKGROUND: Severe mitral regurgitation (MR) with left ventricular dysfunction portends worse outcomes. Over the course of the last two decades, transcatheter repair of the mitral valve offered an alternative therapeutic modality for those deemed inoperable or high risk. Landmark studies such as the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation and Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation trials have shown conflicting results with respect to all-cause death and heart failure rehospitalisations. The Gulf Mitral Transcatheter Edge to Edge Repair registry (Gulf MTEER registry) is a regional registry that captured outcomes in those undergoing transcatheter repair of the mitral valve. The objectives of this study were to describe the baseline characteristics of patients undergoing transcatheter mitral valve repair in the Gulf region and estimate the cardiovascular effects of the mitral transcatheter therapies in routine practice. METHODS: The Gulf MTEER registry is an observational, multicentre, retrospective registry that enrolled all patients undergoing transcatheter repair of the mitral valve from four of the Gulf countries (Saudi Arabia, Kuwait, Bahrain, Oman) between 1 January 2017 and 31 December 2019. Baseline characteristics, echocardiographic parameters and immediate procedural success were reported. The primary outcome was a composite of death and rehospitalisations at 1 year. The secondary outcomes were the individual components of the composite endpoint; that is, death and rehospitalisations at 1 year as well as residual or recurrent MR or worsening New York Heart Association class and a need for repeat repair. RESULTS: A total of 176 patients were enrolled. Men constituted 56.3% of the total. At 1 year the primary outcome occurred in 21.1% (95% CI 15.6, 27.9). The secondary outcomes of death occurred in 5.4% (CI 2.9, 10.0) and rehospitalisations occurred in 16.9% (CI 11.9, 23.3). Univariate analysis revealed that the odds of having death or re-hospitalisation was two times higher if the effective regurgitant orifice (ERO) >40 mm2 irrespective of the therapy. CONCLUSIONS: The Gulf MTEER registry is the first registry in the Gulf region defining the patient population receiving MTEER therapies and evaluating 1-year outcomes. This is a low risk cohort with a high rate of immediate procedural success and low rate of all-cause death and rehospitalisations at 1 year. The odds of an event was two times higher if the ERO ≥40 mm2 with only a signal to higher odds for low left ventricular ejection fraction and larger end systolic dimension.

A strategy to improve adherence to guideline-directed medical therapy (GDMT) and the role of the multidisciplinary team in a heart-failure programme.

BACKGROUND: Heart failure (HF) patients place a heavy burden on the healthcare system because of their frequent need for in-patient treatment, emergency room visits and subsequent hospital stays. To provide proper care and effective therapy, practitioners have streamlined delivery techniques such as clinical pathways, checklists and pocket manuals. However, a description of the establishment of a disease-management programme, including a multidisciplinary team of physicians, clinical pharmacists and nurse specialists is required. The aim of this study was to highlight the role of the multidisciplinary team in a heart-failure programme by assessing the improvement in adherence to guideline-directed medical therapy. METHODS: A retrospective, observational research was undertaken on patients with HF at a cardiac centre in Riyadh, to observe the HF patients' management before (January to December 2014) and after (January to December 2015) the establishment of a programme. RESULTS: The use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers was 75.59% in 2014 at discharge and 81.17% in 2015 (p = 0.249). Beta-blockers use at release increased from 87.83% in 2014 to 94.53% in 2015 (p = 0.021). The flu vaccine was given to 48.24% of patients in 2014 and 75.13% of the patients in 2015 (p < 0.001). The pneumococcal vaccine was administered to 44.22% of patients in 2014 and 75.13% of patients in 2015 (p < 0.001). The ejection fraction improved from 30.21% in the first month to 39.56% in the 12th month (p = 0.001) in patients managed in 2015. CONCLUSION: The multidisciplinary heart-failure programme resulted in a positive effect, in the form of improved patient care after including the clinical pharmacist and nurse specialist.

National Heart Center/Saudi Heart Association 2023 Guidelines on the Management of Hypertension.

Background: Hypertension is a highly prevalent disease in Saudi Arabia with poor control rates. Updated guidelines are needed to guide the management of hypertension and improve treatment outcomes. Methodology: A panel of experts representing the National Heart Center (NHC) and the Saudi Heart Association (SHA) reviewed existing evidence and formulated guidance relevant to the local population, clinical practice and the healthcare system. The recommendations were reviewed to ensure scientific and medical accuracy. Recommendations: Hypertension was defined and a new classification was proposed as relevant to the Saudi population. Recommendations on diagnosis, clinical evaluation, cardiovascular assessment were detailed, along with guidance on measurement modalities and screening/follow-up. Non-pharmacological management is the first line of hypertension treatment. Pharmacological therapy should be used appropriately as needed. Treatment priority is to control blood pressure regardless of the drug class used. The choice of treatment should be tailored to the patient profile in order to achieve treatment targets and ensure patient compliance. Recommendations were provided on pharmacological options available in Saudi Arabia, as well as guidance on the treatment of special conditions. Conclusion: Hypertension management should be based on appropriate screening, timely diagnosis and lifestyle changes supplemented with pharmacological therapy, as needed. Clinical management should be individualized, and careful consideration should be given to special conditions and patient groups.

Saudi Heart Association Position Statement on the Use of Biomarkers for the Management of Heart Failure and Acute Coronary Syndrome.

Background: The burden of acute coronary syndrome (ACS) and heart failure (HF) remains high in Saudi Arabia. Biomarkers can greatly improve the management and outcomes of these conditions, but no official guidance is available on their use in Saudi Arabia. Consensus panel: An expert panel of cardiologists, interventional cardiologists and cardiac surgeon reviewed available evidence and formulated recommendations relevant to clinical practice in Saudi Arabia. Consensus findings: high-sensitivity cardiac troponins play a major role in the diagnosis of ACS and the exclusion of myocardial infarction in patients with HF. Natriuretic Peptides are recommended to determine the likelihood of a diagnosis of HF in a chronic setting and rapidly exclude HF in an acute setting. High-sensitivity cardiac troponins and NT-proBNP have good prognostic ability in ACS and HF. These biomarkers could also facilitate discharge planning and reduce unnecessary hospital admissions and resource wastage. The use of biomarkers should not be excessive and should abide by appropriateness criteria. High-sensitivity assays and NT-proBNP measurements are preferred. Conclusion: By outlining expert recommendations on the best practices in the use of biomarkers, the panel hopes to contribute towards a recognized updated guidance for all healthcare providers in Saudi Arabia on the evidence-based management of HF and ACS.

Heart failure disease management program: A review.

Disease management programs (DMPs) have shown great potential for optimizing care of chronically ill patients, thereby improving health outcomes and patient satisfaction. This had led to an overall reduction in healthcare costs. Longer life expectancy has led to increased utilization of healthcare facilities, which may lead to a rise in costs. DMPs are an effective means of improving care and compliance and ultimately curbing inappropriate resource utilization. The present study reviews different definitions proposed for disease management, its components, the evidence behind it, and the conditions for success. It also examines heart failure management as an example of a DMP, exploring the complexity surrounding implementation of guideline-based approaches in patient care. A literature search on DMPs was conducted using PubMed, MEDLINE, and Google Scholar, including heart failure management programs from articles published from 2000 to 2020. This reviewed emphasized on the management of important biomarkers and cardiovascular indicators such as glycemic levels, urine output to improve efficacy of disease management programme during patient treatment. The review concluded that diseases like heart failure can be combat by improving the quality of care for patients and reducing the burden on the public healthcare system. Moreover, DMPs have proved to be an effective way of improving care and compliance with treatment.

Therapeutic Properties of Highly Selective ß-blockers With or Without Additional Vasodilator Properties: Focus on Bisoprolol and Nebivolol in Patients With Cardiovascular Disease.

Bisoprolol and nebivolol are highly selective ß1-adrenoceptor antagonists, with clinical indications in many countries within the management of heart failure with reduced left ventricular ejection fraction (HFrEF), ischaemic heart disease (IHD), and hypertension. Nebivolol has additional vasodilator actions, related to enhanced release of NO in the vascular wall. In principle, this additional mechanism compared with bisoprolol might lead to more potent vasodilatation, which in turn might influence the effectiveness of nebivolol in the management of HFrEF, IHD and hypertension. In this article, we review the therapeutic properties of bisoprolol and nebivolol, as representatives of "second generation" and "third generation" ß-blockers, respectively. Although head-to-head trials are largely lacking, there is no clear indication from published studies of an additional effect of nebivolol on clinical outcomes in patients with HFrEF or the magnitude of reductions of BP in patients with hypertension.

Continuation of Angiotensin Converting Enzyme Inhibitors in Acute Heart Failure.

PURPOSE: The aim of this study was to show whether blocking the deleterious effects of neurohormonal activation from furosemide by the use of ACEI/ARBs, or the improvement of renal perfusion by using these drugs allows better diuresis and renal function preservation. PATIENTS AND METHODS: This is a prospective, randomized study in which patients with chronic heart failure were included. Patients admitted for ACEI/ARBs maintenance with acute decompensated HF were added in the study. The patients were divided into two groups: group 1 had ACEI/ARBs continued during admission and group 2 had stopped taking them. Patients with acute heart failure were provided with angiotensin II receptor blockers. Therefore, the present study aims to differentiate between the uses of ACEI/ARBs blocking the deleterious effects of neurohormonal activation or the improvement of renal perfusion by holding these drugs to allow better diuresis and renal function preservation in a young population. RESULTS: The results showed that the mean age of 32 patients of group 1 was 58±15.3 and for group 2 56±15.6. On day of analysis, BP was 113/65±11.9/6.5 and 108/66.9±14.1/9.8, weight was 68.4±19.8 kg and 73.7±20.2 kg, net volume balance of urine output was 2810.3±1011.8 mL and 3941.7±2849.7 mL, and length of stay was 11.75±6 and 7.9±3.7 days for groups 1 and 2, respectively. There was no significant difference in SBP (p=0.2926), DBP (p=0.7369), weight (p=0.4798), glomerular filtration rate (GFR) (p=0.7), and volume balance (p=0.166). However, there was statistically significant difference in length of hospital stay (p=0.0392). CONCLUSION: The study concluded that continuing ACEI/ARBs or holding them during IV diuresis had no difference in the effect on kidney function or diuresis. Length of stay appears to be shorter for those who held their ACEI/ARBs.

Health Care Delivery for Heart Failure Patients During The COVID-19 Pandemic; A Consensus of The Saudi Heart Failure Working Group (SAUDI-HF).

The Coronavirus disease 2019 (COVID-19) pandemic led to global and national rapid health system changes to treat the affected patients and prevent the spread of the virus. The social distancing, redirecting resources, and nationwide lockdown led to the cancellation of non-urgent hospital visits and interruption of continuity of care for patients with chronic cardiac conditions such as heart failure (HF). This consensus document addresses the domains of health care delivery that are affected by the pandemic. It explains the current situation of health care delivery to heart failure patients and further recommendation on how to overcome this. Thus, maintaining quality and continuity of care to the HF population.

Heart Failure in the Middle East Arab Countries: Current and Future Perspectives.

For many years, data about heart failure (HF) was only limited to Western countries but in the last few years, well designed heart failure registries have been conducted in many developing countries. The purpose of this review is to summarize the current status regarding the epidemiology and management of heart failure in Middle East Arab countries (MEACs) by analysis of the results of the latest HF registries performed in these countries and to anticipate future perspectives, quality initiatives and areas of research and development. Data has shown that the average age of affected individuals is at least 10 years younger than their Western counterparts. Heart failure with preserved ejection fraction was generally under-represented in these registries to less than 30% of the whole population of heart failure. Coronary artery disease (CAD) constitutes about 55% of causes of heart failure in this region in comparison to about 70% in Western countries. An area that needs development is the investment in establishing specialized heart failure programs to cut the circle of non-compliance and repeated HF admissions to the hospitals. Advances in heart transplantation and mechanical circulatory support will continue to slow down and we are not expecting major changes in the near future but on the other hand, implantation of electronic devices like ICD and CRT is expected to increase significantly in the coming years in these countries.

Saudi Heart Association (SHA) guidelines for the management of heart failure.

Heart failure (HF) is the leading cause of morbidity and mortality worldwide and negatively impacts quality of life, healthcare costs, and longevity. Although data on HF in the Arab population are scarce, recently developed regional registries are a step forward to evaluating the quality of current patient care and providing an overview of the clinical picture. Despite the burden of HF in Saudi Arabia, there are currently no standardized protocols or guidelines for the management of patients with acute or chronic heart failure. Therefore, the Heart Failure Expert Committee, comprising 13 local specialists representing both public and private sectors, has developed guidelines to address the needs and challenges for the diagnosis and treatment of HF in Saudi Arabia. The ultimate aim of these guidelines is to assist healthcare professionals in delivering optimal care and standardized clinical practice across Saudi Arabia.

Clinical Presentation, Predictors, and Outcomes Among Mineralocorticoid Receptor Antagonist (MRA)-Eligible Acute Heart Failure Patients in the Heart Function Assessment Registry Trial in Saudi Arabia (HEARTS).

Mineralocorticoid receptor antagonist (MRA) therapy is indicated after myocardial infarction in patients with acute heart failure (AHF) with an ejection fraction ≤40% and lacking contraindications. We analyzed clinical presentations, predictors, and outcomes of MRA-eligible patients within a prospective registry of patients with AHF from 18 hospitals in Saudi Arabia, from 2009 to 2010. For this subgroup, mortality rates were followed until 2013, and the clinical characteristics, management, predictors, and outcomes were compared between MRA-treated and non-MRA-treated patients. Of 2609 patients with AHF, 387 (14.8%) were MRA eligible, of which 146 (37.7%) were prescribed MRAs. Compared with non-MRA-treated patients, those prescribed MRAs more commonly exhibited non-ST-segment elevation myocardial infarction, acute on chronic heart failure, past history of ischemic heart disease, and severe left ventricular systolic dysfunction; were more commonly administered oral furosemide and digoxin; and had higher in-hospital recurrent congestive HF rates. Mortality did not significantly differ ( P > .05) between groups. In Saudi Arabia, 37.7% of eligible patients received MRA treatment, which is higher than that in developed countries. The lack of long-term survival benefit raises concerns about systematic problems, for example, proper follow-up and management after hospital discharge, warranting further investigation.

Atrial Fibrillation in Patients Hospitalized With Heart Failure: Patient Characteristics and Outcomes From the HEARTS Registry.

Effect of atrial fibrillation (AF) on short- and long-term outcomes in heart failure (HF) is controversial. Accordingly, we examined this relationship in a national multicenter project using data from the Hearts Function Assessment Registry Trial in Saudi Arabia that studied the clinical features and outcomes of patients admitted with de novo and acute on chronic HF. Out of 2593 patients with HF, 449 (17.8%) had AF at presentation. Patients with AF were more likely to be males and older (mean age 65.2 ± 15.0 vs 60.5 ± 14.8 years) to have a history of ventricular tachycardia/ventricular fibrillation (3.1% vs 1.9%) or cerebrovascular accident (15.0% vs 8.5%). However, they were less likely to have diabetes (66.0% vs 55.9%) or coronary artery disease (55.6% vs 42.3%). The 1-, 2-, and 3-year crude mortality rates were significantly higher in patients with AF (23.2% vs 18.3%, 27.4% vs 22.3%, and 27.8% vs 23.2%, respectively). However, there was no significant difference in mortality after adjusting for covariates. Thus, in patients admitted with HF, AF upon presentation was not associated with increased mortality.

Attitude of the Saudi community towards heart donation, transplantation, and artificial hearts.

OBJECTIVES: To understand the attitudes of the Saudi population towards heart donation and transplantation. Methods: A survey using a questionnaire addressing attitudes towards organ transplantation and donation was conducted across 18 cities in Saudi Arabia between September 2015 and March 2016.  Results: A total of 1250 respondents participated in the survey. Of these, approximately 91% agree with the concept of organ transplantation but approximately 17% do not agree with the concept of heart transplantation; 42.4% of whom reject heart transplants for religious reasons. Only 43.6% of respondents expressed a willingness to donate their heart and approximately 58% would consent to the donation of a relative's organ after death. A total of 59.7% of respondents believe that organ donation is regulated and 31.8% fear that the doctors will not try hard enough to save their lives if they consent to organ donation. Approximately 77% believe the heart is removed while the donor is alive; although, the same proportion of respondents thought they knew what brain death meant. Conclusion: In general, the Saudi population seem to accept the concept of transplantation and are willing to donate, but still hold some reservations towards heart donation.

Clinical characteristics, management and outcomes of patients with chronic heart failure: Results from the heart function assessment registry trial in Saudi Arabia (HEARTS-chronic).

BACKGROUND: Several registries have described patients hospitalized with heart failure (HF), but only few looked at outpatients in the ambulatory setting mostly without long-term follow-up. We sought to determine the clinical characteristics, management, and 1-year outcomes of patients with chronic HF in Saudi Arabia. METHODS: Part of a prospective multicenter nationwide registry; HEart function Assessment Registry Trial in Saudi Arabia (HEARTS) and included chronic HF patients referred to four HFCs between September 2009 and December 2011. RESULTS: We enrolled 685 patients with mean age 55.66±15.97years, 70.1% were men and 96.1% were Saudis. The main etiologies of HF were CAD (38.8%), dilated cardiomyopathy (36.5%), and hypertension (10.5%). Severe left ventricular dysfunction was present in 70.6% and median NT-proBNP was 2934.37pg/ml. The prescription rates of evidence based therapies (EBTs) before admission to HFC, at discharge from 1st clinic visit, and at 1-year follow up were 90%, 91% and 94% for beta-blockers, 79%, 80%, and 86% for ACEi/ARBs and 44%, 45%, and 42% for aldosterone antagonists; respectively. ICD was inserted in 21.9% and CRT in 6.6% at enrollment and increased to 29.1% and 8.8% after one year respectively. The all-cause mortality rate at 1year was 9% and 93.7% of which was cardiac-related. The all-cause one-year hospitalization rate was 39% and the total emergency room visit rate was 50%. CONCLUSIONS: Chronic HF patients in Saudi Arabia are younger, commonly have severe LV systolic dysfunction and have relatively high annual mortality and re-hospitalization rates.

Long-Term Mortality Rates in Acute De Novo Versus Acute-on-Chronic Heart Failure: From the Heart Function Assessment Registry Trial in Saudi Arabia.

AIM: The heart function assessment registry trial in Saudi Arabia (HEARTS) is a national multicenter project that compared de novo versus acute-on-chronic heart failure (ACHF). METHODS AND RESULTS: This is a prospective registry in 18 hospitals in Saudi Arabia between October 2009 and December 2010. The study enrolled 2610 patients: 940 (36%) de novo and 1670 (64%) ACHF. Patients with ACHF were significantly older (62.2 vs 60 years), less likely to be males (64% vs 69%) or smokers (31.6% vs 36.7%), and more likely to have history of diabetes mellitus (65.7% vs 61.3%), hypertension (74% vs 65%), and severe left ventricular dysfunction (52% vs 40%). The ACHF group had a higher adjusted 3-year mortality rate (hazard ratio, 1.6; 95% confidence interval [CI] 1.3-2.0; P < .001). CONCLUSION: Patients with ACHF had significantly higher long-term mortality rates than those with de novo acute heart failure (HF). Multidisciplinary HF disease management programs are highly needed for such high-risk populations.

Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: 2014 updates.

The Saudi Association for Pulmonary Hypertension (previously called Saudi Advisory Group for Pulmonary Hypertension) has published the first Saudi Guidelines on Diagnosis and Treatment of Pulmonary Arterial Hypertension back in 2008.[1] That guideline was very detailed and extensive and reviewed most aspects of pulmonary hypertension (PH). One of the disadvantages of such detailed guidelines is the difficulty that some of the readers who just want to get a quick guidance or looking for a specific piece of information might face. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and helpful to clinicians dealing with PH patients to select the best management strategies for the typical patient suffering from a specific condition. This Guideline was designed to provide recommendations for problems frequently encountered by practicing clinicians involved in management of PH. This publication targets mainly adult and pediatric PH-treating physicians, but can also be used by other physicians interested in PH.

Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Pulmonary hypertension due to left heart disease.

Pulmonary hypertension (PH) due to left heart disease is the most common cause of pulmonary hypertension in the western world. It is classified as WHO PH group II. Different pathophysiologic abnormalities may take place in this condition, including pulmonary venous congestion and vascular remodeling. Despite the high prevalence of WHO group 2 PH, the major focus of research on PH over the past decade has been on WHO group 1 pulmonary arterial hypertension (PAH). Few investigators have focused on WHO group 2 PH; consequently, the pathophysiology of this condition remains poorly understood, and no specific therapy is available. Clinical and translational studies in this area are much needed and have the potential to positively affect large numbers of patients. In this review, we provide a detailed discussion upon the pathophysiology of the disease, the recent updates in classification, and the diagnostic and therapeutic algorithms.

Clinical features, management, and short- and long-term outcomes of patients with acute decompensated heart failure: phase I results of the HEARTS database.

AIMS: The HEart function Assessment Registry Trial in Saudi Arabia (HEARTS) is a national multicentre project, studying clinical features, management, short- and long-term outcomes, and mortality predictors in patients admitted with acute decompensated heart failure (ADHF). METHODS AND RESULTS: Our prospective registry enrolled 2610 ADHF patients admitted to 18 hospitals in Saudi Arabia between October 2009 and December 2010, and followed mortality rates until January 2013. The patients included 66% men and 85.5% Saudis, with a median age (interquartile range) of 61.4 (15) years; 64% had acute on chronic heart failure (HF), 64.1% diabetes mellitus, 70.6% hypertension, and 55.7% CAD. Exacerbating factors for hospital admission included acute coronary syndromes (37.8%), infections (20.6%), non-compliance with low-salt diet (25.2%), and non-compliance with HF medications (20%). An LVEF<40% was found in 73%. In-hospital use of evidence-based medications was high. All-cause cumulative mortality rates at 30 days, 6 months, 1 year, 2 years, and 3 years were 8.3, 13.7, 19.5, 23.5, and 24.3%, respectively. Important independent predictors of mortality were history of stroke, acute on chronic HF, systolic blood pressure<90 mmHg upon presentation, estimated glomerular filtration rate<60 mL/min, and haemoglobin<10 g/dL. CONCLUSION: Patients with ADHF in Saudi Arabia presented at a younger age and had higher rates of CAD risk factors compared with those in developed countries. Most patients had reduced LV systolic function, mostly due to ischaemic aetiology, and had poor long-term prognosis. These findings indicate a need for nationwide primary prevention and HF disease management programmes.