January - June 2007 The The DEAR Heart Program Program:The Profile of the Filipino Adult DEAR Heart

Symptomatic Heart Failure patients based on the data derived from pilot phase of the D.E.A.R. Heart Program from Nov. 1, 2002 to Dec. 31, 2004. The National Heart Failure Registry Program (hospital-based)

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Jesus Jorge, MD, Delfin Encarnacion, MD, Sharon-Marisse Lacson, MD, Maria Concerias-Lim Quizon, MD, Annette Borromeo, MD, Romeo Divinagracia, MD, Ramon Abarquez, MD, Aquileo Rico, MD, Carmencita Lingan, RN
BACKGROUND The DEAR Heart(Dysfunction Established And Registered adult symptomatic Heart failure patients) Program is a developmental registry program to surveil adult symptomatic heart failure(HF) patients being admitted to tertiary hospitals in the Philippines. Adult symptomatic HF patients admitted to the ER or direct- to-room are logged on to the HF logbook, a DEAR Heart registry form is inserted to the chart, and data are encoded and analyzed utilizing EpiInfo 6. Data analyses from1078 patients registered in 6 pilot hospitals from Nov. 1, 2002 to Dec. 31, 2004 are as follows: The mean age of patients is 60 years(median age of 62); 57% are male; 1/3 of patients are jobless; 52% are first admissions and 48% are readmissions; median length of hospital stay (LOS) is 7 days and the mean LOS is 10 days; abnormal chest/lung findings are present in 91% of patients; 98% of chest x-rays done are abnormal; among patients who underwent 2DEcho, 52% have preserved LV systolic function; Diuretics are the most commonly used drugs (76% on admission, 68% on discharge); The most common risk factors for the development of HF are: HPN (64%), Smoking(54%), DM(41%), Dyslipidemia(38%), and Overweight(21%); 30% of patients have no identifiable precipitating causes for HF; Underlying causes of HF are: Ischemic Heart Disease Syndromes 52%, Valvular Heart Diseases 20%, Cardiomyopathies 11%, Uncontrolled Hypertension 5.7%, Tachyarrhythmias 4%, and Congenital Heart Diseases 3.4%; The mortality rate is 10%; 55% of deaths are attributable to progression of HF, 32 % to cardiac arrhythmias or SCD, and 13% to causes other than HF; distribution of comorbid problems are: HPN (12.2%), DM (7.4%), Chronic Renal Insufficiency(3.6%), COPD(1.6%), Hyperthyroidism(1.1%), Secondary HPN (0.7%), and Hypothyroidism(0.3%); Strongly associated with in-hospital mortality are chest pain as chief complaint and a heart rate of >95/min. The DEAR Heart Program provides us with the opportunity to profile adult symptomatic HF patients in the Philippines. This leads to identification of research needs and improvement in treatment protocols among this subset of cardiac patients.

METHODS

RESULTS

CONCLUSION

In the United States it is claimed that heart failure(HF) will continue to be a growing problem mainly because of the recent advances in therapeutic strategies for underlying cardiovascular diseases and an increase in degenerative forms of cardiovascular diseases as the population ages and advances . It has been estimated in the US that the hospitalization costs of heart failure exceed $13 billion annually. In the Philippines there is no existing program to surveil noncommunicable diseases. There is no local data estimating the burden of cardiovascular diseases and there has been no attempt to specifically profile the heart failure

population. These may partly explain why there are no substantial local large-scale or multicenter clinical trials on cardiovascular diseases in general and heart failure in particular. A National Heart Failure Registry Program, with D.E.A.R. Heart (Dysfunction Established And Registered adult symptomatic Heart Failure patients) as its information handle, was designed as an information technology-driven program to effectively, and continuously, register adult patients with symptomatic heart failure (HF) being admitted to tertiary hospitals nationwide. It was conceptualized in August 2002 as a

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developmental, collaborative program as it included government and non-government agencies such as the Heart Failure Society of the Philippines (HFSP), The Society of Cardiovascular Nurse Practitioners of the Philippines, Inc. (SCVNPPI), the Philippine Heart Associations (PHA) Councils on Heart Failure, Cardiomyopathy and Cardiovascular Surgery, and the National Epidemiology Center of the Department of Health (NEC-DOH). Astra-Zeneca funded the program from planning to pilot testing. Objectives: The main objective of the program is to set up an effective ongoing registry of symptomatic adult HF patients being admitted to tertiary hospitals to be able to locally profile HF patients based on the registry. The specific questions which the DEAR Heart program will interrogate among patients registered therein are: 1) What is the clinical profile of symptomatic adult heart failure patients admitted to tertiary hospitals? 2) What are the modes of management for these patients? 3) What are the hospitalization outcomes? 4).What are the readmission rates? METHODS The DEAR Heart program has been envisioned to target accredited tertiary hospitals ten(10) of which are categorized as PHA-accredited training hospitals in cardiology and cardiovascular surgery. Registry Entry Criteria: 1. ER or direct to room hospital admission of patients aged 19 and above 2. With signs and symptoms consistent with the diagnosis of heart failure of whatever underlying cause based on the modified Framingham criteria Data gathering among implementing hospitals will have to follow a simple 4-step procedure: 1. Patients who fulfill entry criteria are logged into the DEAR Heart logbook and a DEAR Heart registry form is inserted onto their charts 2. The registry form is completed by cardiology fellows or Internal Medicine residents. 3. Data are then encoded and analyzed by individual implementing hospital

4. Data is submitted or relayed to the central data bank for encoding collation, and analysis During the pilot phase of the program, hard copies of the registry forms are collected by the program coordinators of each implementing hospital and submitted to the Philippine Heart Association office. Data are then encoded, collated and analyzed by the program coordinators at the National Epidemiology Center. A. The DEAR Heart registry form: The developmental DEAR Heart HF registry form is made up of five (5) pages and interrogates mainly nine (9) items as follows: 1. Background information/Demographics 2. Clinical profile as to Symptomatology 3. Admitting Physical Examination Findings 4. Admitting Laboratory examination results 5. Modes of management 6. Discharge diagnosis 7. Co-morbid conditions identified 8. Outcome of hospitalization 9. Discharge medications B. The DEAR Heart logbook The DEAR Heart logbook is a standard logbook devoted to symptomatic heart failure patients admitted at the ER or other inpatient units where the individual patient was directly admitted. The data entered into the HF logbook are the patients name, hospital number, date of admission, and admitting impression. C. Software/encoding process The software program for encoding, collation, and analysis to be utilized in this registry program is Epi Info 6 (version 6.04d, January 2001). Epi Info 6 is a word processing, database, and statistics program mainly for public health. Epi Info 6 will be made available to the implementing hospitals and central data bank. D. DEAR Heart central data bank The central repository of data or the DEAR Heart central data bank was envisioned to be located at the PHAs Hearthouse and/or the National Epidemiology Center. It will collect, collate, and analyze data from implementing hospitals and will report data on a quarterly or bi-annual basis. The program plan is for the PHA to eventually set up a secure website- or an electronic web-based, user-friendly system for the DEAR Heart program so that implementing hospitals can easily relay data.

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E. Information Flow It has been envisioned that the information flow will be from implementing hospital to the central data bank, and vice-versa for national benchmarking purposes. RESULTS of the DEAR Heart Program (pilot expansion phase) 1078 patients from 6 implementing Hospitals (PHC, VMMC, RMC, PSH-Cebu, PGH, Iloilo Med Hospital) from November 1, 2002 to December 31, 2004 The DEAR Heart Program was conceptualized in August of 2002. A Technical Working Group was set up in September of 2002 and a month-long pilot testing at the Philippine Heart Center(PHC) started in November1, 2002. This pilot eventually expanded as 5 other hospitals implemented the registry program. These hospitals, in chronologic order of implementation, were the Veterans Memorial Medical Center (VMMC), the Rizal Medical Center, The Perpetual Succour Hospital of Cebu (PSH), the Philippine General Hospital (PGH), and the Iloilo Doctors Hospital (IDH). Analyses included only those patients registered from November 1, 2002 to December 31, 2004 for the sole purpose of preliminary reporting for the 2005 Philippine Heart Association (PHA) convention. A total of 1078 patients were registered during the period November 1, 2002 to December 31, 2004.The number of patients registered in each of the 6 implementing hospitals during the pilot expansion phase of the program is shown in Table 1. The accompanying pie diagram below shows that 71.4 % of patients were those registered at the Philippine Heart Center. I. Background Information/Demographics Among 1078 patients registered into the DEAR Heart program, statistical analysis of the background and demographic data will show that 57% (613/1078) were male and 43% (465/1078) were female. The age range in years of patients is 19 to 92; the mean age is 60; the median age is 62; and the mode is 64 years (with standard deviation of +/-17). Table 2 shows that 53% of patients belong to those >60 years. As part of the Background information and Demographics of patients registered during the pilot phase of the program, Tables 3 and 4 show the distribution of patients according to the attributes of occupation and educational attainment, respectively.

Table1. Distribution of patients registered at the 6 implementing hospitals during pilot expansion of the DEAR Heart program from November 1, 2002 to December 31, 2004.

Implementing
Hospital PHC VMMC RMC PSH PGH IDH TOTAL

2002

2003

2004

Total

35

541 49

35

590

194 63 91 65 16 24 453

770 112 91 65 16 24 1078

8.4% 10.4%

6%

1.5% 2.2

PHC

VMMC

RM

Table 2. Distribution of 1078 patients registered during the pilot expansion phase of the DEAR Heart program according to age-range.

Age in years 1 9-29 30 40 41 - 60 61 - 75 >75

Percent(n = 1078) 7.0 7.5 33 32 21

Table 3. Distribution of 1078 patients registered during pilot expansion of the DEAR Heart program according to occupation.

Occupation Jobless Employee Housewife Retirees Businessmen Self-employed Managers

% (n=1078) 27 20 15 13 10 5 <5

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II. Clinical Profile The symptomatic profile of these 1078 patients registered in this pilot expansion phase were analyzed in terms of the distribution of patients according to the chief complaints as shown in Table 5, and the distribution of symptoms other than the chief complaint as shown in Table 6. Patients registered were also profiled according to the risk factors for the development of HF. Table 7 and the corresponding bar diagram below show that the 5 most common risk factors for the development of HF among hospitalized patients registered during the pilot phase of the DEAR Heart program are hypertension, smoking, diabetes mellitus, dyslipidemia and overweight.

Precipitating factors are defined as those factors which trigger or initiate the worsening of heart failure. Table 8 shows the distribution of these precipitating factors among patients registered from the period of November 1, 2002 to December 31, 2004. Among the 1078 patients registered into the DEAR Heart program during the pilot period from November 1, 2002 to December 31, 2004, 52% were first admissions and 48% were readmissions for the same symptoms. According to their length of stay (LOS), the range is < 1 to 133 days, with the mean LOS at 10 days, mode LOS at 3 days and the median LOS at 7 days.
Table 6. Distribution of 1078 patients registered during the pilot expansion of the DEAR Heart program according to symptoms other than the chief complaint

Table 4. Distribution of 1078 patients registered during pilot expansion of the DEAR Heart program according to educational attainment

Symptoms other than chief complaint Shortness of Breath Easy Fatigability Orthopnea Exertional Dyspnea Paroxysmal Nocturnal Dyspnea Bipedal edema Angina Sudden onset of severe and progressive dyspnea Palpitation

Percent (n=1078) 84 78 63 53 44 40 37 21 20

Educational Attainment No formal education Elementary High School factor 5 most common chief com risk of HF identified during the p symptomatic adult heart College into the DEAR H Vocational Heart pr Post-graduate 50

Percent(n=1078) 0.4 10 30 55 2 3

70
percent(n=1078)

60 40 50 40
30

30 20 20 10 0
0 10

Table 5. Distribution of 1078 patients registered during the pilot expansion phase of DEAR Heart program according to the 5 most common chief complaints

Table 7. The 5 most common risk factors for the development of heart failure during the pilot expansion phase of the DEAR Heart program

Chief Complaint Difficulty of breathing(dyspnea) Chest Pain Shortness of Breath Easy Fatigability Edema

Percent (n=1078) 45 17 13 7 3.1

Risk Factors for the development of HF Hypertension Smoking Diabetes Mellitus Dyslipidemia Overweight

Percent (n = 1078) 64 54 41 38 21

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III. Admitting Physical Examination The profiling of these 1078 symptomatic heart failure patients according to the physical examination findings during their admission is shown below in Table 9. The mean systolic BP was 123 mmHg (SD +/- 28), with a mean diastolic BP of 76 mmHg (SD +/- 16). The mean heart rate (HR) was 88 beats/min (SD +/- 21) and the mean respiratory rate (RR) of 23/min (SD +/- 7). Neck Vein Engorgement was observed in 54% of patients and Abnormal Chest/Lung findings was present in 91% of patients. The apex beat was observed to be displaced in 64 %, cardiac rhythm was noted to be irregular in 30%, and Bipedal edema was observed in 30% of patients. IV. Admitting Laboratory Examinations 965 out of the total of 1078 patients had a chest radiogram. Among these patients, 98% (947/965) of the chest x-rays were abnormal. Table 9 below shows the distribution of abnormal findings among these patients

Table 8. Distribution of Precipitating or Triggering factors for the worsening of heart failure symptoms among 1078 patients registered during the pilot expansion phase of the DEAR Heart program

who underwent a chest radiograph. Out of a total of 1078 patients, 761 underwent a 2dimensional echocardiogram during the admission. Table 11 shows the distribution of LV function based on Ejection Fraction (EF) among the patients who underwent 2dimensional echocardiography during. Patients with an EF of > 55% was categorized as those with Normal LV function; those with an EF between >45 to 55% were categorized with mild LV systolic dysfunction; those with an EF of 30 to < 45 % were categorized as moderate LV systolic dysfunction; and those with an EF < 30% were categorized to have severe LV systolic dysfunction.(Categorization of LV function from Normal to Severe is based on the American Society of Echocardiography Recommendations) V. Modes of Management Table 12 and the corresponding bar diagram below show the distribution of medications being given during the admission of patients during this phase of the registry program. Among symptomatic adult HF patients, nearly 80% received diuretics during their admission.

Precipitating Factors

Percent(n =1078) 34 21 20 11

None identified Systemic Infection Inappropriate Reduction of Treatment Arrhythmias(tachyarrhythmias or bradyarrhythmias) Development of Acute Unrelated Illness(Acute Renal Failure, Acute-on-top-of Chronic Renal Failure, Anemia of Blood Loss) Administration of Cardiac Depressants (antineoplastic agents, alcohol)

Table 10. Distribution of Abnormal Chest X-ray results among patients registered during the pilot expansion phase of the DEAR Heart program (LV= Left Ventricle, RV = Right Ventricle, LA = Left Atrium)

Abnormal Chest X-rays LV Cardiomegaly Pulmonary Congestion RV Enlargement LA Enlargement Pleural Effusion

Percent (n = 947) 62 23.5 7 6 2.3

7 1

Table 9. Physical Examination findings among 1078 patients registered during the pilot expansion phase of the DEAR Heart program.

Physical Examination findings on Admission Systolic Blood Pressure Diastolic Blood Pressure Heart Rate Respiratory Rate Neck vein Engorgement Congestive Rales Displaced Apex Beat Irregular cardiac rhythm Bipedal Edema Mean = 123 mm Hg (SD +/- 28) Mean = 76 mmHg (SD +/- 16) 88 beats/min(SD +/- 21) 23/min (SD of +/- 21) 54% 85% 64% 30% 43%

Table 11. . Distribution of LV function based on Ejection Fraction (EF) among 761 patients who underwent 2-D Echo during the pilot expansion phase of the DEAR Heart program. Note: 31% (85/278) of those with NORMAL LV function (>55%) are patients with valvular heart disease.

LV Systolic Function according to Ejection Fraction Normal ( EF > 55%) Mild LV systolic dysfunction ( EF >45 to 55) Moderate LV systolic dysfunction (EF 30 to 45%) Severe LV systolic dysfunction (EF <30%)

Percentage (n = 761)

37 15 30

18

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A total of 429 procedures were performed among patients registered during the pilot expansion phase of the DEAR heart program. Table 13 shows the distribution of procedures among these patients. VI. Discharge Diagnoses The most common discharge diagnoses among patients registered during the pilot phase of the DEAR Heart program are Ischemic Heart Disease Syndromes, Valvular Heart Diseases, Cardiomyopathies, Uncontrolled Hypertension, Sustained Tachyarrhythmias, and Congenital Heart Diseases. Table 14 and its corresponding bar diagram below show the distribution of these. VI. Comorbid problems are diseases or disorders that are identified only during the current hospitalization and are unrelated to the HF state. Table 15 below shows the comorbid problems identified during the pilot phase of the DEAR Heart program.

VIII. Outcomes of Hospitalization The data regarding outcomes of hospitalization among 1078 patients registered during the pilot expansion phase of the DEAR Heart Program shows that almost 85% of symptomatic HF patients are discharged as improved and that the mortality rate is 10% as shown below in Table 16. Among those who died, an analysis of the causes of death among patients registered had shown that 55% of deaths were attributable to progression of HF, 32 % were attributable to cardiac arrhythmias or sudden cardiac death, and 13% were attributable to causes other than HF as shown in Table 17.
Table13. The distribution of procedures done on patients registered during the pilot expansion phase of the DEAR Heart program

Procedures done Coronary Angiography Cardiovascular Surgery Transcatheter Therapy Intra-aortic Balloon Counterpulsation Other Procedures(dialysis, mechanical ventilation, noncardiac surgery)

Percent (n= 1078) 17 8 3 2 10

Table 12. Distribution of medications given on admission of 1078 patients registered during the pilot expansion phase of the DEAR Heart program
Medications used durin distribution of patients ac the admision diagnos
80 percent of total(n percent (n=1078) = 1078) 70 60 60 50 50 40 40 30 30 20 10 20 0 10

Medication used during

Percent(n = 1078)

Diuretic ACEI Cardiac Glycoside Vasodilator Betablocker Antithrombotic Anticoagulant 1 ARBs medications IV Inotropics Antiarrhythmics Calcium Antagonist

76 58 53 51 34 32 30 14 14 10 10

Table 14. Distribution of discharge diagnoses among patients registered during the pilot expansion phase of the DEAR Heart program

Discharge diagnosis Ischemic Heart Disease Syndrome: (Chronic Stable Angina = 49.8%) (Acute Coronary Syndrome=50.2%) Valvular Heart Disease Cardiomyopathy Uncontrolled Hypertension Sustained Tachyarrhythmia Congenital Heart Disease

Percent (n=1078)

52.3 20.2 11.1 5.7 4.0 3.4

Bar graph showing distribution of medications given during the admission of 1078 patients registered during the pilot expansion phase of the DEAR Heart

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Table15. Comorbid problems identified during confinement of patients registered during the pilot expansion phase of the DEAR Hear program

Comorbid conditions Primary/Essential Hypertension Diabetes mellitus Chronic Renal Insufficiency Chronic Obstructive Pulmonary Disease Hyperthyroidism Secondary Hypertension Hypothyroidism

Percent (n = 1078) 12.2 7.4 3.6 1.6 1.1 0.7 0.3

Table 16. The distribution of outcomes of hospitalization among patients registered during the pilot expansion phase of the DEAR Heart program

Outcomes of hospitalization Improved Status Quo Worsened Mortality

Percent (n = 1078) 84 5 <1 10

IX. Discharge Medications Table 18 and its corresponding bar diagram below show the distribution of oral medications prescribed among 969 patients who were registered and discharged during the pilot expansion phase of the DEAR Heart Program. An attempt to analyze risk factors for in-hospital mortality was made using univariate analyses and multivariate logistic regression analyses. Table 19 below show that chest pain as the chief complaint, systolic BP, diastolic BP, mean HR, use of IV inotropics on admission, transcatheter therapy, and intraaortic balloon counterpulsation are risk factors for in-hospital mortality utilizing univariate analysis. Multivariate analysis however shows that only chest pain as the chief complaint and a heart rate greater than 95/min were the factors significantly associated with in-hospital mortality (P < .005).

Table18. Distribution of medications prescribed among 969 patients registered and discharged during the pilot phase of the DEAR Heart program. Pie diagram on Outcomes of Hospitalization

Medications prescribed on discharge Diuretics Cardiac Glycoside ACE I Vasodilator Betablocker Antithrombotic Anticoagulant ARBs Calcium Antagonists Antiarrhythmics Inotropics

Percent ( n = 969)

68 56 56 50 38 32 26 14 12 9 0.9

Table 17. The distribution of causes of death among 109 patients who died among those registered during the pilot expansion phase of the DEAR Heart program

Medications prescr
80 70

Causes of Death Progression of HF( cardiogenic shock, pulmonary edema) Cardiac Dysrhythmia/ Sudden Cardiac Death Sepsis Others(includes hemorrhagic shock, hospital-acquired pneumonia, CVA, respiratory failure)

Percen(n= 109)
Percent (n=969)

60 50 40 30 20 10 0

55 32 3 10

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Table19. Risk factors associated with in-hospital mortality by univariate analysis (BP- blood pressure, SWMA- segmental wall motion abnormality, 2D-Echo-two-dimensional echocardiography)

RISK FACTOR Chest pain as chief complaint Systolic BP(mean) Diastolic BP Mean Heart Rate Segmental Wall Motion Abnormality (SWMA) on 2D- Echo IV Inotropics on admission Transcatheter Therapy Intra- Aortic Balloon Counterpulsation

DEAD 32/109 111 mmHg(SD +/- 29.5) 70 mmHg(SD +/- 15.2) 95/min(SD +/- 22.6) 46/109 (42%) 51/109 (46.8%) 7/109 (6.4%) 11/109 (10.1%)

ALIVE 142/913 125 mmHg(SD +/- 27.9) 77 mmHg(SD +/- 16.2) 87/min(SD +/- 20.4) 299/913 (32.7%) 89/913 (9.7%) 23/913 (2.5%) 13/913 (1.4%)

P value < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.062 (NS) < 0.000 0.033 < 0.0001

Table 20. Risk factors associated with in-hospital mortality by multivariate analysis

RISK FACTOR Chest Pain Systolic BP(111 mmHg) Diastolic BP(70 mmHg) Heart Rate (95/min)

P value 0.002 0.114 0.056 < 0.0001

DICUSSION The DEAR Heart program is the first of its kind in the history of Philippine cardiovascular medicine and epidemiology. Its history can be traced back to a consensus meeting held during the 2002 (August) annual convention of the Heart Failure Society of the Philippines. This meeting included the Philippine Heart Associations Council on Heart Failure and the Department of Health. The consensus generated then was to come up with a registry on heart failure. The Philippine Heart Associations Council on Heart Failure took this as the cue to spearhead a registry on adult symptomatic heart failure patients being admitted to tertiary hospitals nationwide. The registry program was first called the (hospital-based) National Heart Failure Registry Program. Later on, DEAR Heart (for Dysfunction Established And Registered adult symptomatic Heart Failure patients) was adopted as its information handle and advocacy tool. The DEAR Heart program conforms to the basic definition of clinical registries as a surveillance tool: it is an observational study of actual medical practice; it collects data on what is done based on the clinical circumstances; data are analyzed in a periodic function to

permit analysis of trends. But mainly, the DEAR Heart program revolved around the concept that an effective continuous registry of hospitalized symptomatic heart failure patients will lead to an identification of research needs among this subset of cardiac patients. It is hoped that identification of research needs will translate to local clinical researches and improvement in local treatment protocols for heart failure. In September 2002, a technical working group was set up to plan, strategize, pilot, and fully implement the program. Its members are its authors. From the period October 2002 to November 2004, the DEAR Heart Program has been advocated to 10 hospitals. At the end of 2004, six (6) hospitals had been implementing pilot testing of the program namely PHC, VMMC, UP-PGH, RMC, PSH, and Iloilo DH. As mentioned, the data gathered from 1078 patients registered in these 6 hospitals during the period November1, 2002 to December 31, 2004 have been encoded, collated, and analyzed for presentation during the 2005 annual PHA convention. Based on the results of the statistical analyses several insights are gained from the DEAR Heart pilot program results: The Filipino adult symptomatic HF patients are younger with the mean age at 60 years (median age = 62; mode = 64 years) compared to their United States or European counterparts. United States data show that the mean age of patients who are hospitalized with the primary diagnosis of HF is 72 years1,2. Our data show that 53% of admissions are >60 years old while US data show that 80% of their admissions are >65 years of age2.

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European data show that nearly 70% of the admissions belong to those > 75 years of age3. The insight gained from this is that Filipino heart failure patients become burdened with the cost of hospitalization and at the same time become less productive for their families even before the retirement age of 65. This also translates to an added strain on the limited resources of this countrys Medicare system (Philhealth). The Filipino adult symptomatic HF patients are predominantly male (57% vs 43%). United States and European data show an almost equal distribution of HF between the sexes with their data showing females dominating incidence beyond the age of 75 years.1,3 In terms of educational attainment as an attribute of the patient population, 85% of symptomatic Filipino adult HF patients belong to those who had at least high school education. Our data had also shown that 1/3 of patients are jobless. The US data (2001 NHANES I Epidemiologic Follow Up Studies) had shown that <High School Education is an attributable risk factor for the development of HF.4 Our data imply that, in this country, joblessness is a population attribute associated with the development of HF. Length of Hospital Stay (LOS) is a critical determinant of the cost of hospitalization. The DEAR Heart data show that the median length of hospital stay (LOS) among Filipino patients with symptomatic HF is 7 days (mean LOS =10 days). US data show a median length of hospital stay of 5 days (mean LOS = 6.5 days).2 United States 2004 data show that the estimated direct and indirect costs of HF total US$25.8 billion. The estimated contribution of the cost of hospitalization is US$13.6 billion. 1 The cost implications of this finding to a country whose budgetary appropriation for health services is severely limited can only be matched by the cost implications to the individual patient. This finding that symptomatic adult Filipino heart failure patients stay longer in the hospital compared to their US counterparts should also lead us to the more relevant question: Are we

practicing best-of-care compared to the more developed countries? A review of the 2001 updated ACC/AHA practice guidelines for the evaluation and management of HF will show that the focus of the guidelines are on patients with chronic systolic and diastolic HF. The committee that made up the task force on these updated guidelines qualify that they specifically did not consider Acute HF and that it might merit a separate set of guidelines 5. The DEAR Heart program therefore provides us with the opportunity to do local clinical researches and contribute to practice guidelines formulation among this subset of the cardiac population. The finding that some form of dyspnea predominate the symptoms of patients during admission indicate that pulmonary congestion is the most common presenting clinicopathophysiologic condition. It is corroborated by the finding that 93% of abnormal chest/lung findings on physical examination are congestive rales. The finding that only 24% of abnormal chest x-rays show pulmonary congestion may be reflective of the phenomenon of radiologic lag. Diuretics are the most commonly used drug (76% on admission, 68% on discharge). This reinforces the finding that pulmonary congestion is the predominant clinico-pathophysiologic or hemodynamic subset among the hospitalized symptomatic heart failure population. Studies have shown that about 2/3 of patients with decompensated heart failure are those defined hemodynamically to have elevated wedge or filling pressures (wet and warm type). 6 Our data reinforce those studies. Arranged from the most to least frequent, DEAR Heart pilot data show that the most common risk factors for the development of heart failure are: Hypertension (64%), Smoking(54%), Diabetes Mellitus(41%), Dyslipidemia(38%), and being Overweight(21%). Our findings differ from the United States data derived from the 2001 NHANES I Epidemiologic Follow Up Study that show risk factors for the development of HF as follows : Coronary Heart Disease = 62%, Smoking

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= 17%, Hypertension = 10 %, Overweight = 8%, Diabetes Mellitus = 3.1%, Valvular Heart Disease = 2.2%. Our findings suggest that public health prevention programs should particularly focus on Hypertension, Smoking, and Diabetes. The technical working group defined precipitating factors as those factors that trigger or initiate worsening of heart failure symptoms (decompensation). As shown above in Table 8, more than 30% of patients did not have precipitating causes for heart failure; The rest of the patients were identified to have precipitating factors as follows: systemic infection (21%), inappropriate reduction of treatment (20%), arrhythmias (11%), development of unrelated illnesses (7%), and administration of cardiac depressants (1%). The insight that may be gained from our data is that about a third of heart failure patients will inevitably have a progression of myocardial depression to such an extent that cause symptoms to worsen and lead to hospitalization. This insight disagrees with the expectation that worsening symptoms of heart failure is typically caused by identifiable trigger or initiating factors. USA data show estimates that, at any one time, about 80% of heart faiure patients are in a chronic stable state while 20% of patients are acutely decompensated.7,8 To date, there is no US or European data that could give us an estimate of decompensated HF patients with identifiable versus those without identifiable precipitating factors. The definition of preserved systolic function among developed countries is an ejection fraction greater than 45%. Our data show that 52% of our patients belong to this category and does not differ from United States or European data. The caveat is that more than one-third of our patients who have an EF >45% are those with valvular heart disease. Our data show that in terms of the underlying anatomic cause of heart failure, patients were distributed as follows: Ischemic Heart Disease Syndromes 52%, Valvular Heart Diseases 20%, Cardiomyopathy 11%, Uncontrolled

Hypertension 5.7%, Tachyarrhythmia 4%; and Congenital Heart Disease 3.4%. Our data varies from those of the United States and Europe. In the US, CAD is the underlying anatomic cause of HF in 2/3 of cases, the remainder have nonischemic Cardiomyopathy with known or with no known cause. 1 EFICA data (Epidmiologie Francaise de lInsuffisance Cardiaque Aigu) show that 60% are due to Ischemic Heart Disease Syndromes, 28% Dilated Cardiomyopathy , 25% Valvular Heart Diseases, 21% Hypertension. 10 This finding clearly underscores the importance of valvular heart diseases as causes of symptomatic heart failure among Filipinos. The implication is that local treatment algorithms should be examined to expedite correction of these among patients with valvular heart diseases... Our data show that the mortality rate among the 1078 Filipino adult patients hospitalized for symptomatic heart failure during the pilot phase of the DEAR Heart program is 10% (109/1078). 55% of these deaths were ascribed to progression of HF while only were ascribed to 32% to SCD. United States data (CDC/NCHS 2002) show a mortality rate of 6%.11The insight gained with our finding is the need for us to bring down this mortality rate. Assuming the DEAR Heart program is continued, it would be most relevant to find out if locally there are limitations to inhospital practice situations which impact adversely on in-hospital survival. The technical working group defined comorbid problems as those conditions identified during the course of hospitalization but are not related to the heart failure syndrome/state. As shown in Table 15 these are Hypertension (12.2%), Diabetes Mellitus (7.4%), Chronic Renal InsufficiencyI(3.6%), Chronic Obstructive Pulmonary Disease(1.6%), Hyperthyroidism(1.1%), Secondary Hypertension (0.7%), and Hypothyroidism(0.3%). Our results differ materially from the findings of USAs ADHERE regarding co-morbid conditions as US data in

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this registry show the following rates of comorbidities: history of hypertension (72%), coronary artery disease (57%); 44% had diabetes, 35% had a history of hyperlipidaemia, 31% had atrial fibrillation, and 31% had chronic obstructive pulmonary disease or asthma. Clearly the definition lies in how comorbidities are defined. The technical working group believes that although comorbidities may in themselves be risk factors they should be treated or considered as risk factors for the development of heart failure if they are conditions derived from the past medical history. The technical working group contends that comorbidities are conditions that the clinician identifies only during the hospitalization and accompany but are unrelated to the heart failure state. The technical working group attempted to identify factors which may be associated with inhospital mortality. Significantly associated with mortality by univariate analysis are: Chest pain, Systolic & Diastolic BP, Heart Rate, IV inotropic drug use, Transcatheter therapy, and use of IABC. By multivariate analysis, Chest pain as chief complaint & Admission Heart Rate > 95/min are factors strongly associated w/ significant inhospital mortality.

Limitations of the DEAR Heart program 1. Lopsidedness in patient distribution among hospitals - not a true national profile CAVEAT: The program is developmental and has been piloted first at the Philippine Heart Center which is a tertiary, subspecialty referral center for cardiovascular diseases since 1975. The Philippine Heart Center receives referrals from all over the country and inarguably has the most number of cardiovascular cases. 2. Limitations as to design of registry elements not all admitting laboratory exams were included in the registry elements such as Hgb, Hct, serum creatinine, BUN, Albumin, serum electrolytes etc.,etc.,. All of these are known to have an impact on the severity of the heart failure symptoms, length of hospitalization, and other outcome

parameters. CAVEAT: the registry program is developmental and there is a need to improve on the registry elements. The technical working group decided to leave out these elements and to focus on those that would confirm the primary diagnosis or underlying cause of heart failure as our resident epidemiologist puts it: FOCUS DEMANDS SACRIFICE The registry form has been revised in 2005. 3. There is no analysis regarding readmission ratesa parameter reflective of morbidity-of patients as 4 out of the 6 hospitals had implemented the program only in 2004. Future Directions As stated, the DEAR Heart program is a developmental program to continuously and effectively surveil symptomatic heart failure patients being admitted to tertiary hospitals. As stated, it is hoped that the program paves the way for clinical researches and improvement in treatment protocols among this subset of cardiac patients. It has been envisioned that we will eventually be able to set up a data base infrastructure and an information flow system whereby tertiary hospitals can relay data to the central databank so that researchers, individual cardiologists, relevant government and non-government agencies, and implementing hospitals can have access to data therein. It is envisioned that we will be able to set up a website for this registry program utilizing a user-friendly log-on password system. It has been envisioned that as we accumulate data with this registry, we will be able help government and non-government agencies to formulate preventive and interventional programs on cardiovascular diseases, particularly heart failure. In a way, the DEAR Heart program is about THINKING BIG- that the Philippines could be a lead center for clinical researches in heart failure this side of the globe; STARTING SMALL- with a model of a program to surveil and continuously profile symptomatic HF patients; and ACTING NOW! - piloting, expanding, and fully implementing the DEAR Heart program. REFERENCES
1. 2. AHA & ASA Heart Disease and Stroke Statisitics 2004 Update ADHERE: ADHERE heart failure treatment registry reaches 100,000 patient casemilestone.6November 2003.http://

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w w w. a d h e r e r e g i s t r y. c o m / n e w s / p r e s s _ r e l e a s e s / PR_03_11_06.html (21 December 2004) (ADHERE is an ongoing ADHF registry in the US called ADHERE for Acute Decompensated National Heart Failure Regsitry. It is considered the largest database for ADHF involving more than 250 hospitals. It was established in October 2001 and is now the most extensive acute heart failure registry in the world, with more than 100 000 patients enrolled to date. 3. Cleland JG, Swedberg K, Follath F et al. The EuroHeart Failure Survey programmea survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J 2003;24:442 (EuroHeart Failure Survey - survey screened consecutive deaths and discharges during 20002001 predominantly from medical wards over a 6-week period in 115 hospitals from 24 countries belonging to the ESC, to identify patients with known or suspected heart failure) 4. NHANES I Epidemiologic Study in the United States, 2001. www.educ.gov/nchs/products/elec_prods/subject/nhefs.htm 5. www.acc.org ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the adult: a report of the ACC/AHA Task Force on Practice Guidelines(Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure) 2001 6. Nohria A et al JAMA, 2002; 287: 628-640 7. AHA & ASA Heart Disease and Stroke Statisitics 2005 Update 8. Heywood JT, ADHERE Investigator Meeting Report; July 1517, 2004; New Orleans, Louisiana 9. Fonarow GC. The Acute Decompensated Heart Failure National Registry (ADHERE): opportunities to improve care of patients hospitalized with acute decompensated heart failure. Rev Cardiovasc Med 2003;4(Suppl. 7):S21S30.

10. Zannad F, Cohen-Solal A, Desnos M et al. Clinical and etiological features, management and outcomes of acute heart failure: the EFICA cohort study. Eur Heart J 2002;4(Suppl.):579 11. Centers for Disease Control and Prevention(CDC)/National Center for Health Statistics (NCHS) 2002

ACKNOWLEDGEMENTS 1. Office of Education and Research, Philippine Heart Center 2. PHA Presidents 2002 to 2003 3. Astra-Zeneca Philippines 4. Enrique Fabio Posas, MD, FPCC 5. Head, Dept. of Adult Cardiology Head, PSH-Cebu 6. Head, Department of Internal Medicine, VMMC 7. Head, Department of Adult Cardiology, UP-PGH 8. Head, Department of Internal Medicine, RMC 9. Head, Department of Internal Medicine, IDH 10. Head, Department of Cardiology, Makati Medical Center 11. Head, Department of Adult Cardiology University of Sto.Tomas 12. Head, Department of Adult Cardiology, The Medical City 13. Head, Department of Internal Medicine, Mary Johnstons Hospital 14. Head, Department of Adult Cardiology, Chinese General Hospital 15. Herdie Hizon of the National Epidemiology Center 16. Directors, National Epidemiology Center-DOH, 2002 & 2003